1. Women and HIV Lucille Sanzero Eller, PhD, RN Associate Professor Rutgers, The State University of New Jersey College of Nursing A Local Performance Site of the NY/NJ AETC September 2009

2. Objectives (1) 1. Discuss the epidemiology of HIV in women. 2. Describe gender-specific symptoms in HIV+ women. 3. Discuss ARV treatment considerations for HIV+ women.

3. Objectives (2) 4. Identify psychological factors in HIV+ women. 5. Discuss contraception and pregnancy in HIV+ women. 6. Describe assessment and counseling issues for women with HIV.

4. Epidemiology of HIV in Women (1) Proportion of AIDS cases in women steadily increased since HIV epidemic began – 1985 - 8% women – 2006 - 27% women Women of color disproportionately infected – Black and Hispanic women comprise 25% of U.S. female population 82% of women with HIV in the U.S.

5. Epidemiology of HIV in Women (2) HIV infection in women in 2004 – leading cause of death for black women aged 25 to 34 years – 3rd leading cause of death for black women aged 35–44 years – 4th leading cause of death for black women aged 45–54 years and for Hispanic women aged 35–44 years (CDC, May 2006)

7. Race/ethnicity of Women 2005: New AIDS Diagnoses and Percentage of U.S. Population (CDC, 2007) New AIDS Diagnosis Black 66% White 16% Latina 16% Other 1% CDC, HIV/AIDS SurveillanceReport, Vol. 17, Revised Edition; June 2007. U.S. Female Population Black 12% White 69% Latina 13% Other 6%

9. HIV Transmission in Women  Most common routes of HIV infection for women  sex with an HIV-positive man  sharing injection drug works with someone with HIV  Male to female transmission is 1.9 times more effective than female to male transmission; women are about twice as likely as a man to contract HIV infection during unprotected vaginal intercourse

10. Viral load  Viral load in women  After adjustment for differences in measurement method, baseline CD4 + cell count, age, and clinical symptoms, HIV-1 RNA levels were 32% to 50% lower in women than in men at CD4 + counts >200 cells/mm 3  Despite lower viral loads, HIV disease progresses at the same rate in women as in men (Rezza et al., 2000)  Current clinical guidelines do not make a distinction by gender for the initiation of HAART

11. HIV-related Hormonal Changes (1)  HIV can affect the body's ability to produce and maintain hormone levels  Changes in the balance of estrogen, progesterone, or testosterone can lead to multiple symptoms (Margolese, 2004)

12. HIV-related Hormonal Changes (2)  Symptoms of hormonal imbalance:  Abnormal menstrual cycles, possibly including early menopause  Weight loss  Headaches  Mood swings  Depression

13. HIV-related Hormonal Changes (3)  Symptoms of hormonal imbalance:  Sleep disturbances  Fatigue  Decreased bone density  Vaginal dryness  Lack of sexual desire  Difficulty getting pregnant

14. HIV and Menstrual Problems (1)  Menstrual cycle changes  Increase in premenstrual symptoms  Changes may be due to  HIV itself  ARVs  other co-factors that may occur with HIV disease such as drug use

15. HIV and Menstrual Problems (2)  Hypermenorrhea- predisposes women to anemia, already a chronic problem in women with HIV  Amenorrhea- promptly evaluate for underlying causes  pregnancy  ovarian cyst  ovarian failure and premature menopause

16. HIV and Osteopenia  Bone density in HIV+ (n=263) and HIV- (n=232) women 40 years and older (Arnsten et al., 2006)  Osteopenia prevalence regardless of ART use:  27% in HIV+ women  19% in HIV- women  Higher risk of osteopenia if:  Black  Underweight  Used opiates

17. HIV and Menopause (1)  “Ms Study” examined natural history of menopause in HIV-infected and drug using women (Schoenbaum, 2005)  571 women, 52.9% HIV positive  median age 43 years  53% with history of illicit drug use  89% women of color

18. HIV and Menopause (2)  Onset of menopause significantly differed:  46 years [Interquartile Range (IQR) 39-49 years ] for HIV+ women  47 years [IQR 39-48 years] for HIV- women  Those with CD4+ counts <200 cells/mm3 had earliest onset (median age 42.5 years)

19. HIV and Menopause (3)  No association between receipt of HAART and onset of menopause  Earlier onset of menopause combined with HIV disease contributes to risk of dyslipidemia and osteopenia

20. AIDS Complications in Women (1)  AIDS complications unique to women:  recurrent vaginal candidiasis  severe pelvic inflammatory disease  cervical dysplasia  cervical cancer

21. AIDS Complications in Women (2)  HIV+ women at higher risk of cervical dysplasia, a precursor to cervical cancer  Risk of cervical cancer associated with:  immune deficiency (declining CD4 counts and higher HIV RNA levels)  human papillomavirus (HPV) which occurs in more than 60% of women with HIV (Abularach & Anderson, 2005)

22. HIV and Cervical Cancer (1) Cervical Cancer Incidence is up to 9 times higher in HIV+ women Presents at more advanced stages Is less responsive to therapy

23. HIV and Cervical Cancer (2)  CDC Pap screening recommendations:  Pap smear when first diagnosed, and again 6 months later; then once yearly for life  Women with cervical abnormalities or CD4 counts <200 cells/mm 3 should be screened every 6 months for life

24. HIV and Oral Symptoms  Studies have shown a significant relationship between high viral load and both oral candidiasis and hairy leukoplakia (Greenspan et al, 2000; 2004; Patton et al., 2000)  Recurrence and incidence of candidiasis are reduced by HAART, and that recurrence is reduced independent of CD4 count and HIV RNA level  HAART does not reduce the incidence of hairy leukoplakia or oral warts in women (Greenspan et al., 2004

25. HIV and Women: Studies (1)  The Women's Interagency HIV Study (WIHS)  established in 1993  investigated the impact of HIV infection on women  recruited 2066 HIV-positive and 575 HIV- negative women from six sites in the U.S.  The Women and Infants Transmission Studies (WITS)  multi-site observational study established in 1989  enrolled 2336 HIV-infected pregnant women and 1887 infants born to them

26. HIV and Women: Studies (2)  10 primary care sites in the HIV Research Network (HIVRN) (N=19,500) (Gebo et al., 2005)  HIV+ women less likely than HIV+ men to receive prescriptions for the most effective treatments for HIV infection

27. HIV and Women: Studies (3)  Those less likely to receive clinically indicated ART:  <40 y.o.; women; African-Americans; IDUs; the uninsured or those with private insurance  Those more likely to receive clinically indicated ART:  older patients; men; Whites; Hispanics; those with risk factors other than IDU; those with Medicare coverage

28. HIV and Women: Treatment (1) Recommendations for treatment of women of reproductive age:  Indications for initiation of therapy and goals of treatment are same as for other adults and adolescents  Avoid Efavirenz for the woman who wants to become pregnant or who does not use effective and consistent contraception Panel on Clinical Practices for Treatment of HIV Infection, 2008

29. HIV and Women: Treatment (2) Recommendations for treatment of women of reproductive age:  For the woman who is pregnant, an additional goal of therapy is prevention of mother-to-child transmission, with a goal of viral suppression to <1,000 copies/mL  Selection of an ARV combination should consider known safety, efficacy, and pharmacokinetic data of each agent during pregnancy ( Panel on Clinical Practices for Treatment of HIV Infection, 2008)

30. Lipodystrophy Syndrome (1)  Metabolic and clinical features include:  insulin resistance  impaired glucose tolerance  type 2 diabetes  hypertriglyceridemia  hypercholesterolemia  increased free fatty acids (FFA)  decreased high density lipoprotein (HDL)  fat redistribution

31. Lipodystrophy Syndrome (2) Factors that increase risk of lipodystrophy syndrome include:  increasing age  current use and total duration of antiretroviral therapy, including NRTIs and PIs, but not NNRTIs Carr, A. (2003). HIV lipodystrophy: risk factors, pathogenesis, diagnosis and management. AIDS, 17 (1), S141-S148.

32. Lipodystrophy Syndrome (3) Also associated with lipodystrophy are: Gender AIDS diagnosis greater CD4 lymphocyte and HIV RNA responses to antiretroviral treatment low body weight pre-therapy elevated C-peptide and triglyceride levels after about 1 year of therapy use of the dual PI combination ritonavir– saquinavir use of thymidine analogues Carr, A. (2003). HIV lipodystrophy: risk factors, pathogenesis, diagnosis and management. AIDS, 17 (1), S141-S148.

