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Part A: Module A3 Session 2

Management of HIV Disease in Women. Part A: Module A3 Session 2. Objectives. Describe the etiology and clinical presentation of STIs and gynecological problems in HIV-infected women Discuss the treatment and management of these infections and gynecological problems

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Part A: Module A3 Session 2

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  1. Management of HIV Disease in Women Part A: Module A3 Session 2

  2. Objectives • Describe the etiology and clinical presentation of STIs and gynecological problems in HIV-infected women • Discuss the treatment and management of these infections and gynecological problems • Discuss the prevention of OIs in pregnancy • Discuss treatment protocols in-country

  3. Gynecological Problems and STIs • Vaginal discharge • Lower abdominal pain and fever (PID) • Genital sores (ulcers or blisters) • Genital warts • Malignancies • Amenorrhea and intermenstrual bleeding

  4. Vaginal Discharge: Etiology • Gonococcal infection • Chlamydia trachomatis • Trichomonas vaginalis • Bacterial vaginosis • Candidiasis

  5. Management and Treatment • General: Follow the national STI management guidelines. Ensure treatment of partners Candidiasis: • recurrent episodes (even after treatment) • episodes persistent as HIV disease progresses • regular intermittent treatment may be needed for frequent recurrences

  6. Management and Treatment Treatment • Intravaginal: Miconazole 200 mg suppository/day x 3days; clotrimazole 100 mg tab vaginal bid x 3days or qd x 7 days; clotrimazole 1% cream, Miconazole 2% cream qd x 7days, or nystatin pessary qd or bid • Oral: Fluconazole 150 mg po x 1 Ketaconazole 200 mg po/day x 7 days or bid x 3 days

  7. Lower Abdominal Pain and Fever (PID)

  8. Etiology • Gonococcal infection • Chlamydia trachomatis • Mixed bacterial infections (including anaerobes) • TB

  9. Management and Treatment • Women should report symptoms promptly to ensure early diagnosis and treatment • Treat bacterial infections aggressively with broad spectrum antibiotics, e.g., ciprofloxacin 500 bid x one week • If STD is the cause, follow the national STD management guidelines. Ensure treatment of partners

  10. Management and Treatment, continued • Exclude acute conditions (i.e., appendicitis, ectopic pregnancy, etc.) • If patient does not respond to treatment, refer for blood test to exclude pregnancy in presence of negative urine pregnancy test. Also need to exclude pelvic abscess or TB • Huge pelvic abscesses may be found in immunosuppressed patients following pelvic infection or surgical procedures • Drainage and appropriate antibiotic therapy to cover aerobic and anaerobic organisms is necessary

  11. Genital Sores (Ulcers or Blisters)

  12. Etiology • Syphilis • Chancroid • Lymphogranuloma venereum (LGV) • Herpes simplex

  13. Management and Treatment • Herpes simplex in HIV-infected patients: • Recurrent, more severe, may spread to buttocks and abdomen. In late HIV disease, lesions persistent, extensive, and extremely painful • Give supportive treatment: pain relief and gentian violet • Oral acyclovir 200 mg qid x 5 days reduces pain and promotes healing. Severe cases: treatment may be extended for 2-3 weeks. Note: Oral acyclovir usually not used to prevent prenatal HSV transmission • In case of secondary infection, give antibiotics: co-trimoxazole 2 tabs bid or cloxacillin 250 mg qid x 5 days

  14. Genital Herpes

  15. Genital Warts • Etiology • Condylomata acuminate. This should be distinguished from • Condylomata lata (due to secondary syphilis) • Management and treatment • Tend to be more common and severe in persons with HIV • Treat with topical podophyllin 20% twice a week or remove by surgery or electro-cauterization • If due to secondary syphilis, follow the national STD management guidelines. Ensure treatment of partners • Counsel on prevention of transmission to partner

  16. Malignancies • Etiology • Cervical cancer, CIN • Kaposi’s sarcoma • Management and treatment • Extensive surgical intervention should not be undertaken if equally effective treatments, such as radiotherapy can be given • Cancer response to surgery, radiotherapy, and chemotherapy is often not good in HIV seropositive patients if their immunological status is severely compromised

  17. Amenorrhea and Intermenstrual Bleeding • Etiology • Menstrual disturbances-often associated with chronic ill health; are frequent in women with HIV • May be linked to general deterioration and weight loss due to HIV disease

  18. Amenorrhea and Intermenstrual Bleeding, continued • Management and treatment • Exclude other causes such as pregnancy, perimenopause, uterine fibrosis, genital tract infections, cervicitis, PID, TB, cancer • Menses may return after treatment of other infections and weight gain • Best management: provide counseling and reassurance • If the woman is sexually active and not using an effective method of contraception consistently, do a pregnancy test

  19. Prevention of OIs in Pregnancy

  20. Prevention of OIs in Pregnancy

  21. Prevention of OIs in Pregnancy

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