Gynecologic challenges of the HIV positive female

Dr. Orville P. MorganConsultant

Obstetrician/GynaecologistVJH

Gynaecologic Challenges

Infectious Menstrual disorders Neoplasia Reproductive/fertility

Infectious diseases

Vaginal candidiasis HSV HPV PID Pelvic abscess Endometritis TB

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

Clinical Diagnosis

Thick white discharge Pruritus Dypareunia Dysuria Ulceration

Diagnosis

KOH preparation shows yeast Pap smear/culture shows yeast

and the patient has symptoms of a vaginitis

Category B illness

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

Recurrent Candidiasis

Ketoconazole x 6 months

HSV

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.

HSV

HSV-1 droplets, kissing, ora-genital contact

HSV- 2 penile- vaginal, anal intercourse

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

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

HPV

Skin warts Anogenital warts Cervical cancer Vulval cancer Penile ca, respiratory papillomas,

conjunctival papillomas, oral cavity lesions

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.

HPV & HSV

Immunosupression inhibits the clearance of HPV

Immunosupression promotes HPV reactivation

Patients have greater number of precancerous lesions

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

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.

Pelvic Abscess

Tubo-ovarian abscess frequent complication of PID

Constitutional symptoms often absent.

Surgical intervention

Menstrual abnormalities

Related to advanced disease Amenorrhea IMB Shortened cycle Active virus shedding greatest in

luteal phase R/o malignancies, infections incl TB

Neoplastic challenges

Cervical carcinoma Vulval carcinoma Uterine lymphomas

CIN & HIV

HGSIL category B Multifocal dyplasia (vagina, anus)

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

Reproductive Challenges- Contraception

Condoms Tubal ligation,(Decreased condom

use) IUCD(?contraindicated) OCP, (Decreased condom use) Depoprovera, (Decreased condom

use)

Reproductive challenges-fertility

Sero-positive male, sero-negative female

Sero-positive female Obstetric outcomes

Thank you

Neither this man nor his parents sinned……..

..the work of God might be displayed in his life

John 9:3