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ABSTRACT: We sought to assess the effects of long-term use and safety of the levonorgestrel-releasing (LNG)-intrauterine system (IUS) among human immunodeficiency virus (HIV)-infected women in comparison with HIV-infected women not using the device.
Fifteen women using the LNG-IUS and their 25 age- and CD4(+) lymphocyte count-matched control subjects with annual follow-up data were followed up for 5 years.
No unplanned pregnancies or pelvic infections occurred among the LNG-IUS users. Altogether, 12 (80%) of the LNG-IUS users continued its use up to 5 years. Annual CD4(+) lymphocyte counts were similar in the LNG-IUS users and control subjects throughout the follow-up period. The hemoglobin levels increased initially (P < .005) and remained higher among the LNG-IUS users (P < .02). Pap smears displayed non-squamous intraepithelial lesion cytology in ≥ 85% of cases in both groups.
No unfavorable effects on the course of HIV infection were noted during long-term use of the LNG-IUS. Dual protection by means of an LNG-IUS and condoms might be an ideal contraceptive strategy for HIV-infected women.
American journal of obstetrics and gynecology 10/2010; 204(2):126.e1-4. · 3.28 Impact Factor
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ABSTRACT: The prevalence of cervical intraepithelial neoplasia (CIN) is high among HIV-infected women. Decreased CD4 lymphocytes, high human immunodeficiency viral load (HIVL) and human papillomavirus (HPV) infection are risk factors for CIN. We characterized the prevalence, risk factors and prognosis of histologically-verified CIN among systematically followed HIV-infected women enrolled from a low HIV-prevalence population. The study population comprised 153 HIV-infected women followed between 1989 and 2006. The mean +/- SD duration of follow-up was 5.6 +/- 3.8 years. Demographic as well as treatment-related data were derived from medical reports. During the follow-up, 51 subjects (33%) displayed CIN (16% CIN 1 and 18% CIN 2 +), whereas 102 subjects had Pap smear results of normal cells, atypical squamous cells of uncertain significance, or signs of low-grade squamous intraepithelial lesion (LSIL) but no CIN in histological specimens from the cervix. Only one case of cancer of the uterine cervix was detected. Pap smears were reliable in screening for CIN; 75% of patients with CIN had high-grade squamous intraepithelial lesion (HSIL) or LSIL in Pap smears taken at the time of dysplasia. The incidence of CIN decreased from 12.7 to 3.5 (per 100 subjects) between 2000 and 2005 (P = 0.07). The risk of CIN was not associated with decreased levels of CD4 lymphocytes, duration of HIV infection, use of antiretroviral medication or plasma HIVL. In univariate analysis, bacterial vaginosis (BV) was associated with a significantly increased risk of CIN, whereas parity was associated with lower risk of CIN. Each delivery lowered the risk of CIN by 30% (P = 0.02). The significantly lower risk of CIN among parous women (P = 0.04) persisted in multivariate analysis. CIN was treated by means of loop electrosurgical excision procedure (LEEP), (n = 34). The recurrence rate was low; seven subjects (14%) had a recurrence of CIN during follow-up. The nadir of CD4 lymphocytes was lower (P = 0.04) and the HIVL higher (P = 0.03) among subjects with recurrence of CIN. Duration of HIV infection, use of antiretroviral medication and positive margins in LEEP specimens were indistinguishable among subjects with vs. without recurrence of CIN. The prevalence of CIN is high among systematically managed HIV-infected women. However, the incidence of CIN decreased during the 21st century. BV was associated with an increased risk of CIN whereas parous women had lower risk of CIN. However, the patients with and without CIN could not be distinguished on the basis of previously described risk factors. Regular follow-up by means of Pap smears is warranted in all HIV-infected women.
International Journal of STD & AIDS 02/2008; 19(1):37-41. · 1.09 Impact Factor
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ABSTRACT: Safe and effective contraception is needed for women infected with human immunodeficiency virus (HIV). The levonorgestrel-releasing intrauterine system (LNG-IUS) is an effective long-term contraceptive that reduces menstrual bleeding and may reduce the risk of pelvic inflammatory disease. Yet, little is known about LNG-IUS use in HIV-infected women.
