Transcript Women’s Health in Resource

Women’s Health in ResourceLimited Settings
RAMONA BHATIA, MD
2013
Outline
 Introduction to international women’s health issues
 HIV
 Prevention of maternal to child transmission (PMTCT)
 Pre-exposure prophylaxis (PrEP)
 Other maternal issues
 Unsafe abortion
 Other women’s health issues
Introduction
 Undergraduate and medical training at Northwestern
 Clinical experience in India
 Residency at Baylor College of Medicine, Houston, TX
 County and VA hospital settings
 Infectious Diseases Fellow at Northwestern
 Research Associate at Center for Global Health
 HIV outcomes
 HIV and global health
Importance of Women’s Health
 In many resource-limited settings (RLS), there is a
lack of access to ob-gyne specialists
 Physicians must manage all aspects of health care,
including gyne and ob issues
 Students on almost every rotation will be expected to
care for women and deal with women’s health
problems
Importance of Women’s Health
Addressing women’s health is a necessary and
effective approach to strengthening health systems
overall – action that will benefit everyone. Improving
women’s health matters to women, to their families,
communities and societies at large.
Improve women’s health – improve the world.
--WHO, Women and Health, 2009
Top Global Causes of Mortality in Women
WHO, 2008
All ages
RLS
Lower respiratory infections (11%) >HIV/AIDS>
Diarrheal diseases
High income
countries
Ischemic heart disease (15%)>Stroke>Alzheimer’s Disease
Children
RLS
Lower respiratory infections (18%)>Diarrheal diseases>
Malaria
High income
countries
Congenital abnormalities (23%)>Prematurity and low birth
weight>Neonatal infections
Top Global Causes of Mortality in Women
WHO, 2008
Adolescents
RLS
HIV/AIDS (10%) > Lower respiratory infections>
Malaria
High income
countries
Road traffic accidents (28%)>Suicide>Homicide
Adults
RLS
HIV/AIDS (23%)> TB> Maternal hemorrhage
High income
countries
Breast cancer (11%)>Lung, tracheal, or bronchial
cancers>Ischemic heart disease
Global Trends in Women’s Health
In low-income countries, mortality is mainly
associated with infectious diseases [with] trends
towards non-communicable diseases and injuries in
higher-income countries.
-WHO, 2008
HIV and Women’s Health
WHO, 2010; CDC.gov
 In 2008, 15.7 million women living with HIV/AIDS
globally

12 million in sub-Saharan Africa
 In sub-Saharan Africa, women account for 60% of
HIV infections

Approx. 20% in U.S.
 Women’s HIV issues:
 Vertical transmission in pregnancy
 Serodiscordance and PrEP
 Stigma and fear of disclosure
 Problems accessing HIV care
Mother to Child Transmission of HIV
WHO, 2008; CDC.gov
 HIV is transmitted in utero, at labor and delivery, or
through breastfeeding
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
Overall 15-30% risk (30% in utero and 70% intrapartum)
Breastfeeding additional 5-20%
 Almost all (>90%) childhood HIV is due to maternal
transmission
 In 2008, 1.4 million HIV+ women gave birth in RLS,
and there were 430,000 new pediatric infections

90% of pediatric cases and deaths in Sub-Saharan Africa
 In 2005, 142 children contracted HIV from their
mothers in the U.S.
Children (<15 years) estimated to be living with HIV,
by WHO Region, 2010
Europe
19 000
Americas
58 000
[44 000 – 74 000]
South-East Asia
140 000
[15 000 – 25 000]
[92 000 – 190 000]
Eastern
Mediterranean
42 000
[28 000 – 57 000]
Africa
Western Pacific
[2.8 million – 3.5 million]
[33 000 – 46 000]
3.1 million
39 000
Total: 3.4 million [3.0 million – 3.8 million]
Estimated deaths in children (<15 years) from AIDS,
by WHO Region, 2010
Europe
1 300
South-East Asia
[<1 000 – 1 800]
Americas
3 600
[2 100 – 5 100]
Eastern
Mediterranean
12 000
[6 800 – 18 000]
4 100
[2 800 – 5 500]
Africa
Western Pacific
[200 000 – 260 000]
[2 200 – 3 400]
230 000
2 700
Total: 250 000 [220 000 – 290 000]
Antiretroviral Therapy (ART) for PMTCT
WHO, PMTCT Strategic Vision, 2010
 ART prophylaxis reduces risk of vertical transmission
to <2%
 PMTCT with ART is the cornerstone of caring for
HIV+ pregnant women globally
 Other interventions:
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Primary prevention of HIV in women
Testing ALL pregnant women for HIV
Family planning and prevention of unwanted pregnancies in
HIV+ women
Disparities in PMTCT
WHO, Progress Report, 2010
 In the U.S., vertical transmission has been “virtually
eliminated”

