Women and HIV
February 15, 2019
Table of Contents
- A Look at the Numbers
- Is HIV Different for Men and Women?
- Treatment in Women Living with HIV: Effectiveness, Side Effects, and Drug Interactions
- Gynecological Issues in Women Living with HIV
- Pregnancy and HIV
- In Conclusion
More than 35 years have passed since the first diagnosis of AIDS (Acquired Immune Deficiency Syndrome) in the US. While there were a handful of women among the first cases, AIDS was thought to mostly affect gay men. However, as the years passed, women have emerged as another group hard hit by the HIV/AIDS epidemic. Globally, women living with HIV account for half of all people living with HIV, and in many countries, women living with HIV outnumber men living with HIV. Across the globe, transgender women (transwomen) are affected by HIV to a much greater degree than other groups. The proportion of transwomen living with HIV is estimated to be 49 times higher than the proportion of people living with HIV in the general adult population.
In the US
In 2016, almost one in five new HIV diagnosis in the US were among women. African-American women are especially affected. African-American adolescent and adult women made up only 13 percent of the US female population and accounted for more than six of every ten new HIV cases among women in 2016. Latinas made up 17 percent of the US female population and accounted for 16 percent of all new HIV cases among women. For African-American women, the rate of HIV diagnosis was 16 times that of white women in the US. For Latinas, it was more than three times that of white women.
Though not often talked about, American Indian/Alaskan Native communities experience the third-highest HIV rate of any racial group in the US. And while Asian/Pacific Islander communities may not be as heavily impacted by HIV, cultural factors may leave women in these communities vulnerable to acquiring HIV or make it harder for them to connect to HIV care. For more information on these factors, see our fact sheet on HIV among US women of different races or ethnicities.
Between 2011 and 2015, the number of new HIV diagnoses among all women dropped 16 percent. Although African-American women and Latinas continue to be disproportionately affected by the epidemic, new HIV diagnoses have declined among women of color, as well.
HIV affects both younger and older women. In fact, the rate of HIV diagnoses in older women has been rising recently; in 2013, women aged 45 and older accounted for 37 percent of new HIV diagnoses – more than twice the proportion of women 13 to 24 years old (14 percent).
The World Health Organization (WHO) estimates that almost 18 million adults living with HIV in 2014 were women. Although women account for approximately half of all people living with HIV worldwide, the percentage of women who are living with HIV varies widely among countries. Estimates suggest that one in three people living with HIV in the United Kingdom are women; almost four out of ten people living with HIV in India are women; and almost six in ten people living with HIV in sub-Saharan Africa are women. The Joint United Nations Programme on HIV/AIDS (UNAIDS) reports that only 21 percent of teen girls (ages 15 to 19) worldwide know enough about HIV to help them stay HIV-negative.
Transgender women: Across the globe, transwomen are affected by HIV to a much greater degree than other groups. It is estimated that the proportion of transwomen living with HIV is 49 times higher than in the general adult population. This is true whether transwomen are living in low-, middle-, or high-resource countries. Worldwide, 19 out of 100 transwomen in a given population will be living with HIV. For more information, see our fact sheet on Transwomen Living with HIV.
Older women: The number of older women living with HIV has been rising, not only because the rate of older women who have newly acquired HIV has increased, but because more women living with HIV are living longer, healthier lives and are aging with HIV. Older women deal with two stigmas – that of living with HIV, a disease spread through sexual contact or drug use, and that of being older. As a result, many older women are first diagnosed with HIV at a later stage of infection, when their immune systems are quite weakened.
Heterosexual sex (sex between a male and female) is the most common way of getting HIV (or mode of transmission) among women in the US. During heterosexual sex, HIV is passed almost twice as easily from men to women as from women to men. More than eight out of every ten women living with HIV in the US get the virus through sex with a man living with HIV. Heterosexual sex is also the main source of HIV transmission for women in many other countries in Africa, South America, and Western Europe.