Six HIV-infected women had the LNG-IUS inserted between March 1998 and October 2002, and were systemically followed for a mean of 45 months. Indications for LNG-IUS use were contraception in four women and menorrhagia in two women.
The LNG-IUS was well tolerated, and menstrual bleeding was reduced in all women. Blood hemoglobin levels increased in each subject, with mean levels being 123 g/L (SD=11.7) before LNG-IUS insertion and 135 g/L (SD=8.7) at 1 year (p=.01). Levels of circulating CD4 lymphocytes and Pap smear findings remained unchanged.
Our limited experience with LNG-IUS use in HIV-infected women is encouraging. The LNG-IUS may be used as an alternative to uterine surgery in HIV-infected women with menorrhagia.
Contraception 02/2007; 75(1):37-9. · 2.72 Impact Factor
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ABSTRACT: Safe and effective contraceptives are needed for human immunodeficiency virus (HIV)-infected women. The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective contraceptive with additional health benefits. The objective of this study was to evaluate the effects of the LNG-IUS among HIV-infected women.
Twelve systematically managed HIV-infected women were studied prospectively. Following a 2-month run-in period, the subjects had an LNG-IUS inserted and were followed up for 1 year. Patterns of bleeding, blood haemoglobin and CD4-lymphocyte content, plasma HIV RNA, serum levels of LNG, of estradiol (E(2)) and of ferritin and genital shedding of HIV RNA were monitored.
Menstrual bleeding was reduced significantly during the use of the LNG-IUS; this was associated with slight increases in serum haemoglobin and ferritin levels. Serum E(2) concentrations remained in the follicular range in all subjects. Among subjects using antiretroviral medication, the proportion of cervicovaginal lavage specimens with detectable HIV RNA was 10% before and after the insertion of the LNG-IUS.
The effects of the LNG-IUS on bleeding patterns, body iron stores and ovarian function were similar to those seen in healthy women. Genital shedding of HIV RNA was not affected by the LNG-IUS. These data encourage further studies on the effects of the LNG-IUS on reproductive health among HIV-infected women.
Human Reproduction 12/2006; 21(11):2857-61. · 4.47 Impact Factor
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ABSTRACT: HIV-infected women have high risk for precancerous lesions of the uterine cervix. We studied the prevalence and risk factors of squamous intraepithelial lesions (SIL) among systematically followed HIV-infected women enrolled from a population with low HIV prevalence. The study population consisted of 108 HIV-infected women enrolled between 1989 and 2003 with a mean follow-up 4.4 years. Risk factors of SIL were assessed based on samples collected during 2000-02. The overall rates of atypical glandular cells of uncertain significance (AGUS), atypical squamous cells of uncertain significance (ASCUS), low-grade SIL (LSIL) and high-grade SIL (HSIL) were 4, 24, 15 and 5%, respectively. Reduced CD4-lymphocyte count was associated with an increased prevalence of SIL, whereas duration of HIV infection (< or > or =5 years), use of antiretroviral medication, or HIV viral load (<50 or > or =50 copies/mL) was not. The cumulative risk of developing SIL after 1 and 5 years was 17% (95% confidence interval [CI] 7-27%) and 48% (95% CI 33-63%), respectively. The cumulative risk of SIL was increased among women younger than 31 years (P = 0.04) as well as in women displaying high initial HIV viral load (P = 0.01). Our results from a low HIV-incidence population re-emphasize the importance of guidelines for cytologic screening of HIV-seropositive women.
International Journal of STD & AIDS 12/2006; 17(12):831-4. · 1.09 Impact Factor
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ABSTRACT: Antiretroviral medication and good obstetric practice have greatly reduced the rate of vertical transmission of human immunodeficiency virus (HIV) infection. The incidence of HIV infection has remained low in Finland. Universal antenatal screening has been offered to all pregnant women since 1998.
