1. Part A/Module A3/Session 2 Part A: Module A3 Session 2 Management of HIV Disease in Women

2. Part A/Module A3/Session 2 Objectives 1.Describe the etiology and clinical presentation of STIs and gynecological problems in HIV-infected women 2.Discuss the treatment and management of these infections and gynecological problems 3.Discuss the prevention of OIs in pregnancy 4.Discuss treatment protocols in-country

3. Part A/Module A3/Session 2 1.Vaginal discharge 2.Lower abdominal pain and fever (PID) 3.Genital sores (ulcers or blisters) 4.Genital warts 5.Malignancies 6.Amenorrhea and intermenstrual bleeding Gynecological Problems and STIs

4. Part A/Module A3/Session 2 Vaginal Discharge: Etiology  Gonococcal infection  Chlamydia trachomatis  Trichomonas vaginalis  Bacterial vaginosis  Candidiasis

5. Part A/Module A3/Session 2 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

6. Part A/Module A3/Session 2 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

7. Part A/Module A3/Session 2 Bacterial VaginosisVulvo- vaginal Candidiasis TrichomoniasisGonorrheaChlamydia Causes Replacement of normal lactobacillus with mixed flora e.g. gardnerella vaginilis, mycoplasma hominis Candida albicans Trichomonas vaginalis Neisseria gonorrhea Chlamydia trachomatis Clinical features and diagnosis Homogeneous grayish or yellowish discharge Clue cells on microscopy Vaginal PH >4.5; Positive whiff test (i.e. fishy odor of discharge before or after addition of 10% KOH) Diagnosis requires at least 3 of above clinical features Thick, white discharge with pruritus. Vulvar burning, vaginal soreness, dyspareunia, dysuria. Diagnosis: clinical symptoms + identification of budding yeast on a wet mount or KOH prep or Gram stain of vaginal discharge Profuse, malodorous, often frothy, yellow-green discharge and vulvar irritation. May have: urinary symptoms, dyspareunia, Diagnosis: Saline wet mount will show motile trichomonads in positive culture Commonly asympto- matic Commonly asympto- matic

8. Part A/Module A3/Session 2 Lower Abdominal Pain and Fever (PID)

9. Part A/Module A3/Session 2 Etiology  Gonococcal infection  Chlamydia trachomatis  Mixed bacterial infections (including anaerobes)  TB

10. Part A/Module A3/Session 2 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

11. Part A/Module A3/Session 2 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

12. Part A/Module A3/Session 2 Genital Sores (Ulcers or Blisters)

13. Part A/Module A3/Session 2 Etiology  Syphilis  Chancroid  Lymphogranuloma venereum (LGV)  Herpes simplex

14. Part A/Module A3/Session 2 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

15. Part A/Module A3/Session 2 Genital Herpes

16. Part A/Module A3/Session 2 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

17. Part A/Module A3/Session 2 Malignancies  Etiology Cervical cancer, CIN Kaposi’s 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

18. Part A/Module A3/Session 2 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

19. Part A/Module A3/Session 2 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

20. Part A/Module A3/Session 2 Prevention of OIs in Pregnancy OI Prevention Regimen PCP TMP-SMX is recommended with dapsone as the alternative. Due to theoretical concerns for teratogenicity, providers may choose to withhold prophylaxis in the 1 st trimester or use aerosolized Pentamidine Toxo- plasmosis Primary prophylaxis: TMP-SMX is recommended with theoretical concerns for teratogenicity in 1 st trimester. Pyrimethamine regimens should be avoided Secondary prophylaxis: This is a risk:benefit issue with concerns for teratogenicity of pyrimethamine vs. recurrent toxoplasmosis; most clinicians favor continued treatment Primary toxoplasmosis during pregnancy should be managed by a specialist

21. Part A/Module A3/Session 2 Prevention of OIs in Pregnancy OIPrevention Regimen TB INH + pyridoxine regimens preferred for prophylaxis; some providers avoid INH in 1 st trimester---concerns for teratogenicity Perform chest x-ray to R/O active TB with lead apron shields RIF and RBT appear safe during pregnancy; experience is limited Avoid PZA, especially during 1st trimester MAC Primary prophylaxis: Azithromycin preferred, but some providers withhold prophylaxis in 1st trimester. Experience with RBT is limited. Clarithromycin is teratogenic in animals; use with caution S. pneumoniae Pneumovax may be given. Due to “HIV viral burst” some delay vaccination until after ART

22. Part A/Module A3/Session 2 Prevention of OIs in Pregnancy OIPrevention Regimen Fungal infections General: Avoid azoles (Fluconazole, Ketaconazole, and Itraconazole) due to teratogenicity Cryptococcosis, histoplasmosis, and coccidioidomycosis: For secondary prophylaxis Amphotericin B is preferred instead of azoles, especially during 1 st trimester CMV Standard recommendations apply HSV Oral acyclovir during late pregnancy to prevent prenatal HSV transmission is controversial, but usually not used; acyclovir prophylaxis to prevent severe recurrences may be indicated VZV exposure: Non-immune host VZIG within 96 hrs. of exposure is recommended Human papilloma virus (HPV) Avoid intravaginal 5 fluorouracil