Overview Of Women And HIV From The International Aids Conference, Vancouver, B.C.
There was a whole track devoted to women at this year's conference, encompassing several hundred oral presentations, posters & plenary sessions. Research on women is finally increasing. Unfortunately, this has not yet benefited many women with AIDS because so much more needs to be done. Most of the studies designated for women have been in the area of perinatal transmission. (Editor's note: Perinatal studies are not about women with AIDS at all. They're about the health of our children.) Other areas studied are psycho-social problems and women specific prevention strategies.
Women are finally beginning to be included in some clinical drug trails, such as combination therapy and protease inhibitor studies.
HPV & Dysplasia
There was interesting data on anal HPV infection and anal dysplasia in women. In one study, 27% of the women with HIV infection had abnormal anal pap smears. These women had low grade dysplasia and/or HPV (Human Papilloma Virus). Only 6% of the HIV negative women had abnormal paps.
Women who have a history of cervical/vaginal HPV or dysplasia are at high risk for anal HPV. You don't have to have anal sex to get anal HPV or dysplasia.
Several studies showed that women with HIV infection are 3 to 8 times more likely to get cervical HPV, dysplasia, and invasive cervical cancer (ICC) than women who are negative.
In women with HIV infection these cancers are harder to treat. They may not respond to treatment and can get worse even with medication, especially with lower T-cell levels.
Now we know that women should also be screened for anal cancer. There is still controversy over whether or not biannual colposcopy is needed on a routine basis or only with abnormal pap smear.
Vaginal and oral candida (yeast) infections continue to be problems for HIV+ women. Oral thrush was associated with lower CD4s ( around 273 ), and cigarette smoking.
Another study showed 37% decreased rates of vaginal candidiasis and 49% decreased rates of oral candidiasis with fluconazole prophylaxis. Drug resistance is still a problem because if you develop resistance to fluconazole and then get any fungal based infection your treatment option may be limited to Amphotericin B. Still, according to this one study, it may not be a bad idea to try to prevent yeast infections, if you've had problems in the past or if your T-cells are low.
There was a major report on female-controlled contraception among heterosexual women. Data was presented showing increased acceptance of the female condom. Eighty-seven percent of heterosexual women surveyed would like to use female controlled condoms, while 63% prefer the male condom.
Three female condoms are now available, Bikini Condoms (latex), "Women's choice"(latex), and "Reality" (polyurethane). HIV, CMV and other sexually transmitted viruses cannot penetrate latex or polyurethane. The polyurethane condom has an estimated 97% efficacy (similar to latex condoms).
Vaginal microbicides were also discussed. Microbicides are substances which kill germs. It may become possible for women to protect themselves from becoming infected with HIV by using vaginal microbicides. Non-oxynol-9 is a detergent type of microbicide found in many brands of lubricant. However, N-9 is known to cause ulcerations in some women leaving them more prone to HIV infection. In addition to nonoxynol-9 there are other classes of compounds being studied. These include 3TC and ddI. Out of 35 agents being studied, only 2 are in advanced clinical trials. Unfortunately, none of these microbicides will become available for several years.
The shedding of HIV in cervical and vaginal fluids was shown to increase with lower CD4 levels. There is 50% more virus in vaginal fluids when the T-cells fall below 200. Several studies suggest that there may be an increased risk of transmission "from" women to their partners at times when they have Sexually Transmitted Diseases, genital ulcers or lower T-cells.
The national WIHS study reported preliminary data on menstrual abnormalities. Amenorrhea (absence of menses for 90 days or more.) was shown to occur more frequently in HIV+ women. HIV infected women in this study were 3 times more likely to have lost their periods. It is even more common in women with T-cells under 50. Amenorrhea in HIV+ women was mostly attributed to a central cause, (hormonal malfunctioning from the brain), not from problems in the ovaries.
There were also several studies on wasting in women. Two studies showed that women tend to lose relatively more fat than men. Scientists think this may be due to declining levels of the female hormones estrogen and progesterone (the same hormones which make women "curvy" at puberty - due to fat deposits). This is in contrast to more muscle loss in men due to low testosterone.
Another study on wasting showed a 50% decrease of testosterone levels in women, related to wasting. Presumably, dysregulation or malfunctioning of both female and so-called male sex hormones in women contribute to wasting in women. (both men and women have both estrogen and testosterone normally). A study is going to begin to look at male-sex hormone replacement therapy in women. (Call-213. 343.8291for details.) A study on the use of megace for wasting in women reported that while women gained on average 6-8 pounds, the weight gain was not sustained when CD4s were under 50. (Megace is a synthetic progesterone.) The weight gain was associated with improved appetite. Decreased oral food intake is the number one cause of weight loss.
(Editors Note: Marinol in capsule form, is a highly successful therapy for appetite stimulation and weight gain. It is also commonly used to control nausea and vomiting associated with chemotherapy. Ask your doctor!)
This is the area perceived to be about women that is receiving the most attention. There is now the theoretical possibility of decreasing the rate of woman to newborn transmission down to 2%. This is still a goal, not a reality.
Maternal Viral Load & CD4s: Numerous studies reported increased transmission with high maternal viral loads. Currently, treatment should be aimed at both reducing viral loads and raising CD4 counts as much as possible. All studies seem to suggest a relationship between increased viral load, and increased chance of transmitting HIV to the fetus. However, some women with low viral loads do transmit, while others with high viral levels do not. Therefore, a specific "threshold", under which transmission will not occur has not yet been determined.
Duration of 2nd Stage Labor: Prolonged duration of time from full cervical dilation to delivery was found to be associated with transmission, suggesting that delivery should be rushed if possible.
Rupture of Membranes: Both inflammation and/or prolonged rupture of the placental membranes (bag of waters) were shown to be associated with increased transmission. This means that vaginal-cervical infections should be treated and prolonged rupture of membranes, should be avoided.
C-Sxn: Prevention of transmission by elective Cesarean section (C-Sxn) remains controversial. This year additional light was shed on the subject by studies which showed reduced transmission but only when C-Sxns were performed prior to the onset of labor and rupture of membranes.
Antiretroviral Therapy: Studies have been trying to determine which of the three treatment time points from the 076 perinatal transmission study are crucial for success; treatment of pregnant women during pregnancy or delivery, or treatment of the newborn. The answer is still not in, but one U.S. study did not treat the newborns, and showed comparable transmission rates to ACTG 076.
Finally studies are beginning to look at drug resistance and the use of combination therapy in pregnancy. Preliminary results show drug resistance rates similar to those from non-pregnant women.
Other Factors: Various other things associated with the risk of transmission are genital ulcers, having symptoms of HIV/AIDS and low levels of natural killer cells.
Women make up about 46% of all the AIDS cases. Compounded by the social factors which plague women regardless of HIV status, this situation is immensely complex.
Take Home Message
The take home message is that we are finally beginning to see some studies on women. Many questions, however, still remain unanswered. We don't know the impact of hormonal factors on the metabolism and effects of medications, or on the immune system nor on wasting and it's treatment. We have a long way to go and need the active participation by all of us to both prevent HIV infection, and to improve research opportunities, treatment and quality of life for women.
This article was provided by Women Alive. It is a part of the publication Women Alive Newsletter.