We analyzed the outcomes of 52 pregnancies among 45 HIV-infected mothers delivering at our department during 1993-2003. A multidisciplinary team planned the management strategy individually and supported the mother's adherence to treatment.
The incidence of HIV infection among women delivering in our hospital district increased from 0.6/10,000 (95% CI 0-1.6) to 4.8/10,000 (95% CI 1.4-8.2) between 1993 and 2002. HIV infection was diagnosed during pregnancy in 40% (18/45) of the mothers. Antiretroviral medication was used prior to pregnancy in 17 (33%) cases; in 34 (66%) cases of the pregnancies, medication was started during the pregnancy. A good virological response (i.e. HIV RNA load <1000/ml during the last trimester) to antiretroviral medication was achieved in 90% (36/40) of the patients; in 60% (24/40) of cases, the HIV RNA load was below the assay detection limit. One mother with advanced HIV infection succumbed to pneumonia shortly after delivery. Of the infants, 92% were born at term, and their mean (+/-SD) birth weight was 3350 +/- 395 g. The Caesarean section (CS) rate was 25% (13/52). All newborns were in good condition, and their mean umbilical pH was 7.23. All newborns received antiretroviral medication. One infant was infected with HIV, the mother was found HIV-positive postpartum. None of the infants born to mothers known to be HIV positive were infected.
A combination of universal antenatal screening and multidisciplinary management allows individualized treatment and prevents vertical transmission of HIV infection.
Acta Obstetricia Et Gynecologica Scandinavica 10/2005; 84(10):945-50. · 1.77 Impact Factor
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Duodecim; lääketieteellinen aikakauskirja 02/2002; 118(13):1405-9.
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Päivi Lehtovirta
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ABSTRACT: The purpose of the present study was to examine the outcome of pregnancies among HIV-infected women in Helsinki, use of the levonorgestrel-releasing intrauterine system (LNG-IUS) among HIV-infected women and the prevalence and risk factors of cytological and histologically proven cervical lesions in this population. Between 1993 and 2003 a total of 45 HIV-infected women delivered 52 singleton infants. HIV infection was diagnosed during pregnancy in 40% of the mothers. Seventeen of the mothers received antiretroviral (ARV) medication prior to pregnancy and in 34 cases, the medication was started during pregnancy. A good virological response (i.e. HIV RNA load <1000/mL during the last trimester) to ARV medication was achieved in 36/40 (90%) of the patients in whom HI viral load measurements were performed. Of the infants, 92% were born at term, and their mean (±SD) birth weight was 3350±395 g. The Caesarean section rate was low, 25%. All newborns received ARV medication and none of the infants born to mothers with pre-delivery diagnosis of maternal HIV infection were infected. The safety and advantages of the LNG-IUS were studied prospectively (n=12) and retrospectively (n=6). The LNG-IUS was well tolerated and no cases of PID or pregnancy were noted. Menstrual bleeding was reduced significantly during use of the LNG-IUS; this was associated with a slight increase in haemoglobin levels. Serum oestradiol concentrations remained in the follicular range in all subjects. The key finding was that genital shedding of HIV RNA did not change after the insertion of the LNG-IUS. The mean annual prevalence of low-grade squamous intraepithelial lesions (SIL) was 15% and that of high-grade SIL was 5% among 108 systematically followed HIV-infected women during 1989 2003. A reduced CD4 lymphocyte count was associated with an increased prevalence of SIL, whereas duration of HIV infection, use of ARV