Gynecologic challenges of the HIV positive female

1. Gynecologic challenges of the HIV positive female Dr. Orville P. Morgan Consultant Obstetrician/Gynaecologist VJH

2. Gynaecologic Challenges • Infectious • Menstrual disorders • Neoplasia • Reproductive/fertility

3. Infectious diseases • Vaginal candidiasis • HSV • HPV • PID • Pelvic abscess • Endometritis • TB

4. Vaginal candidiasis • Vulvo-vaginitis • Fulminant • Resists standard treatment • Sign of advancing disease • Increases risk of virus transmission • Inflammatory changes only on Pap smear with isolation of candida specie • Most often candida albicans

6. Clinical Diagnosis • Thick white discharge • Pruritus • Dypareunia • Dysuria • Ulceration

7. Diagnosis • KOH preparation shows yeast • Pap smear/culture shows yeast and the patient has symptoms of a vaginitis • Category B illness

8. Treatment • Azole drugs usually topically for 7 days • DS suppositories for 3 days • Oral Rx fluconazole 150-200mg stat or itraconazole 200mg for three days • HIV positive patient – topical agents for 14 days may be appropriate

9. Recurrent Candidiasis • Ketoconazole x 6 months

10. HSV

11. HSV & HIV • HSV seropositivity increases the risk of acquiring HIV x 2 ? Upregulation HIV replication • HSV-2 infection increases the risk of transmitting HIV • HIV positive individuals may have more frequent outbreaks • In severely immunocompromised individuals lesions may be atypical.

12. HSV • HSV-1 droplets, kissing, ora-genital contact • HSV- 2 penile- vaginal, anal intercourse

13. Diagnosis &Treatment of HSV • Diagnosis clinical • Acyclovir 400mg q6h x 10/7, 800mg bd • Valacyclovir(prodrug) 1000mg daily, 500mg daily • Famciclovir 500mg daily, 250mg daily • Foscarnet IV tid

14. Dietary Management HSV • HSV contains more arginine vs lysine • Foods high in Lysine Fish, chicken, beef, milk, cheese, beans(not peas), vegetables • Lysine 390mg daily • Avoid gelatin, chocolate, oats, soyabeans, peanuts,whiteflour

15. HPV • Skin warts • Anogenital warts • Cervical cancer • Vulval cancer • Penile ca, respiratory papillomas, conjunctival papillomas, oral cavity lesions

17. HPV & HIV • HPV detection in HIV infected women may be as high as 83%(5x the general population) • 20% of dually infected women with no evidence of cervical disease will develop cervical disease within 3 years. • HIV infected women are at greater risk for developing cervical cancer caused by HPV infection.

18. HPV & HSV • Immunosupression inhibits the clearance of HPV • Immunosupression promotes HPV reactivation • Patients have greater number of precancerous lesions

19. HPV & HIV • More likely to be infected with multiple types. • Correlation between lower CD4 counts and higher number of multiple types of HPV • More likely to have large condylomas • More likely to experience treatment failures for cervical dysplasia

20. PID • Patients admitted for PID more likely to be HIV positive • Symptoms may be muted • Fortunately responds equally to standard therapy • More likely to have an adnexal mass on ultrasound.

21. Pelvic Abscess • Tubo-ovarian abscess frequent complication of PID • Constitutional symptoms often absent. • Surgical intervention

22. Menstrual abnormalities • Related to advanced disease • Amenorrhea • IMB • Shortened cycle • Active virus shedding greatest in luteal phase • R/o malignancies, infections incl TB

23. Neoplastic challenges • Cervical carcinoma • Vulval carcinoma • Uterine lymphomas

24. CIN & HIV • HGSIL category B • Multifocal dyplasia (vagina, anus)

25. Treatment of CIN • Colposcopy LEEP • Eradication of SIL almost impossible -goal to prevent progression to HGSIL • 5-Fluorouracil vaginal cream has been shown to be useful in reducing recurrence rates • HAART may lead to “normal” behaviour of CIN

26. Reproductive Challenges- Contraception • Condoms • Tubal ligation,(Decreased condom use) • IUCD(?contraindicated) • OCP, (Decreased condom use) • Depoprovera, (Decreased condom use)

27. Reproductive challenges-fertility • Sero-positive male, sero-negative female • Sero-positive female • Obstetric outcomes

28. Thank you Neither this man nor his parents sinned…….. ..the work of God might be displayed in his life John 9:3