Infection with the human immunodeficiency virus (HIV) had emerged as a major health problem for women in the United States. Family physicians can play an important role in the detection and care of HIV-infected women. The epidemiology and natural history of HIV infection in women were reviewed. HIV infection is now a leading cause of morbidity and mortality among young women in the United States, particularly women of racial and ethnic minorities. Most cases of acquired immunodeficiency syndrome (AIDS) in women occur as a result of injection-drug use or heterosexual transmission.
Based on limited information, women and men appear to have similar AIDS-defining conditions. Gynecological problems are common n HIV-infected women. Pregnancy does not seem to be affected by early HIV infection, but women with advanced disease might be at increased risk for obstetric complications. More women need to be included in natural history studies and clinical drug trials. Early awareness of HIV infection and better access to health care services are required to improve the treatment and survival of HIV-infected women.
Acquired Immunodeficiency Syndrome (AIDS) has been declared the public health threat of the century (1 cited in 2). The US Surgeon General has designated it as the nations number one health priority (2). AIDS is a disease that affects the immune system. The term immunodeficiency refers to the inability of the immune system to function properly, thus making the individual susceptible to a variety of infections not typically found in a healthy immune system (3). A syndrome is a group of symptoms or illnesses originating from one cause. The main agent causing AIDS is a retrovirus known as Human Immunodeficiency Virus (HIV).
HIV is the agent of a sexually transmitted disease that can also be contracted through blood transfusions or IV drug use; the disease can also be passed on to a fetus during pregnancy. When people are infected with HIV, they are not necessarily also infected with AIDS. A person is not infected with AIDS until HIV reduces immune function to a certain level or when one or more serious illnesses related to HIV occurs. (4) Everyone is at risk of contracting the HIV virus, although women with HIV/AIDS face more difficulties living with this disease than do men.
HIV/AIDS women are of special interest because they are the major source of infection of infants. Not only do they have to think about the effects on their own lives, but also they must think about their infants if they choose to conceive. In my paper, I will review the ways in which HIV/AIDS affects women differently than men, through clinical issues and gynecological manifestations. I will also discuss the virus itself and issues concerning HIV positive women who are planning to conceive.
WHAT IS AIDS? In early 1983, a team at the Pasteur Institute in Paris, France led by Dr. Luc Montagnier first announced the discovery of HIV (5). They originally named it LAV, or lymphadenopathy-associated virus. However, it was not until the American team, led by Dr. Robert Gallo, called the virus HTLV-3 or human T-cell lymphotrophic virus that both teams collaborated and simplified it to just HIV (5). HIV can cause a range of conditions, of which AIDS is the worst. For example, it can lead to persistent swelling of the lymph nodes (5). Other people may have more serious symptoms but still show no sign of AIDS. This condition is known as AIDS related-complex ( ARC) (5).
Some of the symptoms of ARC include swollen glands, severe or chronic diarrhea, severe fatigue, rapid unexplained weight loss, drenching night sweats, fevers, and yeast infections, Although it can be serious, ARC is not fatal (5). The cause of AIDS is not fully understood. There are other factors are involved in the development of AIDS. Once a person tests positive to HIV, alcohol or drug use, poor nutrition, high stress levels, frequent exposure to other disease (especially sexually transmitted disease), have all been suggested to increase the risk of developing full blown AIDS (5). HIV transmission can be tracked accurately.
However, anxiety surrounds AIDS because its transmission from one person to another is not fully understood. Many people believe that it is possible to get AIDS through, normal everyday contact with an infected person. This is not the case. The majority of the people infected with HIV have contracted it through sexual intercourse with an infected person (5). Bodily fluids such as blood, semen, and vaginal secretions all may contain the virus. Using a condom can decrease the risk of contacting the HIV virus during intercourse with an infected partner. Another method of infection is through blood transfusion during surgery.
A person may receive untested, infected blood, therefore containing the disease. Through mid 1992, 2% of HIV infected adults and 12% of HIV infected children were infected with HIV via blood transfusion (15). However, the ELISA (enzyme linked immunosorbent assay) test was developed to screen the nations blood supply before used during transfusion procedures (15). Sharing needles during IV drug use is yet another method of contracting HIV. Infected users pass the needle back and forth increasing the risk of spreading HIV. Finally, another method of transmitting this disease is from mother to infant during pregnancy.
