HIV Infection Among Incarcerated Women
HIV infection among incarcerated women has become a hidden epidemic in the United States. Factors that contribute to this epidemic include an increase of over 500% in the absolute number of women incarcerated in 1999 compared to 1980, and a higher seroprevalence of HIV in incarcerated women compared to US women in general (3.5% vs. 0.1%, see Figure 1).(1) Together, these factors have led to a steady increase in incarcerated women with HIV infection, compared to a plateau in the number of HIV-positive male offenders over the past five years.
HIV infection has affected women of color disproportionately in the US as a whole, and the overrepresentation of women of color among incarcerated women magnifies the impact of HIV infection in prisons. In the year 2000, in Texas (which ranks second only to California for the number of women incarcerated), 22.8% of HIV-positive incarcerated women were White, 72.4% were Black, and 4.8% were Hispanic.(2)
Figure 1. Factors Contributing to Increased Risk of HIV Among Incarcerated Women that Should Trigger HIV Screening, Treatment and Prevention Education
Numerous studies have shown that the same behaviors that lead to incarceration put women at increased risk for HIV infection.(23, 24, 25) Links between drug use, sex work, victimization, poverty, race and HIV explain the prevalence of HIV-infected women behind prison walls.
The dramatic increase in the number of HIV-infected women who are incarcerated means that more and more correctional healthcare providers will be faced with the challenges of caring for these women, and will need to know the gender specific medical issues involved in providing care for women with HIV. In addition, there are complex psychosocial issues such as depression, substance abuse, and prior physical and sexual abuse that impact this population more frequently than their HIV-infected, non-incarcerated counterparts (see "Spotlight" in this issue).(3, 4, 5) These co-morbidities may interfere with their ability to cope with a stigmatized, chronic illness that requires adherence to a complex medical regimen for successful treatment.
HIV Testing in the Correctional Setting
Many of the issues regarding HIV testing for women have been addressed previously in this newsletter (HEPP News April 2000, June 1999). However, given the high prevalence not only of HIV infection, but also high risk behaviors in incarcerated women, HIV risk education is perhaps the most important part of HIV pre- and post-test counseling.
Education regarding safer sexual practices and other risk reduction is an essential part of pre-test counseling because this is when such counseling can have a real impact. This information can (and should) be repeated at post-test counseling, since a woman testing negative may erroneously conclude that her behaviors are not so risky after all. Two other critical components of post-test education should include discussion of the benefits of early diagnosis and education regarding repeated testing, especially if potential exposure continues.
The personnel providing pre- and post-test counseling must realize that for many women, access and opportunity for healthcare outside the prison walls are limited by multiple psychosocial and logistical obstacles. Incarceration is a unique opportunity for education and empowerment of these women regarding health promotion, disease prevention, and disease process. However, incarceration does create real concerns about loss of confidentiality and fear of stigma that can prevent women from presenting for voluntary testing while in custody. HIV testing and education should be offered more than once during incarceration, especially to women with the following conditions: pregnancy, diagnosis of prior or current sexually transmitted disease, diagnosis of cervical neoplasm or dysplasia, diagnosis of Hepatitis B or C, history of commercial sex work, history of sexual abuse, or history of drug use.
Treatment of HIV-Infected Women
The initial medical evaluation of an HIV-infected woman should include a thorough past medical history, social history, and review of systems as outlined in Table 1. Given the high rate of STDs and cervical neoplasia in HIV-infected women, physical examination beyond the standard exam should include pelvic exam with Pap smear and STD screening (see "HIV 101" in this issue and HEPP News, April 2000). Laboratory evaluation should include screening for other blood-borne infections (Hepatitis B and C), TB exposure (PPD), and baseline hematology and chemistries, including liver panel (both for baseline prior to beginning therapy, and to screen for other co-morbid conditions), as well as CD4 counts and HIV viral load.
Current Recommendations for Initiating Antiretroviral Therapy
In February 2001, the Panel on Clinical Practices for Treatment of HIV Infection convened by the Department of Health and Human Services (HHS) revised its guidelines for the use of antiretroviral agents in adults (see HEPP News, February 2001).(6) The most recent change in the HHS guidelines are the recommendations regarding initiation of therapy in the asymptomatic HIV-infected patient, which were summarized in the February 2001 issue of HEPP News. (It must be noted that these recommendations apply only to chronically infected patient, not to patients with acute HIV infection). The recommendation to wait for a CD4 count of <350 or a viral load of >50,000 by PCR (i.e., more advanced infection) is in reaction to the greater appreciation of the adverse metabolic effects of long term antiretroviral therapy. Adverse effects can be seen with all the classes of agents currently available, and for most people with HIV infection, therapy will be continued lifelong. Thus, the new HHS guidelines recommend delaying initiation of therapy until the risk of disease progression justifies the risk of antiretroviral therapy. However, there is reason to believe these guidelines will be modified again this year due to new information on gender differences in viral loads.
