Women With HIV Infection

by Diana Antoniskis, M.D.

Epidemiology Of the over 33 million adults living with HIV infection worldwide, almost half (47%) are women. Most women are affected in their reproductive years, and almost all HIV infections in children (>90%) are due to mother-to-child transmission (also known as MTCT). AIDS cases in American women > 60 years old are also increasing. There were 102 cases reported to the CDC in this age group in 1986 (most were transfusion recipients) while in 1996, there were 305 cases reported (69% were heterosexually acquired). It remains important to keep HIV infection in the differential diagnosis of many clinical syndromes, regardless of the sex or age of the patient. Risk Factors Currently, most US women acquire HIV heterosexually through sex with an HIV-infected partner. Often, this partner has a history of injectable drug use or bisexuality (which may or may not be known to the woman).

In the United States, the percentage of women with AIDS has tripled fom 1985 (7%) to 1999 (23%). Of new infections in American women, the CDC estimates that approximately 75% were infected heterosexually. Over half of the newly infected women are African-American and nearly 20% are Hispanic. HIV/AIDS remains one of the leading causes of death for American women aged 25 to 44. HIV infection is a growing threat to women worldwide. Clinicians need to be aware of this potential for infection and keep a high index of suspicion for HIV. We also need to continue to counsel women regarding safer sex practices and empower them to use protective methods of birth control such as female condoms. When women are diagnosed early with HIV infection, they have an opportunity to treat this potentially fatal illness and lead longer and more productive lives. Common Gynecologic Disorders in HIV-Infected Women Frequent, Severe Vaginal Yeast Infections (weekly fluconazole can be used for prevention without development of resistance) Chronic/Severe Herpes Simplex Infection (occasionally with development of acyclovir resistance, and requiring drugs such as intravenous foscarnet) Idiopathic Genital Ulcers, often confused with herpes (can be treated with thalidomide in non-pregnant women) Pelvic Inflammatory Disease (PID) which can relapse and require more aggressive treatment Human Papillomavirus (HPV) infection causing abnormal pap smears (women with HPV and HIV co-infection should have pap smears done every 6 months) Menstrual Irregularities (currently an area of active study)

Other Risk Factors for Heterosexual Acquisition of HIVt Presence of other sexually transmitted diseases, especially those that cause genital ulceration Uncircumcised male partner Cervical ectopy Sex during menses or bleeding during intercourse Advanced HIV disease in the infected partner (high viral load, low CD4 cell count) Psychosocial factors: alcohol use, childhood sexual abuse, current domestic abuse, use of crack or cocaine

Clinical Course of HIV In Women Studies performed in the 1980's indicated that women had a worse prognosis with HIV infection when compared to men. However, when these studies were controlled for time of diagnosis and antiretroviral treatment, the sex difference in prognosis was eliminated. However, there is recent evidence to suggest that women have lower viral loads than men at the same stage of infection. Several recent studies performed both in the US and Europe show that, particularly in early stage HIV infection, women may indeed have lower viral loads than men. However, in a large CDC-sponsored cohort, there was no significant gender difference in survival or time to development of AIDS despite these differences in viral load. As of late 2000, there are no gender-specific recommendations for institution of HIV therapy in guidelines developed either by the International AIDS Society or the US Department of Health and Human Services. However, clinicians should be aware of the potential for HIV progression in women with lower viral loads, especially in early HIV infection. The frequency of CD4 and viral load monitoring should be increased accordingly.

Mother to Child Transmission (MTCT) of HIV This is an area in which great strides have been made in terms of antiretroviral therapy; the incidence of MTCT of HIV in the US has fallen 50-75% since the routine use of antiretroviral therapy during pregnancy in HIV infected women! It is for this reason that current recommendations are to offer HIV testing to all pregnant women in the United States. Unfortunately, these strides need to be translated to the developing world, where over 500,000 infants are still infected perinatally each year. There are several exciting new programs and research studies in place to address this pressing issue.

Factors that Increase the Risk of Mother to Child Transmission (MTCT) of HIV Maternal drug use High viral load in the mother Inflammation of the fetal membranes (chorioamnionitis) Prolonged period between membrane rupture and delivery (more than 4 hours) Breast inflammation (mastitis) increases the risk of MTCT via breast milk-it is not recommended that HIV-infected mothers breast feed in the US, the issue remains controversial in developing countries

Current treatment guidelines recommend that women with HIV be treated as they would (based on CD4 count and viral load) if they were not pregnant, with inclusion of zidovudine (AZT, Retrovir) in the combination therapy if at all possible. This is based on a large body of evidence showing safety of zidovudine in pregnancy and few long-term side effects in the infant. There is a transient anemia in the infant after delivery which usually resolves without treatment. It should be noted that efavirenz (Sustiva) should be avoided in pregnancy since it has been shown to cause birth defects. A notable exception to the "treat as if not pregnant" recommendation is that of women with high CD4 counts and low viral loads. They should still be offered at least zidovudine monotherapy during pregnancy, since MTCT can occur at even low viral load levels. It would be wise to consult with an expert in HIV treatment prior to instituting therapy. HIV resistance testing should be obtained prior to institution of therapy in pregnant women in order to determine the optimal use of antiretroviral therapy. Conclusions In summary, HIV infection is a growing threat to women worldwide. Clinicians need to be aware of this potential for infection and keep a high index of suspicion for HIV. We also need to continue to counsel women regarding safer sex practices and empower them to use protective methods of birth control such as female condoms. When women are diagnosed early with HIV infection, they have an opportunity to treat this potentially fatal illness and lead longer and more productive lives.

Many of the clinical answers valued by HIV physicians and health care providers can only be answered truly by long term research. Please consider referring patients to The R&E Group for participation in a clinical trial. Call R&E staff at (503) 229-8428 or 1 (800) 875-8428 and ask about our open studies.