Women in Prison and HIV
01-12-2000 by Hernán Reyes
Extract from "HIV in Prisons: A reader with particular relevance to the newly independent states", chapter 9, pp.193-218, World Health Organization-Europe "HIPP" (Health in Prisons Project), 2001.
Hernan Reyes MD*, International Committee of the Red Cross
Women prisoners often come from marginalized, socially deprived and often high-risk backgrounds for HIV. Many of them may already be infected with HIV on entering a prison. Prison medical care should be tailored to the special needs of women in prison, and be equipped and staffed to recognise and manage the diseases that facilitate HIV transmission -- or accompany AIDS. Most important, the detaining authorities and their health staff should take advantage of the women’s stay in custody provide education on prevention and on how to stay healthy. Prison may be a unique moment in these women’s lives in which they have access to such care and counselling.
Women are at a greater risk than men of contracting HIV from sexual intercourse. Those women who eng age in intra-venous drug use have an additional risk, as they often also have unprotected sex with their drug partners, or engage in sex for money. Barrier methods for protection are often not used by women because their male partners are recalcitrant about them. Sexually transmitted infections, quite common in female prisoners, and often undetected, are a major factor in the spread of HIV, as they enhance transmission as well as diminishing general resistance in the patient. Treatment of these diseases is paramount if transmission of HIV is to be reduced.
The manifestations of HIV disease and AIDS in women are largely gynecological. All degrees of cervical dysplasias are closely related to infection with Human Papilloma Virus, and enhanced by HIV. Pregnancy and childbirth present specific pitfalls for women with HIV, needing special counselling and management.
-Women’s health issues and the prison environment
- Women are more at risk than men
- Influence of sexually transmitted infections other than HIV
- Other risk factors in transmission of HIV to women
- Sociocultural and gender factors influencing HIV transmission to women
- HIV prevention for women
- Woman having sex with other women (WSW)
- Clinical manifestations of HIV disease in women
- HIV and specific gynaecological manifestations
- Irregularities of the menstrual cycle
- HIV, human papilloma virus, dysplastic lesions of the cervix and cervical cancer
- Efficacy and toxicity of anti-retroviral drugs in women
- Viral load and prognosis in women
- HIV and pregnancy
- Pregnancy, opportunistic infections and anti-retroviral treatment
- Mother-to-Child transmission of HIV
- Obstetrical and post-partum measures to avoid HIV transmission from mother to child
Women’s health issues and the prison environment
Women have always made up a very small proportion of the overall prisoner population worldwide. In its Global Report on Prisons published in 1993, Human Rights Watch estimated the proportion to be within 3 - 7% of the male population. There are no reliable current global figures at the time of this writing, but the women prisoner population would seem to be increasing, at least in those countries where substance abuse is a major issue. In the United States, there was an increase of 500% in the numbers of female inmates in Federal and State prisons between 1980 and 1999 to a total of approximately 85 000.
Most prison systems are designed with male inmates in mind, which explains why living conditions for women prisoners are often not tailored to their specific needs. The United Nations Standard Minimum Rules acknowledge that separate provision of facilities for women can be “disproportionately costly. Whatever the arrangement found for separation of the sexes, the fundamental issue of catering to women’s specific needs is often neglected. Basic requirements such as greater access to showers when women prisoners have their monthly periods, or making sanitary napkins available, are often simply not provided for. Not all women’s prisons cater for prisoners who are pregnant although some of them do provide for mothers with newborn babies or infants.
As women prisoners are fewer than males, the health services provided for women are sometimes minimal or second-rate and referral to outside facilities is also often more difficult than for male prisoners. Security rules during outside transfers are applied without gender consideration, and in recent years outrageous situations have been revealed in some western countries, women prisoners being handcuffed to their beds while in labour.
With the advent of HIV infection and AIDS, a new problem has arisen for women prisoners. HIV and AIDS have specific manifestations in women, and the prison environment may considerably complicate proper administration of medical care and follow-up for women with HIV. Documented studies in the USA have shown that heterosexual contact is becoming the leading risk exposure for American women of all age groups, even more so than injection for drug use. Women are the fastest growing populations being infected with HIV – and young adolescent women are those most at risk through heterosexual contacts. Infection through the sharing of needles and syringes when injecting drugs is obviously a high-risk activity for both sexes, and women engaging in sex with drug users are at further risk from sexual transmission if they do not protect themselves. Women arrested for drug-related offences or for prostitution are therefore at high risk for already being infected with HIV when they enter the prison system. In many countries, many or most will not know their HIV status, and experience has shown that prisoners’ knowledge about HIV is scanty, unreliable and often based on street rumours rather than facts.
Women going through the prison system – whether they have HIV or not – have a unique opportunity to receive education on HIV. Education for women prisoners on HIV should be tailored to th e needs of the different age groups and professions, specifically including and catering for women who engage in commercial sex. Cultural sensitivities should be respected, but trained staff should not shy away from frank and open discussions on sexuality, condoms, safer forms of sex and other issues that women may never again have an opportunity to learn about. Counselling on testing should be given, and testing for HIV offered to those in high-risk groups on a voluntary basis.
Such treatment as is available for the outside community should be made available for women prisoners. Particular care should be given to concurrent diseases, such as sexually transmitted infections, and accompanying diseases such as tuberculosis. As for men prisoners, condoms should be made available for women who have family visits. Women may enter prison pregnant or become so during family visits. Prison medical services should cater to the specific needs of pregnant women, and again offer counselling on HIV testing and different alternatives available during surveillance of pregnancy, delivery and post-partum care including breastfeeding.