medication and HI viral load were not. The cumulative risk of any type of SIL was 17% after one year and 48% after five years among patients with initially normal Pap smears. The risk of developing SIL was associated with young age and a high initial HI viral load. During the follow-up 51 subjects (n=153) displayed cervical intraepithelial neoplasia (CIN), (16% CIN1 and 18% CIN 2-3). Only one case of cancer of the uterine cervix was detected. Pap smears were reliable in screening for CIN. Both nulliparity (p<0.01) and bacterial vaginosis (p<0.04) emerged as significant risk factors of CIN. In conclusion, a combination of universal antenatal screening and multidisciplinary management allows individualized treatment and prevents vertical transmission of HIV. Use of the LNG-IUS is safe among HIV-infected women and cervicovaginal shedding of HIV RNA is not affected by use of the LNG-IUS. The risk of cervical pre-malignant lesions is high among HIV-infected women despite systematic follow-up. WHO:n tilastojen mukaan maailmassa on jo lähes 40 miljoonaa HIV-positiivista ihmistä. Epidemian alussa HIV-infektiota pidettiin vain homoseksuaalisten miesten tautina, mutta nykyisin naisia on jo lähes puolet sairastuneista. Suomessa todettiin 60 uutta HIV-infektiota naisilla vuonna 2006; aiempina vuosina luku on ollut 20 40. HIV-infektioon liittyy naisilla erityisiä haasteita ja ongelmia: - vaikutukset raskauksiin ja sikiön tartuntariski - hormonaalisen ja kierukkaehkäisyn aiheuttama kohdunkaulan viruserityksen kasvu -lisääntynyt kohdunkaulan solumuutosten ja kohdunkaulan syövän riski. Väitöskirjatyössä selviteltiin HIV-positiivisten naisten raskauksien kulku ja lapsen ennuste kymmenen vuoden ajalta Helsingin Naistenklinikalla, levonorgestreeliä erittävän hormonikierukan edut ja turvallisuus sekä kohdunkaulan solu- ja kudosmuutosten esiintyvyys ja riskitekijät. Vuosina 1993 2003 HIV-positiivisten naisten synnytyksiä oli 52. Naisista 40 % sai tietää HIV-positiivisuudestaan ensi kertaa alkuraskauden seulontatestissä. Raskaudenaikaiselle HI-virus-lääkitykselle vaste oli hyvä; 90 %:lla naisista loppuraskauden virusmäärät olivat alle 1000 kopiota/mL. Lapset syntyivät hyväkuntoisina ja keskikokoisina. Sektioprosentti oli matala (25 %); monissa Euroopan maissa se on kohonnut 90 %:iin. Kukaan lapsista ei saanut tartuntaa. Hormonikierukka todettiin turvalliseksi HIV-positiivisilla naisilla. Raskauksia tai infektioita ei esiintynyt. Kuukautisvuodon määrä väheni ja veren hemoglobiini-pitoisuudet nousivat. Päähavainto oli, että kohdunkaulan viruseritys säilyi samanlaisena ennen ja jälkeen hormonikierukan laiton, eikä sen käyttö täten näytä lisäävän tartuntariskiä. Papa-näytteiden solumuutosten vuosittainen esiintyvyys oli korkea; lievien muutosten 15 % ja vaikeiden muutosten 5 %. Samaan aikaan valtakunnallisessa papa-seulonnassa vastaavia muutoksia esiintyi 1,6 %:lla seulotuista. Matala CD4-solutaso osoittautui riskitekijäksi näille muutoksille. Riski papa-muutoksille oli vuoden jälkeen 17 % ja viiden vuoden jälkeen 48 % niillä naisilla, joilla seurannan alussa oli normaali papa-koe. Nuori ikä ja korkeat HI-virusmäärät lisäsivät papa-muutosten riskiä. Kohdunkaulan koepalanäytteissä 51 naisella esiintyi patologisia muutoksia; HIV-positiivisia naisia oli seurannassa 153. Yksi kohdunkaulan syöpä todettiin seurannan aikana. Sekä synnyttämättömyys että emättimen bakterielli tulehdus lisäsivät kudosmuutosten riskiä. Yhteenvetona: - HIV-seulonta alkuraskaudessa, HI-viruslääkitys raskauden aikana ja synnytysten yksilöllinen hoito ovat tehokkaita keinoja sikiön tartunnan ehkäisemiseksi - hormonikierukka on turvallinen ja tehokas ehkäisykeino HIV-positiivisilla naisilla - kohdunkaulan solu- ja kudosmuutosten esiintyvyys on korkea myös systemaattisesti seuratuilla HIV-positiivisilla naisilla.