33. Lipodystrophy Syndrome (4) In a study of 2258 patients, women were twice as likely as men to have lipodystrophy Morphologic AlterationWomen Men Fat loss only 9.3% 12.2% Fat accumulation only 10.1% 7.7% Both fat loss & accumulation 22.4% 9.7% Galli M, Veglia F, Angarano G, et al. Correlation between gender and morphologic alterations in treated HIV patients. Program and abstracts of The 1st IAS Conference on HIV Pathogenesis and Treatment; July 8-11, 2001; Buenos Aires, Argentina. Abstract 505

34. Lipodystrophy Syndrome (5) Morphologic changes of lipodystrophy syndrome vary by gender: Women tend to experience fat accumulation in the abdomen and breasts Men tend to experience fat depletion from the face and extremities

35. Contraception (1)  WIHS study- effects of hormonal contraceptives on HIV RNA and CD4 counts (Cejtin et al., 2003)  1721 women 50 y.o. or less, not menopausal  controlled for CD4 count, tobacco use, age, race, ART use, and a history of AIDS-defining illnesses  No effect on viral load; small increase in CD4 count, not clinically significant

36. Contraception (2)  WIHS study- effects of hormonal contraceptives on effectiveness of HAART (Chu et al., 2005)  77 hormonal contraceptive users matched with non-users on age, race, and pre-HAART CD4 count and viral load  Followed from point of HAART initiation  No effect on CD4+ cell count and viral load responses to HAART

37. Contraception (3)  Hormonal contraceptives can interact with ARVs and cause any of the following:  decreased contraceptive effectiveness  increased concentrations of the ARV  decreased concentrations of the ARV e.g. Fos-Amprenavir should not be co- administered with hormonal contraceptives  Amprenavir increases blood levels of both estrogen and progestin  oral contraceptives decrease Amprenavir levels

38. Contraception (4)  Copper IUDs  are associated with increased menstrual flow and duration  May contributing to HIV transmission risk  May contribute to anemia in HIV+ women

39. Stigma  Stigma of HIV disease has several negative consequences  secrecy and unwillingness to disclose serostatus  fear of being identified as HIV positive  isolation  reduced access to care  difficulties with medication adherence  unwillingness to seek social support (Carr & Gramling, 2004)

40. Social Support (1)  Social support includes the provision of  Emotional support  esteem  affiliation  Instrumental support  financial  housing  Informational support  advice  information

41. Social Support (2)  Women with HIV receive less social support than demographically similar women  Social support decreases as symptoms of HIV increase (Hough et al., 2003; Klein et al., 2000)  Social support reduces psychological distress and is a critical element in effective coping with HIV (Hough et al., 2005)

42. Social Support: INSPIRE Study (1)  Baseline data of INSPIRE (Interventions for Seropositive Injectors-Research and Evaluation) study (Knowlton et al., 2006)  Examined role of social support in facilitating effective HAART use in 446 IDUs  34% female, 69% Black, 26% homeless, median age 43 years

43. Social Support: INSPIRE Study (2)  Adjusted odds of undetectable viral load (UVL) 3X higher in those with  high social support  stable housing  CD4 > 200  Adjusted odds of achieving UVL almost 60% higher (AOR = 1.57) in those reporting better patient-provider communication

44. Social Support: INSPIRE Study (3)  Interventions to facilitate effective HAART use in IDUs should promote  social support functioning  patient-provider communication  stable housing  drug abuse treatment (Knowlton et al., 2006)

45. Social Support  Study of social support in 147 poor, young (M=36 y.o., SD=7) urban, African American (87%) mothers with HIV (Hough et al. 2005)  47% of primary support network, who provided the most salient support, were children  few friends, and almost no health care providers were reported as sources of social support

46. Social Support: Assessment  Scale to assess social support in HIV+ women and abused women is the Interpersonal Support Evaluation List (ISEL) (Cohen et al., 1985)  Scale available at http://www.psy.cmu.edu/~scohen/ISEL.html

47. Social Support: Study of Unsupportive Social Interactions (1)  Presence of friends, family, significant others is not necessarily supportive  Unsupportive social interactions may be detrimental  Study of relationship-specific unsupportive social interactions and depression in 146 HIV+ women (Scrimshaw, 2003)