Women are more at risk than men
HIV is found in the semen of infected men, both in the seminal fluid and in mononuclear cells. In infected women, HIV is found in cervico-vaginal secretions. Heterosexual transmission of HIV is more likely from man-to-woman than from woman-to-man. Several studies have shown that HIV transmission is about eight times more likely from man-to-woman than vice-versa. This is taking vaginal heterosexual contacts into account – anal sex enhances the risk of transm ission for both men and women.
The fact that there are presently many more men infected with HIV than women of course increases the chances of women becoming infected by their partners than the other way around. Moreover, there is unquestionably a greater likelihood of women becoming infected through heterosexual intercourse for several reasons. The volume of semen is greater than the volume of cervico-vaginal secretions. HIV is found in greater concentrations in semen than in vaginal fluids. The surface area of the female genital tract exposed to contact is greater than that in the male, and finally the Langerhans cells of the cervix may provide a portal of entry for HIV.
Influence of sexually transmitted infections other than HIV
Vulval and vaginal inflammations increase the likelihood of acquiring HIV infection. Sexually transmitted infections (STIs) apart from HIV increase the chances of HIV infection during sexual intercourse. The figures vary, but the increased risk of acquiring or transmitting HIV from sexual intercourse is 2 to 5 times higher if the woman has such an infection. This is due to the fact that any genital ulceration or other disruptions of the normal mucosal defence mechanisms make it easier for HIV to enter the bloodstream.
Any genital ulceration or ulcer disease such as genital herpes, chancroid or syphilis (primary chancre stage) will increase the risk for HIV infection. In women, these infe ctions often go undetected for long periods of time, either because they are asymptomatic or because the lesions caused are not visible, being inside the female genital tract. Other STIs that are not ulcerative such as chlamydia, trichomoniasis and gonorrhoea also increase the risk of HIV transmission. Women with STIs also have an associated diminished immune response, also making infection with HIV more likely.
Inversely, genital ulcers or other genital tract infections in the HIV-infected male will also increase the likelihood of HIV transmission to healthy women, as these affections are accompanied by leukocytosis, which increases the HIV viral load in the semen coming into contact with the woman’s genital tract. High viral load in the male partner may also be found in those persons with recently acquired (acute) HIV infections or, inversely, in those with advanced stages of HIV infection. In both cases, the risk of acquiring HIV for a female sexual partner will be increased.
Studies (in Africa) have shown that effective treatment of sexually transmitted infections can, in situations where the epidemic is not yet full-blown, decrease HIV transmission by up to 40%. Furthermore, as the predominant mode of transmission of both STIs and HIV is sexual, STI monitoring may offer a useful indicator of change in sexual behaviour.
Other risk factors in transmission of HIV to women
Any other factor that causes ulcerative lesions on the female genital tract will also increase the likelihood of HIV infection. Cervical e ctopia, whereby the normal squamous epithelium of the cervix is replaced by a single-layered columnar epithelium normally found within the cervical canal will make the cervix more friable and thus more vulnerable to HIV infection. The same is true with an ectropion of the cervix, with prolapsus of the columnar epithelium of the cervical canal outside the cervical os.
Tearing and bleeding during sexual intercourse may come about during “rough sex”, particularly with younger women, through “dry” sex (i.e. without lubrification) or of course violent rape. Such lesions increase the risk of the woman acquiring HIV. Anal intercourse without lubrification (and condom protection) is particularly dangerous, as the anal mucosa is fragile and can easily tear and bleed.
Most recently, non-circumcision of men has come under fire as being a risk factor for men acquiring HIV (and thereby becoming infectious for their subsequent partners). Some investigators have claimed that men with foreskins are more likely to transmit HIV to healthy women than circumcised men, because of the relatively large contact area between foreskin tissue and the female genital tract. More research is necessary, and multiple factors influencing sexual behaviour and HIV susceptibility make this point difficult to ascertain. Furthermore, studies incriminating preputial Langerhans cells in the transmission of HIV are controverted and based on as yet scant evidence. There is at the present time no reason for any additional alarm among women with partners having intact foreskins.
Intercourse with HIV positive men during menstruation or during bleeding from other causes will increase the risk of HIV infection in women. It is not yet certain whether hormonal contraception, with its modifications of the vaginal epithelium during the different phases of the artificial cycle, is a factor in increasing HIV transmission. Progesterone causes thinning of the vaginal epithelium , which may increase vulnerability to HIV. Further well-controlled research is as yet necessary before recommendations can be made.
Finally, certain sub-types of HIV would seem to be transmitted more efficiently by heterosexual intercourse than others. This could explain the initial differences in the epidemiology of the disease between the USA and Western Europe on the one hand and Sub-Saharan Africa and South East Asia on the other. More research is also underway in this area.
Socio-cultural and gender factors influencing HIV transmission to women
Women are at a greater risk of acquiring HIV than men because cultural and societal conditions are such that women are often not in a position to control their own bodies. Gender inequalities, lack of education and employment, and poverty force many women into commercial sex work in order to feed their families or just to survive. These women are particularly at risk for HIV infection, as their clients, sometimes with offers of extra payment often require unprotected sex.
In the same light, even though women may be monogamous, many are at high risk for HIV because of the often irresponsible sexual behaviour of their partner. Women in many cultures cannot even suggest the use of condoms to their partners, as this is taken as an accusation (often deserved!) of infidelity. Often women are simply “expected” to defer to men’s sexual needs and are not in a position to ha ve any control over when, and under what circumstances, sexual intercourse takes place. They are thus severely constrained in their ability to protect themselves, even if they have the knowledge and the means to do so. Also, women who seek information on sexuality and HIV prevention are at a risk of being considered “promiscuous”, and “loose”. In the same light, the stigma of being known to be HIV positive can be much more burdensome and damning for women than men in many cultures.
