2. Gynecologic challenges of the HIV positive female Dr. Orville P. Morgan Consultant Obstetrician/Gynaecologist VJH

3. Gynaecologic Challenges Infectious Menstrual disorders Neoplasia Reproductive/fertility

4. Infectious diseases Vaginal candidiasis HSV HPV PID Pelvic abscess Endometritis TB

5. Vaginal candidiasis Vulvo-vaginitis Fulminant Resists standard treatment Sign of advancing disease Increases risk of virus transmission Inflammatory changes only on Pap smear with isolation of candida specie Most often candida albicans

7. Clinical Diagnosis Thick white discharge Pruritus Dypareunia Dysuria Ulceration

8. Diagnosis KOH preparation shows yeast Pap smear/culture shows yeast and the patient has symptoms of a vaginitis Category B illness

9. Treatment Azole drugs usually topically for 7 days DS suppositories for 3 days Oral Rx fluconazole 150-200mg stat or itraconazole 200mg for three days HIV positive patient – topical agents for 14 days may be appropriate

10. Recurrent Candidiasis Ketoconazole x 6 months

11. HSV

12. HSV & HIV HSV seropositivity increases the risk of acquiring HIV x 2 ? Upregulation HIV replication HSV-2 infection increases the risk of transmitting HIV HIV positive individuals may have more frequent outbreaks In severely immunocompromised individuals lesions may be atypical.

13. HSV HSV-1 droplets, kissing, ora-genital contact HSV- 2 penile- vaginal, anal intercourse

14. Diagnosis &Treatment of HSV Diagnosis clinical Acyclovir 400mg q6h x 10/7, 800mg bd Valacyclovir(prodrug) 1000mg daily, 500mg daily Famciclovir 500mg daily, 250mg daily Foscarnet IV tid

15. Dietary Management HSV HSV contains more arginine vs lysine Foods high in Lysine Fish, chicken, beef, milk, cheese, beans(not peas), vegetables Lysine 390mg daily Avoid gelatin, chocolate, oats, soyabeans, peanuts,whiteflour

16. HPV Skin warts Anogenital warts Cervical cancer Vulval cancer Penile ca, respiratory papillomas, conjunctival papillomas, oral cavity lesions

18. HPV & HIV HPV detection in HIV infected women may be as high as 83%(5x the general population) 20% of dually infected women with no evidence of cervical disease will develop cervical disease within 3 years. HIV infected women are at greater risk for developing cervical cancer caused by HPV infection.

19. HPV & HSV Immunosupression inhibits the clearance of HPV Immunosupression promotes HPV reactivation Patients have greater number of precancerous lesions

20. HPV & HIV More likely to be infected with multiple types. Correlation between lower CD4 counts and higher number of multiple types of HPV More likely to have large condylomas More likely to experience treatment failures for cervical dysplasia

21. PID Patients admitted for PID more likely to be HIV positive Symptoms may be muted Fortunately responds equally to standard therapy More likely to have an adnexal mass on ultrasound.

22. Pelvic Abscess Tubo-ovarian abscess frequent complication of PID Constitutional symptoms often absent. Surgical intervention

23. Menstrual abnormalities Related to advanced disease Amenorrhea IMB Shortened cycle Active virus shedding greatest in luteal phase R/o malignancies, infections incl TB

24. Neoplastic challenges Cervical carcinoma Vulval carcinoma Uterine lymphomas

25. CIN & HIV HGSIL category B Multifocal dyplasia (vagina, anus)

26. Treatment of CIN Colposcopy LEEP Eradication of SIL almost impossible -goal to prevent progression to HGSIL 5-Fluorouracil vaginal cream has been shown to be useful in reducing recurrence rates HAART may lead to “normal” behaviour of CIN

27. Reproductive Challenges- Contraception Condoms Tubal ligation,(Decreased condom use) IUCD(?contraindicated) OCP, (Decreased condom use) Depoprovera, (Decreased condom use)

28. Reproductive challenges- fertility Sero-positive male, sero-negative female Sero-positive female Obstetric outcomes

29. Thank you Neither this man nor his parents sinned……....the work of God might be displayed in his life John 9:3