HIV Infection
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Indications for HIV testing in gynaecology
Infection with HIV may be associated with increased severity & poorer prognosis in conditions such as pelvic inflammatory disease & cervical intraepithelial neoplasia.
Wasting syndrome or AIDS-defining infections may complicate the management of various gynaecological conditions, & increase the risks associated with general anaesthesia.
However, in the era of Anti-Retoviral Treatment (ARVs) the situation is much improved. Life expectancy on ARVs exceeds 30 years providing the patient does not react to the ARVs or the virus develop resistance.
Indications for HIV testing in gynaecology
In truth…… every single patient who has been sexually active should be asked if they have tested, & if not it should be explained why it might be advisable.
General remarks
- Testing for HIV, and CD4 count/viral load, cannot be done without first obtaining informed consent from the patient
- A second ELISA test is done on the same blood specimen to confirm a positive result. Patients can only be told of positivity after the second ELISA
- Post-test counseling for positivity must be done in private & with the help of an interpreter, if necessary
- CD4 count testing +/- viral load is required in all HIV positive patients. A low CD4 count is not, on its own, a reason to withdraw treatment for any condition though it may be modified
- Any patient with a CD4 count less than 200 should receive sulphamethoxazole /trimethoprim (Bactrim) 2 tablets orally daily, & TB prophylaxis (Isoniazid 300mg qid with Pyridoxine 50mg qid) according to protocols & be referred to the local clinic
- Consider associated conditions including TB in any immune-compromised patient. It should be considered in all pregnancy visits
Treatment
- Indications to treat may change. Currently all HIV positive patients are offered treatment
- The standard Fixed Dose Combination (FDC) regimen may consist of Tenofovir (TDF) 300mg, Lamividine (3TC) 300mg & Efavirenz (EFV) 600mg each day; Nevirapine (NVP) may replace TDF if contraindicated, Zidovudine (AZT) if TDF is contraindicated & Abacavir(ABC) if TDF & EFV are contraindicated. Many first & second line regimens exist
- If treatment is to be offered please refer to the local clinics for prescription, assessment, follow up
- Occupational exposure to HIV (needlesticks, cuts or splashes) must be managed in accordance with the hospital protocol. There should be no delay in washing exposed sites with antiseptics, & starting ARVs. Risk is small.