STD Quarterly-Women and the spread of HIV/AIDS: Recognizing the female face in U.S. epidemic

Women represent 30% of new HIV infections and 23% of new cases of AIDS

Are you talking to your female patients about HIV/AIDS? It’s time that you start the dialogue. In the United States, women represent 30% of new HIV infections and comprise 23% of new cases of AIDS.1,2 Women of color are especially impacted by the disease. In 1999, African-American females accounted for 63% of new AIDS cases in women; 18% were Hispanic.2

The clock is ticking. According to a national survey, just 32% of women polled say they have spoken with a health care provider about HIV/AIDS; 20% say they have discussed the risks of being infected with HIV.3

Clinicians need to have a high index of suspicion when it comes to women and HIV/ AIDS, says Jean Anderson, MD, associate professor of gynecology and obstetrics in medicine at Baltimore-based Johns Hopkins University. Anderson is editor of the just-released A Guide to the Clinical Care of Women with HIV, published by the HIV/AIDS Bureau of the Rockville, MD-based Health Resources and Services Administration. The manual provides practical, experience-based advice and treatment guidelines for clinicians treating women with HIV. (The publication is available free of charge in print and Internet form. See the resource listing on p. 3.)

The reality of the disease has changed much faster than the medical community’s perceptions, states Anderson. Many clinicians still believe that injection drug users comprise the majority of the female HIV-infected population; however, the majority of new cases are heterosexually transmitted. According to the Atlanta-based Centers for Disease Control and Prevention (CDC), 75% of annual new infections are due to heterosexual transmission, with 25% attributed to injection drug use.4

While women of all ages are affected by HIV/AIDS, the disease is most prevalent among women in their childbearing years, notes Anderson. In 1999, 18% of new AIDS cases reported in women were among those ages 20-29, with 68% among those ages 30-49.5

Women with HIV/AIDS face their own set of challenges, contends Anderson. Since they are often diagnosed later and generally have poorer access to care and medications, women tend to have higher viral loads and lower CD4 counts, she notes. Women living with HIV/AIDS also must contend with vulnerability related to reproductive issues and domestic violence, says Anderson.

"Women with HIV suffer more from stigma and are more vulnerable in some ways than men to violence, to abandonment, and to neglect of their own care, because they are basically caretakers for others," she notes.

Check prevention models

For clinicians to help women in HIV prevention, they must tap into the "power of the provider," says Ann O’Leary, PhD, senior behavioral scientist in the Division of HIV/AIDS Prevention in the CDC’s National Center for HIV, STD, and TB Prevention.

"I think health care providers have a great deal of credibility and a great deal of respect from people," says O’Leary, co-editor of two books on women and AIDS. "If the health care provider says something is important, people really take it to heart."

O’Leary just conducted a workshop on two effective prevention programs at the annual meeting of the Washington, DC-based National Family Planning and Reproductive Health Association. Both programs are primary prevention interventions that have been shown to be effective on a biological outcome: STD infection. By reducing or eliminating STDs such as syphilis, gonorrhea, chlamydia, and herpes, clinicians may aid in reducing new HIV infections, as the presence of these STDs has been found to enhance HIV acquisition and transmission.

A study of the first prevention model, Project RESPECT, shows that interactive, client-centered HIV/STD counseling resulted in an overall reduction in STD incidence of about 30% after six months and 20% after 12 months of follow-up.6 The STD reduction occurred among men and women and was observed consistently at all five study sites, according to the analysis. (Contracep-tive Technology Update reported on the project on p. 3 of the STD Quarterly inserted in the May 2001 issue. See resource listing on p. 3 to download information on Project RESPECT.)

The second prevention model, a one-on-one provider/patient intervention that can be done
in 20 minutes, also is well-suited for the family planning clinic environment, says O’Leary, a co-author of its analysis. The evaluation is in press and should be published by the close of this year, she reports.

Strides made in HIV/AIDS

Antiretroviral therapy and early detection represent two important strides in HIV care for women, says Anderson.

When it comes to perinatal transmission, research shows that use of zidovudine during pregnancy and the neonatal period reduces the rate of mother-to-child HIV transmission by approximately two-thirds.7,8 New cases of AIDS in newborns declined 67% between 1992 and 1997, due in large part to increased treatment with zidovudine.9

The adoption of "universal, routine testing with patient notification" for prenatal HIV testing by the Washington, DC-based American College of Obstetricians and Gynecologists (ACOG) and the Elk Grove Village, IL-based American Academy of Pediatrics also play an important role in early detection, says Anderson. The groups issued their opinions following the 1998 recommendation by the Bethesda-based Institute of Medicine. (CTU reported on ACOG’s provider awareness campaign in the August 2000 issue, p. 96.)

The development of antiretroviral therapies, and the approach to their use known as HAART (highly active antiretroviral therapy), has made a significant impact on HIV care, notes Anderson. HAART uses a combination of drugs to hit the virus at different points in its life cycle, which helps to suppress viral replication down to very low levels.

Due to therapeutic advances in care and prevention of vertical transmission, more women who know they are HIV-infected are choosing to become pregnant, states Anderson. Clinicians should discuss birth control options with these women and recognize that some may opt for pregnancy. Anderson suggests that clinicians consult the newly published A Guide to the Clinical Care of Women With HIV for information on preconception care. (See resource box, p. 3.)

"Women need to be counseled and educated about all the issues before they become pregnant, so that those who don’t want to get pregnant can be helped to use the most effective method, and those who do want to become pregnant can be educated about HIV in pregnancy and what advances we’ve made in terms of transmission," she states.

References

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. Atlanta: U.S. Department of Health and Human Services; 1999.

2. Henry J. Kaiser Family Foundation. Key Facts: Women and HIV/AIDS. Menlo Park, CA: Henry J. Kaiser Family Foundation; May 2001.

3. Henry J. Kaiser Family Foundation. National Survey of Americans on HIV/AIDS. Menlo Park, CA: Henry J. Kaiser Family Foundation; conducted Aug. 14-Oct. 26, 2000.

4. Centers for Disease Control and Prevention. HIV/AIDS Update. A Glance at the HIV Epidemic. Atlanta: U.S. Department of Health and Human Services; 2001.

5. Centers for Disease Control and Prevention. HIV/AIDS Surveillance in Women. Atlanta: U.S. Department of Health and Human Services, L264 Slide Series; 1999.

6. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. JAMA 1998; 280:1,161-1,167.

7. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994; 331:1,173-1,180.

8. Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. N Engl J Med 1996; 335:1,621-1,629.

9. Lindegren ML, Byers RH, Thomas P, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA 1999; 282:531-538.

To view or download the Adobe Acrobat format of the publication, A Guide to the Clinical Care of Women With HIV, published by the HIV/AIDS Bureau of the Health Resources and Services Administration, visit http://hab.hrsa.gov/womencare. htm. To order free copies of the guide, contact:

Womencare, Parklawn Building, Room 11A-33, 5600 Fishers Lane, Rockville, MD 20857. Fax: (301) 443-0791 (Attention: Womencare). E-mail: womencare@hrsa.gov.

To download counseling protocols, quality assurance protocols, and further information about Project RESPECT, go to the following Centers for Disease Control and Prevention web page: