Gynecologic issues in the HIV-infected woman

Barriers to recommended gynecologic care in an urban United States HIV clinic

BACKGROUND

Despite an increased risk for cervical cytologic abnormalities, HIV-infected women frequently miss their gynecology appointments. We examined barriers to adherence with gynecologic care in an urban HIV clinic.

METHODS

We conducted a cross-sectional survey of 200 women receiving gynecologic services in an urban HIV clinic, followed by focus groups. Primary outcomes included (1) missed gynecology appointments and (2) receipt of a Pap smear in the previous year. Independent variables included sociodemographic characteristics, child care responsibilities, substance use, depressive symptoms, social support, interpersonal violence, CD4 count, and HIV-1 RNA. We conducted multivariable logistic regression to examine associations between independent variables and outcomes. We then held two focus groups designed to gather opinions on and increase our understanding of the key findings from the survey.

RESULTS

Of 200 women, 69% missed at least one gynecology appointment, and 22% had no Pap smear in the past year. In logistic regression, moderate (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.4-6.7) and severe (OR 3.1, 95% CI 1.3-7.5) depressive symptoms and past-month substance use (OR 2.3, 95% CI 1.0-5.3) were associated with missing an appointment in the prior year. An education level of less than high school (OR 0.3, 95% CI 0.1-0.6) compared with high school diploma or greater was associated with not having a Pap smear in the previous year. When analyses were limited to women with a cervix (n = 166), moderate (OR 2.5, 95% CI 1.1-5.7) and severe (OR 2.5, 95% CI 1.0-6.3) depressive systems remained significantly associated with missing a gynecology appointment in the previous year and age >50 (OR 0.3, 95% CI 0.1-0.9), an HIV-1 RNA > 50 (OR 0.4, 95% CI 0.2-0.9), and education level less than high school (OR 0.2, 95% CI 0.1-0.5) were associated with not having a Pap smear in the past 12 months. Qualitative analysis of the focus group data suggested that fear, inclement weather, and forgetting appointments may contribute to missed gynecology appointments.

CONCLUSION

Gynecologic healthcare is underused among HIV-infected women. We found that depressive symptoms, substance use, fear of the gynecologic examination, and simply forgetting about the appointment may be barriers to gynecologic care. Interventions targeting these barriers may improve use of gynecologic care among this population.

Stress and coping in women living with HIV: a meta-analytic review

To examine effects between stressors and coping mechanisms on behavioral health outcomes a meta-analysis was conducted using forty empirical articles which sampled 7,602 adult women living with HIV/AIDS in the U.S. (M = 36.3 years). Three independent reviewers conducted searches in abstract databases from 1997 to present day. Articles reporting effect sizes amongst psychosocial stressors and coping mechanisms with indices of behavioral/mental health were selected. The meta-analyses revealed that in a time frame characterized by the widespread availability of anti-retroviral medication, poor mental health outcomes were predicted, in a similar manner, by psychosocial stress and HIV/AIDS symptomology. Significant effects were also observed with functional impairment, though to a lesser degree. Coping by avoidance and social isolation predicted more severe mental health outcomes. Spirituality and positive reappraisal predicted greater psychological adaptation than did social support seeking. Despite advancements in anti-retroviral treatment for women, HIV/AIDS symptoms and acute and/or chronic psychosocial stress pose the same threat to behavioral and mental health. In the face of these stressors, positive reframing appears to promote psychological adaptation in a way which may lead to positive health outcomes in women living with HIV/AIDS.

HIV women's health: a study of gynecological healthcare service utilization in a U.S. urban clinic population

BACKGROUND

Women infected with HIV have a high rate of many gynecological problems. Adherence to recommended gynecological care among women enrolled in our urban HIV clinics was hypothesized to be low.

METHODS

We conducted an analysis of data from the Johns Hopkins HIV Clinical Cohort Database examining demographic and clinical predictors of clinic visit adherence by women in the HIV primary care and HIV gynecological clinics.