HIV prevention for women
The use of condoms as protection against HIV infection has been shown to be effective. Unfortunately, women in general, and particularly in high-risk environments such as intra-venous drug user, are often not in a position to make sexual partners use latex protection. The bottom line is that it is ultimately not the woman who wears the condom. This is even truer in situations of coercion, as often exist in such communities, and between prostitutes and pimps.
It must be said that while not all prostitution is forced, most women who sell their bodies do so out of dire necessity. Women whose lives have been disrupted by war, vulnerable refugee situations, catastrophes or simply disrupted lives and divorce, sometimes have to resort to commercial sex work. Prostitutes risk violence at the hands of their clients or loss of income if they insist on the use of condoms. Increasingly, however, prostitutes are coming together, or working in brothels and demanding their clients use condoms. Female condoms, first marketed in 1993, have also b een promoted and distributed, so that women have a greater say in the use of barrier protection against HIV infection. These are polyurethane vaginal sheaths that cover the female external genitalia, and may offer barrier protection against other STIs as well as HIV. These condoms do not as yet have wide acceptance, either by women or men, although some studies look promising. Their cost is however, most often prohibitive. Again, women are very often not in a position to convince their male partners to use any barrier method, for cultural, religious or societal reasons.
Women in most countries identify fear of coercive sex, fear of violence (mainly domestic) and fear of economic abandonment as the main reasons they cannot insist their partners use condoms. Vaginal microbicides or viricides that would prevent the transmission of STIs (including HIV) have been proposed and are currently under study.
Nonoxynol-9, a potent viricide in vitro has been tested in Nairobi, but results are not yet conclusive, as it produces vaginal irritation and vulvitis. Such agents might be better than nothing in contexts where condoms are not acceptable and pregnancy is either desired or not an obstacle. Further studies are needed, but these products would have the advantage of being truly female-controlled, technically easy to use and relatively inexpensive.
In prisons, condoms should be made available for family visits, ideally without a complicated or demeaning procedure involved to obtain them, such as having to request them from staff. Condoms could be made available in the visiting room for all users, whether or not they are requested. Counselling about condoms should be available as well, as many women will not necessarily understand why they should use condoms with their partners. Realistically, many fewer women than men prisoners actually have “intimate” visits with husbands. Whether or not those who do are in a position to insist on condom use is not known.
The not fully formed genital tract (particularly the immature cervical epithelium) and the scant vaginal secretions of young adolescent women put them at greater risk of contracting HIV than mature women because they provide less of a barrier to the virus. Increased heterosexual transmission may also be at least partially due to the natural occurrence of cervical ectopy and ectropion. In poverty-stricken countries, young women are often under pressure to engage in commercial or transactional sex (occasionally exchanging of sex for material goods or favours). Some resort to prostitution to support their families or to pay for their schooling. In some countries, where virginity is required at marriage, young women resort to unsafe alternative sexual practices, such as unprotected anal sex, putting themselves more than ever at risk for acquiring HIV.
In young people, and particularly young adolescent women, merely “educating” by simplistic counselling on abstinence or rational sexual behaviour, with the accent on using condoms, may not be sufficient. Sexuality is still a taboo subject in many countries, and particularly where young women are concerned. In any educational programmes on HIV/AIDS outside, but even more inside prisons, information should be given by trained physicians and psychologists and include not only biological and epidemiological information, but also culturally appropriate but frank and open discussions about sexuality and self-respect. Women should not merely be told that condoms should be used. There should be open discussions about the very real difficulties in getting some men to use them, and counselling offered by experienced educational staff on how best to convince male partners to use them. This type of education is essential for prostitutes, and prison could be an ideal forum to pr ovide both knowledge and practical advice for when they return to the outside world. Information and counselling on appropriate contraception should be provided, particularly to young adolescent women, and for any women of childbearing age.
Finally, and particularly with young adolescent women, there need to be more candid discussions on sexuality, contraception and the prevention of HIV. Adolescents rightly ask why condoms, that used to be considered one of the most unreliable form of contraception, and are now trumpeted as infallible for HIV prevention. Young women try sex with and without condoms and understandably feel that there is a difference. These issues need to be frankly addressed, otherwise the message will be counterproductive and therefore ignored. Prisons could provide a forum for a last chance of reaching marginalized and often confused women who upon release will be most at risk of contracting HIV.
Woman having sex with other women (WSW)
There would seem to be a small, but as yet undocumented, risk of HIV transmission associated to sexual contacts between women. HIV infection will of course depend on what exactly these practices involve. Oral sex between women would seem to pose a relatively low risk of transmission, but no real data is available at the present time. Any practices involving shared sex toys or dildos, which can be contaminated by vaginal secretions and also cause trauma to the genital tract, may be riskier. Any such instruments should be thoroughly cleaned and disinfect ed with bleach after use, and preferably not shared.
Latex barriers (dental dams or newer user-specific similar items) have been encouraged for WSW during cunnilingus. The acceptability of such barrier protection methods is not known in different countries and cultures.
What makes the risk for HIV transmission difficult to assess is that WSW often inject drugs, engage in commercial sex, and often have sex with bisexual or heterosexual men as well. WSW can be strictly lesbian or bisexual. Studies have not been possible because of the very low number of WSW without any other risk factor, particularly who do not use drugs. HIV is certainly present in the cervical and vaginal secretions of HIV infected women, but the risk of transmission needs further study.
