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HIV and the Female Genital Tract -- What Does It Mean for HIV Prevention?

Fall 2016

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HIV Prevention in the Female Genital Tract

What Strategies Can Women Use to Prevent HIV?

The HIV prevention toolbox continues to grow, offering multiple strategies to prevent the sexual transmission of HIV depending on a person's needs and preferences. Many women are especially interested in the types of prevention methods which they can control for themselves. Recent biomedical advances have created new options for female-initiated HIV prevention; however, widespread access remains an issue, and more traditional or longstanding prevention strategies are still important to promote. The following prevention approaches are options that you should be prepared to discuss with clients:


Condoms

Internal (sometimes referred to as female) condoms and external (sometimes referred to as male) condoms are highly effective strategies for women to reduce their risk of sexual HIV transmission, when used consistently and correctly. For a long time, the internal condom was the only female-initiated HIV prevention option available to women. Unfortunately, uptake of internal condoms among women has been low due to lack of awareness about this method and how to use it, poor acceptability among some women, and the relatively high cost compared to external condoms .9,18 Furthermore, a woman's ability to actually control this method is limited because it can't be used covertly.

The use of internal and/or external condoms may be preferable to many women because they offer several advantages including effective pregnancy and STI prevention, and they do not involve side effects that may result from the use of antiretroviral drugs for prevention.9,19


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PrEP and PEP

Oral pre-exposure prophylaxis (PrEP) involves taking a pill containing antiretroviral drugs every day, starting before being exposed to HIV and continuing afterwards. Studies have shown that daily oral PrEP, when used consistently and correctly, is a highly effective strategy for reducing the risk of the sexual transmission of HIV in women.20,21 However, adherence to oral PrEP appears to be especially important for females having vaginal sex. There is some evidence showing that oral PrEP takes longer to reach maximum drug levels in vaginal tissues compared to rectal tissues and also that drug levels can decrease quickly in the vagina if PrEP is not taken every day.22-24

Post-exposure prophylaxis (PEP) involves the use of antiretroviral drugs after a single, unintended exposure to HIV. HIV-negative women can use PEP to reduce their risk of HIV transmission after a sexual encounter where there was a significant risk of HIV exposure. Some women may be offered PEP after a sexual assault.25 Guidelines recommend that PEP should be started as soon as possible after the exposure (within maximum 72 hours) and that pills must be taken every day for 28 days.26 PEP is more likely to work the earlier it is started and with greater adherence to the full course of pills.26

Both PrEP and PEP can be initiated by women and taken discreetly, if necessary. In some cases, it may be difficult to hide daily PrEP and/or PEP use from intimate partners, who may question its use. In addition, antiretroviral drugs may cause (usually temporary) side effects that can be difficult to tolerate or to hide from others. It is also important to note that PrEP and PEP do not offer any protection against STIs (such as herpes, chlamydia or gonorrhea) or pregnancy.

Antiretroviral drugs are expensive and cost is a significant barrier to accessing PrEP and PEP because the drugs are not currently covered by most public or many private health insurance plans in Canada.


Treatment to Prevent HIV

The consistent and correct use of antiretroviral treatment (ART) by people living with HIV to achieve and maintain an undetectable viral load is a highly effective strategy to help prevent HIV transmission.19 An HIV-negative woman with an HIV-positive partner would have a substantially reduced risk of getting HIV as long as the HIV-positive partner takes ART consistently and correctly and has a viral load that remains undetectable. A woman living with HIV could also use this approach to greatly reduce the risk of passing HIV to her HIV-negative partner(s).


What About Women Who Are Trying to Conceive?

An HIV-negative woman who wishes to conceive a child with an HIV-positive partner now has several options available to reduce the risk of getting HIV while trying to get pregnant. This may include treatment of their HIV-positive partner and timed natural intercourse, "sperm washing" with intrauterine insemination or in vitro fertilization, and PrEP. Serodiscordant couples who want to conceive a child should seek expert advice to tailor conception and HIV prevention approaches to their specific needs.27,28


Implications for HIV Prevention in Women

It is important for service providers who work with women to understand the biology of HIV transmission in females so that they can communicate this information to women while providing appropriate prevention counselling.

There are several key messages that can be given to female clients about the risk of HIV transmission through vaginal sex:

  • A healthy female genital tract has protective defences that can fight HIV infection; however, it also has biological vulnerabilities that contribute to a greater risk of HIV infection compared to men.
  • Inflammation in the female genital tract is associated with an increased risk of HIV infection. Inflammation can be caused by STIs, vaginal conditions, friction during sex, and cleansing practices (such as douching), among other things.
  • STIs and other vaginal conditions (such as bacterial vaginosis) may increase risk, even if they are not symptomatic. Women should be tested for STIs regularly and treated if necessary.
  • Women with diverse needs and preferences have prevention options available to them for reducing their risk of getting HIV, including methods they can initiate themselves and those that require greater partner involvement.
  • Women in a serodiscordant relationship who want to conceive have several options for preventing HIV transmission within the relationship, and should seek expert medical advice to review these options.

When counselling women about their risk for HIV transmission through vaginal sex and their prevention options:

  • Provide women with information that helps them understand the biological factors that may increase their vulnerability to HIV in the female genital tract.
  • Counsel women about behaviours, practices and biological factors that may put them at increased risk of HIV, and encourage regular HIV and STI testing for women who are at high risk.
  • Inform women about the highly effective HIV prevention options that can help them to reduce their risk of HIV infection (condoms, PrEP and an undetectable viral load), and counsel them on the need for women to be highly adherent when taking daily oral PrEP.
  • Discuss combination prevention options based on type and frequency of sex, personal preferences and desire to become pregnant (or not).
  • Discuss risk behaviours other than vaginal sex, recognizing that many women may also be at risk for HIV transmission through anal sex or other sexual practices, or through injection drug use.
  • Whenever possible, address other risk factors that may influence a woman's risk of getting HIV and/or impact her ability to prevent HIV infection, such as food insecurity, housing instability or intimate partner violence.
  • Be aware of other services and providers that female clients can be connected to as appropriate, to address other identified issues (for example, mental health and addiction services, housing assistance, etc.).


Resources

Camille Arkell is CATIE's Knowledge Specialist, Biomedical Science of Prevention. She has a Master's of Public Health degree in Health Promotion from the University of Toronto, and has been working in HIV education and research since 2010.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
 

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