RESULTS

Between January 2002 and April 2006, 1,086 women had 26,401 scheduled appointments to the two clinics, of which 21,959 were to HIV primary care and 4,442 were to HIV gynecological care. There were 12,097 (55%) completed primary care visits and 1,609 (36.2%) completed HIV gynecological visits (p < 0.001, accounting for clustering). By multivariate analysis, age <40 years (OR 0.81, 95% CI 0.70-0.94) and substance abuse (OR 0.67, 95% CI 0.61-0.73) were associated with a decreased likelihood of attending an HIV primary care appointment. African American race (OR 0.63, 95% CI 0.45-0.90), CD4 count <200 cells/mm(3) (OR 0.73, 95% CI 0.56-0.95), and substance abuse (OR 0.57, 95% CI 0.45-0.71) were associated with a decreased likelihood of attending an HIV gynecological appointment.

CONCLUSIONS

This analysis determined that the rate of clinic visit adherence is significantly lower for HIV gynecological care than for HIV primary care in the same population of women. Factors associated with HIV gynecological clinic visit noncompliance included African American race/ethnicity, substance use, and more advanced immunosuppression. We have planned additional quantitative and qualitative studies to examine the associations with and barriers to HIV gynecological care, with the goal of creating appropriate interventions toward improving gynecological healthcare utilization among women enrolled in urban HIV clinics.

Gynaecological morbidity among HIV positive pregnant women in Cameroon

OBJECTIVE

To compare the prevalence of gynaecological conditions among HIV infected and non-infected pregnant women.

METHODS

Two thousand and eight (2008) pregnant women were screened for HIV, lower genital tract infections and lower genital tract neoplasia at booking antenatal visit.

RESULTS

About 10% (198/2008) were HIV positive. All lower genital tract infections except candidiasis were more prevalent among HIV positive compared to HIV negative women: vaginal candidiasis (36.9% vs 35.4%; p = 0.678), Trichomoniasis (21.2% vs 10.6%; p < 0.001), gonorrhoea (10.1% vs 2.5%; p < 0.001), bacterial vaginosis (21.2% vs 15.2%; p = 0.026), syphilis (35.9% vs 10.6%; p < 0.001), and Chlamydia trachomatis (38.4% vs 7.1%; p < 0.001). Similarly, HIV positive women more likely to have preinvasive cervical lesions: low-grade squamous intraepithelial lesion (SIL) (18.2% vs 4.4%; p < 0.001) and high-grade squamous intraepithelial lesion (12.1% vs 1.5%; p < 0.001).

CONCLUSION

We conclude that (i) sexually transmitted infections (STIs) are common in both HIV positive and HIV negative pregnant women in Cameroon, and (ii) STIs and preinvasive cervical lesions are more prevalent in HIV-infected pregnant women compared to their non-infected compatriots. We recommend routine screening and treatment of STIs during antenatal care in Cameroon and other countries with similar social profiles.

HIV and menopause: a review

The use of highly active antiretroviral therapy (HAART) has resulted in dramatic reductions in morbidity and mortality of HIV infected individuals. With increasing life expectancy, a growing population of women will experience menopausal transitions while infected with HIV. Changes associated with menopause may affect HIV disease progression, and HIV-infected women may experience menopause in a different way from that of uninfected women. Age at natural menopause among non-HIV-infected white and Hispanic women is on the average 51 years, and that of African American women is 49 years. Several studies have shown that the mean age of menopause in HIV-infected women is 47-48 years. This is likely due to factors other than HIV infection that predict early menopause, such as drug use, smoking, and low socioeconomic status. It may be difficult to separate out HIV symptoms from menopausal symptoms. The additive effects of menopause, HIV infection, and HAART on changes involving bone, lipid, and glucose metabolism need further investigation. Likewise, there is a need for a better understanding of the prevalence and manifestations of depression among these women.