Clinical manifestations of HIV disease in women
The only major difference in the specific AIDS-defining diseases between men and women is the significant discrepancy in the rate of Kaposi’s sarcoma (KS). KS is most common among homosexual or bisexual men, less common in heterosexual men and rare (reportedly less than 2%) in women. This may be due to an associated human herpes virus, but further studies are needed to clarify the issue. Invasive cervical cancer, obviously only in women, is the other pathology that is linked to HIV/AIDS (see below). A few cases of aggressive breast cancer in women with HIV have been reported. Other AIDS-defining diseases are essentially the same in both sexes. Symptoms and signs of HIV in the initial stages of infection are not differen t from those observed in men. HIV infected women may suffer from fever, muscular and joint pains, diarrhoea and vomiting and from swollen lymph glands. This latter sign, when found elsewhere than in the inguinal region, is the only physical finding that may be more common in women with HIV than men.
Vaginal infections by Candida albicans is the most frequent cause for women with HIV initially to seek medical attention, occurring in more than a third of cases. Studies have shown that 40% of HIV-infected women have no symptoms during the first years following infection. Other initial manifestations in women with HIV, in order of the frequency, are: swollen lymph nodes, bacterial pneumonia, acute retroviral syndrome and oral thrush (oropharyngeal candidiasis). It should be remembered in the prison context, that bacterial infections, particularly respiratory ones with Streptococcus pneumoniae and Hemophilus influenzae occur more frequently in IV drug users with HIV in both women and men. Table 18 summarizes clinical conditions, which are highly suspicious of HIV infection, and warrant counselling and testing.
Table 18. Clinical conditions warranting specific HIV counselling and testing
Recurrent episodes of genital Herpes Simplex (more than two episodes within 6 months, or the frequency doubling within a year)
Severe or combining lesio ns of genital Herpes Simplex or candidiasis
Other genital ulcerating diseases (chancroid, syphilis, apthous genital ulcers, lymphogranuloma venereum)
Condyloma acuminata recalcitrant to conventional therapy or in multifoci
An abnormal Pap smear
PID (pelvic inflammatory disease) or persisting STI
HIV and specific gynaecological manifestations
The four most common gynaecological manifestations of HIV in women are vaginitis with Candida Albicans, human papilloma virus (HPV), cervical disorders associated with HPV and pelvic inflammatory disease (PID).
This yeast infection is quite common, particularly among women taking oral contraceptives or broad-spectrum antibiotics. For this reason, it is often not recognised as a potential warning sign for HIV, even among women potentially at high risk for HIV, such as prostitutes or intra-venous drug users. This oversight could lead to delays in treatment, and therefore be detrimental to the overall prognosis. Untreated yeast infection also enhances the risk of HIV transmission to sexual partners. Symptoms and clinical signs typical of vaginal candidiasis are secretion of a thick white (“cheesy”) vaginal discharge, severe itching, pain wh en urinating and pain during sexual intercourse (dyspareunia). The gynaecological examination shows swelling and erythema of the labia minora, and the direct wet-mount exam under the microscope detects characteristic filaments.
Local therapy usually consists of miconazole nitrate cream, or clotrimazole vaginal tablets (ovules). Systemic therapy with oral ketoconazole, fluconazole, itraconazole or amphotericin B may be necessary in some cases (see Chapter 8).
Other gynaecological infections and pelvic inflammatory disease
Other gynaecological infections are extremely common among women infected with HIV. Pelvic inflammatory disease (PID) tends to be more severe and more prolonged in HIV-positive than in HIV-negative women. This may require changes in antibiotic therapy, but initial standard therapy is the same for women with PID, with or without HIV. Studies have shown a twofold increase in the formation of tubo-ovarian abscesses, hence the more need for surgical management in women with HIV and PID. The main agents for PID are Neisseria Gonorrhoeae and Chlamydia Trachomatis , i.e. the same for women with or without HIV.
Herpes simplex genital infection
Genital infections by herpes simplex virus type 2 frequently occur in women with HIV. The disease may last longer than in HIV negative women, be more severe and reoccur more frequently. Ulcerative manifestations of the disease can be particularly severe, and most often correlate with the severity of the immune deficiency of the patient. The most common manifestations of recurrent herpes infection occur on the labia majora and minora, and the buttocks.
As is the case with men, chronic peri-anal herpes infection is an AIDS-defining condition, although it occurs much less frequently in women than in homosexual men.
Trichomoniasis is almost twice as common in women with HIV as in women without HIV (28% versus 16% in one study). Treatment and diagnosis are the same as in usual gynaecological practice (see Chapter 8).
Reports vary from country to country but syphilis has been reported to be increasing in the general population in many areas. Testing for syphilis is obligatory in many countries, and reporting all confirmed cases to a central medical authority is required as well. In the NIS, testing of prisoners is frequently done systematically for both syphilis and HIV, despite WHO guidelines for HIV testing of prisoners. However, syphilis infection can increase the risk of contracting HIV, and as HIV accelerates the progression of syphilis into neurosyphilis, it is justified to counsel women at risk to test for both diseases, as they are transmitted in the same way.
Primary syphilis is more difficult to detect in women than in men, as the chancre is most often hidden from view inside the female genital tract, and is asymptomatic.
