• New York State Department of Health. Medical care for menopausal and older women with HIV infection. New York (NY): New York State Department of Health; 2008 Mar. 10 p. [22 references]

This is the current release of the guideline.

• Human immunodeficiency virus (HIV) infection
• Menopause
• Mental health disorders and substance use
• Sexual dysfunction

Counseling
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening

Allergy and Immunology
Family Practice
Geriatrics
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology
Psychiatry

Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Substance Use Disorders Treatment Providers

To discuss prevalence and identification of human immunodeficiency virus (HIV) in women over the age of 50, primary health care for HIV-infected older women, the implications of initiating highly active antiretroviral therapy (HAART) and/or hormone replacement therapy, and the psychosocial issues that may affect older women living with HIV infection

Menopausal and older women with human immunodeficiency virus (HIV) infection

Evaluation/Diagnosis/Screening

1. Including human immunodeficiency virus (HIV) infection in the differential diagnosis for flu-like illnesses
2. Routine primary healthcare including gynecological evaluation, cytologic screening, post-hysterectomy cervical screening, screening for sexually transmitted infections, mammography, and bone mineral density measurement
3. Mental health assessment using brief screening instruments and including the following components: cognitive impairment, depression, anxiety, alcohol and substance use, psychiatric history, psychotropic medications, psychosocial assessment and others
4. Assessment for sexual dysfunction

Management/Prevention

1. Risk reduction counseling for prevention of sexually transmitted infections and human immunodeficiency virus (HIV) transmission
2. Use of highly active antiretroviral therapy (HAART)
3. Hormone replacement therapy (HRT)
4. Patient education about risks and benefits of HAART and HRT, possible side effects and drug-drug interactions, weight control, improved nutrition, and smoking cessation
5. Use of alternatives to HRT
6. Referrals to mental health and substance use specialists if indicated

Effectiveness of highly active antiretroviral therapy (HAART) and hormone replacement therapy

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with human immunodeficiency virus (HIV) infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

*Current committees include:

• Medical Care Criteria Committee
• Committee for the Care of Children and Adolescents with HIV Infection
• Dental Standards of Care Committee
• Mental Health Committee
• Women's Health Committee
• Substance Use Committee
• Physician's Prevention Advisory Committee
• Pharmacy Committee

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

None provided

The type of evidence supporting is not specifically stated.

Appropriate medical care for menopausal and older women with human immunodeficiency virus (HIV)-infection

Adverse Effects and Drug-Drug Interactions

• Risks of initiating highly active antiretroviral therapy (HAART) include metabolic complications, such as lipid disorders, insulin resistance and diabetes, altered body fat distribution, and, consequently, a higher risk of cardiovascular disease. These antiretroviral (ARV)-related complications can be difficult to diagnose and manage in older patients who may have the same, age-related, pre-existent metabolic abnormalities. Another potential risk of HAART includes bone loss, although the relationship among HIV infection, ARV therapy, and bone loss in women remains unclear. Components of HAART, in particular nucleoside reverse transcriptase inhibitors (NRTIs) and protease inhibitors (PIs), have been associated with a decrease in bone density. However, some evidence does exist for higher bone density in women exposed to nevirapine.
• HAART medications are known to interact with major classes of drugs that are commonly used to treat older patients, such as antidepressants, anticonvulsants, lipid-lowering agents, and many antibiotics and antifungals.
• Potential adverse effects of hormone replacement therapy

Because amprenavir and fosamprenavir levels are reduced with ethinyl estradiol and norethindrone use, they should not be used with hormone replacement therapy.

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with HIV infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

Guidelines Dissemination

Guidelines are disseminated to clinicians, support service providers and consumers through mass mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative, the AIDS Educational Training Centers (AETC) and the HIV/AIDS Materials Initiative. Printed copies of clinical guidelines are available for order from the New York State Department of Health (NYSDOH) Distribution Center for providers who lack internet access.

Guidelines Implementation

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AETC. The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

Getting Better
Living with Illness
Staying Healthy

Effectiveness
Patient-centeredness

• New York State Department of Health. Medical care for menopausal and older women with HIV infection. New York (NY): New York State Department of Health; 2008 Mar. 10 p. [22 references]

Not applicable: The guideline was not adapted from another source.

2008 Mar

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Women's Health Committee

Committee Chair: Mary Jo Fink, MD, Columbia Center for Family Medicine, New York, NY

Vice-Chair: Barbara C Zeller, MD, Project Samaritan AIDS Services, Inc , Bronx, NY

Committee Members: Machelle Allen, MD, Bellevue Hospital Center , New York, NY; Kathryn Anastos, MD, Montefiore Medical Center, Bronx, NY; Jeffrey M Birnbaum, MD, MPH, SUNY Downstate Medical Center, Brooklyn, NY; Susan E Cohn, MD, MPH, University of Rochester Medical Center, Rochester, NY; Vanessa E Cullins, MD, MPH, MBA Planned Parenthood Federation of America, New York, NY; Katherine D LaGuardia, MD, MPH, FACOG, Ortho-McNeil Pharmaceutical, Inc., Raritan, NJ; Howard Minkoff, MD, Maimonides Medical Center, Brooklyn, NY; Diane M Rudnick, MEd, New York State Department of Health AIDS Institute, New York, NY; Renee Samelson, MD, MPH, Albany Medical Center, Albany, NY; Diane J Tufaro, NP, AIDS Care Center, Valhalla, NY; Janice R Verley, MD, SUNY at Stony Brook, East Meadow, NY; Mary Vogler, MD; Weill College of Medicine, New York, NY; Barbara L Warren, BSN, MPH, PNP, New York State Department of Health AIDS Institute, Albany, NY

AIDS Institute Staff Liaison: Gina M Brown, MD, New York City Department of Health and Mental Hygiene, New York, NY

Principal Contributor: Barbara Zeller, MD, Project Samaritan AIDS Services, Inc., Bronx, NY

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on July 3, 2008.