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 more than 500 percent 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 percent vs. 0.1 percent). The dramatic increase in the number of HIV-infected women who are incarcerated means that more correctional health care 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.

Given the higher prevalence of not only 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. 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.

The initial medical evaluation of an HIV-infected woman should include a thorough past medical history, social history and evaluation for symptoms of gynecologic infections, depression and underlying opportunistic illness. 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. By far, the most important part of the initial encounter with an HIV-positive woman is identifying potential obstacles to adherence with treatment and return to clinic. A critical component of continuing care is linking the patient with care providers to access once she is released.

The Department of Health and Human Services guidelines on initiating antiretroviral therapy rely heavily on HIV-1 viral load as a predictor of disease progression. Yet much of the data linking viral load to development of AIDS comes from longitudinal studies of male populations, and 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. 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 regimen, it is generally agreed that zidovudine should be a part of any antiretroviral regimen prescribed during pregnancy unless absolutely contraindicated.

HIV-infected incarcerated women have particularly high rates of cervical cytological abnormalities, STDs and certain gynecologic infections. Research indicates that vaginal infections are slightly more common among HIV-infected incarcerated women than noninfected incarcerated women, while the prevalence rates of STDs are high among incarcerated women compared to free-living women overall.

Correctional facilities can expect to care for an increasing number of HIV-infected women. Health care 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.

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