Women and HIV: An expanded perspective
In this issue of the Cleveland Clinic Journal of Medicine, Drs. Short and Anderson give an overview of the epidemic of human immunodeficiency virus (HIV) infection in US women and the various aspects of health care of this group, including pregnancy.1 They introduce a much broader topic and bring to light a number of additional concerns.
HIV PREYS ON THE VULNERABLE
The authors review epidemiologic trends and the evolving demographics of HIV, which deserve specific discussion.
In the early years of the epidemic, ie, the early 1980s, HIV infection in women was overshadowed by the epidemic in men, particularly men who have sex with men. The epidemic in men who have sex with men remains the larger component of the HIV picture in the United States. But worldwide, HIV is an evenly balanced problem, with nearly half of all infections occurring in women.2 Women have received much more attention recently.
In the United States, about 300,000 women are living with HIV, and 10% of them are unaware of it. Between 1985 and 2013, the number of HIV cases in US women tripled.
The epidemic continues to disproportionately affect women of color. Two-thirds of all women with HIV are African American,2 and estimates suggest that 1 of every 32 African American women will acquire HIV during her lifetime. On a positive note, there was a 20% reduction in new infections among African American women between 2008 and 2010.3
The epidemic preys on the vulnerable and is fueled by poverty, lack of education (general and health literacy), substance abuse, and restricted access to health care. Major metropolitan areas such as New York, Washington, DC, Miami, and Los Angeles are “hot spots,” where high concentrations of infected people reside.4
Many women underestimate or do not perceive their susceptibility. They unknowingly acquire HIV infection from their male partners, many of whom are unaware of their infection. Some of their partners may lead a dual life of bisexuality. In some areas, an estimated 20% of men who have sex with men also engage in sex with women.5 If these women contract the disease, they may be diagnosed at a late stage and when they are symptomatic, or coincidentally during pregnancy and childbirth.
Negotiating safe sex practices can be difficult for a woman. She may perceive or lack empowerment to do so, fearing rejection, isolation, or violence. Sexual violence may have been initiated in childhood, through intimate partners, rape, sex trafficking, or prostitution. Patterns vary throughout the world, but sexual violence is more common than perceived.6 Because of shame, embarrassment, and isolation, many victims do not seek medical care and so may carry undiagnosed infections. Even when they access care, they are less likely to remain in the HIV care system.7 Greater efforts are needed to reach these women, make them feel supported in care, and keep them in the system.
TESTING IS CRUCIAL
Diagnosis remains a weak link in the chain of care for both men and women. Success has been noted in the form of a marked reduction in cases of mother-to-child transmission, thanks to near-universal opt-out screening during pregnancy or at delivery.
If appropriate routine testing were done for all people, as advocated by the US Centers for Disease Control and Prevention guidelines,8 more cases could be diagnosed, behaviors changed, and treatment offered. Control of HIV through treatment can lead to a 96% reduction in transmission between serodiscordant partners, as demonstrated in HPTN 052, an ongoing phase 3 trial.9 Early diagnosis and treatment offer the potential for improved immune regeneration and healthier lives.
