When the HIV epidemic was at its peak, in the 1980s, it was widely held to be principally a disease of gay men. In the US, Europe and Australia little attention was paid to HIV infection in women. When the true nature of the global epidemic was elucidated in the 1990s, it became apparent that heterosexual sex was the principal means of transmission of HIV in the developing world. Today it is estimated that 35 million people are infected worldwide and half of these are women.

Approximately 27 000 people live with HIV in Australia, of whom some 3500 (13 per cent) are women, a proportion that has remained stable for many years.¹ HIV diagnoses have been slowly increasing since 1996, and in 2013 there were 1236 new diagnoses in Australia, of which 161 occurred in women. Most of the transmission to women is through heterosexual contact, most usually associated with a partner from a country with known high prevalence of HIV, and only four per cent occurring from a known bisexual partner. Injecting drug use remains a rare form of HIV transmission. HIV rates are extremely low among female sex workers. Transmission from an infected woman to a female sexual partner is extremely rare, and has not been reported in Australia.² However, risk factors for HIV are not always easily discernible, a principle that underlies current Australian guidelines advising HIV testing as a routine part of antenatal care for all women.³

HIV damages the immune system mainly by its effect on CD4 cells. These lymphocytes are responsible for the co-ordination of the immune response, in particular in regard to opportunistic, fungal and viral infections. CD4 deficiency also predisposes the infected patient to a number of malignancies, especially non-Hodgkin lymphoma and Kaposi’s sarcoma. In addition, HIV has direct effects upon the brain and lymphoid tissue of the gut.

Despite a number of promising candidates, there is still no effective vaccine against HIV, so prevention of infection remains the mainstay of the public health message. An HIV-infected woman poses a risk of transmission to her sexual partner and to her child. Both risks are significantly reduced, but not completely eliminated, by the use of antiretroviral drugs that lead to an undetectable viral load. Affordable antiretrovirals are now available in the developing world and it is estimated that 67 per cent of HIV-positive pregnant women in low-and middle-income countries received them to prevent transmission to their babies in 2013.⁴

Obstetrics and gynaecology concerns

While the numbers of HIV-positive women in Australia remain relatively low, HIV infection in the community is of relevance to obstetricians and gynaecologists, especially because of the risk of mother-to-child transmission pre-, intra- and postpartum. Furthermore, there are a number of reproductive health issues that affect HIV-infected women that need to be considered.

Increasing numbers of men and women living with HIV are choosing to have children. Between 2004 and 2013, 372 babies were born to women with HIV infection in Australia. Thirteen of these babies have perinatally acquired HIV infection; in over half of these cases, the woman was diagnosed with HIV after the birth of the child.¹ Routine antenatal screening for HIV allows successful intervention, which virtually eliminates perinatal transmission. With appropriate management, the chance of HIV transmission to a baby born to a mother who has HIV is less than 0.5 per cent.⁵

In the absence of Australian national guidelines for the care of HIV in pregnancy, it is possible to draw on US and UK guidelines, although there are some differences between the two that need consideration when devising local guidelines for multidisciplinary care.^{6 7 8} Prevention of mother-to-child transmission includes antiretroviral treatment for the mother. In known HIV infection, treatment is usually commenced before conception, but should otherwise be started as early as possible after diagnosis of HIV in pregnancy, with the aim of maintaining an undetectable viral load. Maternal and fetal well-being are the most important considerations in determining the mode of delivery. Caesarean section offers no further reduction in transmission risk over vaginal delivery if the viral load of the mother is undetectable. However, if viral control has not been achieved, caesarean section is advised. Intrapartum instrumentation and invasive monitoring should be avoided. The newborn is also given a course of antiretrovirals for four weeks and should be exclusively bottle-fed.

Condoms remain integral to prevention of transmission of infection, unless conception is desired. Contraception for HIV-positive women is complicated by interactions between the combined oral contraceptive pill and HIV medications, and additional measures are usually recommended. Hormonal and copper intrauterine devices are considered to be safe and effective, but depo-medroxyprogesterone acetate has been implicated in increasing the risk of HIV transmission and is not usually a contraceptive of choice if acceptable alternatives are readily available.⁹

Human papillomavirus (HPV) immune surveillance may be impaired in HIV-infected women and the risk of cervical cancer is increased. Women with HIV tend to have higher rates of abnormalities on Pap smears and, despite advances in HIV treatment over the last decade, an annual Pap smear is still advised, rather than two-yearly as is generally recommended.¹⁰

HIV infection is associated with increased rates of premature menopause (less than 40 years of age). Early loss of ovarian function and childbearing capacity occurs in about seven per cent of infected women compared to less than one per cent women without HIV. Early menopause (between 40 and 44 years) is also more common, again affecting about seven per cent of women with HIV.¹¹ At present, there are no published data on the safety and efficacy of hormone replacement therapy in relation to menopause symptoms, cardiovascular risk and bone health for women living with HIV, which complicates informed decision-making.¹²