Universal “opt-out” testing for HIV for all pregnant women
 In RLS, only half of HIV+ pregnant women receive
ART for PMTCT
 Only one-third of pregnant women are tested for
HIV in RLS
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WHO guidelines recommend early HIV testing
Repeat testing indicated in third trimester
Percentage of pregnant women who received an HIV test in RLS
WHO, 2011
Epidemic update and health sector progress towards Universal Access Progress Report
Coverage of antiretroviral medicine for PMTCT in RLS (2010)
WHO, 2011
Epidemic update and health sector progress towards Universal Access Progress Report
Gaps in reaching 90% of HIV+ pregnant women on ART
WHO, 2011
Epidemic update and health sector progress towards Universal Access Progress Report
ART for PMTCT
Antiretroviral (ARV) drugs reduce perinatal
transmission by several mechanisms, including
lowering maternal antepartum viral load and
providing infant pre- and post-exposure
prophylaxis. Therefore, combined antepartum,
intrapartum, and infant ARV prophylaxis is
recommended to prevent perinatal transmission of
HIV.
-DHHS, 2012
PMTCT in the U.S.: antenatal and intrapartum
DHHS, 2012
 HIV+ pregnant women are started ART
 Usually ASAP; definitely before 14 weeks (second trimester)
 Preferred regimen depends on resistance, side effects, etc.
 Efavirenz (EFV) is avoided due to neural tube defects
 ART usually continued for life
 They also receive intravenous zidovudine (AZT)
during labor and delivery
 C-section is recommended for women with untreated
HIV or a viral load of >1,000/mL
PMTCT in the U.S.: infant care
 Within 12 hours of birth, the infant is given AZT
 This is continued for 6 weeks
 The infant undergoes HIV testing at 14-21 days, 1-2
months, and 4-6 months
PMTCT in RLS vs U.S.
WHO, Rapid Advice, 2009
 Universal ART to treat pregnant women is not the
norm for RLS, which represents a major difference
from the U.S. standard of care
 In RLS, PMTCT can be accomplished by either fully
treating the mother as in the U.S. OR administering
a prophylaxis regimen to the mother