Infants may be infected with HIV while in the womb or possibly at birth if the mother is infected (5). HIV/AIDS was first identified in the United States among gay and bisexual men, and for the first decade of the epidemic, the disease was primarily associated with homosexuality and intravenous drug use in men (6). In recent years, there has been a growing realization that HIV/AIDS is spreading rapidly among women, and rates of HIV infection in women may eventually mirror those in the global epidemic (6). Approximately 61,4000 women had been diagnosed with AIDS in the United States as of December 1994 (7).
In the last decade, the proportion of AIDS cases in women has nearly tripled (7). In 1985, there was a 7%increase of AIDS cases among women, which grew to almost 20% in 1996 (8). Of that total number of cases reported among women, the proportion attributable to heterosexual contact also increased (9). In 1994, AIDS cases in women attributable to transmission via heterosexual contact surpassed the number attributable to transmission via injection drug use; however, sexual contact with a man who injects drugs accounts for the majority of heterosexual acquired AIDS cases (9).
AIDS is the fourth leading cause of death in women ages 25-44 years in the United States (9), and is the leading cause of death among African-American women in the same age group (10). Yet women remain understudied and overlooked. The lack of research specific to women leaves health care providers unprepared to recognized and respond to womens symptoms or experiences and uninformed about their health needs (11). As a result, women are diagnosed at later stages of clinical deterioration and receive fewer health care services to help them survive the illnesses associated with AIDS (11). Therefore, women die sooner from AIDS than men do.
Clinical Manifestations: A recent surveillance study has indicated that from 1995 to 1996 there has been a 23% decrease in the number of deaths from AIDS (6). There has also been a 6% decrease in the number of HIV-infected individuals diagnosed with AIDS (6). The decrease in AIDS-related morbidity and mortality are attributed to the improvements in the medical care, as well as the increased availability of therapies. However, these decreasing trends do not concern women infected with HIV and AIDS. During this same time, women with AIDS-related illnesses increased by 2% with only a 10% decrease in the numbers of AIDS related death (6).
The differences reported for women are due to the increasing AIDS cases in women and the lack of drug therapies specific to women (6). In 1982, the Center for Disease Control and Prevention (CDC) developed a case definition of AIDS based on a list of related diseases and lab evidence for or against HIV infection (12). Over the years, this definition has been modified and used for epidemiological studies and clinical assessments, which frequently tied it to the provisions of certain health and social services (12).
In 1993, the CDC expanded the case definition for AIDS in adolescents and adults when they added invasive cervical cancer to the list of AIDS-related diseases (6 12). Although women develop recurrent and resistant gynecological problems as a consequence of HIV infection, they do not meet the CDC criteria for an AIDS diagnosis (12). Hence, without this diagnosis, many women are unable to receive health benefits and services available to those with an official AIDS diagnosis (12).
Further data that show that women with AIDS do not survive as long after diagnosis as men and, once diagnosed, become sick faster and die sooner than men with AIDS (12). Some studies suggest this be attributed to gender differences or to delay diagnosis of women, inferior access to health care and poor utilization of service (12). Utilization of the prescribed drug therapies may affect the course of HIV/AIDS in women. Evidence suggests that a number of HIV-infected women are reluctant to take antiretroviral drugs because of concerns about their effectiveness and side effects, as well as beliefs that drugs are experimental (6).
Many women have negative views of available drug therapies because of the lack of relationship between them and their health care providers (6). Consequently, women decide against taking the drugs to help their HIV infection. These clinical manifestations underscore the immediate need for more aggressive study of HIV infection in women. With more extensive research and clinical care, women living with the infection may be able to avoid further AIDS-related illnesses and women without the disease may be able to reduce their risk of infection. Gynecologic Manifestations:
Until recently, AIDS diagnoses have excluded the serious gynecologic manifestations of HIV that have been identified in women for some time (7). Most of the illnesses associated with HIV are found in uninfected women, but occur less frequently, or severity (10). Although the CDC has only recognized cervical cancer in the case definition of AIDS, providers must be alert to the other female-specific conditions that their patients might encounter (12). Candidasis: Vaginal Candidasis has been described as one of the earliest manifestations of immunosuppression in women (12). Refactory Candidasis may be an early warning of HIV infection (7,12).
In an early study, 24% of women had chronic refactory Vaginal Candidasis as a complaint (7). As the illness progresses, the vaginal infection may move to esophageal and tracheal involvement, and ultimately to the stomach in some very severe cases (12). Candida infection of the esophagus has been reported as the most frequent AIDS-defining symptoms in early studies of HIV-positive women (12). It is so common because of the frequent use of antibiotic (13). However, this illness usually responds well to the conventional treatment in women with early HIV infection, but advanced therapy may be called for in a more severe case (13).