Sharing HIV-contaminated syringes for injecting drugs is another common mode of transmission.
Until recently, little research had been done on women and HIV. While many questions remain unanswered, available information shows that HIV affects men and women differently in some ways:
- When women are first diagnosed, they tend to have lower viral loads (amount of HIV in the blood) compared to men who are newly diagnosed
- Women generally have lower CD4 cell counts than men with similar viral loads
- Women are most often diagnosed when pregnant, considering becoming pregnant, or hospitalized with acute (initial) illness
- Women are more likely than men to develop bacterial pneumonia
- Women have higher rates of herpes infection than men
- Women get thrush (a yeast infection) in their throats more often than men
- Men are eight times more likely than women to develop Kaposi's sarcoma or KS (a cancer-like disease caused by a herpes virus)
Women tend to be diagnosed with HIV later in their disease than men and fewer women than men are getting HIV treatment. Women may delay getting medical care and treatment and choose not to disclose their HIV status for several reasons, including:
- Limited access to health care due to lack of insurance and/or transportation
- Unstable housing
- Fear of violence in the home (domestic violence)
- Other responsibilities, such as child care or caring for a sick family member
- The stigma associated with HIV
- Problems with substance abuse or addiction
- Lack of financial resources and/or social support
- Mistrust of health care providers and/or the medical system
- Taking care of everyone but themselves and not putting themselves first
Numerous studies have shown that, if a person living with HIV is taking HIV drugs and their viral load has reached undetectable levels (not enough HIV in their bloodstream for a test to measure), that person cannot transmit HIV to a sexual partner who is HIV-negative. This is true for men as well as women, but there is still more research needed into how this exciting development affects women in particular – especially when it comes to breastfeeding children, or the often unfair power dynamics women experience in their relationships. For more information, please see our fact sheet Undetectable Equals Untransmittable: Building Hope and Ending HIV Stigma.
HIV treatment studies (clinical trials) have traditionally included very few of women. As a result, most information on the effectiveness and safety of HIV drugs comes from research done in men. This under-representation of women in studies is slowly beginning to change. For more information on how The Well Project is working to improve research for women living with HIV, please visit our page on the Women's Research Initiative on HIV/AIDS.
Existing research has found little difference in the effectiveness of HIV treatment for women and men. Women living with HIV who begin treatment as recommended to do as well as men living with HIV. Although treatment seems to work as well in women as in men, the side effects may differ:
Rashes: Women living with HIV are more likely than men to experience skin rashes from HIV drugs.
Liver problems: Women are more likely to experience liver problems as a side effect of certain HIV drugs. In fact, women with a CD4 count above 250 are warned against starting a drug combination with Viramune (nevirapine) because of the risk of dangerous liver problems.
Body shape changes: Some studies have found that women living with HIV experience different types of body shape changes than men. Women may experience more fat gain in their breasts and waists.
Weak bones: It is known that women in general are at increased risk of developing osteoporosis (weak bones) after menopause, but studies have also shown that living with HIV increases a person’s risk of weaker bones. This means both men and women living with HIV are at higher risk of osteoporosis. However, the risk for bone weakness in women living with HIV is three times higher than it is for men living with HIV.
Differences in side effects between men and women may be due to interactions between HIV treatment and female hormones. They may also be the result of women's smaller physical size. Standard doses of drugs are usually based on research in men.
Women living with HIV do need to be careful about drug interactions. Certain HIV drugs can affect the levels of other drugs in the body. For example, several HIV drugs can affect the levels of birth control pills and change how effective those pills are at preventing pregnancy.
It is important for women living with HIV to be treated by health care providers who have experience in treating women with HIV. Tell your health care provider about all your medical conditions and any medications you are taking. If you experience side effects from your HIV drugs, be sure to ask your health care provider for help.