With both strategies, infants receive prophylaxis
PMTCT Regimens in RLS: treating the mother
WHO, Executive Summary, 2012
 For women with CD4 cell count <350/mm3 or WHO
Stage 3 or 4, initiate lifelong ART
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Recommended regimens the same as for non-pregnant adults
AZT, lamivudine (3TC), and nevirapine (NVP) or EFV
 Recent updated WHO guidelines have added “Option
B+” for all pregnant HIV+ women to receive lifelong
ART irrespective of CD4 cell count
PMTCT Regimens in RLS:
prophylaxis
 For women with CD4>350/mm3, two options
 In Option A, AZT started at 14 weeks, single-dose
NVP given at labor, and AZT/3TC given at labor and
daily through 7 days postpartum
 In Option B, ART starting as early as 14 weeks and
continued intrapartum and through childbirth if not
breastfeeding or until 1 week after cessation of all
breastfeeding
PMTCT Regimens in RLS:
prophylaxis given to the infant
 In Option A, NVP from birth until 1 week after
cessation of all breastfeeding; or, if not breastfeeding
or if mother is on treatment, through age 4–6 weeks
 In Options B and B+, NVP or AZT from birth
through age 4–6 weeks
 The infant is tested at for HIV after birth
Breastfeeding
 Risk factors that increase HIV transmission:
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Duration of breastfeeding
Skin breakdown/mastitis
Maternal HIV viral load
 In the U.S., HIV+ mothers are counseled not to breastfeed
 In RLS, each country decides what will result in highest
rates of “HIV-free survival of HIV-exposed infants”
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In RLS, antibodies from breast milk help combat infectious diarrhea
 If breastfeeding is chosen:
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Mother or infant should be on ART for at least duration
Exclusive breastfeeding should occur for first 6 months
Breastfeeding should stop only when a adequate and safe diet can
be provided
PMTCT Options in RLS
WHO, 2012
CD4<350
CD4>350
Infant Receives
Option A
First line ART regimen
Antepartum: AZT
starting as early as 14
weeks gestation
Intrapartum: at onset of
labor, single-dose NVP
and first dose of
AZT/3TC
Postpartum: daily
AZT/3TC through 7 days
postpartum
Daily NVP from birth
until 1 week after
cessation of all
breastfeeding; or, if not
breastfeeding or if
mother is on treatment,
through age 4–6 weeks
Option B
First line ART regimen
ART starting at 14 weeks
gestation and continued
intrapartum and
through childbirth or 1
week after breastfeeding
Daily NVP or AZT from
birth through age 4–6
weeks
Option B+
First line ART regimen
First line ART regimen
Daily NVP or AZT from
birth through age 4–6
weeks
PMTCT Summary
U.S.
RLS
Vertical transmission
Virtually zero
1,000 new childhood
infections/day
HIV testing in pregnant
women
Universal, “opt-out”
Approx. one-third tested
PMTCT for pregnant
HIV+ women
Lifelong treatment
Can be either lifelong
treatment or prophylaxis
Infant prophylaxis
Yes
Yes
Breastfeeding for HIV+
mothers
Not recommended
Country-dependent
PrEP
 Women usually acquire HIV via heterosexual sex
 Serodiscordant couples (particularly if partner not on ART)
 Partner non-disclosure or unawareness
 Lack of condoms due to unavailability or loss of power
 Sexual abuse or violence
 HIV post-exposure prophylaxis (PEP) has been used
in cases of unanticipated HIV exposure
 PrEP recently approved for some anticipated HIV
exposures
PrEP
WHO , Guidance on PrEP, 2012
 High quality data on tenofovir (TDF)/emtricitibine
(FTC; Truvada) on prevention of HIV in high-risk
male homosexuals and serodiscordant couples
 iPrEx trial: 90% HIV reduction in men who have sex
with men who were adherent to Truvada
 Partners PrEP trial: 90% HIV reduction in
serodiscordant couples who were adherent to
Truvada
PrEP
 In July 2012, Truvada FDA approved for PrEP for
men who have sex with men and heterosexually
active women and men
 In June 2013, the CDC added an indication for
injection drug users
PrEP
 In women, PrEP could be useful for women to
protect themselves in cases where partner is not on
ART or where conception is desired
 Not widely used in U.S. and RLS yet
 Many unanswered questions:
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Duration
Monitoring and HIV testing
Side effects
Disparities in Maternal Mortality
WHO, Trends in Maternal Mortality, 2012
 WHO defines maternal death as:
The death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and site of the pregnancy, from
any cause related to or aggravated by the pregnancy or its management
but not from accidental or incidental causes
 In 2010, 287,000 maternal deaths occurred globally
 85% of these occurred in RLS including:
 Sub-Saharan Africa (56%)
 Asia (29%)
 Two countries accounted for a third of global maternal
deaths: India at 19% (56,000) and Nigeria at 14% (40,000)
 Lifetime risk of maternal death in RLS is 1/150

1/3800 in developed world
Causes of Maternal Mortality
 In RLS, top etiologies include:
 Hemorrhage (34%)
 Infection (10%)
 HTN (9%)
 HIV/AIDS (6%)
 Unsafe abortion (4%)
 The main obstacle to progress for better health for
mothers is the lack of skilled care
Unsafe Abortion
WHO, Safe and Unsafe Induced Abortion, 2008
 Globally, 210 million pregnancies occur each year
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80 million are unintended
86% of abortions occur in RLS
43.8 million induced abortions in 2008: 22.2 million safe and 21.6
million unsafe
 Women in RLS may not have access to safe, legal,
affordable abortion facilities and may resort to unskilled
or traditional practitioners
 The WHO defines unsafe abortion as: a procedure for
terminating an unintended pregnancy carried out either
by persons lacking the necessary skills or in an
environment that does not conform to minimal medical
standards, or both
Disparities in Unsafe Abortion
 Almost all unsafe abortions take place in developing
countries
 In 2008, 38 million induced abortions in developing
countries

21 million (56%) were unsafe and 17 million (44%) were safe
 Highest rates of abortion are in Latin America/
Caribbean and Africa