Chlamydia trachomatis and Neisseria Gonorrhoeae
Inflamma tion of the cervix (cervicitis) due to either infection may enhance transmission of HIV from an infected partner. The diagnosis should be made as soon as possible to avoid the risk of contracting HIV. Treatment and management of both infections are the same as for women who are HIV negative (see Chapter 8).
Women at risk for venereal diseases, even if asymptomatic, should be medically counselled and offered a thorough pelvic examination and any bacteriological tests deemed necessary, as all sexually transmitted infections enhance vulnerability to HIV infection through sexual intercourse.
Irregularities of the menstrual cycle
Women in custody are submitted to the constant stress of prison life, and amenorrhea and irregularities of the menstrual cycle are common among prisoners. Relatively little is known about speci ficities of menstrual variations in relation to HIV. Several studies have been carried out comparing menstruation between women with and without HIV. No differences have been found relating to amenorrhea, spotting, irregular cycles or breakthrough bleeding in the two groups compared.
A recent study of the viral content of cervico-vaginal fluids during the different phases of the menstrual cycle showed preliminary evidence that viral content was highest both during menstrual flow, and during the luteal phase (generally two weeks after menstruation, in a normal four-week cycle). More research needs to be done on possible variations in viral content of secretions according to the hormonal cycle.
Menstrual irregularities may increase the risk of the partner’s exposure to HIV. Also, an irregular cycle makes it more difficult to predict the fertility period, complicating calculations for either conception or avoidance of pregnancy.
HIV, human papilloma virus, dysplastic lesions of the cervix and cervical cancer
Dysplastic lesions of the cervix are linked to infection by Human Papilloma Virus (HPV), which is believed to be an etiologic factor in cervical cancer. Evidence to date shows there is an increase in the occurrence and the aggressiveness of cervical cancer in women with HIV. Cervical cancer is classified as an AIDS-defining diagnosis.
Screening for cervical dysplastic lesions, so as to detect any precursor lesions for cervical cancer, should be part of all gynaecological examinations. Such screening should be part of medical care provided for women prisoners, and the risks of cervical dysplastic lesions and their management duly explained to prisoners at risk for such lesions by trained medical staff.
Screening for precursor lesions, and HPV
About 95% of cervical condyloma, all grades of dysplasia and invasive cervical cancer have been shown to contain DNA from HPV. Detection of cervical cancer is performed routinely in Western countries by regular Papanicolaou smears, and regular clinical controls with colposcopy. Pap-smear screening detects early signs of precursor lesions in the transition zone between the squamous epithelium on the cervix and the columnar single-cell layered epithelium of the cervical canal, the zone where dysplasia occurs. The initial dysplasia is known as cervical intra-epithelial neoplasia or CIN. This dysplasia can precede invasive carcinoma of the cervix by several years. CIN staging varies from I to III according to specificities of the dysplasia.
The epithelium in the transition zone is the place where infection by human papilloma virus is known to concentrate. HPV infection is very common, affecting up to one third of all young adult women, and a significant proportion of men (around 8% in one study). There are several types of HPV, some associated with condyloma (genital warts), some associated with mild dysplastic changes in the cervical epithelium. Genital warts in women with HIV may be larger, multifocal and more likely to reappear than in women who are HIV negative. Other types of HPV however, are associated with more severe CIN lesions (stages CIN II and III) and can lead to invasive carcinoma of the cervix.
Immunosuppression (as seen in patients undergoing organ transplantations) enhances the risk for cervical dysplastic lesions. HIV and HPV are transmitted in the same way, and HPV may actually enhance HIV transmission from an infected male partner.
In women with HPV infection, contracting HIV may reactivate a dormant infection or prolong a persistent infection with HPV, due to the decline in immune response due to HIV. The connection between HPV and precursor lesions of cervical cancer, and the fact that HPV and HIV enhance each other, logically lead to the fact that cervical dysplasias are more than twice as common in women with HIV than in HIV-negative women.
Pap-smear testing is not infallible, as dysplasias of the transition zone tested may not be accessible to the sampling. Local inflammatory reactions, as may be the case in HPV infections, may make the Pap diagnosis difficult. Because of the association between HPV and HIV, some researchers have recommended routine colposcopy in women with HIV, so as to determine a baseline, to be then followed up either by Pap smears or colposcopy according to findings. However, colposcopy is more costly, time consuming and requires specially trained personnel on hand for correct interpretation.
Regular Pap smears every six months have been recommended for women with HIV, particularly those with advanced immunodeficiency. It must be noted that 15% of the dysplasia in women with HIV was limited to vulvar, vaginal or perianal lesions, not detected of course by a Pap smear. Careful inspection of the whole internal and external pudendal area should accompany all screening by Pap smears. Any persistent genital inflammation that is unresolved after treatment for Neisseria Gonorrhoae , Trichomonas Vaginalis or Chlamidia Trachomatis should be referred for colposcopy.
Treatment of CIN lesions
Treatment of CIN lesions are basically the same for both women with and without HIV. CIN I lesions are not treated, as they do not lead to carcinoma, while CIN II and CIN III lesions must be treated to avoid development of full-blown cervical cancer. The treatment is the same, and the treatments available are several, among which cryotherapy, laser vaporisation and electrical surgical excision for the minor, entirely visible lesions, and cervical conisation for all other more serious cases.
Studies have shown that the prognosis for recurrence of CIN after treatment is four to five times higher in women with HIV, within a year after initial treatment. Research on how to prevent this enhancement due to HIV status is ongoing, some treatment regimens calling for regular, local application of 5-fluoro-uracil cream.
