From LN ArmasKolostroubis, MD, at 12th Annual Ryan White HIVAIDS Program Clinical Conference, IASUSA

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Women with HIV Issues in Primary Care
Laura N. Armas-Kolostroubis, MDClinical
DirectorTexas/Oklahoma AIDS Education and
Training Center
From LN Armas-Kolostroubis, MD, at 12th Annual
Ryan White HIV/AIDS Program Clinical Conference,
IASUSA.
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Primary Care of HIV-Infected Women

• Transmission
• Natural history and disease progression
• ARV sex specific considerations
• Age specific health maintenance and screening
• Pre-conception and inter-conception counseling
• Gynecologic problems
• Menopause and bone health
• Psychosocial considerations

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Slide 3
From LN Armas-Kolostroubis, MD, at 12th Annual
Ryan White HIV/AIDS Program Clinical Conference,
IASUSA.
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Women Have Higher CD4 Cell Counts
Hubert.XIV International AIDS Conference. No.
ThOrC1448.
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Estimated differences in mean Log10 HIV RNA
between men and women
Viral load lower in women
Viral load higher in women
Study n Moore (VI) 1173 Sterling
(1999) 71 Evans 42 Sterling (2001) 202 Moore
(V) Farzadegan 527 Anastos (IV) 2859 Rezza 415 L
yles 149 Moroni 2011 Anastos (III) Moore
(IV) Katenstein 391 Junghans (H) 1337 Junghans
(IDU) Anastos (II) Moore (III) Bush 40 Anastos
(I) Moore (II) Moore (I) Kalish 494
750 0
Studies in ascending order of CD4 count
Number represents total in study and not total
in strata Gandhi M. 9th CROI, Seattle, 2002,
775-W
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Gender and Treatment Response

• Virologic
• Women have at least equivalent response to
  PI-based ARV therapy as men1-3
• Immunologic
• Women have at least equivalent CD4 cell responses
  to HAART as men2-4
• Outcome
• Women do not experience more rapid progress of
  HIV infection than men at equal levels of VL5

1.Keiser P, et al. XIV Int AIDS Conference,
Barcelona 2002, 5962 2. Palella F, et al. ibid,
5967 3. Cernohous P, et al. ibid,
5972 4.Giordano T, et al. ibid, 5965 5. Hubert
JB, et al. ibid, 1448
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Women and HIV Initial Antiretroviral Regimen
Considerations

• Episodic pregnancy-related ART
• Delayed initiation of therapy and sub-optimal ART
  common
• Clinical implication and/or effect on long-term
  outcome unknown at this time
• Women specific medical complications
• Osteoporosis
• Cardio-vascular Disease
• Non HIV related malignancies
• Optimal management strategies
• Reproductive life puberty to Menopause
• Management of pregnancy
• Long term complications
• Access to care

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Race and Gender Disparities in the Use of HAART
HIV Research Network (HIVRN)Persistent
differences exist in access to HAART by gender,
race, and use of injection drugs
Multivariate analysis odds ratio of receiving
HAART at 10 primary care sites.
Gebo KA, et al. J Acquir Immune Defic Syndr.
20053896-103.
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Trends in the Use of Suboptimal Therapy in Women
DHHS Category of Initial Regimens in WIHS by Year
100
80
Preferred/alternate
60
Proportion
Unlisted
40
Contraindicated
20
0
1998
1999
2000
2001
2002
2003
2004
Year

• WIHS Report
• Inappropriate use of ART regimens, contrary to
  USPH guidelines, persists
• Inappropriate therapy results in suboptimal
  response

Cocohoba JM, et al. 14th CROI 2007 San
Francisco, CA. Poster 784.
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Estimated number of births to women living with
HIV infection, 2000-2006
2006 estimate (8,650 8900) is 30 gt 2000
estimate (6075 6422)
Office of Inspector General (Fleming), 2002
Whitmore, et al. CROI, 2009
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Live birth patterns among HIV-infected women
before and after the availability of HAART A.
Sharma, Minkoff et al Am J Obstet Gynecol
2007196541

• Live birth rate per 1000 person-years

• 2,488 HIV vs. 974 HIV-

• Among HIV, the HAART era live birth rate was
  150 higher than in the pre-HAART era (P.001)
  vs. a 5 increase among HIV- women
• The rate of increase in live birth rate was
  higher for
• women 35 years old (vs. younger than 25 years,
  P.02)
• with more than a high school education (vs. less
  than high school, P.05)

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Timing of Antiretroviral (ARV) Prophylaxis and
Risk of Perinatal HIV Transmission
Estimated Transmission Rate
Wade,et al. 1998 NEJM 3391409-14 Guay, et al.
1999 Lancet 354795-802 Fiscus, et al. 2002 Ped
Inf Dis J 21664-668 Moodley, et al. 2003 JID
167725-735 Kourtis, et al. 2006 Lancet Inf Dis
6726-732
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What is Preconception Care

• Preconception care aims to promote the health of
  women of reproductive age before conception and
  thereby improve pregnancy-related outcomes
• 10 recommendations in this report to improve a
  womans health before conception, whether before
  a first or a subsequent pregnancy

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Reproductive History

• Gynecological History
• Sexual History
• Partner History
• Couple History

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Health Screening

• Reproductive awareness
• Environmental toxins and teratogens
• Nutrition and folic acid
• Genetics

• Substance use, including tobacco and alcohol
• Medical conditions and medications
• Infectious diseases and vaccination
• Psychosocial concerns
• Depression
• Violence

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Pre-conception Counseling for PLWHA

• Transmission occurs at any stage of conception
• Inform of need of ARV to prevent MTCT
• Risk of transmission to partner
• HIV PrEP, virologic suppression in both
• Resistant strains
• Other STDs
• Optimize maternal health status
• Folic acid
• Virologic suppression and immunologic recovery
• Other conditions weight, DM, HTN
• Not just for women

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Other

• Open discussion
• Avoid confrontation about decision
• Provide several options and reassurance
• Consult experts
• Discuss adoption as an option