Sexual and reproductive health of women living with HIV in Finland

Introduction: Modern HIV therapy has dramatically changed the life expectancy of HIV-positive people. For the past 20 years, annual cervical screening with Papanicolaou (PAP) smears has been recommended for all women living with HIV (WLWH) due to the excess risk of squamous intraepithelial lesions (SIL) and invasive cervical cancer. Increasing life expectancy and good physical health has led to an increasing number of WLWH desiring children. Subjects and methods: Study I comprised 560 WLWH from Helsinki University Hospital and major Danish HIV clinics. These women were given a questionnaire on sexuality, fertility, and their perception on the mother-to-child transmission (MTCT) risk of HIV. Study II comprised 369 WLWH attending HIV care at Helsinki University Hospital during 2002–2013 and included in total 2033 PAP smears. We analysed the temporal changes in PAP-smear findings and risk factors for SIL. In Studies III and IV, we combined the National Infectious Diseases Register, the Medical Birth Register, and the Finnish Maternity Cohort register to identify all WLWH who had delivered at least one child and all children born in these deliveries. Studies III and IV comprised 212 women with 290 deliveries after their HIV diagnosis. We analysed factors associated with maternal HIV diagnosis only during the pregnancy, the mode of delivery, and national MTCT rate. Results: In all studies, women were in good physical health with good HIV treatment results. In Study I, most WLWH lived in a sero-discordant steady relationship and had one or more children; 4% were pregnant and 25% desired pregnancy. One-quarter had tried to conceive without success. Of all women, 15% overestimated the MTCT risk. In Study II, PAP-smear findings improved significantly with time. At each individual’s last PAP-smear, 90% of the findings were normal. In multivariate analysis, consecutive normal PAP-smear findings reduced the risk of any SIL, and it was also reduced with CD4>500 cells/μL as compared to CD430 years, living outside of the Helsinki metropolitan area, and Eastern European origin. The proportion of immigrants increased from 18% before 1999 to 75% during 2011–2013; they were diagnosed and treated equally to native Finns. In Study IV, 75% delivered vaginally. For most CSs (64%), the indication was obstetric. No MTCT occurred if the mother was diagnosed before the delivery. Conclusions: Most WLWH in Finland have excellent treatment results and have a strong desire for children. These treatment results, together with a systematic cervical screening, have led to mostly normal PAP-smear findings and low risk of SIL and cervical carcer. By combining PAP-smear- and HIV-related data, it is possible to identify low risk women and screen them less rigorously. WLWH with good HIV treatment results can safely deliver vaginally. We showed that national elimination of MTCT is feasible in a high-income, low-prevalence country. The cornerstone is to enable all women (and men) of fertile age to know their HIV status and to treat all of them equally, regardless of CD4 count or immigration status.