Almost exclusively unsafe in both regions
Morbidity and Mortality from Unsafe Abortions
WHO, Safe and Unsafe Induced Abortion, 2008
 5 million women are hospitalized each year and
47,000 women die due to complications of unsafe
abortion

1 maternal death per 500 unsafe abortions
 62% of these deaths in Africa
 Case fatality rate for Africa=470/100,000 abortions
 Case fatality rate for U.S.=0.6/100,000 abortions
 Other morbidities include:
 Infertility
 Genital trauma and development of fistulas, which can lead to
infection, stigma, etc.
Unsafe Abortion: implications
WHO, Safe and Unsafe Induced Abortion, 2008
 The number of unsafe abortions is increasing
 Availability of effective contraceptive methods
results in reducing unintended pregnancies and the
incidence of abortion
 Three out of four induced abortions could be
eliminated if the need for family planning were fully
met
 Restrictive abortion laws are correlated with high
mortality from abortion
Other Important Global Women’s Health Issues:
cervical cancer
WHO, Cervical Cancer, HPV, and HPV Vaccines, 2008
 Due to HPV; sexually transmitted
 The leading cause of cancer death of adult women in
the developing world and the second most common
cancer among women worldwide
 80% of cases and highest mortality in RLS
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Sub-Saharan Africa highest incidence
India highest number of cases
 Virtually no screening and/or treatment in many
developing countries
Other Important Global Women’s Health Issues:
violence against women
WHO, Multi-country Study on Women’s Health, 2005
 The UN/WHO define violence against women as:
any act of gender-based violence that results in, or is likely to
result in, physical, sexual or mental harm or suffering to
women, including threats of such acts, coercion or arbitrary
deprivation of liberty, whether occurring in public or in
private life
 WHO study shows up to 60% of women experience
sexual or other physical violence by a male partner

Highest rates in Peru and Ethiopia; lowest in Japan
 Most common reasons for not seeking help include
thinking violence is normal and fear of repercussions
Case
Mary is a 16 year old female with HIV who is
20 weeks pregnant with her second child. She
is coming to see you in the family practice
clinic in Cape Town. She has not seen a
physician for prenatal care. She feels well.
She takes no medications and has no other
medical problems.
Her physical examination is normal.
She is very worried about her baby being born
with HIV.
WHO.org
Discussion
 What can you tell her about her risk for HIV
transmission to the baby?
 How can she reduce this risk?
 What other counseling does she need?
Summary
 In RLS, women’s morbidity and mortality are largely
preventable and due to a lack of skilled care/resources

So visiting med students will be expected to help manage these issues
 Women face unique challenges in RLS including an
excessive burden of infectious diseases
 PMTCT is crucial to controlling HIV in RLS
 Empowerment through education (i.e., family planning,
contraception, domestic violence support, etc.) is critical

Medical students can help with this
http://aidsinfo.nih.gov/contentfiles/lvguidelines
/peri_recommendations.pdf 2012
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For serodiscordant couples who want to conceive, expert consultation is recommended so that approaches can
be
tailored to specific needs, which may vary from couple to couple (AIII). It is important to recognize that
treatment of the
infected partner may not be fully protective against sexual transmission of HIV.
• Partners should be screened and treated for genital tract infections before attempting to conceive (AII).
• For HIV-infected females with HIV-uninfected male partners, the safest conception option is artificial
insemination,
including the option of self-insemination with a partner’s sperm during the peri-ovulatory period (AIII).
• For HIV-infected men with HIV-uninfected female partners, the use of sperm preparation techniques
coupled with either
intrauterine insemination or in vitro fertilization should be considered if using donor sperm from an HIVuninfected male
is unacceptable (AII).
• For serodiscordant couples who want to conceive, initiation of antiretroviral therapy (ART) for the HIVinfected partner is
recommended (AI for CD4 T-lymphocyte (CD4-cell) count ≤550 cells/mm3, BIII for CD4-cell
count >550 cells/mm3). If
therapy is initiated, maximal viral suppression is recommended before conception is attempted (AIII).
• Periconception administration of antiretroviral pre-exposure prophylaxis (PrEP) for HIV-uninfected
partners may offer an
additional tool to reduce the risk of sexual transmission (CIII). The utility of PrEP of the uninfected
partner when the
infected partner is receiving ART has not been studied.
 For a list of topics for “other” section
 http://www.who.int/reproductivehealth/publication
s/en/