Women with HIV Infection Guidelines Committee, February 2009
Primary care clinicians should address women’s health issues in the provision of routine HIV care. In addition to a comprehensive gynecological history and examination, clinicians should provide sexual risk-reduction counseling for all HIV-infected women.
Strategies that may help alleviate a woman’s concerns about undergoing a pelvic examination include the following: addressing the patient’s fears, explaining each step of the examination prior to performing it, using a smaller speculum, and/or postponing the pelvic examination until the patient becomes more acquainted with the clinician. Also, some women may prefer to be examined by a female clinician.
Elements of a gynecological history for HIV-infected women include the following:
- Age of menarche
- Menstrual history: frequency, duration, last menstrual period
- Number of pregnancies and outcomes: full-term and premature births, miscarriages, terminations
- Date of last Pap test and results
- History of abnormal Pap tests
- History of GYN procedures: LEEP, ablation, cone biopsy, hysterectomy, tubal ligation
- History of STIs, bacterial vaginosis, multiple or difficult to treat vaginal yeast infections
- Contraceptive use and needs
- Genitourinary symptoms: vaginal discharge, vaginal pain, dysuria, genital/rectal warts or ulcers, bleeding
Elements of a gynecological physical examination for HIV-infected women include the following:
Breast: Examine for: Masses, nipple discharge, dimpling, enlargement. Refer women ≥40 for annual mammogram.
Pelvis: Examine for friable cervix, venereal warts (HPV), vaginal discharge, classic and atypical herpes simplex virus (HSV), ulcerative genital disease, cervical motion tenderness, lesions on the vulva or perineum
Perianal: Examine for visible anal lesions (particularly HSV and/or HPV), evidence of skin abnormality around the anus (Candida), hemorrhoids. Perform digital rectal examination (baseline and annually). Refer women with abnormal anal physical findings for high-resolution anoscopy and/or examination with biopsy
Cervical cytology: Obtain cervical Pap test at baseline, 6 months after baseline, then annually as long as results are normal.
- Abnormal results should be repeated every 3 to 6 months until two successive normal Pap tests are reported
- Perform colposcopy for women with abnormal Pap test results; follow-up varies on a case-by-case basis
- Refer women with cervical HSIL for high-resolution anoscopy and/or examination with biopsy
- Anal Cytology:
- Obtain anal Pap test for women with a history of anogenital condyloma or abnormal cervical/vulvar histology (baseline and annually)
- Refer women with abnormal anal cytology for high-resolution anoscopy and possible biopsy
Syphilis screening:* RPR or VDRL with verification of reactive tests by confirmatory FTA-Abs or TP-PA (baseline and at least annually). Screen patients with continued high-risk behavior every 3 months.
Gonorrhea and chlamydia screening:*Screen all sites of exposure, including the cervix, rectum, and pharynx, as follows:
- Sexually active women under the age of 25 at baseline and at least annually
- Women 25 years of age or older if they have or have had a recent STI, have multiple sexual partners, have had a new sexual partner, or have a sexual partner with symptoms of an STI (baseline and at least annually)
- Screen for gonorrhea using culture or nucleic acid amplification tests (NAT)
- Screen for chlamydia using immunofluorescence or DNA amplification
*Patients who continue to engage in unsafe sexual practices are at increased risk for STIs. More frequent screening may be indicated for patients at higher risk.