AIDS rate increases among American women

Look into the face of AIDS, and you may well be staring at the 26-year-old woman who just asked you for a birth control pill prescription.

Women now account for 19% of the nation’s adult AIDS patients, according to a recent article in the Journal of the American Medical Association.1 Between 1991 and 1995, there was a 63% increase in women diagnosed with AIDS, says Pascale Wortley, MD, MPH, a medical epidemiologist with the Atlanta-based Centers for Disease Control and Prevention (CDC), Division of HIV/ AIDS Prevention, and co-author of the article.

The article is an analysis of CDC national surveillance data collected by state and local health departments through June 1996 on women 13 and older with AIDS. It reports that by the end of 1995, 67,400 U.S. women had been diagnosed with AIDS; 11,500 were diagnosed in 1995 alone.

By examining trends by age group and birth cohort, researchers found the incidence rate increased substantially among young women (born between 1970 and 1974) who acquired AIDS through heterosexual contact. The trends suggest that successive cohorts of young women may be at risk for HIV as they enter their teen-age and young adult years, say Wortley and fellow CDC researcher and co-author Patricia Fleming, PhD.

Wortley observes, "One of the things we point out is that when you look at AIDS diagnoses in 15- to 19-year-olds or those age 20 to 24 — and you exclude gay men so you’re just looking at injection drug users, heterosexual contact — there is a predominance of women. This means women become at risk at a younger age than men do, so you have to target them for prevention even before they enter that risk period when they first start having sex or first start injecting drugs."

AIDS incidence rates were the highest among black women, increasing from 30.1 per 100,000 in 1991 to 50.1 in 1995. Among Hispanic women, these numbers increased from 17.9 to 23.8. Researchers found AIDS incidence rates were highest in the Northeast, with a 1995 figure of 22.3 per 100,000 women. The greatest increase by region was recorded in the South, where figures jumped from 6.4 adult female cases per 100,000 women in 1991 to 11.1 cases in 1995.

When CDC researchers studied women by year of birth, they noted steep increases in those born between 1970 and 1974, indicating they were infected during the late 1980s when syphilis hit epidemic proportions in the United States. Although the information is not definitive, the rise in syphilis cases may have played a role in the subsequent upsurge in HIV/AIDS, since syphilis rates were highest in young women, Wortley says.

Public health officials are now looking at women-only HIV clinics to reach those at risk for HIV infection. One such program in Panorama City, CA, developed by the Northeast Valley Health Corp. in San Fernando, CA, increased the number of its female clients by 43% in 1997 by encouraging women to be tested and encouraging HIV-positive women to get treatment, says Kedron Parker, MSW, case management supervisor at Northeast Valley Health’s HIV Division.

"In a clinic formerly geared toward gay men, we feel that we have been able to create a friendly atmosphere that encourages women to take charge of their own health care," Parker says.

When the clinic opened in January 1997, it offered a full range of services for men and women, including mental health care, outpatient medical care, case management, nutrition, health education, acupuncture, massage, and an HIV-dedicated dental clinic. The missing piece was a lack of visibility of HIV-positive women in the clinic and community, she says.

Northeast Valley gathered several female patients and asked, "What message do you have for women in this community?" The women developed the message, "Women: Get Tested, Get Support, and Get Early Treatment. Women Get AIDS." That slogan became the basis of a public relations campaign that included a press conference, where women’s stories about their experiences with HIV/AIDS earned front-page notice. Clinic patients also chose to represent the facility at community events and co-present a poster session at the National Conference on Social Work in Los Angeles and the National Conference on Women and HIV in Pasadena, CA.

Reaching Latina women has been a challenge, Parker says. Spanish language media were reluctant at first to cover the topic. One successful strategy called for a health educator to accompany a patient on a popular Spanish-language radio show. This allowed information to be shared and gave a voice to the challenges of HIV-positive women.

Working with recent immigrants has proven to be a challenge since many are socially isolated and unaware of any HIV community, Parker says. "Our potluck dinners, ‘Mujeres Unidas/Women Together,’ have helped these women see that there are many women from all walks of life dealing with this disease. Sharing food and stories, we have seen our clients open up to our staff and to each other, become much more connected with the clinic and more involved with their health care."

The Women’s Clinic is not a separate facility. Northeast Valley chose to concentrate its female patients’ appointments one morning a week and staffed the clinic with female providers. "Not only has this given our women clients an opportunity to interact with each other and our female treatment advocate, but it has highlighted women’s health issues among our staff. We have had several inservices with cutting-edge specialists in women and HIV and have raised awareness about these issues in Northeast Valley’s other clinics as well."

‘What do you do to protect yourself?’

It’s going to take some effort to help women understand the importance of protection from HIV, say public health officials. But it can begin with one simple question to your female patients: What do you do to protect yourself from AIDS?

Don’t think about whether the woman is married or single, old or young, straight or gay. Just add that question to your normal practice pattern, advises Felicia Guest, MPH, CHES, director of training at the Southeast AIDS Training and Education Center at Emory University in Atlanta and a co-author of Contraceptive Technology. If you’re worried about offending patients, you may preface the remark with "I’m going to ask you something that I ask everybody," she suggests.

Two other simple questions she asks are: "Have you ever had an HIV test? Would you like to get one today?" By treating an HIV test like any other routine test or immunization, you remove the barriers patients may place around it, she says.

Family planning providers need to stress the importance of adding condoms to patients’ current contraceptive methods for adequate HIV protection, Wortley says. Patients may think HIV risks are covered by their contraceptive method. Providers need to explain how dual methods, incorporating the use of a male or female condom, add protection needed to reduce HIV risk, she says. (See story on counseling strategies, p. 38.)

Reference

1. Wortley PM, Fleming PL. AIDS in women in the United States. JAMA 1997; 278:911-916.