Invasive Cervical Carcinoma
Invasive cervical carcinoma (ICC) is an AIDS-defining disease. However, although the incidence of ICC is much higher in countries with limited resources and little or no screening, for reasons that are not clear, ICC is not a leading cause of death in women with HIV. It is possible that in regions, such as Sub-Saharan Africa, where high numbers of women are infected with HIV, they do not live long enough to develop ICC.
When ICC is discovered in women with HIV, however, the carcinoma is usually of advanced stage, significantly more so than in similar women without HIV. Metastasis to lymph nodes is found twice as frequently as in HIV negative women, and there is almost a uniform relapse (100%) of women with ICC and HIV after treatment in just a few months time. Women with HIV thus have a particularly poor prognosis when they are diagnosed with ICC.
Other areas affected by HPV
HPV may affect areas other than the cervix, particularly in patients with HIV. Genital warts can be treated with habitual therapies such as trichloroacetic acid, cryotherapy with liquid nitrogen, or by surgery or laser for extensive cases.
Anal cancer may be associated with HPV, as well as malignancies of the vulva and the vagina. Anuscopy should be recommended in women with both HIV and HPV infections, and careful evaluation done on the entire pudendal area during gynaecological examinations. Anal squamous intraepithelial lesions are more prevalent in women with than without HIV. Receptive anal intercourse undoubtedly plays a role in HPV transmission. It is not known whether fingers or sex toys can lead to contamination by HPV in women or men.
Efficacy and toxicity of anti-retroviral drugs in women
Women were not included in initial drug trials with antiretroviral agents, so that little is known about gender-specific differences between the sexes in this area. Treatment schemes are evolving, and as yet are essentially the same for men and w omen. Some recent studies have sought to obtain data for women, and would seem to indicate that reverse transcriptase inhibitors and protease inhibitors have the same efficacy in both men and women (see Chapter 6). Toxicities may be however different, as women have lower mean body weight and lower mean haemoglobin levels than men. A study on the toxicity of ritonavir combined with reverse transcriptase inhibitors reported more nausea, vomiting, physical malaise and fatigue in women than men. Diarrhoea was more common in men than in women. Other differences in toxicity were reported concerning protease inhibitor nelfinavir. At similar levels of efficacy, women experienced more abdominal pain, itching and skin rashes than men did. Again, diarrhoea appeared more frequently in male patients.
Abnormal accumulations of body fat, a condition known as lipodystrophy syndrome and well-documented in men, appears to be a complication of treatment with antiretroviral therapy in women as well. A recent study with indinavir reported such changes in 18% of women, causing increased abdominal girth, increased breast size, wasting in limbs and facial fat and development of the characteristic “buffalo hump” (posterior high cervical fat pad), although this manifestation is more common in men than in women. Another study with two or more antiretroviral drugs reported abnormal fat distribution in 10% of the women.
Several antiretroviral drugs react with oral contraceptives. Reverse transcriptase nevirapine specifically metabolizes ethinyl estradiol, leading to a clinically relevant decrease in the levels of this hormone. Protease inhibitors such as ritonavir and nelfinavir have also been shown to decrease levels of ethinyl oestradiol. The main point is to underline that several antiretroviral agents interfere with the metabolism of oral contraceptives.
Viral load and prognosis in women
The levels of viral load in plasma in men versus women have been studied extensively, but have given conflicting results. Progression of HIV to AIDS associated to viral load, in similar comparisons, has also given controversial results. The differences may be due to discrepancies in methodology or in different CD4+ cell counts (see Chapter 6 for the relationship between CD4+, LC and clinical prognosis). Further study is needed to find out whether the level of viral load is really different in women patients, because guidelines for treatment up to now have been based on data coming from male patients. For the moment, there is not sufficient reason to modify current treatment guidelines for women.
Early studies indicated that the prognosis of women with AIDS was significantly worse than that for men. More recent work shows that these differences were due above all to the fact that women had less access to diagnostic facilities and to proper medical care.
There would seem to be no difference regarding survival of women versus men with AIDS, if they receive an equivalent level of medical care and treatment. Progression in the disease also seems to be the same in both genders. The studies published, however, were conducted in countries where treatment was available and provided efficiently to all patients.
HIV and pregnancy: general considerations
In prison it is not uncommon for a woman to discover she is pregnant at the same time she discovers she has HIV infection. The psychological burden of being in prison, leaving behind her family, a new pregnancy and discovering her HIV status can be devastating for women who are often fragile and vulnerable. They may also have apprehensions about their pregnancy, about infecting their baby, and about losing custody of the newborn. Ethical dilemmas can arise if the woman refuses to disclose her diagnosis of HIV to the baby’s father. In all cases, much empathy and patient counselling are paramount to ensure the best conditions possible for mother and baby in what is always a complicated situation. Patient confidentiality should not be waived under the pretext that the woman is a prisoner, but some informed disclosure may be necessary to those who need to know, so as to obtain the best possible medical care (for example, in planning a caesarean section).
Immune function is suppressed as a normal effect of pregnancy in both HIV positive and negative women. In early pregnancy, levels of both immunoglobulin and complement are reduced, and there is a significant decrease in cell-mediated immunity during pregnancy. Research has shown, however, that these normal changes do not accelerate the progression from HIV to AIDS in women with asymptomatic HIV who are pregnant. There may be some such effect in women in advanced stages of HIV disease, but more research is necessary to confirm this.
