Clinical Management of the HIV-Infected Woman
A Podcast Discussion With Kimberly Smith, M.D., M.P.H., and Valerie Stone, M.D., M.P.H.
December 11, 2009
Bonnie Goldman: Moving right along, let's turn to: What are the non-infectious comorbidities that are more common in HIV-infected women? Dr. Smith?
Kimberly Smith: You could debate whether it's non-infectious, certainly, one of the ones that stands out the most is cervical cancer. That obviously modifies our management for women, although I will say that men are starting to catch up in the sense that now we're doing rectal Pap smears that are parallel to the cervical Pap smears that we have been doing for women forever.
Valerie Stone: I would add that we know that obesity is most common in African-American women in the United States. Probably, obesity is most common in that subset of people living with HIV.]
I think that I have seen data on that. I have not seen data that shows clearly that diabetes or high blood pressure are most common with either women with HIV or women of color with HIV. But it follows that it may be the case, particularly diabetes.
Kimberly Smith: I agree with you about the obesity issue. But if we think about hepatitis C, we're not seeing that more commonly in women than in men. Same thing would be true for hepatitis B; not more common -- if anything, it's less common in women than in men.
Some of the typical comorbidities that we're managing the most are cardiovascular disease related, but they are not more common in women.
It's not like HIV disease transforms women into something different than what they are when they are not HIV infected. The differences that exist between men and women who aren't HIV infected are obviously not changed. I can't think of anything that HIV adds to the mix, other than the AIDS-associated cancers. There's really not a big gender difference.
Valerie Stone: I do think that mental health challenges are common in HIV-infected people, but that depression is clearly more common in HIV-infected women than men. And it's quite prevalent.
I also think that a history of substance abuse, particularly serious substance abuse, tends to be more common in women living with HIV than men.] Of course, that depends on the population you look at. But when you look at a very mixed population like we follow here at Massachusetts General Hospital, it's clear that there are more challenges with substance abuse in the women, compared to the men.
There is a lot of underreporting of the alcohol abuse and other substance abuse among gay men.] But for the ones that underreport it, it often is in the range where they are functional. So I do think the challenges in that regard are greater for women than for men with HIV.
Bonnie Goldman: What are the primary care guidelines regarding monitoring for cervical cancer? Dr. Smith?
Kimberly Smith: I know there's this debate now about whether they should be spread out for HIV-negative women (i.e., not done every year, but done every couple of years). For HIV-infected women, there hasn't been a change. Basically, HIV-infected women should be screened at least every year and, arguably, every six months if they've ever had an abnormal Pap smear. There's not really been much change from that standpoint. The controversy with HIV-negative women is that there's some suggestion that we're probably overdoing it by doing Pap smears every year; and that they probably can be spread out to every two years for women who have never had an abnormal Pap, and maybe even further than that; and that you don't need to start doing them until women are at least 21 years of age.
It's controversial, and it should be. Because, depending on the populations that you're talking about, if you don't start looking for some of the women who may be at more high risk until they are 21, you may be finding more women with more advanced disease that you could have caught earlier if you were starting earlier. But it really depends on the population that you're talking about.
Bonnie Goldman: In closing, do you think that with the growth in the numbers of female researchers that more questions will be answered about gender differences in HIV? Dr. Stone?
Valerie Stone: I think that there's a wide range of different questions out there, and I think that there's a tremendous amount of interest in disparities in the care of women with HIV among women researchers. I've been really impressed with new data and important new questions in that regard, that we've seen with the growth of women researchers and researchers of color.
I think, when it comes to clinical trials, Dr. Smith is better equipped to answer this than me; but I think that we've been seeing a growth in the number of women researchers over the past 10 to 15 years. I think that there's been incredible progress in the approach to getting women in clinical trials, and also in cohort studies that have enrolled women, followed them closely, and answered a lot of important clinical questions - as in, for example, both HERS [Heart and Estrogen/progestin Replacement Study] that the CDC [U.S. Centers for Disease Control and Prevention] funded and, over the past 10 years or so, WIHS, which the NIH [U.S. National Institutes of Health] has funded.
So, I think the answer is yes, but I think we've been seeing that for a few years now.
Bonnie Goldman: Dr. Smith?
Kimberly Smith: I think that what has happened in the last few years is that women researchers have been pushing for there to be more industry-based studies that enroll higher numbers of women, and that there's an effort to really study drugs as they come out in large numbers of women. I do think that the FDA [U.S. Food and Drug Administration] has somewhat responded to that demand, and so we are starting to see some of the larger studies making sure that they enroll a substantial proportion of women.
Some studies -- for example, the GRACE study -- are being designed specifically to look at newer drugs in women. I think that move is an important one. If we don't have enough women in the trials from the beginning, then we won't identify drug toxicities that may be more prevalent in women until very late into the process, years after they have been approved. So I do think that those demands coming from female HIV investigators have started to bear some fruit.
Obviously, WIHS has contributed a tremendous amount to our understanding about HIV disease in women. What we're getting from that is invaluable. It's one thing to be able to answer some questions in cohort studies, sort of understanding the natural history of HIV disease in women, which is a lot of what WIHS is able to do.
What other groups, like the ACTG, have done, and are continuing to do, are answer more clinical trial type questions. One of the big ACTG studies that is enrolling at present, is the PROMISE [HAART Standard Version of the Promoting Maternal and Infant Survival Everywhere] study, and it is looking at whether women who have a high CD4 cell count and are basically only starting therapy because they are pregnant -- and might not otherwise, based on the guidelines, need therapy -- are better off.
Once they deliver, should they stay on antiretroviral therapy, or should they go off treatment until their T-cell count drops down to a point where they would need therapy based on the guidelines? Questions like that are everyday types of questions that are really important for us to answer for women for their long-term health. They are controversial questions. But I think it's important to be doing those studies.
The experience of female HIV investigators, as well as that of some male HIV investigators that have taken an interest in women, has led to a number of unanswered questions. I think that we're beginning to start to see studies that are really designed to answer those questions. I'm encouraged that there's a lot more important information coming forward in the future.
Bonnie Goldman: Thank you so much, Dr. Smith and Dr. Stone, for an enlightening discussion. There's so much to cover, and so little time, this was a good beginning, thanks again!
This transcript has been lightly edited for clarity.
To view the previous installment in HIV Management Today, "New Paradigms of First-Line HIV Therapy: Determining When (and With What) to Start," click here.
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