Clinical overview
HIV does not just produce immunodeficiency in the abstract — in the gynaecology clinic it produces patterned, predictable changes in the prevalence, presentation, severity, and natural history of common conditions. A registrar in South Africa needs to know these patterns because they shift screening thresholds, treatment regimens, and follow-up frequency for HIV-positive patients. This chapter complements hiv-counselling by focusing on what HIV does to gynaecological organs, the diseases it amplifies, and how clinical management must adapt.
Core knowledge
Cervical disease
HIV-related HPV persistence drives CIN at the cervical transformation zone.
- HPV acquisition and persistence: HIV-positive women acquire HPV more frequently, clear it less, and harbour multiple high-risk types simultaneously. The interaction between HIV and HPV is bidirectional — HIV impairs HPV clearance; HPV (particularly high-risk types) and the associated inflammation may modestly increase HIV shedding.
- CIN incidence and progression: 2–4× higher than HIV-negative; faster progression CIN1 → CIN2/3 → invasive carcinoma.
- Cervical cancer: AIDS-defining illness; in SA accounts for a substantial fraction of cervical cancer presentations. Younger age at diagnosis, more advanced stage at diagnosis.
- Screening adjustment: see cervical-screening-sa for SA NDoH 2023 protocol — HIV-positive women screened at diagnosis and every 3 years (more often if abnormal), regardless of age.
- Treatment: LEEP and other excisional treatments are effective; recurrence higher in HIV-positive women, especially with low CD4 and uncontrolled viral load. See cin-management.
Vulval and vaginal disease
- Genital warts (condyloma): more numerous, larger, more refractory to treatment.
- VIN and vulval cancer: increased risk, similar HPV mechanisms. See vulvar-epithelial-hyperplasia and vulval-carcinoma.
- Recurrent vulvovaginal candidiasis: more common; long-term suppressive antifungal therapy may be needed. See candidiasis.
- Herpes simplex: more frequent recurrences, severe and atypical lesions, slower healing, sometimes resistant to standard aciclovir doses → escalate.
- Molluscum contagiosum: larger, more numerous, persistent.
- Bacterial vaginosis: more common; may contribute to PID and vertical-transmission risk.
Pelvic inflammatory disease
- More severe presentations with higher rates of TOA. See acute-pelvic-infection.
- Genital TB (TB-PID): consider in chronic/atypical presentations.
- Lower threshold for admission and surgical intervention.
- Lower CD4 counts and detectable viral load predict worse outcomes.
Sexually transmitted infections
- Higher prevalence of all STIs (co-acquisition risk).
- Syphilis may have atypical presentations, more rapid progression to neurosyphilis.
- Chancroid, lymphogranuloma venereum more common in HIV-positive populations.
- Routine STI screening at HIV diagnosis and annually thereafter.
- See sti-pathology and discharge-and-ulcers.
Menstrual disturbances
- Amenorrhoea more common (multifactorial: low body weight, chronic illness, hypothalamic suppression, premature ovarian insufficiency).
- Heavy menstrual bleeding occurs in some patients on protease-inhibitor-based regimens (drug effect on coagulation; mostly historic).
- Anaemia from chronic disease + HMB compounds.
- Menstrual symptoms often improve with ART and immune reconstitution.
Fertility and ovarian function
- HIV itself does not impair fertility significantly when virally suppressed.
- Premature ovarian insufficiency more common; possible direct or indirect effects (cytokines, prior chemotherapy for opportunistic malignancies).
- Counselling around conception in serodiscordant couples — U=U applies; safe natural conception when partner suppressed; sperm-washing rarely needed now.
Pregnancy
- HIV affects ANC, intrapartum, postpartum — see hiv-in-pregnancy for full chapter.
- Increased risk of preterm birth, low birth weight, stillbirth (improving with effective ART).
- Increased risk of postpartum infections, endometritis.
- Vertical transmission < 1% with optimal Prevention of Vertical Transmission (PVT) care (see hiv-counselling for the PVT protocol).
Contraception and HIV
- Most methods compatible with ART.
- Drug interactions: efavirenz reduces levonorgestrel implant efficacy → dual method recommended. Dolutegravir-based regimens generally interaction-free with hormonal contraception.
