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surveillance case definition for AIDS now includes HIV-infected women who have invasive
cervical carcinoma.[392]
Vaginal intraepithelial neoplasia (VAIN) can be screened by Pap smear testing. VAIN is
more likely to occur in HIV seropositive women, and they are less likely to clear HPV than
seronegative women. Though higher grade VAIN or carcinoma is more likely to occur in HIV-
infected women, it is still uncommon.[948]

Vulvar condyloma acuminatum is more common in women with HIV infection, but can
regress, particularly when the CD4 lymphocyte count is higher. Vulvar intraepithelial neoplasia
(VIN), regardless of grade, occurs more frequently among HIV-seropositive than HIV-
seronegative women. Vulvar carcinoma in HIV seropositive women is uncommon.[949]
Pap smears should be obtained on women infected with HIV on a yearly basis, or at more
frequent intervals if an abnormal Pap smear is obtained.[208] Cervical carcinomas in HIV-
infected women are more likely to be invasive and have a worse prognosis than in uninfected
women.[950] Marked debilitation with advancing HIV illness may lead to absence of normal
menstrual cycles, a non-secretory endometrium, and ovarian atrophy with loss of follicles.

BREAST.—The breast can be involved with both benign and malignant diseases in
persons with HIV infection. Benign conditions may include gynecomastia in males and
increased adipose tissue deposition as part of the lipodystrophy seen in both men and women on
antiretroviral therapy (ART). Gynecomastia is most likely to occur in men receiving ART and is
strongly associated with efavirenz therapy.[951,952] ART may be associated with just an
increase in fat, or lipomastia.[953]
In women the breast may be involved by tuberculous mastitis. There is an increased risk
for mastitis, and infections with Pseudomonas aeruginosa can be particularly severe. HIV
infection is a contra-indication to breast implantation because of the risk for infection.
Pseudoangiomatous stromal hyperplasia (PASH), a keloid-like stromal hyperplasia with
myofibroblast and vascular proliferation, has been reported in association with HIV infection,
and PASH can present as a rapidly enlarging mass lesion. Although there is no link between
breast cancer and HIV infection, women with HIV who develop breast cancer do so at an earlier
age, have a greater likelihood of bilateral breast involvement, and have an increased rate of
metastatic disease. In addition to breast cancer, Kaposi sarcoma and non-Hodgkin lymphoma
have also been reported in women with HIV infection.[954] Intramammary lymph nodes
involved with lymphadenopathy of HIV infection may mimic breast masses.[955]

FERTILITY AND REPRODUCTION.—HIV-infected persons of reproductive age retain
fertility for childbearing. HIV-1 is intermittently present in the genital tract at variable
concentrations in both men and women. Semen analysis in asymptomatic HIV-1- infected men
without antiretroviral therapy shows findings consistent with fertility. Spontaneous pregnancy
rates, however, appear reduced in HIV-1-infected women when compared with HIV-1-negative
women. A higher prevalence of sexually transmitted diseases in HIV-infected women may
increase the risk for tubal infertility. Though seroconcordant couples could practice self-
insemination, HIV-1 superinfection of the woman could occur and could enhance disease
progression. HIV-1-infected patients have various assisted reproduction techniques (ART)
available. ART with semen processing has been an effective means of generating pregnancies