Originally developed by:
Health Care Education &
Training, Inc.
HIV Screening and Women’s Health
Section 4:
Gynecological Manifestations of
HIV Infection
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.
2
HIV Screening and Women’s Health
Objective for Section 4:
1. Discuss gynecological problems that indicate a
need for HIV screening, including:






3
Vaginal discharge/irritation
Abnormal uterine bleeding/amenorrhea
Abnormal Pap smear
Genital warts
Genital ulcers
Pelvic/abdominal pain and Pelvic Inflammatory
Disease (PID)
HIV Screening and Women’s Health
Co-Occurrence of HIV and Gynecologic Disorders
Women with gynecologic disorder(s) at enrollment
41%
59%
(Minkoff et al., 1999)
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HIV Screening and Women’s Health




Anogenital warts
Syphilis
Amenorrhea
Symptomatic
candidiasis
 Oncogenic HPV
 Abnormal Pap smear
CDC HIV/AIDS Classification System:
GYN Manifestations
A
Asymptomatic
B
HIV-related
symptoms
C
AIDS-defining
conditions
1.
>500 mm3
(> 29%)
 Recurrent Vaginitis
 Cervical Cancer,
invasive
Genital Tract TB
2.
200-499 mm3
(14-28%)
 Cervical Dysplasia
Cervical Carcinoma
in situ
 Genital Tract
Lymphoma
CMV Endometritis
3.
<200 mm3
(<14%)
5
HIV Screening and Women’s Health
Vaginal Discharge/Irritation




6
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
HIV Screening and Women’s Health
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
Credit: Jean R. Anderson, MD
7
 Recurrent yeast vaginitis is
the most common
presenting symptom of HIV
infection
HIV Screening and Women’s Health
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:




8
Weight loss
Chronic disease
Substance abuse
Use of progesterone (for appetite stimulation or
contraception)
HIV Screening and Women’s Health
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
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HIV Screening and Women’s Health
Abnormal Pap Smears in HIV Positive
Women
Genital Tract Neoplasia
Pap Smear Screening - WIHS Cohort
followed for 3.5 years
Benign
Ascus
LGSIL
HGSIL
Cancer
10
Cumulative Risk
HIV +
HIV 33%
67%
28%
23%
34%
8%
5%
3%
0.4%
0%
HIV Screening and Women’s Health
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
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HIV Screening and Women’s Health
HPV as a Common Presenting Symptom of HIV
Before Treatment
After Treatment
Credit: Cliggott Publishing
Credit: Cliggott Publishing
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HIV Screening and Women’s Health
Genital Ulcers
 Diseases which present with genital ulcers and may be
associated with HIV disease include: herpes, syphilis,
chancroid, cytomegalovirus, lymphogranuloma
venereum, granuloma inguinale, and tuberculosis
 Women with HIV often experience more severe
manifestations of these diseases due to
immunosuppression
 Genital ulcers serve as a portal of entry for HIV; thus
women affected by such ulcers are at a greater risk of
infection
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HIV Screening and Women’s Health
Pelvic/Abdominal Pain
 Pelvic inflammatory disease (PID) or pregnancy
are common causes of pelvic pain
 Many studies have shown an increased
prevalence of HIV in hospitalized PID patients,
indicating that providers should offer women with
PID an HIV test
 All pregnant women should be offered an HIV
test, as part of routine prenatal care
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HIV Screening and Women’s Health
Resources
 AIDS Education and Training Centers
www.aidsetc.org
 Cervical Cancer Screening and the HIV-Infected Woman slide set
 Human Papillomavirus and the HIV-Infected Woman slide set
 Common Sexually Transmitted Diseases and the HIV-Infected
Woman slide set
 Title X Family Planning Regional Training Centers
http://opa.osophs.dhhs.gov/titlex/ofp-training-granteeslisting.html
 Health Resources and Services Administration, HIV/AIDS
Bureau
http://hab.hrsa.gov/publications/womencare05/index.htm
 A Guide to the Clinical Care of Women with HIV, 2005 edition, Ed.
Jean R. Anderson
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HIV Screening and Women’s Health
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16
HIV Screening and Women’s Health
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HIV Screening and Women’s Health
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HIV Screening and Women’s Health
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HIV Screening and Women’s Health