Behind the Frontline:
Women, HIV and Reproductive Health
by Enid Vázquez
Gynecologist Dr. Patricia
Garcia is director of the Women’s Program at the Comprehensive
HIV Center at Northwestern Memorial Hospital in Chicago. She
spoke at the South Side HIV Care Providers Forum in Chicago
in January, from which these notes are taken.
She’s only 13 …
This month has been hard
for me. I delivered the youngest HIV-positive pregnant patient
I ever have—13 years old, with the smallest infant I’ve ever
delivered—15 ounces. The results were good—HIV-negative baby
by two PCR tests [viral load]. It’s a common story—an older
boyfriend. He’s 18. He infected her with chlamydia, herpes
and HIV all at the same time.
Newly diagnosed
Half of the newly diagnosed
women at our clinic are pregnant. Why? Because that’s when
we uniformly test women [with their permission]. I’m sure
it’s the same throughout the country. What a bad time to get
diagnosed.
Adolescents
In the U.S. in 1999, of the
post-natally infected adolescents, 51% were girls. Why? For
starters, negotiating for condoms is harder when the boyfriend’s
older, like that couple—13 and 18.
It’s not just behavioral.
Girls are at greater risk for biological reasons. The endocervix
comes outside [of the uterus] during menarchy [the start of
menstruation] and during pregnancy. HIV targets the white
blood cells on the endocervix, so it’s easier to become infected.
Having a baby
[Another doctor says, “More
women are coming to me with the same question—can I have a
baby? This includes couples where the man is positive and
the woman is negative.”]
In February of 2002, the
association of reproductive endrocrinologists admitted that
HIV is a chronic illness and they should help people with
HIV like they would anyone else. They help cystic fibrosis
carriers, and half the children get it. They also help people
with muscular dystrophy.
HIV is not in the sperm.
It’s in the white blood cells of free virus floating in seminal
fluids. So you separate the sperm from free virus and white
blood cells. Endrocrinologists do this every day [for HIV-negative
men].
There was a lot of compelling
data at Barcelona [the International AIDS Conference held
last July]. The semen centrafuges down. You use regular PBS
washing. It centrafuges back up. It’s a two-step process,
routine lab work. There’s not an absolute zero risk. It’s
$200 to $250 to process the sperm. It’s more to use PCR to
check for [the virus] before insemination.
We used a Boston lab for
one woman, but with no success. FedEx’ing the processed semen
back and forth is not [good] enough. We’re establishing a
procedure with a local endrocrinologist now who’s willing
to work with us. Just because the American Society for Reproductive
Medicine changed its policies doesn’t mean that there are
doctors all over the place willing to help people with HIV.
Positive women and negative
men can do insemination at home with a syringe. I just delivered
twins to someone who did this.
I also think adoption is
an important option that needs to be raised.
Pregnancy health care
It’s just like any other
disease—control the disease. What if she has 500 T-cells and
a 1,000 viral load and she’s cruising along on no therapy?
If she gets pregnant, she has to face therapy. There’s a greater
transmission risk at 1,000 viral load.
ACTG 076 found that the heaviest
women had only a 26% reduction in transmission to their infants
[using AZT during pregnancy]. All the others had a 79% reduction.
Together, the reduction was 66%. So maybe we can adjust the
dose. [AIDS Clinical Trials Group Study 076 established the
effectiveness of Retrovir (AZT) for the prevention of mother-to-infant
transmission.]
You can’t ignore high blood
pressure or diabetes. These are big issues, and HIV may be
the least of their concern. Those other diseases could kill
them during pregnancy.
If they have an abortion,
the sedative is important. They can’t be given methergine,
because it can cause prolonged sedation if the woman’s on
a protease inhibitor. I know of one woman who almost died
recently because of this.
The CDC [U.S. Centers for
Disease Control and Prevention] say there’s no difference
between opting out and opting in [of counseling to go with
HIV testing]. I think that’s a big injustice.
The counseling is very important.
We’ll find very few positive women. But counseling them on
how to protect themselves against sexually transmitted disease
is the greater public health benefit.
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