Management of HIV Disease in Women
اسلاید 1: Part A: Module A3Session 2Management of HIV Disease in Women
اسلاید 2: ObjectivesDescribe the etiology and clinical presentation of STIs and gynecological problems in HIV-infected womenDiscuss the treatment and management of these infections and gynecological problemsDiscuss the prevention of OIs in pregnancyDiscuss treatment protocols in-country
اسلاید 3: Vaginal dischargeLower abdominal pain and fever (PID)Genital sores (ulcers or blisters) Genital warts Malignancies Amenorrhea and intermenstrual bleedingGynecological Problems and STIs
اسلاید 4: Vaginal Discharge: EtiologyGonococcal infectionChlamydia trachomatisTrichomonas vaginalisBacterial vaginosisCandidiasis
اسلاید 5: 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 progressesregular intermittent treatment may be needed for frequent recurrences
اسلاید 6: Management and TreatmentTreatment 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 bidOral: Fluconazole 150 mg po x 1 Ketaconazole 200 mg po/day x 7 days or bid x 3 days
اسلاید 7:
اسلاید 8: Lower Abdominal Pain and Fever (PID)
اسلاید 9: EtiologyGonococcal infectionChlamydia trachomatisMixed bacterial infections (including anaerobes)TB
اسلاید 10: Management and Treatment Women should report symptoms promptly to ensure early diagnosis and treatmentTreat bacterial infections aggressively with broad spectrum antibiotics, e.g., ciprofloxacin 500 bid x one weekIf STD is the cause, follow the national STD management guidelines. Ensure treatment of partners
اسلاید 11: Management and Treatment, continuedExclude 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
اسلاید 12: Genital Sores (Ulcers or Blisters)
اسلاید 13: EtiologySyphilisChancroidLymphogranuloma venereum (LGV)Herpes simplex
اسلاید 14: 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 painfulGive supportive treatment: pain relief and gentian violetOral 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 transmissionIn case of secondary infection, give antibiotics: co-trimoxazole 2 tabs bid or cloxacillin 250 mg qid x 5 days
اسلاید 15: Genital Herpes
اسلاید 16: Genital WartsEtiologyCondylomata acuminate. This should be distinguished fromCondylomata lata (due to secondary syphilis)Management and treatmentTend to be more common and severe in persons with HIVTreat 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 partnersCounsel on prevention of transmission to partner
اسلاید 17: Malignancies EtiologyCervical cancer, CINKaposi’s sarcomaManagement and treatmentExtensive 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
اسلاید 18: Amenorrhea and Intermenstrual Bleeding EtiologyMenstrual 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
اسلاید 19: Amenorrhea and Intermenstrual Bleeding, continuedManagement and treatmentExclude other causes such as pregnancy, perimenopause, uterine fibrosis, genital tract infections, cervicitis, PID, TB, cancerMenses may return after treatment of other infections and weight gainBest management: provide counseling and reassuranceIf the woman is sexually active and not using an effective method of contraception consistently, do a pregnancy test
اسلاید 20: Prevention of OIs in Pregnancy OIPrevention RegimenPCPTMP-SMX is recommended with dapsone as the alternative. Due to theoretical concerns for teratogenicity, providers may choose to withhold prophylaxis in the 1st trimester or use aerosolized Pentamidine Toxo-plasmosis Primary prophylaxis: TMP-SMX is recommended with theoretical concerns for teratogenicity in 1st 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
اسلاید 21: Prevention of OIs in Pregnancy OIPrevention RegimenTB INH + pyridoxine regimens preferred for prophylaxis; some providers avoid INH in 1st 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. pneumoniaePneumovax may be given. Due to “HIV viral burst” some delay vaccination until after ART
اسلاید 22: Prevention of OIs in Pregnancy OIPrevention RegimenFungal 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 1st 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
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