Living with HIV

Extraordinary advances have been made in HIV treatment. In 1990, the disease was essentially a death sentence and everyone who was infected was expected to die. Long-term survival was recognised, but rare. When combination antiretroviral therapy became widely available, in 1996, it was soon shown that CD4 decline could be halted and reversed, even in advanced disease. By 2005, most patients could be managed with a three-drug, single- tablet daily regimen. Life-long therapy is required, however; as the virus quickly reappears in the circulation on cessation of treatment. There are no major differences in the clinical course of HIV in men and women and recommendations for the timing and type of treatment are identical, except during pregnancy. Women with HIV treated with antivirals can now expect a close to normal life expectancy.¹³

More recently, the concept of ‘treatment as prevention’ has been promoted. Patients with early infection are highly infectious and so it is argued that the sooner they start treatment, the lower the risk of transmission to their partners. This intervention may reduce the number of new infections and lessen the overall risk of transmission at a population level. Pre-exposure prophylaxis is another recent facet of HIV prevention, whereby an individual at high risk of HIV infection takes a two-drug antiretroviral tablet daily to reduce their risk of HIV acquisition. Adherence is essential and, at present, cost prohibits widespread uptake of this approach.

Despite these dramatic advances in care and life expectancy, isolation and fear of disclosure of status are common aspects of many individual stories of living with HIV. Women who are parents face additional tough decisions about if, when and how to tell their children and uncertainty about the consequences for their family should their status become known.¹⁴

Conclusion

Women living with HIV in Australia are a minority within a minority, which poses particular challenges for women and their service providers. The strong and understandable desire for privacy in relation to an HIV diagnosis can reduce women’s confidence in accessing services. Women may need to travel long distances to specialist centres to receive care, especially in relation to pregnancy. Nevertheless, the outlook for HIV-infected women and their children is excellent if they receive appropriate care and treatment.Obstetricians and gynaecologists have an important role to play in this regard.

1. The Kirby Institute: HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2014 HIV Supplement. The Kirby Institute, University of New South Wales, Sydney NSW.
2. Chan SK, Thornton LR, Chronister KJ et al: Centers for Disease Control and Prevention (CDC). Likely female-to-female sexual transmission of HIV–Texas, 2012. MMWR Morb Mortal Wkly Rep 2014;63(10):209-12.
3. Australian Health Ministers’ Advisory Council 2012, Clinical Practice Guidelines: Antenatal Care – Module 1. Australian Government Department of Health and Ageing, Canberra. See: www. health.gov.au/antenatal accessed 17 March 2015.
4. WHO HIV/AIDS statistics See: www.who. int/hiv/data/en/ accessed 17 March 2015.
5. McDonald AM, Zurynski YA, Wand HC et al: Perinatal exposure to HIV among children born in Australia, 1982-2006. Med J Aust. 2009; 190(8): 416-20.
6. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. 28 March 2014. Available at http://aidsinfo. nih.gov/guidelines/html/3/perinatal- guidelines/0 accessed 17 March 2015.
7. British HIV Association and Children’s HIV Association: Guidelines for the management of HIV infection in pregnant women (2014 interim review) see: www. bhiva.org/documents/Guidelines/ Pregnancy/2012/BHIVA-Pregnancy- guidelines-update-2014.pdf accessed 17 March 2015.
8. Giles, Michelle L. HIV and pregnancy: how to manage conflicting recommendations from evidence-based guidelines. AIDS 2013; 27(6): 857-862.
9. Editorial. End of the debate on hormonal contraception and HIV risk? Lancet Infectious Diseases 2015;15(2):131 see: www.thelancet.com/journals/laninf/article/ PIIS1473-3099(15)70011-3/fulltext
10. Samuel MI, Welch J, Tenant-Flowers M et al: Care of HIV-positive women aged 50 and over – can we do better? Int J STD AIDS 2014; 25(4): 303-5.
11. Editorial. End of the debate on hormonal contraception and HIV risk? Lancet Infectious Diseases 2015;15(2):131 see: www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)70011-3/fulltext
12. Kanapathipillai R, Hickey M, Giles M: Human immunodeficiency virus and menopause. Menopause 2013; 20(9): 983-90.
13. May MT, Gompels M, Delpech V et al: UK Collaborative HIV Cohort (UK CHIC) Study. Impact on life expectancy of HIV-1 positive individuals of CD4+ cell count and viral load response to antiretroviral therapy. AIDS 2014;28(8): 1193-202.
14. Kalichman SC, DiMarco M, Austin J, Luke W, Kari DiFonzo K. Stress, Social Support, and HIV-Status Disclosure to Family and Friends Among HIV-Positive Men and Women Journal of Behavioral Medicine 2003; 26(,4):315-332.