WOMEN & HIV DISEASE

1. WOMEN & HIV DISEASE Janet L. Mitchell, M.D., M.P.H., F.A.C.O.G. Director of Outreach Department of OB/GYN & Reproductive Medicine Lincoln Medical & Mental Health Center Bronx, NY

2. Epidemiology • HIV Care • Gynecological • Obstetrical

3. EPIDEMIOLOGY

4. AIDS Incidence* for Women and Percentage of AIDS Cases, January 1986 - June 1999, United States 8,000 30 25 6,000 20 Percent of Cases Number of Cases 4,000 15 10 2,000 5 0 0 1990 1993 1986 1987 1988 1989 1991 1992 1994 1995 1996 1997 1998 1999 Half-Year of Diagnosis* *Adjusted for reporting delay

5. AIDS Rates per 100,000 Women Reported in 1999 2.1 * 2.0 * * 1.8 1.7 1.2 1.2 NH 1.3 30.0 1.6 14.8 MA 2.5 3.4 RI 7.2 9.2 1.2 CT 13.0 1.9 1.8 4.6 19.6 NJ 2.0 2.1 5.5 2.1 0.9 14.1 DE 2.5 7.4 5.2 MD 21.0 2.7 3.6 93.4 DC 6.7 5.9 1.5 0.9 4.7 3.0 15.0 Rate per 100,000 <5 6.3 9.1 13.4 _ 7.4 5 9.9 11.0 10+ 23.2 * * <5 cases VI 30.1 PR 21.3 1.6 US rate: 9.3 N=10,780

6. Women 15-34 Years of Age Living with HIV Infection* and AIDS,1999 107 16 5 4 2 208 67 60 2 24 184 10 24 65 450 13 1 MA 2864 400 5 4 183 RI 47 CT 40 20 353 688 62 20 77 176 263 570 NJ 951 1716 57 28 395 192 110 DE 65 1150 67 178 68 893 MD 348 664 13 36 61 277 69 303 DC 182 1372 301 807 283 257 221 76 160 49 35 17 932 345 95 747 HIV AIDS 653 543 202 487 213 N=15,190 N=16,318 1258 1196 Confidential HIV Reporting** 404 2727 8 2447 PR VI 17 Required 18 30 563 Pediatric only * For areas with confidential HIV infection surveillance. Includes 180 women who were residents of areas without HIV infection surveillance but who reported by areas with HIV infection surveillance. **HIV cases reported by patient name † Confidential HIV infection surveillance initiated in 1999.

7. AIDS Cases and Rates in Adult/Adolescent Women, by Race/Ethnicity, Reported in 1999, United States Rate per Percent 100,000 Race/Ethnicity Number 2 1,924 18 White, not Hispanic 63 Black, not Hispanic 6,784 49 Hispanic 1,948 18 15 63 1 1 Asian/Pacific Islander American Indian/ <1 40 5 Alaska Native 10,780 100 9 Total* *Includes 21 women of unknown race/ethnicity

8. AIDS in Women, by Exposure Category Reported in 1999, United States Sex with men of Sex with other or injection drug user Heterosexual † unspecified risk 11% transmission 29% 40% Other/ not identified* Injection drug use 32% 27% Transfusion recipient 1% *Includes patients whose medical record review is pending; patients who died, were lost to follow-up, or declined interview and patients with other or undetermined modes of exposure; Includes sex with a bisexual male, a person with hemophilia, a transfusion recipient with HIV infection, or an HIV-infected person with an unspecified risk †

9. AIDS in Women, by Exposure Category and Age at Diagnosis, Reported in 1999, United States Age at Diagnosis (in years) 13-19 20-29 30-49 50+ Exposure Category N=180 N=1,289 1,929 N=7,361 % % % % Injection drug use 9 17 32 17 47 39 37 42 Heterosexual contact Transfusion recipient 2 2 1 1 Other/not identified* 29 38 36 49 *Includes patients whose medical record review is pending; patients who died, were lost to follow-u p, or declined interview and patients with other or undetermined modes of exposure

10. AIDS Rates per 100,000 Women, by Region and Race/Ethnicity, Reported in 1999, United States 120 White, not Hispanic 104.0 Black, not Hispanic 100 Hispanic 80 57.1 60 Rates per 100,000 46.9 40 28.0 18.1 20 8.8 6.2 4.4 3.6 2.5 2.3 1.0 0 Northeast South North Central West N=4,128 N=4,581 N=759 N=947 Region* *Excludes Puerto Rico and territories

11. HIV CARE

12. “Women should be treated for their disease first.”

13. AIDS Cases by Age and Sex Reported 1981-1999, United States 40,000 35,000 Male N=609,326 Female N=124,045 30,000 25,000 Number of Cases 20,000 15,000 10,000 5,000 0 0 10 20 30 40 50 70 80 90 60 Age at Diagnosis

14. Trends in Annual Rates of Death from Leading Causes of Death Among Black Women 25-44 Years Old, USA, 1982-1998 National Center for Health Statistics National Vital Statistics System *Preliminary 1998 data

15. Trends in the Percentage Distribution of Deaths from HIV Infection, By Sex, USA, 1987-1997 National Center for Health Statistics National Vital Statistics System

16. Trends in the Percentage Distribution of Deaths from HIV Infection, By Race, USA, 1987-1997 *Asian, Pacific islander, or American Indian National Center for Health Statistics National Vital Statistics System