48. Social Support: Study of Unsupportive Social Interactions (2)  28% asymptomatic, 29% symptomatic, 43% with AIDS  Mean age 35.6 years (SD D 5.6)  African American (33%), Puerto Rican (34%), White (33%)  Incomes: 36% < $10,000; 48% $10,000 and $19,999; 26% $20,000+  70% married or steady partner  73% mothers  55% IVDUs

49. Social Support: Study of Unsupportive Social Interactions (3)  Unsupportive social interactions from family  direct negative effect on depressive symptoms  Unsupportive interactions from a lover/ spouse and friends  interactive effect on depression  independently predicted high levels of depressive symptoms (Scrimshaw, 2003)

50. Social Support: Study of Unsupportive Social Interactions (4)  Number of HIV-related physical symptoms significantly associated with more unsupportive social interactions from all three sources:  family  lover/spouse  friends (Scrimshaw, 2003)

51. Assessment of Unsupportive Social Interactions (1)  Assess unsupportive illness-related social interactions during the past month Responses range from never (1) to all the time (5)  Ask whether others: 1. Were trying to be overly optimistic or cheerful 2. Were avoiding you or was uncomfortable being with you 3. Were unwilling to listen to you talk about the illness (Siegel et al., 1994; 1997)

52. Assessment of Unsupportive Social Interactions (2)  Ask whether others: 4. Resented the demands the illness placed on them 5. Said or did things that you found unhelpful or disturbing 6. Made you more dependent on assistance than you needed to be (Siegel et al., 1994; 1997)

53. Assessment of Unsupportive Social Interactions (3)  Questionnaire should be completed three times, once each for  lover/spouse  family  friends  Calculate 3 separate summary scores (i.e., the sum of the six items) to assess the frequency of unsupportive social interactions in each type of relationship ( Scrimshaw, 2003)

54. Depression (1)  In a study of 765 HIV+ women, 42% had chronic depressive symptoms, and another 35% had intermittent depressive symptoms  (Ickovics, et al., 2001  Depression is associated with:  poorer virologic response  increased likelihood of immunologic failure  incident AIDS defining illness  higher risk of all-cause, but not AIDS-related, death

55. Depression (2)  Depression following HAART initiation was associated with a greater likelihood of HAART discontinuation (Anastos et al., 2005; Ickovics et al, 2001)  Psychotherapy, pharmacotherapy or combination of both can be used to treat depression  Self-care strategies for management of depressive symptoms used effectively by people with HIV include prayer, meditation, talking to others, using distraction, and exercise (Eller et al., 2005)

56. HIV and Pregnancy (1)  80% of HIV+ women are of childbearing age; consider in ART regimen selection See Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - April 29, 2009 Available at: http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf

57. HIV and Pregnancy (2)  Care should include routine, regular education and counseling about pregnancy/ contraception  Assess for factors associated with unplanned pregnancies  substance abuse by the woman or her partner  mental illness  domestic violence

58. HIV and Pregnancy (3)  About 1/3 of HIV+ women and men receiving medical care in the U.S. desire children in the future (Chen, 2001)  20% of serodiscordant couples would practice unsafe sex in order to conceive (Klein, 2003)

59. HIV and Pregnancy: Counseling (1)  Impact of HIV on pregnancy course/outcome  Impact of pregnancy on HIV progression  Other reproductive issues based on maternal factors  coexisting drug/alcohol use  advanced maternal age  hypertension, hyperglycemia, hepatic toxicity, anemia (Anderson, 2005; CDC, 2009)

60. HIV and Pregnancy: Counseling (2)  General preconception issues  nutritional counseling (e.g. folic acid)  importance of early and ongoing prenatal care  Long term health of mother and care for children (guardianship issues) (Anderson, 2005)

61. HIV and Pregnancy: Counseling (3)  Perinatal transmission  Discuss and provide ARVs during pregnancy regardless of woman’s HIV RNA level  Breastfeeding not recommended in U.S. since safe, affordable, feasible, culturally acceptable alternatives are available  Use of antiretrovirals and other medications in pregnancy  Safe conception if partner HIV-negative (Anderson, 2005)

62. HIV and Pregnancy: CDC HIV Screening Recommendations (4)  Screen all adults ages 13–64 in health care settings; repeat screening annually if at high risk  Include screening in all prenatal testing, unless the patient declines; repeat screening in 3 rd trimester for women at high- risk for HIV  HIV testing of newborns if mother’s HIV status unknown

