Fact Sheet: Number 2 (1994)

HIV Infection and Women

Understanding the epidemiology and clinical presentation of women with AIDS deserves special attention because of their unique role in childbearing, childcare, transmission, and differences in clinical problems from those of men.

Incidence
Women represent the fastest growing group of HIV infected persons in the United States and abroad. HIV is now the most common cause of death in African-American women of childbearing age. As of October 31, 1994 53,978 women in the United States were reported to have AIDS (13% of all AIDS cases), 256 in Indiana (8% of Indiana cases). The prevalence of infection is highest in large cities, paralleling the prevalence of injecting drug use, but cases have been identified in rural settings as well. In one study reported in 1988 from the Northeast, the rate of seropositivity of new-born infants was measured, a reflection of the seropositivity of pregnant women. In inner city hospitals 1 out of 125 live births was seropositive for HIV whereas for suburban hospitals the incidence was slightly less than 1 out of 3000. Although not specifically addressed, the incidence of HIV seropositivity of infants born in rural/suburban hospitals was four times as high as that in suburban hospitals, significantly greater than that in suburban only hospitals. Whether this difference in rural incidence is a function of peculiarities of the individual hospitals is unclear and has not been further studied. In Indiana, results of surveys of HIV infection in state residents are being analyzed.

Risks
Injecting drug use and unsafe sexual practice remain the two major modes of transmission, but approximately 10% of infected women can identify no known risk.

With regard to unsafe sex, the rate of transmission of male to female may be higher than the risk of transmission of female to male. Padian (cited in Worth, 1994) found in studies of discordant partners, i.e. one partner infected and one uninfected, the risk of transmission from male to female was 15 to 20% about twice the risk of transmission of female to male. Factors which may increase the risk of sexual transmission include sex with an individual with advanced disease, genital sores, anal intercourse, and failure to use condoms.

Who should be tested?
All females with any of the following risks:

• Sex with someone known to be infected or at high risk (including injecting drug user, bisexual male, hemophiliac or a male from those countries where heterosexual transmission is common).
• Use of injecting drugs at least once since 1978. History of multiple sexual partners.
• History of transfusion with blood or blood products from 1978 and 1985.
• Past or current resident of a country with a high incidence of HIV-infection such as certain Caribbean or sub-Saharan African countries.
• History of artificial insemination since 1978, unless donor was screened for HIV.

It should be noted however, that in one study if testing had been restricted to women with acknowledged risk factors, only 57% of those infected would have been identified.

Any sexually transmitted disease (STD) may be an indication of HIV infection since the behaviors which lead to one may lead to the other. Infections which are associated with genital ulcers such as genital herpes, syphilis and particularly in other countries, chancroid increase the rate of transmission of HIV. Any woman with an STD should be strongly encouraged to undergo HIV testing and even in the absence of an STD many recommend that any woman with more than one partner who has not always used condoms should be counseled and tested for HIV.

Other women which should be tested include those with fever, night sweats, unexplained weight loss, generalized lymphadenopathy, recurrent bacterial infections, persistent, recurrent or unusually severe vaginal candidiasis or other unexplained systemic symptoms. Because the case definition of AIDS in women includes cervical cancer, those with moderate to severe cervical dysplasia, intraepithelial neoplasia or squamous cell carcinoma should be tested.

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How is AIDS different in women than in men?
Presentation of advanced HIV infection (AIDS) in women is similar to that of heterosexual men in that the most common infection is pneumocystis pneumonia (PCP). At least one group has reported that esophageal candidiasis as the most common AIDS defining illness. Kaposi's sarcoma, a relatively common affliction in homosexual men is much less common in heterosexual men and women possibly because of transmission of an undefined infectious agent in gay populations.

Two diseases deserve special note. Cervical cancer which has been associated with infection by papillomavirus which is sexually transmitted is now part of the case definition for AIDS. In a study from Louisiana approximately one out of five HIV infected women had intraepithelial cancer. PAP smear may not be adequate to make an early diagnosis. The response of HIV-associated cervical carcinoma to treatment and its overall prognosis appears to be worse than in non-HIV infected women in the relatively small numbers of patients reported. Thus HIV infected women are recommended to see a gynecologist every 6-12 months and may require special testing. Severe vaginal yeast infections (Candidiasis) are common in HIV infected women. Whether medication should be used to prevent them is not clear.

Studies of survival usually have found no difference between HIV-infected males and females. In a study which found that women had a poorer outcome, it is not clear if this difference is accounted for by medical considerations alone.

Lastly, pregnancy complicates the care of HIV infected women. Because HIV infection occurs most frequently in women of childbearing age, the problem is not uncommon. Complicated moral and philosophical issues and the need for well-informed counselling accompany any HIV-associated pregnancy. In the United States women infected with HIV have approximately a 25-35% chance of passing the infection on to their newborns. Women with advanced disease are more likely to transmit HIV to their babies. Even women with relatively mild disease with CD4 counts (the lymphocyte which is infected by HIV) below 400 are more likely to transmit the virus.

Prevention
Most HIV infection is preventable. Women must be informed of the risks and the importance of universal precautions both in their personal and professional lives. Condoms need to be easily available, perhaps in non-commercial settings such as a doctor's office. Epidemiology research may define risk groups further and behavioral research may find cultural and gender-based behaviors which put women at risk. Getting the message out to rural communities may be particularly challenging as there may be perceptions of invulnerability in presumed monogamous relationships and isolation from the problems which are associated with AIDS in large cities. Once a woman is infected, doctors must remember HIV infection in their differential diagnoses and become informed regarding appropriate management.

On a personal level women must:

• Be informed. The best protection is abstinence or a long-term monogamous relationship with an uninfected partner, such as in marriage.
• Take responsibility for their own protection.
• Limit their number of partners. Know their partners well.
• Use latex concoms. Condoms decrease risk.
• Avoid risk behaviors: particularly intercourse, injecting drug use, and oral sex.
• Be creative with lower risk behaviors.
• Keep informed on possible low risk behaviors such as use of the female condom and withdrawal.
• If using injecting drugs, never share needles or syringes. Get help to stop.
• Avoid using the sponge as it does not prevent HIV infection. Know that a diaphragm or cervical cap decreases the transmission of some but not all STDs.
• Individuals should contact their physician or local health department for more information about HIV prevention.

Sources of Information

Worth, L. A. (1994). HIV infection in women. In P. A. Cohen, M. Sande, & P. A. Volberding (Eds.), The AIDS knowledge base (pp. 1-21). Boston, MA: Little, Brown and Company.

Hoff, R., Berardi, V. P., Weiblen, B. J., Mohoney-Trout, L., Mitchell, M. L. & Grady, G. F. (1988). Seroprevalence of human immunodeficiency virus among childbearing women: Estimation by testing samples of blood from newborns. New England Journal of Medicine, 318, 525-530.

Spence, M. R., & Reboli, A. (1991). Human immunodeficiency virus infection in women. Annals of Internal Medicine, 115, 827-829.

Clark, R. A., Brandon, W., Dumestre, J. & Pindaro, C. (1993). Clinical manifestations of infection with the human immunodeficiency virus in women in Louisiana. Clinical Infectious Diseases, 17, 165-172.

Indiana State Department of Health: Division of HIV/STD. (1994). HIV/AIDS surveillance: clinical data and research: monthly summary report. November 1.

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