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New Developments in HIV Care for Women

Epidemiology

The proportion of cases among women has increased dramatically from 1993 to the present. Each year the proportion of cases has increased steadily, with women constituting a larger amount of the total cases. In 1995 women constituted 19% of cases.

For the year ending in December 2006, statistics reveal that 32% of women have contracted AIDS from personal IV drug use, 38% from heterosexual transmission (29% from sex).

By 1993 approximately 107,000 women were infected.

Heterosexual Transmission (HT)

Male IDUs are the main reservoir for heterosexual transmission in women.

In 1995 heterosexual contact was the dominant mode of transmission for the majority of women in almost all regions of the U.S.

Regions with the highest rates in women correspond to those where seroprevalence is highest in male IDUs.

HT is responsible for 8,112 AIDS cases in adults from December of 2006- December of 2006, 3,105 cases (6%) in men and 5,007 (38%) of all cases in women. In 1983-84 HT was responsible for 3% of all cases among women.

Heterosexual Transmission of AIDS Among Young Women

Probably the most alarming trends are in young women ages 13-25. It is estimated that 20% of younger adults will progress to AIDS within 5 years; they are considered rapid progressors.

These trends are important to note.

Classification of Heterosexual Transmission

Heterosexual Transmission requires a history of heterosexual contact with a partner who has HIV infection, AIDS or risk factors for HIV infection (IDU, hemophilia, etc).

Disproportionate Amounts of AIDS in Women of Color

1.    Twelve percent of all women in the U.S. are African-American.

2.    As of December 2006, 56% of all the women with AIDS were African-American. Seventy-six percent of all women with AIDS and eighty-one percent of perinatally acquired AIDS are in African-American or Hispanic people. The rates of heterosexual transmission in women of color are way out of proportion.

A.    Heterosexual Transmission

1.    The UN estimates that 2/3 of infected women worldwide may have had only their own husbands as sexual partners. Many other observations support the concept that the number of sexual partners may not be the major factor.

B.    What is Driving Greater Male to Female Transmission?

1.    There is increased virus in semen and an increased volume of semen versus vaginal secretions.

2.    The surface areas of the vagina and cervix are much greater.

C.    Natural History -So What's Different?

1.    Gynecologic issues are a large domain of women and AIDS with women having a great deal more morbidity from gynecologic issues.

D.    Non-Gynecological Differences

1.    Benson from Rush notes that major differences included the greater incidence of candida infections of other mucosal surfaces, especially the esophagus. Candida esophagitis has been increasing in frequency as the epidemic has increased. All studies of women have found it to be quite common.

E.    Skin Manifestations of HIV and Differences between Men and Women

1.    Seborrheic dermatitis is the most common skin condition. In men it is common on the face, chin, nasal area, auditory canal, and axilla.

2.    In women it appears in the axilla, between the breasts, in the groin.

F.    Kaposi's Sarcoma

1.    It is the initial presentation in 30% of all people with AIDS but is found in less than 2% of women. More commonly described in homosexual men.

G.    Progression and Survival Differences

1.    Results of initial early studies analyzing survival suggested there was a difference based on gender. Regardless of the risk group or race.

H.    Use of Antiretroviral Therapy in Women

1. Disappointingly there is still a paucity of data about efficacy and toxicity of antiretroviral drugs in women. Initial studies of AZT did not include women. Although more recent studies have sought participation from women their participation is still low.2.    Cotton and colleagues present data from 1987-1990 when women accounted for 6.7% of 11,909 ACTG clinical trial participants.

I.    OI Prophylaxis and CMV Antibody Screening

1.    Appropriate OI prophylaxis is necessary for both women and men.

A.    Transmission of HIV

1. The myth circulating is that lesbians are at no risk for contracting AIDS.

2.    Lesbians and bisexual women are a very heterogeneous group.

B.    1993 San Francisco and Berkeley Women's Study.

1.    The survey examined 498 lesbians and bisexual women 17 years or older randomly sampled at 25 public locations.

IV: HIV and Pregnancy

A.     Pregnancy and Its Effect on HIV

1.    Pregnancy itself has an immunosuppressive effect on all women with an expected decline in CD4 lymphocytes.

2.    Preliminary studies indicate that CD4 counts take longer to return.

B. Transmission of the Virus

1.    The vast majority of infections result from vertical transmission during pregnancy, delivery.

C.    AZT and Pregnancy

1.    AZT appears to limit the transmission of HIV to fetuses.

2. NIAID ACTG 076 study started in August 1991. The original data published included (364) mothers at 50 U.S. sites and 9 French sites. All women had > than 200 T-cells and were antiretroviral negative.3.    100 mg of AZT five times a day or 200 mg three times a day was given between the 14th and 34th weeks.

D.    Toxicity of AZT?

1.    AZT can interfere with DNA polymerase, and increased rates of cancer (liver and vaginal) have been seen in the offspring of mice treated.

E.    What other types of ARV Therapy Can be Used During Pregnancy?

1.    This is clearly an area where a paucity of data exists.

F.    New Recommendations for Pregnant Women

1.    Assess the CD4, viral load and clinical indicators to determine the optimal antiretroviral medications.

2.    Monotherapy even with AZT is not optimal therapy given our understanding.

G.    If the Pregnant Woman Has No Prior Use of ARVs

1.    Discuss the risks and benefits of starting therapy before or after the 14th week.

H.    If the Woman is Already Receiving ARVs When She Finds She is Pregnant?

1.    Therapy should be continued. If after discussion of the risks and benefits the patient elects not to continue all of her medications until the completion of the first.

I.    What is Recommended for a Woman in Labor with No Prior Use of ARVs?

1.    Administration of IV AZT during labor is recommended and a six week course.

J.    Avoidance of Sustiva in Pregnant Women

1.    In animal studies using Sustiva in pregnant monkeys severe birth defects (intracranial defects including anencephaly) have occurred. It is unknown whether this will occur in humans or is specific to this cohort. I would recommend withholding use until this is better clarified.