Part A: Module A3

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

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Gynecological Problems and STIs

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

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Vaginal Discharge Etiology

• Gonococcal infection
• Chlamydia trachomatis
• Trichomonas vaginalis
• Bacterial vaginosis
• Candidiasis

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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

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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

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Lower Abdominal Pain and Fever (PID)
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Etiology

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

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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

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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

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Genital Sores (Ulcers or Blisters)
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Etiology

• Syphilis
• Chancroid
• Lymphogranuloma venereum (LGV)
• Herpes simplex

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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

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Genital Herpes
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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

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Malignancies

• Etiology
• Cervical cancer, CIN
• Kaposis 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

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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

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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

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Prevention of OIs in Pregnancy
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Prevention of OIs in Pregnancy
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Prevention of OIs in Pregnancy