Background
Basic Epidemiology and PrevalenceIn the United States, women account for a growingproportion of patients with human immunodeficiencyvirus (HIV) and acquired immunodeficiency syndrome(AIDS) (from 7% in 1985 to 27% in 2007) (1). Hetero-sexual contact is responsible for 72% of HIV transmis-sion among women in the United States, and womenof color are disproportionately affected, accounting for80% of HIV-infected women (1, 2). In most women withHIV, the infection is diagnosed during their reproductiveyears.
Antiretroviral Therapy for NonpregnantHIV-infected WomenTreatment of HIV and AIDS should be provided bya health care practitioner with expertise in HIV. Suchexpertise has been shown to be a factor that prolongs thelife of HIV-infected individuals (3, 4). A team approach is optimal to address both the medical and socialcomplexity of HIV infection. In addition to obtaining acomprehensive medical history, including a gynecologichistory and an HIV-related history, a detailed social his-tory also should be obtained. Women with HIV oftenhave life circumstances, such as alcohol or drug addic-tion, psychiatric illness, and domestic violence, that requirespecial attention (5). Appropriate sensitivity is needed toaddress these life circumstances and to treat HIV.In nonpregnant adults, initiation of antiretroviraltherapy is recommended for patients with a history of anAIDS-defining illness (Box 1) or a CD4 T-cell (or CD4)count of less than 500 cells per cubic millimeter. Forpatients with CD4 counts of 500 cells per cubic millime-ter or greater, antiretroviral therapy may be offered (6).Antiretroviral medications select for resistant mutationswhen used as monotherapy; therefore, combinations ofthree or more drugs, often called highly active antiretro-viral therapy (HAART), are used and strict adherence tothe dose regimens is critical. There are currently morethan 20 U.S. Food and Drug Administration (FDA)-approved antiretroviral agents from six medicationclasses that can be used to formulate combination regi-mens. Although long-term experience with antiretroviralagents is still limited, certain drugs merit special con-sideration in the treatment of women. Efavirenz is thepreferred nonnucleoside reverse transc**tase inhibitorfor the patients na?ve to antiretroviral therapy, but it alsois considered a possible teratogen because of data show-ing an increased risk of central nervous system defectsin primates and a small number of case reports of neuraltube defects in humans (FDA pregnancy category D)(7). Women offered efavirenz should be made aware ofthe potential teratogenic effects of this drug when usedduring pregnancy and that it is important to use effectiveand consistent contraception. The nonnucleoside reversetransc**tase inhibitor nevirapine is associated with anincreased risk of symptomatic liver toxicity that can besevere and life-threatening. This risk is greater in womenthan men and is highest among those initiating nevirap-ine therapy with CD4 counts of greater than 250 cellsper cubic millimeter (6). Therefore, nevirapine should not be used as a component of combination therapy inthis setting unless the benefits clearly outweigh the risks.Liver toxicity has not been seen in women undergoingsingle-dose nevirapine therapy during labor for preven-tion of perinatal transmission

完整下載2010-ACOG臨床指南：感染HIV女性的婦科保健