Missed opportunities to address reproductive health care needs among HIV-infected women in antiretroviral therapy programmes

OBJECTIVES

To investigate the delivery of reproductive health care services in an antiretroviral therapy (ART) programme in Cape Town, South Africa.

METHODS

A cross-sectional survey was conducted among 227 consecutive women attending a hospital-based ART outpatient service who had been on ART for at least one month. Semi-structured interviews investigating reproductive health issues and services received were conducted in participants' home language by a trained interviewer.

RESULTS

Sixty-seven per cent of the women were younger than 30 years and 75% were sexually active. The use of both condoms (70%) and hormonal contraceptives (31%) decreased with age, while the prevalence of sterilization (13%) increased with age. Few women knew about emergency contraception (EC) (7%) or termination of pregnancy (TOP) (13%). Approximately 45% of women had had a Papanicolau smear, and this was constant across all age groups. One in 10 women had experienced verbal or physical abuse by an intimate partner since their HIV diagnosis. More than 80% of women had discussed the use of condoms and other forms of contraception with a health care provider since their HIV diagnosis, but less than 5% had discussed EC or TOP, and no woman had discussed issues of partner violence. Discussion These data delineate the large unmet need for reproductive health services among HIV-infected women receiving ART in this setting. While issues related to condom and contraceptive use are relatively well addressed, reproductive health services related to unintended pregnancy and partner violence appear to be neglected. The integration of a broad range of reproductive health services into ART programmes requires urgent attention in both research and policy-making circles.

Effects of human immunodeficiency virus on protracted amenorrhea and ovarian dysfunction

OBJECTIVE

To characterize ovarian failure and prolonged amenorrhea from other causes in women who are both human immunodeficiency virus (HIV) seropositive and seronegative.

METHODS

This was a cohort study nested in the Women's Interagency HIV Study, a multicenter U.S. study of HIV infection in women. Prolonged amenorrhea was defined as no vaginal bleeding for at least 1 year. A serum follicle stimulating hormone more than 25 milli-International Units/mL and prolonged amenorrhea were used to define ovarian failure. Logistic regressions, chi2, and t tests were performed to estimate relationships between HIV-infection and cofactors with both ovarian failure and amenorrhea from other causes.

RESULTS

Results were available for 1,431 women (1,139 HIV seropositive and 292 seronegative). More than one half of the HIV positive women with prolonged amenorrhea of at least 1 year did not have ovarian failure. When adjusted for age, HIV seropositive women were about three times more likely than seronegative women to have prolonged amenorrhea without ovarian failure. Body mass index, serum albumin, and parity were all negatively associated with ovarian failure in HIV seropositive women.

CONCLUSION

HIV serostatus is associated with prolonged amenorrhea. It is difficult to ascertain whether the cause of prolonged amenorrhea is ovarian in HIV-infected women without additional testing.

LEVEL OF EVIDENCE

II-2.

Focus on Women: Linking HIV Care and Treatment with Reproductive Health Services in the MTCT-Plus Initiative

Despite important advances in expanding access to antiretroviral therapy in the countries most heavily affected by HIV/AIDS, there has been little consideration of the connections between HIV prevention, care and treatment programmes and reproductive health services. In this paper, we explore the integration of reproductive health services into HIV care and treatment programmes. We review the design and progress of the MTCT-Plus Initiative, which provides HIV care and treatment services to HIV positive women as well as their HIV positive children and partners. By emphasising the long-term follow-up of families and the provision of comprehensive care across the spectrum of HIV disease, MTCT-Plus highlights the potential synergies in linking reproductive health services to HIV care and treatment programmes. While HIV care and treatment programmes in resource-limited settings may not be able to integrate all reproductive health services into a single service delivery model, there is a clear need to include basic reproductive health services, such as access to appropriate contraception and counselling and management of unplanned pregnancies. The integration of these services would be facilitated by greater insight into the reproductive choices of HIV positive women and men, and into how health care providers influence access to reproductive health services of people with HIV and AIDS.