HIV seems to have little effect on the development, outcome and complications of pregnancy. Nutritional counselling should be given and adequate modifications made to the woman’s food regime when necess ary, as both pregnancy and HIV disease place additional nutritional burdens on women who are often already malnourished when entering prison. Providing Vitamin A supplements to HIV infected pregnant women may be useful, as Vitamin A deficiency has been associated with greater transmission of HIV to the newborn. Initial assessment of women prisoners of groups at risk for HIV who are pregnant should include a detailed history of STIs, and a thorough and professional physical examination with particular attention to detecting any manifestations of HIV. A Pap-smear and any necessary cultures should be performed.
Reported higher rates of ectopic pregnancy in women with HIV may in fact be due to the effects of other concurrent sexually transmitted infections. High rates of syphilis, bacterial pneumonia, urinary tract infections and other infections are all more common during pregnancy in women with HIV. Herpes zoster is common in young women with HIV, and uncommon in the same age group without HIV. Detection of shingles in a young pregnant woman may be an early sign of HIV infection.
Invasive diagnostic procedures such as amniocentesis carry a theoretical risk, for the pregnant woman with HIV, of inoculation of the foetal compartment by the needle that passes through the maternal tissues. If there is a clear indication and desire for amniocentesis, it should be made available with open and understandable counselling.
Premature labour may be more common in pregnant women with HIV, some studies showing rates up to twice those in HIV negative women. Other studies have suggested premature rupture of the membranes and abruptio placentae are also more frequently found in women with HIV. Again, the influence of concurrent or antecedent STIs has to be taken into account in such evaluations. Preterm delivery is particularly worrying because for reasons as yet unclear, pre-term infants are at greatest risk of becoming infected with HIV from the mother. Finally, differences in the birth weight of babies born to women with HIV are not significant from those born to women who are HIV-negative.
Pregnancy, opportunistic infections and antiretroviral treatment
Generally speaking, pregnancy is not a contraindication for the most appropriate antiretroviral therapy or for most management of HIV-related conditions. In developed countries, vertical transmission has been found to range between 16 – 24% without any antiretroviral therapy, and to be around 8% with AZT monotherapy. The risk to the foetus should however always be considered and treatment modified if necessary. If there is no immediately urgent indication for antiretroviral therapy in a woman with HIV who has not as yet received it, it may be most reasonable to withhold such treatment until after 12–14 weeks of gestation. Nausea and vomiting are most common during the first trimester, and could make antiretroviral therapy difficult to tolerate. Also, and to most mothers, most important, the effect of the drugs used on the developing foetus is not known. It is therefore perhaps better to commence therapy once the organogenesis period is past, i.e. in the second trimester. This of course implies that there be adequate determination of gestational age, if necessary with sonographic confirmation.
Prophylaxis for opportunistic infections should be given in pregnancy, as indicated by the clinical stage of HIV infection. Prophylaxis with INH and treatment for tuberculosis should be given when indicated, but streptomycin is contraindicated during pregnancy. There is no reliable information on whether Pyrazinamide can be used safely during pregnancy and breast-feeding (it does pass into milk). This drug should only be considered for use during pregnancy if a drug-resistant form of tuberculosis warrants it.
Prophylaxis for Pneumocystis carinii pneumonia, if indicated, can continue throughout pregnancy with sulfamethoxazole/trimethoprim or pentamidine. The risk to the foetus of giving sulphonamide in the third trimester may be outweighed by the risk to maternal health. Kernicterus has not been reported where the drug was given for the maternal indication, and obviously discontinued for the newborn immediately after birth.
Dermatological conditions are common in women with HIV and treatment may be required. Acyclovir can be used safely, if required, after the first trimester, as can oral fluconazole. Topical imidazole anti-fungal agents or topical gentian violet can be used throughout pregnancy.
Mother–to–child transmission of HIV
Transmission of HIV from a pregnant mother to her unborn child is the most common source of HIV infection in young children. The most effective interventions to reduce this transmission depend upon a pregnant woman knowing her HIV status. Information, counselling dur ing pregnancy, as well as around and after delivery, and voluntary testing services should be available to women prisoners. Access to counselling on termination of pregnancy, and adequate services for safe abortions – where they are legal – should also be available, but should be viewed as an option for the individual woman, and not as a public health intervention for the prevention of HIV transmission. Pre-test counselling should be provided by trained medical staff, such as midwives trained in HIV education.
HIV can be transmitted to the foetus during pregnancy, mainly during the third trimester, or to the baby during labour and childbirth, and during breastfeeding, as HIV is found in maternal milk. The exact mechanism of transmission by breast milk is not yet fully understood. The respective roles of cell-free and cell-associated virus (HIV-1) are not known. Both have been detected in colostrum and mature breast milk. According to UNAIDS, breastfeeding may account for more than one third of all cases of transmission of HIV from mother to child.
The exact relative contribution of each of these events is difficult to ascertain, but most transmission occurs just before or during labour or delivery. Suggested mechanisms for intra-partum transmission of HIV to the baby include direct skin and mucous membrane contact between with cervico-vaginal secretions, ingestion of HIV from these secretions, and ascending infection to the amniotic fluid. The risk of transmission of HIV from mother to child is increased if the woman is in an advanced stage of the disease (AIDS) or if she has a high viral load or a low CD4+ cell count.
Research has shown that the risk of transmission is significantly higher if the mother contracts HIV during pregnancy or while breastfeeding. It is not clear, however, whether viral loads in blood and breast milk are correlated. All preventive measures for HIV should therefore be avail able for pregnant women in prison who have family visits, and proper counselling provided about HIV infection. Whenever relevant, counselling about the utility of condoms during pregnancy, specifically to avoid possible HIV infection, should be explained and encouraged.
