Behind the Frontline: Women, HIV and Reproductive Health
Gynecologist Dr. Patricia Garcia is director of the Women's Program at the Comprehensive HIV Center at Northwestern Memorial Hospital in Chicago. She spoke at the South Side HIV Care Providers Forum in Chicago in January, from which these notes are taken.
She's Only 13 ...
This month has been hard for me. I delivered the youngest HIV-positive pregnant patient I ever have -- 13 years old, with the smallest infant I've ever delivered -- 15 ounces. The results were good -- HIV-negative baby by two PCR tests [viral load]. It's a common story -- an older boyfriend. He's 18. He infected her with chlamydia, herpes and HIV all at the same time.
Half of the newly diagnosed women at our clinic are pregnant. Why? Because that's when we uniformly test women [with their permission]. I'm sure it's the same throughout the country. What a bad time to get diagnosed.
In the U.S. in 1999, of the post-natally infected adolescents, 51% were girls. Why? For starters, negotiating for condoms is harder when the boyfriend's older, like that couple -- 13 and 18.
It's not just behavioral. Girls are at greater risk for biological reasons. The endocervix comes outside [of the uterus] during menarchy [the start of menstruation] and during pregnancy. HIV targets the white blood cells on the endocervix, so it's easier to become infected.
Having a Baby
[Another doctor says, "More women are coming to me with the same question -- can I have a baby? This includes couples where the man is positive and the woman is negative."]
In February of 2002, the association of reproductive endrocrinologists admitted that HIV is a chronic illness and they should help people with HIV like they would anyone else. They help cystic fibrosis carriers, and half the children get it. They also help people with muscular dystrophy.
HIV is not in the sperm. It's in the white blood cells of free virus floating in seminal fluids. So you separate the sperm from free virus and white blood cells. Endrocrinologists do this every day [for HIV-negative men].
There was a lot of compelling data at Barcelona [the International AIDS Conference held last July]. The semen centrafuges down. You use regular PBS washing. It centrafuges back up. It's a two-step process, routine lab work. There's not an absolute zero risk. It's $200 to $250 to process the sperm. It's more to use PCR to check for [the virus] before insemination.
We used a Boston lab for one woman, but with no success. FedEx'ing the processed semen back and forth is not [good] enough. We're establishing a procedure with a local endrocrinologist now who's willing to work with us. Just because the American Society for Reproductive Medicine changed its policies doesn't mean that there are doctors all over the place willing to help people with HIV.
Positive women and negative men can do insemination at home with a syringe. I just delivered twins to someone who did this.
I also think adoption is an important option that needs to be raised.
Pregnancy Health Care
It's just like any other disease -- control the disease. What if she has 500 T cells and a 1,000 viral load and she's cruising along on no therapy? If she gets pregnant, she has to face therapy. There's a greater transmission risk at 1,000 viral load.
ACTG 076 found that the heaviest women had only a 26% reduction in transmission to their infants [using AZT during pregnancy]. All the others had a 79% reduction. Together, the reduction was 66%. So maybe we can adjust the dose. [AIDS Clinical Trials Group Study 076 established the effectiveness of Retrovir (AZT) for the prevention of mother-to-infant transmission.]
You can't ignore high blood pressure or diabetes. These are big issues, and HIV may be the least of their concern. Those other diseases could kill them during pregnancy.
If they have an abortion, the sedative is important. They can't be given methergine, because it can cause prolonged sedation if the woman's on a protease inhibitor. I know of one woman who almost died recently because of this.
The CDC [U.S. Centers for Disease Control and Prevention] say there's no difference between opting out and opting in [of counseling to go with HIV testing]. I think that's a big injustice.
The counseling is very important. We'll find very few positive women. But counseling them on how to protect themselves against sexually transmitted disease is the greater public health benefit.