- IUDs: safe in HIV-positive women (including initiation and continuation); no increase in PID risk.
- DMPA: ECHO Trial reassured no major increase in HIV acquisition; remains available with informed choice.
- See contraceptive-modalities.
Surgical considerations
- HIV-positive status alone is not a contraindication to elective gynaecological surgery.
- CD4 count and viral suppression matter:
- CD4 >200 + suppressed viral load: equivalent surgical outcomes.
- CD4 <200 or unsuppressed: higher infection risk; consider optimising before elective surgery.
- TB co-infection: screen pre-operatively; treat active TB before elective surgery.
- Wound healing: slightly delayed; antibiotic prophylaxis as standard; meticulous technique.
- Anaesthesia: routine; consider drug interactions (ritonavir-boosted regimens with many anaesthetic drugs — consult pharmacist).
- VTE risk: HIV may modestly increase risk; standard pharmacological prophylaxis.
Mental health and psychosocial
- Depression 30–40% in HIV-positive women.
- Trauma overlap (HIV often acquired through sexual violence).
- Stigma — internalised and external.
- Disclosure stress.
- Refer to mental health and support services.
Assessment
Routine gynaecology consultation in HIV-positive woman
A structured approach:
- Confirm ART regimen, adherence, current CD4, current viral load.
- Screen for TB symptoms.
- STI history and current screen.
- Cervical screening status.
- Contraception and fertility intentions.
- Mental health screen.
- Disclosure status and partner status.
- Address presenting problem with HIV context in mind.
Investigations baseline
- Confirm HIV status documented; latest CD4 and viral load.
- TB screening (symptoms, sputum if indicated).
- STI screen (chlamydia, gonorrhoea, syphilis, trichomonas).
- Cervical screen if due.
- HBV/HCV status.
- Pregnancy test if relevant.
- FBC, U&E, LFTs if planning ART changes or surgery.
Management
Adjustments by condition
Cervical lesions:
- Lower threshold for colposcopy.
- More frequent follow-up.
- Aggressive treatment of CIN2/3 — excisional > ablative.
Recurrent infections (candida, BV, HSV):
- Long-term suppressive therapy where appropriate.
- Investigate adherence to ART; ART optimisation reduces frequency.
PID:
- Lower threshold for admission and IV antibiotics.
- Consider TB-PID in chronic cases.
- Surgical management threshold lower.
Surgery:
- Optimise CD4 and viral suppression pre-operatively where elective.
- Standard surgical prophylaxis.
- Postoperative VTE prophylaxis.
Contraception:
- Counsel on drug interactions.
- Encourage dual method for STI + pregnancy prevention.
Fertility care:
- Refer to specialised fertility services if needed.
- Safe conception counselling.
Coordination with HIV care
- Treat HIV care as core: every gynaecological encounter is also an HIV care encounter.
- Pre-prescription drug interaction check (especially rifampicin, ergometrine, simvastatin, antifungals, OCPs).
- Liaise with HIV physician for any changes to ART.
Red flags / pitfalls
- Cervical screening lapses in HIV-positive women — frequent cause of preventable cancer.
- Missing TB-PID — consider in chronic/atypical PID.
- Anchoring on candida without HIV testing — recurrent thrush should prompt HIV screening.
- Hormonal contraception without drug-interaction check.
- Surgical scheduling without CD4/VL review in immunocompromised.
- Failure to disclose discordance in serodiscordant couples being counselled for conception — partner safety.
- Treating HIV-positive teenagers without confidentiality considerations — vertical transmission survivors often have complex disclosure histories.
- Forgetting mental health and trauma — refer routinely.
Evidence anchors
- South African National Department of Health Consolidated HIV Guidelines (2023).
- South African HIV Clinicians Society Adult ART Guidelines (2023).
- WHO Consolidated Guidelines on HIV Testing, Treatment, and Prevention.
- BHIVA UK HIV Guidelines.
- ECHO Trial — DMPA + HIV acquisition.
- Tsepamo — dolutegravir + pregnancy.
- IARC Cervical Cancer in HIV-positive women monographs.
- South African Cervical Screening Guidelines (2023).
- CDC STI Treatment Guidelines (2021).