Herpes Simplex Virus Infection (HSV or genital herpes): Genital herpes simplex infection is dominant in women infected with the HIV virus (7,12). The genital lesions associated with HSV may be an opportunity for the entry of the virus (12). Thus, lesions that last longer than one month should be looked at and tested for HIV infection (7). HSV is sometimes unresponsive to therapy (10) and can be an AIDS-defining condition and require long-term suppressive therapy (7). Pelvic Inflammatory Disease (PID): Several studies have found a high rate of HIV infection among women with pelvic inflammatory disease (13).
Whether HIV is a cofactor or simply a sign for increased risk of infection has yet to be established. One study showed that HIV infected women with pelvic inflammatory disease are less likely to have a white-cell count great than 10,000 (13), which puts a patient at much higher risk for infection. Recommended treatment, is to be hospitalization and treatment with intravenous antibiotics (7,12,13). Further study is needed in many aspects of gynecologic disease in women with HIV. If the epidemic of the female infections is to be reduced, health care providers must receive education about these life-threatening diseases.
Because most HIV infected women are of childbearing age, considerable research has been conducted on pregnancy-related issues. There is a 25% to 35% risk of perinatal transmission (13), with an estimated 50 to 80 percent of infections occurring late in pregnancy or during birth (10). HIV may be transmitted when maternal blood enters the fetal circulation, or by mucus exposure to the virus during labor and delivery (10). Risks of perinatal transmission are increased if the mother has an advanced case of the HIV disease, large amounts of HIV in her blood stream, or few immune system cells, CD4+ T cells, which are the main targets of HIV (10).
Other factors that may increase the risk of transmission are maternal drug use, severe inflammation of fetal membranes, or a prolonged period between membrane rupture and delivery (10,13,14). In one study, HIV infected women who gave birth more than four hours after their fetal membranes were ruptured were twice as likely to transmit the HIV virus to the infant as compared to women who gave birth within that four hour period (10). In the same study, HIV infected women who used heroin or crack/cocaine during pregnancy were also twice as likely to transmit HIV to their babies than were women infected with the virus who were not injecting drugs.
Another risk of transmission is from a nursing mother to her infant (5,10,14). A recent analysis suggested that breast-feeding introduces an additional risk of HIV transmission of about 14% (10). In one case, an uninfected women who received a Cesarean section needed a blood transfusion due to the massive amounts of lost blood. The baby boy was breast fed, and it was later found that the blood that was given to the women was contaminated with HIV. The mother and baby were both tested and both found to carry the antibodies of HIV.
The mother was apparently infected with the disease after delivery. Hence, the baby could have only been infected through breast feeding (5). For this reason, women who are infected with HIV are recommended to stay way from breast-feeding, despite the slight chance of infection (5,10,14). To prevent transmission of HIV to infants, Zidovudine (AZT) (10,13,15) and prophylaxis are recommended for pregnant women (13). There is limited knowledge with AZT. However, it is known that it crosses the placenta and can be detected in fetal tissue and amniotic fluids (13).
When AZT is given shortly before therapeutic abortion of delivery, serum amounts in the newborn are similar to those in the mother; thus reducing the risk of maternal-infant transmission by two thirds (10). AZT is still being studied and perfected. With further advances, AZT may be able to reduce the risk of transmission to an undetectable amount, giving HIV infected women a less stressful decision when deciding whether or not to continue with their pregnancy. More women are becoming infected with HIV. With earlier testing and treatment, women can live with HIV as long as men can.
However, in a male-dominated medical establishment, womens health issues are often ignored (16). Some women go straight to their deaths, while others are diagnosed after it is too late (16). Women need to know more about how they can be infected, and should get tested for HIV if they think that there is any chance that they have been exposed to the virus. This is especially true for pregnant women. Not only are they endangering their own lives, they may be putting an unborn child at risk for a disease that might have been avoidable.
If the cycle of female infection is to be broken, health workers must be able to provide appropriate education, counseling and care to women (16). If women are to receive optimal AIDS health care, research must be done specifically to target women (16). In the meantime, peoples fears and ignorance about HIV and AIDS must end by increasing the education of the affects of HIV on women. Until the understanding of AIDS as it relates to women becomes clear enough to health care workers, women will still suffer from the rising AIDS epidemic.