Women and HIV: Heterosexual Transmission and Gynecologic Manifestations Ann K Avery, MD

1. Originally developed by: Health Care Education & Training, Inc. Women and HIV: Heterosexual Transmission and Gynecologic ManifestationsAnn K Avery, MD

2. Disclosures As stated in the No Conflict of Interest policy maintained by Health Care Education and Training, Ann K Avery, MD, agrees to present the following information fairly and without bias. Funding for this program was provided through the Region V Training Project of Health Care Education and Training. No commercial financial support was used. Approved provider status does not imply endorsement by the provider, ANCC or ISNA of any commercial products displayed in conjunction with this activity.

3. Continuing Education Hours • This event provides participants with the opportunity to earn 1.0 nursing contact hours and/or 1.0 CHES continuing education hours for a $10 processing fee. • In order to receive contact hours participants must attend the entire event and complete and return a sign in sheet, evaluation form, and a pre/post test. • HCET is approved as a provider of continuing nursing education by the Indiana State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

4. Housekeeping • Please complete the Pre-test, Post-test, Sign-in form and Evaluation forms. Fax to HCET at (317) 247-9055 • For assistance with registration or presentation materials, call HCET at 317-247-9008. • For technical issues connecting to the Genesys Conferencing System, call the Genesys Help Desk:1-800-305-5208.

5. Ann K Avery, MD • Ann K. Avery received her MD Case Western Reserve University- School of Medicine and went on to a medical internship in Emergency Medicine at Metrohealth Medical Center in Cleveland, Ohio. Dr. Avery finished her residency in Internal Medicine, also at Metrohealth Medical Center. From 2001 to 2003 Dr. Avery pursued a fellowship in Infectious Diseases, University of Miami/Jackson Memorial Hospital. • Currently Dr. Avery is an assistant professor at the School of Medicine at Case Western Reserve University. Dr. Avery is also the Medical Director of the Cleveland Department of Health and is a staff physician at MetroHealth Medical Center in the Division of Infectious Diseases. • Dr. Avery is a member of several professional organizations including the Infectious Diseases Society of America, the American Sexually Transmitted Diseases Association (ASTDA), and the National Coalition of STD Program Directors (NCSD). She also serves on several community committees and lectures regularly to her colleagues in the field, medical students and the public.

6. Objectives • Describe the routes of HIV transmission in women during heterosexual sex. •  List gynecologic problems that indicate a need for HIV screening. •  Explain the ongoing needs for family planning services experienced by HIV positive women

7. 2007 Contributors from AETC Women’s Health and Wellness Workgroup: • Joyce Alley, RN; Health Care Education and Training, Inc. • Laura Armas, MD; Texas/Oklahoma AETC • Andrea Norberg, MS, RN; AETC National Resource Center • Tonia Poteat, MPH, MMSc, PA-C; Southeast ATEC (SEATEC) • Barbara Schechtman, MPH; Midwest ATEC (MATEC) • Karen Sherman, MA; Health Care Education and Training, Inc. • Jamie Steiger, MPH; AETC National Resource Center The original curriculum was developed in 2002 by MATEC and Health Care Education & Training, Inc.

8. Route of Vaginal Transmission

9. Biologic Factors that Increase HIV Susceptibility Epithelial cells Susceptibility Langerhan’s cells lumen submucosa

12. Progesterone & Increased Vulnerability to HIV-1 (Marx et al., 1996)

13. Young Women and HIV Risk • Young women are at an increased risk for HIV • infection because: • They are biologically vulnerable • They are less likely to be able to negotiate safer sex with an older partner • They may feel invincible • They may be more worried about pregnancy than about STIs and HIV

14. Older Women and HIV Risk Older women are at an increased risk for HIV infection because: • They have physiological changes associated with menopause • They may perceive their risk of infection to be low • They may not think about condom use because they are no longer concerned about pregnancy

15. Female Male (MMWR, July 18, 2003)

16. Discussing Anal Sex with Your Clients • It is imperative that we discuss the risk of STI/HIV • transmission from anal sex, regardless of the • sexual orientation of our clients, since: • Anal sex is prevalent among heterosexuals • Women may have anal sex for pleasure, to prevent pregnancy, or to preserve virginity • Effective prevention methods exist for anal sex (condoms, female condoms)

17. Prevalence of Anal Sex Among Heterosexuals • It is important to discuss the risk from anal sex with • female clients: • In a study of 1,268 sexually active women, 32% (n=432) reported anal sex in the previous six months (Gross et al., 2000) • In a study of men & women aged 13-19, 20% of women and 27% of men reported at least one episode of heterosexual anal intercourse (Moscicki, Millstein, Broering, & Irwin, 1993) • In 2002, 11% of males and females aged 15-19 had engaged in anal sex with someone of the opposite sex (Mosher, Chandra, & Jones, 2002)

18. Anal intercourse and women • In absolute numbers, 7x more heterosexual women than gay men and MSM in the US practice receptive anal intercourse (AI) - a conservative estimate • [Halperin DT.] • Prevalence of AI among heterosexuals is not well defined • Varies regionally by age, population, co-risk • AI is relatively common globally, 5 – 10% in gen. pop. and up to 30-50% of women with other HIV risks engage in AI • Unprotected AI may be a significant source of HIV transmission in many contexts, including those labelled as “heterosexual epidemics.”

19. Biological differences

20. Anatomy 101

21. An act of unprotected anal intercourse is10 to 20 timesmore likelyto result in HIV transmission than an act of unprotected vaginal intercourse.

22. Discussing Oral Sex with Your Clients • It is also imperative to discuss the risk of • transmission of HIV from oral sex, since: • Oral sex is highly prevalent among heterosexuals • Oral sex has been shown to transmit HIV • More than half of adults in the U.S. do not consider oral sex to be sex • Effective prevention measures exist (condoms, dental dams, plastic wrap)

24. Personalized Risk Reduction • Vaginal and anal sex: • Condom use • Female condom use • Abstinence • Reduce # of partners and/or frequency of sex • Limit the use of substances prior to sexual activity • Mutual monogamy with HIV negative partner

25. Personalized Risk Reduction • Oral sex: • Condom use • Dental dams or plastic wrap use • No brushing or flossing prior to performing oral sex • Avoiding ejaculation inside the mouth

26. Personalized Risk Reduction • Injection Drug Use: • Needle exchange • Cleaning with bleach in absence of new needles • No sharing of works • Choose less risky route of use

27. Personalized Risk Reduction • Non-Injection Drug Use: • Reduce intake • Don’t combine drugs • Choose the least risky route of use • Avoid sexual activity when drunk or high

28. How To Pick A Partner Don’t even think about it… • Involved in a crime • Needle drug user • Violent (emotionally, physically, verbally, sexually) You deserve better… • Wants you to have a baby when you are not ready • Doesn’t want you to have friends This could work! • Listens to you • Respects your wishes • Never, ever scares you

29. Gynecological Problems that Indicate a Need for HIV Screening • Vaginal discharge/irritation • Abnormal uterine bleeding/amenorrhea • Abnormal Pap smear • Genital warts • Genital ulcers • Pelvic/abdominal pain and Pelvic Inflammatory Disease (PID)

30. 41% 59% Co-Occurrence of HIV and Gynecologic Disorders Women with gynecologic disorder(s) at enrollment • Anogenital warts • Syphilis • Amenorrhea • Symptomatic candidiasis • Oncogenic HPV • Abnormal Pap smear (Minkoff et al., 1999)

31. CDC HIV/AIDS Classification System: GYN Manifestations

32. HIV and STDs • Synergy between STDs and HIV • ALL clients seeking STD screening should be offered HIV testing at the same time. • All patients between 13 and 64 recommended to have HIV test at least once. ( CDC Oct 2006)

33. Epidemiological Synergy • Co-infection with HIV prolongs the infectiousness on STDs • STDs facilitate HIV transmission by increasing genital HIV-RNA/DNA levels • STDs facilitate HIV acquisition by disrupting epithelial barriers and attracting inflammatory cells • GUD increases risk of HIV 8 fold

34. Synergy between HIV and STIs

35. Vaginal Discharge/Irritation • Women with frequent and/or persistent vaginal discharge should be offered an HIV test • STIs indicate HIV risk behavior and an increased risk for HIV acquisition • Bacterial Vaginosis can increase a woman’s risk of acquiring HIV • Yeast infections are common among women with HIV; therefore, frequent and persistent yeast infections are a cue for HIV testing

36. Recurrent Yeast Vaginitis as a Common Presenting Symptom of HIV • Prevalence of candiasis among HIV positive women is 3-15% • HIV positive women with CD4 cell counts <200 have significantly increased odds of vaginal or oral colonization of Candida • Recurrent yeast vaginitis is the most common presenting symptom of HIV infection Credit: Jean R. Anderson, MD

37. Abnormal Uterine Bleeding • Abnormal uterine bleeding/menstrual disorders are very common among HIV positive women • Bleeding may not be due to HIV disease, but possibly to related factors such as: • Weight loss • Chronic disease • Substance abuse • Use of progesterone (for appetite stimulation or contraception)

38. Abnormal Pap Smear • 30-60% of Pap smears from HIV positive women have cytological abnormalities (Larkin et al., 1999) • 15-40% of these Pap smears exhibit dysplasia (Larkin et al., 1999) • Women with HIV are more likely to have persistence of HPV and cervical dysplasia

39. Abnormal Pap Smears in HIV Positive Women • Genital Tract Neoplasia

40. Cervical Neoplasia • Cervical cancer is an AIDS defining illness • In a study of 2,015 HIV-infected women and 577 seronegative controls, 58% of HIV- infected women had HPV as compared with the seronegative controls of 26% • In HIV positive women, dysplasia is associated with more extensive cervical involvement and is more likely to involve other sites in the lower genital tract

43. Before Treatment After Treatment Credit: Cliggott Publishing Credit: Cliggott Publishing