63. HIV and Pregnancy: Studies (1)  Meta-analysis: 7 studies of effects of pregnancy on HIV disease  No significant differences observed in:  death  HIV disease progression  progression to an AIDS-defining illness  fall in CD4 count to below 200/mm 3 (French, 1998)

64. HIV and Pregnancy: Studies (2)  Effects of pregnancy on HIV disease progression In women with repeat pregnancy (n=329), compared to those with only one pregnancy (n=953)  No significant differences observed in:  viral load  CD4  clinical disease progression (Minkoff et al., 2003)

65. Pregnancy and ARV Treatment: Study (1) Meta-analysis of 14 clinical studies that included European and American studies  ARV use during pregnancy did not increase risk of premature delivery when compared to no therapy [OR 1.01 (95% CI 0.76-1.34)]  Use of protease inhibitor (PI)-containing combinations resulted in an OR for premature delivery of 1.24 (95% CI 0.76-2.02), compared with combinations without PI Kourtis AP, Schmid CH, Jamieson DJ, et al. (2007) http://www.ncbi.nlm.nih.gov/pubmed/17314523

66. Pregnancy and ARV Treatment: Study (2) Meta-analysis of 14 clinical studies that included European and American studies:  Initation of combination regimens before or early in pregnancy may slightly increase risk of prematurity compared with initiation in the second trimester or later [OR 1.71 (95% CI 1.09- 2.67)] Kourtis AP, Schmid CH, Jamieson DJ, et al. (2007) http://www.ncbi.nlm.nih.gov/pubmed/17314523

67. Pregnancy and ARV Treatment (1)  Goals in use of ARVs during pregnancy:  treatment of maternal infection  reduction in the risk of perinatal transmission  Offer standard combination ARV therapy to pregnant women who meet same criteria other adults and adolescents  two NRTIs and a PI or a NNRTI (excluding efavirenz) (Anderson, 2005)

68. Pregnancy and ARV Treatment (2)  Considerations for ARV treatment decisions: (Anderson, 2005)  Treatment for health of the woman  Current information re effectiveness of ART in reducing perinatal transmission  Known or potential effects of ARV drug exposure on the pregnant woman and/or fetus/newborn  importance of adherence

69. Pregnancy and ARV Treatment (3)  Considerations re prevention of mother-to- child transmission (PMTCT) and maternal and fetal safety influence  timing of initiation of treatment  selection of regimens NOTE: Curriculum of the WHO and CDC Prevention of Mother-to-Child Transmission of HIV (PMTCT) Generic Training Package (July, 2008) is available at http://www.womenchildrenhiv.org/wchiv?page=pi-60-00

70. Pregnancy and ARV Treatment (4)  Drugs that cause GI upset  may not be well tolerated in early pregnancy when morning sickness is common  may increase risk for non-adherence  may have inadequate blood levels from vomiting  All ARVs should be discontinued and restarted when the nausea and vomiting is gone or effectively treated

71. Pregnancy and Nevirapine (1)  Potential side effects of nevirapine in pregnancy  Women, esp. with CD4 counts >250/mm 3, are at increased risk for symptomatic, rash- associated, nevirapine-related hepatotoxicity  Deaths from hepatic failure reported  Early non-specific symptoms of hepatotoxicity can be confused with symptoms common in pregnancy (fatigue, malaise, anorexia, nausea)

72. Pregnancy and Nevirapine (2)  Potential side effects of nevirapine in pregnancy (cont.)  Women should be monitored for clinical symptoms and hepatic transaminases (i.e., ALT and AST), particularly during the first 18 weeks of therapy, when toxicity is most likely

73. Pregnancy and Protease Inhibitors (1)  PIs are associated with development or worsening of hyperglycemia or diabetes  Pregnancy also increases risk for glucose intolerance  It is not known conclusively whether the use of PIs in pregnancy will exacerbate risk for development of gestational diabetes

74. Pregnancy and Protease Inhibitors (2)  For women receiving PIs in pregnancy  monitor glucose levels  ask regularly about symptoms of hyperglycemia

75. Lactic acidosis and Hepatic steatosis (1)  May have higher incidence in women  Thought to be due to damage to mitochondrial DNA (mitochondrial toxicity) that is caused by long-term nucleoside analogue use  Reported to occur in infected persons treated with NRTIs for >6 months (Arenas-Pinto et al, 2003; CDC, 2008; McComsey & Lonergan, 2004)

