Women and Disease Progression
Though earlier studies of HIV disease focused mostly on men, ongoing research points to differences between men and women, like those in drug levels (metabolism) and side effects. Some studies report that women have lower viral levels than men. In addition to gender differences, there are potential differences in disease progression seen among women. These may be influenced by issues like age, race and access to treatment. Below are highlights of some presentations that focused on gender issues in HIV disease progression and unique treatment issues for women.
In March 1999, WISE Words reported on gender differences in viral load seen among participants in the ALIVE study (AIDS Linked to the IntraVenous drug Experience). The study found that women had HIV levels about 50% lower than men with similar CD4+ cell counts. It suggested that women with half the viral load of men had the same risk of progression to AIDS.
These findings raised questions as to whether guidelines for starting treatment should be different for women. However, the study did not include information on initial viral levels, an important indicator of disease progression. Experts agree, at the current time, that no changes should be made in the guidelines for using anti-HIV therapy based on gender.
An updated analysis of the ALIVE study examining HIV progression in women was presented at Durban. This time, study volunteers were included only if a blood sample was available within twelve months of testing positive (seroconversion) and at least three subsequent samples were available.
The study enrolled 202 volunteers (46 women and 156 men). Time between seroconversion and first viral load was similar in both men and women (4.3 months and 4.1 months) and fewer than 5% of volunteers received highly active antiretroviral therapy (HAART).
No gender differences in initial CD4+ cell count were noted among volunteers who progressed to AIDS and those who did not. There was also no overall difference in time to AIDS based on gender.
The 2000 ALIVE study suggests that viral load appears to be lower in women than in men early after HIV infection. Also, the same viral load after seroconversion does not carry the same risk of progression to AIDS.
Study researchers recommend re-thinking the treatment guidelines for starting anti-HIV therapy for women. They conclude that it may be appropriate to begin therapy at lower viral loads in women. However, if differences in viral load for men and women are short-term (more prominent only within the first few years after initial HIV infection), it is unclear if starting therapy is necessary. Until the meaning of these viral load differences are fully understood, it may be wise to more closely monitor CD4+ cell counts in women early in disease.
Clearly, starting anti-HIV therapy needs to take into account more than viral load measurements. How you feel about starting therapy, understanding its risks and benefits, considering your CD4+ cell counts and the rate of CD4+ cell decline, and whether you're ready for the sometimes rigorous demands of adherence -- among other factors -- need to be considered when making your decision.
More women over the age of 50 are living with HIV than ever before. Because older age is associated with a decline in the body's ability to fight off infection and disease, it's not surprising that unique concerns and questions exist for older women, not the least of which is how HIV affects menopause.
Another concern is whether older women have a higher risk of disease progression and death than younger women. Earlier studies in men suggested that, at least without treatment, older age affected the rate of disease progression. A study by the WIHS evaluated whether aging affects HIV disease progression. The results were somewhat surprising.
The WIHS study grouped 2,065 women by their age: under 30, 30-39, 40-49, and over 50. Excluding women with AIDS at study entry, researchers analyzed the effect of age on progression to AIDS and death. Other factors like initial CD4+ cell count and use of HAART were also considered.
While in general, older women over the age of 50 tended to be at increased risk of disease progression, using anti-HIV therapy appeared to greatly lessen this risk. In fact, older women who used HAART were among the least likely to progress to AIDS. For unexplained reasons, older women seemed to benefit even more than younger women from using therapy. Also, surprisingly, older women with CD4+ cell counts below 300 tended to fair much better than younger women below 300.
This may be good news for women over 50 but is puzzling for younger women. Researchers did note that a number of non-HIV-related factors, including violence and substance abuse, may contribute to the poorer outcomes of younger women in this study. Factors such as adherence and commitment to using therapy may also play a role. Although these data certainly are encouraging for women over 50, more research is needed to further explain the impact of age on HIV disease progression.
Anemia is common in people living with HIV; and it is especially common among people in later stages of illness and with lower CD4+ cell counts, African-American race and using certain anti-HIV therapies, like AZT (zidovudine, Retrovir). WISE Words has repeatedly encouraged women to check for anemia as it may be especially common among women and its effects include increased risk for disease progression -- as confirmed by a recent study by the WIHS.
The good news is that the same study shows that using HAART for at least 18 months is significantly linked to a resolution of anemia in women. The protective effect of HAART is likely due to the improvement it confers on the immune system, as noted by increases in CD4+ cell counts.
While there are other ways to manage anemia, anemic women considering anti-HIV treatment may be encouraged by these results. Caution in determining the right therapy is needed because certain drugs that are a common part of a HAART regimen, like ritonavir (Norvir), are known to increase the risk of anemia in women.
For more information, read Anti-HIV Therapy Strategies, available through Project Inform's Hotline. For a discussion of gender and viral load, request WISE Words #3.
The decision of when to start therapy is based on many factors. With the increasing number of women in studies, we're beginning to learn more about gender differences in these factors as well as how gender and age affect disease progression and treatment. However, current results are inconclusive More studies focused on these issues in women are needed and should be a key target for womens' AIDS activism.
This article was provided by Project Inform. It is a part of the publication WISE Words. Visit Project Inform's website to find out more about their activities, publications and services.