Initiating Antiretroviral Therapy in Women
The HHS guidelines rely heavily on HIV-1 viral load as a predictor of disease progression; and much of the data linking viral load to development of AIDS comes from longitudinal studies of male populations, such as the MACS cohort.(7, 8) However, multiple studies have shown that women at all stages of HIV infection have lower mean HIV-1 viral loads than men, even after controlling for CD4 count.(9, 10) Researchers at Johns Hopkins University (JHU) and the National Institute of Allergy and Infections Disease (NIAID) recently published results in the New England Journal of Medicine from one of the largest studies ever to examine gender-specific difference in HIV infection, the AIDS Linked to the Intravenous Experience or ALIVE cohort. The study found that women who developed AIDS had a median initial viral load of 17,149 copies/mL, compared to 77,822 copies/mL in men. This sex difference in viral load means that the same viral load measurement does not convey the same risk of AIDS in women and men. Under current treatment guidelines, which suggest initiation of antiretroviral therapy when viral load exceeds 50,000, many women in the ALIVE cohort would have been excluded from HIV therapy. The results of the NIAID and JHU study suggest that decisions concerning the initiation of HIV therapy should emphasize CD4+ count more than viral load.(11)
A possible mechanism for this gender-based discrepancy is a difference in the expression of the HIV virion target on T-cells (CCR5 co-receptor) in women versus men. Portales and others have demonstrated a lower membrane density of CCR5 in women, which they postulate may be caused by the inhibitory effects of progesterone on CCR5 expression.(12) Because the membrane density of CCR5 determines the in vitro infectability of a target cell by an HIV-1 R5 strain, this finding could account for the gender difference seen in HIV-1 viral loads. Thus, clinicians caring for the HIV-infected woman should probably emphasize CD4 T cell count over viral load when making decisions about initiating HIV treatment.
Pregnancy presents another set of considerations for HIV treatment, where there is the additional goal of preventing vertical transmission. Given the decrease in vertical transmission seen with a zidovudine (AZT, Retrovir) alone regimen in PACTG 076, it is generally agreed that zidovudine should be part of any antiretroviral regimen prescribed during pregnancy unless absolutely contraindicated.(13) The 2001 HHS treatment guidelines recommend treatment with combination HAART (updated treatment guidelines, specific to pregnancy, are available here).
It is less clear how to manage the HIV-infected pregnant woman who has a high CD4 count and low HIV-1 viral load. There is no data to suggest that combination therapy would be better than zidovudine monotherapy in preventing vertical transmission, but combination therapy does have the advantage of better virologic suppression for the mother and less chance of developing resistance mutations that might limit options for treatment in the future. The pros and cons of limiting fetal exposure to multiple agents versus preserving options for the mother in the future should be discussed in detail with the patient. The physician and patient should also discuss the potential benefit of cesarean section.
If treatment is to be initiated for the first time during pregnancy, initiation of antiretroviral therapy should wait until the second trimester to minimize teratogenicity and avoid gastrointestinal toxicity during the early stage of pregnancy. Clinicians should avoid using efavirenz (Sustiva) in pregnancy because of evidence of teratogenicity in primate studies. The combination of didanosine (DDI, Videx) and stavudine (D4T, Zerit) should also be avoided because of multiple case reports of hepatic steatosis with lactic acidosis in pregnant women, including three deaths.
Other GYN Considerations
HIV-infected incarcerated women have particularly high rates of cervical cytological abnormalities, sexually transmitted diseases and certain gynecologic infections.(14, 15) Research indicates that vaginal infections are slightly more common among HIV-infected incarcerated women than non-infected incarcerated women, while the prevalence rates of STDs are high among incarcerated women compared to free-living women overall.(16)
Furthermore, high rates of HPV infection, of cervical cytological abnormalities and of invasive cervical cancer, have been found among high-risk HIV-seronegative women and HIV-infected incarcerated women.(17) Most correctional HIV programs have adopted an increased level of vigilance for cervical cancer, leading to the institution of performing pap smears every six months as a routine component of care for HIV-infected women (see "HIV 101" in this issue).
Selected Antiretroviral Toxicities and Monitoring
Lactic Acidosis and Hepatic Steatosis
Women are at higher risk for severe lactic acidosis and hepatomegaly with steatosis. Although rare, these conditions are serious and potentially fatal complications of nucleoside analogue reverse transcriptase inhibitor (NRTI) therapy.(18) Risk factors for this syndrome include gender (female), obesity, and prolonged NRTI therapy.(19) Clinical symptoms are non-specific, but can include nausea, bloating, abdominal pain, anorexia, vomiting, diarrhea, malaise, and weight loss. Because of the difficulty in obtaining an accurate lactate level, monitoring is mainly by clinical symptoms and monitoring the electrolytes (for acidosis) and liver chemistries every three months or when symptoms consistent with the syndrome are present.
Fat maldistribution can be particularly problematic for HIV-infected women when it is manifested as breast enlargement or central obesity, contributing to musculoskeletal back pain and negative body image. The actual incidence of fat maldistribution in patients receiving HAART is unknown as lack of a standardized definition make diagnosis difficult, but estimates range from 6% to 80%. Clinical finding include central obesity, breast enlargement, cervicodorsal fat accumulation (buffalo hump), peripheral fat wasting with extremity wasting and vascular prominence, and facial thinning.(20, 21, 22) All of these morphologic changes develop gradually, usually after several months of therapy.
Correctional facilities can expect to care for an increasing number of HIV-infected women. Healthcare providers have a unique chance to educate and empower this population, which is at increased risk for HIV infection, and has high rates of HIV infection. Providers will need to be aware of the gender-specific issues in HIV care, such as gynecologic complications of HIV infection, management of the HIV-positive pregnant woman, and monitoring for the metabolic toxicities of antiretroviral therapy, which may be more severe or more apparent in women. New appreciation of these toxicities has led to more conservative recommendations for antiretroviral use, which should be interpreted in light of the gender differences seen in HIV-1 viral loads. Regular monitoring of multiple parameters can help pick up metabolic toxicites of antiretroviral therapy before patients are clinically symptomatic.
This article was provided by Brown Medical School. It is a part of the publication HEPP News.