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Impact of HIV medication discontinuation on women
Women were more likely to be nonadherent
As the percentage of women impacted by HIV increases, researchers and clinicians need to learn more about how HIV-infected women differ in adherence and treatment than HIV-infected men.
"Thirty percent of those infected are women, and globally, women account for 50% to 55%, so we're heading toward the global trend," says Mirjam-Colette Kempf, PhD, MPH, a research assistant professor in the department of epidemiology, School of Public Health at the University of Alabama - Birmingham in Birmingham, AL.
"In the past the disease originally was seen mainly in male populations, and so our focus has been mainly on male populations," Kempf says. "Only in the last decade did we see a huge increase among women."
This shifts clinicians' focus to how to keep women well, particularly in the context of younger women likely to be or become mothers, she adds.
"While we know there are metabolic differences in men versus women, I don't think much has been looked at yet in terms of the clinical aspect, how we treat them and how they respond to therapy and management of their disease," Kempf says.
Kempf's study looks at the differences in discontinuation of antiretroviral treatment regimens between women and men.
"Our interest was to look at why patients changed their medications and/or discontinued their medications," Kempf explains. "Again we had the thought in mind that durability of a regimen is very important at this point because they'll be on lifelong therapy, and the longer the regimen can be tolerated by the patient, the better it is for the patient."
So investigators sought to examine any potential differences in men and women with regard to tolerating ART regimens.
They didn't find a significant difference between how long men and women tolerated ART regimens, but they did find differences in why men and women might discontinue their medications.1
"The overall reason given by providers of why both men and women asked for discontinuation and change was virological failure," Kempf says. "It seems like women were more likely to be nonadherent to their medication, and that's why they discontinued their drugs."
Women also were more likely to discontinue their medication due to dermatological symptoms, such as a rash, she adds.
For instance, women given nevirapine are more likely to list a rash as a side effect than are men, she says.
"There is evidence that dermatological symptoms manifested more in women than in men," Kempf says. "And we also see neurologic [issues], such as peripheral neuropathy occur at a higher rate."
Other reasons that were given more frequently for women's discontinuation of ART included constitutional symptoms, including not feeling well, fatigue, and weight gain or loss, Kempf says.
And pregnancy was another factor in women's discontinuation of ART, she adds.
"Another interesting finding that came along was that women were more likely to be off their regimen for a longer time than men," Kempf says. "Once a woman would discontinue her regimen she would stay off her meds a longer period of time than a man would."
Women were less likely to start a new regimen right away, she adds.
This finding goes along with the increase in viral loads and decrease in CD4 cell counts noted in women.
"And while we didn't investigate those long-term outcomes, we can say that based on other studies it looks like women are prone to having less favorable outcomes in the long run," Kempf says. "And we still are not able to understand why because women usually come into care with more favorable clinical characteristics, such as high CD4 cell counts, low viral loads."
A lot of women are diagnosed with HIV while they're pregnant, she notes.
HIV clinicians could note from this research that adherence is different in women versus men, and they should be very vigilant in emphasizing with patients educational messages about adherence, Kempf suggests.
"Patients are aware of potential side effects, but their reasons for stopping therapy can be different," she adds.
"And clinicians need to recognize the fact that once women discontinue therapy they might be off therapy longer than men, and it might be more difficult for them to reinitiate their therapy," Kempf adds.
"So we need to be careful and encourage women to not discontinue their therapy on their own," she says. "And if they do discontinue therapy, then we need to find ways to re-engage them in care and in taking their medications."