76. Lactic acidosis and Hepatic steatosis (2)  Several maternal deaths due to lactic acidosis/hepatic steatosis  All were in women receiving combination of d4T/ddI as part of their ART at the time of conception and for the duration of pregnancy  Non-fatal cases of lactic acidosis have also been reported in pregnant women receiving this combination

77. Lactic acidosis and Hepatic steatosis (3)  Early symptoms of mitochondrial dysfunction are nonspecific and mimic symptoms of pregnancy  nausea and vomiting  abdominal pain  dyspnea  weakness

78. Lactic acidosis and Hepatic steatosis (4)  Pregnant women receiving nucleoside analogue drugs (NRTIs)  should have liver enzymes and electrolytes evaluated more frequently during the last trimester of pregnancy  should have new symptoms evaluated promptly and thoroughly

79. Assessment and Counseling (1)  Women infected with HIV may have more difficulty accessing health care due to:  Fear of disclosure  Lack of financial resources  Lack of transportation  Burden of caring for others, especially children

80. Assessment and Counseling (2)  Women often have difficulty negotiating protective sex due to power differentials  Lack of power may cause women to:  Have sex against their will  Have sex without a condom, against their will (CDC, May 2006)

81. Assessment and Counseling (3)  Lack of power may cause women to (cont.) :  Have sex with a man without knowing whether he has high-risk behaviors (unprotected sex with men, sex with many other partners, injection drug use)  Trade sex for drugs or money  Be unable to talk to their partners about abstinence, faithfulness, and condom use (CDC, May 2006)

82. Assessment and Counseling (4)  Support system: At initial visit and at intervals assess woman’s support system  Who knows her HIV status  Problems encountered with disclosure  Family and/or friends to whom she turns for ongoing support  Barriers to disclosure to sexual or needle- sharing partners

83. Assessment and Counseling (5)  Contraception:  Discuss method of contraception  If pregnant, discuss postpartum contraceptive plans  Educate and counsel about available options to permit informed decision making  Condom use:  Review sexual activity at each visit  Reinforce condom use

84. Assessment and Counseling (6)  Drug use/treatment: At initial visit and at intervals assess past/current substance abuse (tobacco, alcohol, illicit drugs)  Type of substance(s)  Amount of use  Route of administration  Prior drug or alcohol treatment  Counsel about specific risks associated with substance abuse in pregnancy. Treatment should be encouraged and facilitated for active problems

85. Assessment and Counseling (7)  Adherence: Assess and reinforce importance of adherence to prescribed medications before they are initiated and at each visit  Clinical trials: Inform about the availability of and offer participation in clinical trials for which woman is eligible

86. Assessment and Counseling (8)  Advance directives: Discuss advance directives for care in the event of sudden deterioration in the woman’s health  Discuss guardianship plans for children in the event of the mother’s incapacitation or death  Facilitate legal assistance, if needed

87. Key Points (1) 1. The proportion of AIDS cases in women has increased from 8% in 1985 to 27% in 2004. 2. Women of color are disproportionately infected with HIV. 3. HIV’s effect on estrogen, progesterone and testosterone leads to multiple symptoms.

88. Key Points (2) 4. HIV+ women are less likely than HIV+ men to receive HAART. 5. Avoid efavirenz in pregnant women and those at risk for pregnancy. 6. NRTI and PI-related lipodystrophy 2X more common in HIV+ women vs. HIV+ men.

89. Key Points (3) 7. Contraception  Hormonal contraceptives: no sig. effect on CD4+ count, viral load, response to HAART  IUD may increase menstrual flow, transmission risk, anemia 8. Negative consequences of stigma include  Fear of disclosure and identification as HIV+  Isolation; reduced social support  Reduced access  Reduced adherence

90. Key Points (4) 9. Supportive and unsupportive social interactions should be assessed. 10. HIV and pregnancy  Assess risk for unplanned pregnancy  Counsel re impact of HIV on pregnancy and pregnancy on HIV disease  ARVs (treat maternal infection; PMTCT)  potential side effects of nevirapine, PIs  lactic acidosis, hepatic steatosis

91. Key Points (5) 11. Assess and counsel regarding:  Support system  Contraception  Condom use  Drug use and treatment  Adherence  Clinical trial availability  Advance directives  Guardianship  Legal assistance