17. Age-adjusted* Mean Rate of Death from HIV Infection during 1993-1997, By Race / Ethnicity and Geographic Region, USA *Adjusted to the age distribution of the projected year 2000 U.S. population National Center for Health Statistics, National Vital Statistics System

18. Is the Disease Different? • Diagnosis • Presenting complaints • Presenting diagnosis • Presentation • Heterosexual • Over 50 age group • Treatment response • CD4/Viral load • Response to therapies

19. HIV Care • Anti-retrovirals • Prophylaxis • Co-morbid conditions

20. Pharmacokinetic of Indinivir in Menstruating Womenn=6 (age 37±5.4 years, CD4 count 354±137 cells/mm3)

21. GYNECOLOGICAL CARE

22. Women’s Health Issues • Very symptomatic women can develop amenorrhea • No data on the effects of the disease on endocrine status • No data on whether HIV may cause early menopause • Lipodystrophy

23. Gynecological Issues • Abnormal Pap Smears • Pelvic Infections • Vulvovaginal Candidiasis • Sexually Transmitted Diseases (STD’s) • Other Infections • Contraception • Menstruation • The Breast • Menopause

24. Abnormal PAP Smears • Epidemiology • Methodology of PAP Smears • Frequency • Role of Colposcopy • Role of Human Papilloma Virus (HPV)

25. Pelvic Infections • Predisposing Factors • Historical Perspectives • Diagnosis • Treatment

26. Vulvovaginal Candidiasis • Historical Perspective • Definition • Diagnosis • Treatment

27. STDs & Other Genital Infections • Syphilis • Other ulcerative infections • Non-ulcerative infections • Other common vaginal infections

28. Contraception • Abstinence • Barrier methods • Hormonal methods • IUD ?

29. Other Gynecological Issues • Menstruation • Breast lesions • Menopause

30. Menopause • 16% of women diagnosed with HIV > age 45 • CVD leading cause of death after menopause • High rates of HTN and DM in women of color

31. Menopause • Ovarian senescence •  HDL &  cholesterol • Accelerated bone loss •  Cardiovascular Disease (CVD/CAD) • Hot flashes • Atrophic vaginitis • Mood changes

32. Death Rates by Age

33. Replacement Therapy • Estrogen vs. Estrogen/Progestin • Tamoxifen positive effect on lipids & bone density • Raloxifene approved for osteoporosis • Megace and testosterone also used as treatment in HIV

34. “Lipodystrophy”What does it mean?

35. OBSTETRICAL CARE

36. Mother's Exposure Category by Year of Child's Birth for Perinatally Acquired AIDS, 1980-1998, United States 70 Injection drug use 60 50 40 Heterosexual contact Percent of Cases 30 Mother's risk not specified 20 Transfusion 10 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 Year of Birth

37. AIDS in Children <13 Years of Age by Exposure Category Reported in 1999 and Cumulative, United States Cumulative Exposure Category 1982-1999 1999 % Number Number % 232 88 7,943 91 Perinatally acquired 4 2 379 1 Transfusion-associated 235 3 3 1 Hemophilia 26 2 10 161 Other/not reported 100 100 8,718 263 Total

38. AIDS Cases in Children <13 Years of Age, Reported in 1999 and 1999 Population Estimates of Children, by Race/Ethnicity United States U.S. Children AIDS Cases N=51,667,000 N=263 63% 13% 65% 1% 1% 1% 4% 21% 18% 14% Asian/Pacific Islander White, not Hispanic Black, not Hispanic American Indian/ Alaska Native Hispanic

39. Percent of Perinatally HIV Exposed or Infected Children who Received or whose Mothers Received any ZDV* Born1993-March 1999 in 34 States,‡ United States 100 80 60 Percent Receiving Zidovudine 40 20 0 1996 1993 1994 1995 1997 1998 1999 N=1343 N=1437 N=1371 N=1393 N=1466 N=1389 N=302 Quarter-Year of Birth *Any ZDV=Prenatal, intrapartum, or neonatal receipt of Zidovudine to reduce perinatal HIV transmission Includes 34 areas that conduct pediatric HIV Surveillance; data reported through December 1999

40. Time of Maternal HIV Testing among Children Perinatally Exposed or Infected or with AIDS, Reported in 1999,* United States Perinatally Acquired AIDS HIV Exposed** HIV Infected** N=232 N=1966 N=197 Time of maternal HIV test No. % No. % No. % Before or at birth 81 35 1844 94 132 67 After birth 75 32 71 4 39 20 Unknown 76 33 51 3 26 13 • * Excludes 31 children with AIDS reported in 1999 whose HIV exposure category was unknown or other than perinatal ** From 34 areas with confidential pediatric HIV infection surveillance

41. Pregnancy • Pregnancy does not accelerate HIV disease • Stage of HIV disease can impact pregnancy outcome • Perinatal transmission rates depend on multiple factors • The use of anti- retrovirals for the treatment of the woman’s disease  transmission rates

42. Perinatal Transmission Rates • Zidovudine/ ACTG 076 • Combination therapy/HAART • Elective c/section

43. Antiretroviral Pregnancy Registry 1410 Commonwealth Drive Wilmington, NC 28403 telephone (800) 258-4263 fax (800) 800-1052

44. http://hab.hrsa.gov/womencare.htm

45. CDC WEBSITE:http://www.cdc.gov/hiv/graphics.htm