Certain gynecological (GYN) conditions are more common, more serious, and/or more difficult to treat in women living with HIV than in HIV-negative women:
- Some vaginal infections and inflammation, including yeast infections and bacterial vaginosis
- Common sexually transmitted infections or diseases (STIs or STDs), such as gonorrhea, chlamydia, and trichomoniasis
- Genital herpes
- Pelvic inflammatory disease (PID)
Although little conclusive research is available on HIV and menstruation (periods), many women living with HIV report abnormal menstrual periods. Some bleed much more than usual while others stop menstruating altogether.
Human papillomavirus (HPV) is a sexually transmitted infection that causes 99 percent of cervical cancer and can also cause genital warts. Women living with HIV are more likely to be infected with HPV than HIV-negative women. Women living with HIV are also less likely to clear, or get rid of HPV, than HIV-negative women. Women living with HIV, especially those with advanced HIV disease (lower CD4 counts), are more likely to develop dysplasia (abnormal cervical cells) as a result of HPV.
Dysplasia means abnormal cells on the cervix (the opening of the womb). It is often more severe and difficult to treat in women living with HIV than in HIV-negative women. Untreated dysplasia can lead to cervical cancer, a life-threatening illness.
It is important to find HPV early and get treatment to prevent health problems. Regular cervical screening tests are a good way to check for HPV. An abnormal cervical screening test can indicate inflammation, infection, dysplasia, or cancer in the cervix.
The US National Institutes of Health (NIH) guideline recommends that:
- women living with HIV have a complete gynecological examination, including a cervical screening test (e.g., Pap test), when they are first diagnosed with HIV – within one year of starting to be sexually active, for women with other modes of transmission (such as acquiring HIV ar birth or through injection drug use)
- if the initial test is normal, women living with HIV have another cervical screening test 12 months later
- if three tests in a row are normal, then screening is recommended every three years
- women with abnormal tests or dysplasia should receive further testing – the type of test will differ depending on the result.
For more information, see our fact sheet on Caring for a Woman's Body: What Every Woman Should Know about the Care and Prevention of GYN Problems.
There are also three effective HPV vaccines. Since the introduction of the HPV vaccines in the US in 2006, the number of teen girls who have HPV has dropped by more than half. It is important for young people to get vaccinated before they have sex (before they have been exposed to HPV), since people who are already infected with HPV are not protected by the vaccines. There are many strains of HPV, however, so even women with one strain of HPV will benefit from the vaccine, since they will be protected against other strains. The vaccine was found to be safe and effective in women living with HIV. For more information, see our fact sheet on HPV.
With the advances in HIV care and treatment, many women are living longer, healthier lives with HIV. As they think about the future, some of these women are deciding to have the babies they always wanted. Women living with HIV who want to become pregnant should discuss their plans with a health care provider who is very experienced in treating women with HIV. For more information, see our fact sheet on Getting Pregnant.
The good news is that advances in HIV treatment have also greatly reduced the chances that a mother will pass HIV on to her child (mother-to-child transmission). If the mother takes appropriate medical precautions, the rate of transmission can be reduced to fewer than one in 100 births. In addition, studies in the US have shown that being pregnant will not make HIV progress faster in the mother. For more information, see our fact sheet on Pregnancy and HIV.
The number of women living with HIV is growing. It is important that you get tested regularly and do your best to be aware of your risk for HIV. In many countries, including the US, testing for HIV is part of routine health screening and preventive care.
If you test negative, you can take steps to stay that way. If you test positive, you can take steps to stay healthy and prevent passing the virus on to others, including during pregnancy. And while there is no cure yet, many women are living longer and stronger lives with HIV thanks to effective care and treatment.
More research is needed to determine how HIV progresses in women and how HIV drugs affect women’s bodies. However, it does seem that HIV drugs benefit women as much as men. By taking advantage of good health care and treatment as soon as you can, you greatly increase your chances of living a longer and healthier life for you and your loved ones.
[Note from TheBody: This article was originally published by The Well Project on Feb. 9, 2019. We have cross-posted it with their permission.]
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