The chances of transmitting HIV to the baby during childbirth, in the absence of preventive intervention, are about 15-25 % in developed countries. Treatment with a short regimen of zidovudine (short-course AZT) during the last weeks of pregnancy has been shown to reduce the risk by approximately two thirds. The suggested regimen is:
For the mother 100mg orally five times daily, to be started a few weeks before delivery, followed by intra-partum AZT, 2mg per kg of body weight IV over one hour period, then 1mg per kg per hour until delivery.
For the newborn: 2mg per kg every six hours for six weeks
In prisons treatment may not be available, and diagnostic procedures may be limited. Women prisoners with HIV who are pregnant should however receive adequate prenatal counselling and care. Once again, prison should provide a unique forum to deliver information to women who may not have access to it once they leave prison.
The use of Nevirapine could prove to be an appropriate alternative for AZT. Several clinical trials are underway, and preliminary results have been very promising, perhaps even more so than with Zidovudine. The advantage of Nevirapine is that its administration involves giving only two doses: one 200 mg oral dose at the onset of labor, and for the infant a single 2mg/kg oral dose at age 48 – 72 hours. (If the mother r eceives Nevirapine less than one hour prior to actual birth, the infant should be given an identical initial dose, as soon as possible after birth, as well as the normal one at 48-72 hours.) Because pregnant women in prison situations may in many cases have a low compliance rate for pre-natal care and follow-up, such a treatment scheme, involving only two administered doses would be more realistic for such patients. Unfortunately, this medication is as yet unavailable in the NIS.
If a mother just having given birth is known to be HIV-infected, it is preferable to avoid breastfeeding the baby, and supply replacement feeding, so as to reduce the risk of HIV transmission through the milk. This should only be done if the potential risk of HIV transmission is higher than the risk of the baby dying from malnourishment or from infections that could be avoided by the maternal antibodies contained in maternal milk. By associating the AZT regimen to replacement feeding, HIV transmission can be lowered to under 10%.
If preventive health, economic or societal reasons make breastfeeding imperative despite the mother’s HIV positive status, special care should be taken to avoid fissured nipples, mastitis and breast abscesses. Breastfeeding should be suspended immediately in such cases. Proper counselling by experienced midwives or nurses can prevent poor breastfeeding techniques. Modified cow’s milk can be given to infants so as to avoid breastfeeding when the mother is known to have HIV. An infant needs 150ml of milk per kg of body weight per day. To make the formula, add 100ml of cow milk to 50ml of boiled water and add 10g of sugar. A vitamin and mineral supplement containing vitamins A and C and folic acid, as well as iron and zinc should also be added. Formula should be prepared with special attention to hygiene and quality of water.
Obstetrical and post-partum measures to avoid HIV transmission from mother to child
Transmission occurs mainly by contamination of the child during passage through the birth canal. The virus is found in the blood and mucus in the canal. Which should be cleansed by vaginal lavage before and during delivery. Aqueous chlorhexidine 0.25% solution has been suggested for this use, with benzalkonium chloride as an alternative proposal. Lavage may be of paramount importance in cases where the membranes have been ruptured for more than four hours.
Delivery by caesarean section (C-section) reduces the child’s exposure to contaminated fluids in the birth canal, and to the inevitable blood associated with delivery. In Western countries, the C-section is now recommended for all deliveries of HIV-positive women. This procedure is recommended even if the membranes have been ruptured for several hours or more, although opinions still diverge as to the real utility of C-section indication in women with rupture of the membranes of four hours or more, who are already in labour. In developed countries an infusion with AZT (see above) is administered 4 hours before elective C-section and continued until the umbilical cord is clamped. In many countries, however, C-sections in prisons may be impossible to program ahead of time and the hazards of post-operative care should be carefully weighed in taking a decision. There is a risk of delivering an iatrogenically premature baby if there is no precise dating of the pregnancy and an elective C-section is performed. The decision on C-section deliv ery should be made on an individual basis. The risks associated with sepsis following C-section in less than ideal conditions are greater in HIV-positive than in HIV-negative women. Prophylactic antibiotics should be given for both elective and emergency C-sections. Finally, the increased risk of placenta previa, placenta accreta and uterine rupture for future pregnancies should not be neglected.
The duration of labour does not seem to be as important a factor as the duration of rupture of the membranes. Prolonged rupture (more than four hours) is known to considerably increase the risk of transmission of HIV to the foetus (doubling it according to one study), regardless of the mode of delivery. During labour, unnecessarily rupturing the membranes should be avoided. Any invasive procedure that may put maternal with foetal blood in contact, e.g. scalp electrodes or sampling for foetal pH values, should be avoided as far as possible. If a scalp electrode is imperative, however, to determine foetal wellbeing, it should not be excluded.
Women with HIV who present with ruptured membranes at or near term should receive induction with an oxytocin perfusion, taking all obstetrical factors duly into account. If AZT can be administered, it should be given on a separate IV line as it can not be administered together with oxytocin.
Episiotomies should be performed only if there is an obstetrical or serious maternal indication. If an assisted delivery is required, forceps delivery may be preferable to vacuum extraction, because of the risk of micro-lacerations to the baby’s scalp from the vacuum cap. Post-partum care should be similar for women with and without HIV. Women with HIV are more likely to develop post-partum infectious complications, including pulmonary and urinary tract infections, and wound infections (C-section, episiotomy). Mothers should be given instructions on the safe handling of lochia and bloodstain ed sanitary pads and other material.
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* Hernan Reyes MD, FMH, Obstetrics and Gynecology