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Women and HIV

Women and HIV. Lucille Sanzero Eller, PhD, RN Associate Professor Rutgers, The State University of New Jersey College of Nursing A Local Performance Site of the NY/NJ AETC September 2009. Objectives (1). 1. Discuss the epidemiology of HIV in women.

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Women and HIV

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  1. Women and HIV Lucille Sanzero Eller, PhD, RN Associate Professor Rutgers, The State University of New Jersey College of Nursing A Local Performance Site of the NY/NJ AETC September 2009

  2. Objectives (1) 1. Discuss the epidemiology of HIV in women. 2. Describe gender-specific symptoms in HIV+ women. 3. Discuss ARV treatment considerations for HIV+ women.

  3. Objectives (2) 4. Identify psychological factors in HIV+ women. 5. Discuss contraception and pregnancy in HIV+ women. 6. Describe assessment and counseling issues for women with HIV.

  4. Epidemiology of HIV in Women (1) • Proportion of AIDS cases in women steadily increased since HIV epidemic began • 1985 - 8% women • 2006 - 27% women • Women of color disproportionately infected • Black and Hispanic women comprise • 25% of U.S. female population • 82% of women withHIV in the U.S.

  5. Epidemiology of HIV in Women (2) • HIV infection in women in 2004 • leading cause of death for black women aged 25 to 34 years • 3rd leading cause of death for black women aged 35–44 years • 4th leading cause of death for black women aged 45–54 years and for Hispanic women aged 35–44 years (CDC, May 2006)

  6. New AIDS Diagnosis Black 66% White 16% Latina 16% Other 1% CDC, HIV/AIDS SurveillanceReport, Vol. 17, Revised Edition; June 2007. U.S. Female Population Black 12% White 69% Latina 13% Other 6% Race/ethnicity of Women 2005: New AIDS Diagnoses and Percentage of U.S. Population (CDC, 2007)

  7. HIV Transmission in Women • Most common routes of HIV infection for women • sex with an HIV-positive man • sharing injection drug works with someone with HIV • Male to female transmission is 1.9 times more effective than female to male transmission; women are about twice as likely as a man to contract HIV infection during unprotected vaginal intercourse

  8. Viral load • Viral load in women • After adjustment for differences in measurement method, baseline CD4+ cell count, age, and clinical symptoms, HIV-1 RNA levels were 32% to 50% lower in women than in men at CD4+ counts >200 cells/mm3 • Despite lower viral loads, HIV disease progresses at the same rate in women as in men (Rezza et al., 2000) • Current clinical guidelines do not make a distinction by gender for the initiation of HAART

  9. HIV-related Hormonal Changes (1) • HIV can affect the body's ability to produce and maintain hormone levels • Changes in the balance of estrogen, progesterone, or testosterone can lead to multiple symptoms (Margolese, 2004)

  10. HIV-related Hormonal Changes (2) • Symptoms of hormonal imbalance: • Abnormal menstrual cycles, possibly including early menopause • Weight loss • Headaches • Mood swings • Depression

  11. HIV-related Hormonal Changes (3) • Symptoms of hormonal imbalance: • Sleep disturbances • Fatigue • Decreased bone density • Vaginal dryness • Lack of sexual desire • Difficulty getting pregnant

  12. HIV and Menstrual Problems (1) • Menstrual cycle changes • Increase in premenstrual symptoms • Changes may be due to • HIV itself • ARVs • other co-factors that may occur with HIV disease such as drug use

  13. HIV and Menstrual Problems (2) • Hypermenorrhea- predisposes women to anemia, already a chronic problem in women with HIV • Amenorrhea- promptly evaluate for underlying causes • pregnancy • ovarian cyst • ovarian failure and premature menopause

  14. HIV and Osteopenia • Bone density in HIV+ (n=263) and HIV- (n=232) women 40 years and older (Arnsten et al., 2006) • Osteopenia prevalence regardless of ART use: • 27% in HIV+ women • 19% in HIV- women • Higher risk of osteopenia if: • Black • Underweight • Used opiates

  15. HIV and Menopause (1) • “Ms Study” examined natural history of menopause in HIV-infected and drug using women(Schoenbaum, 2005) • 571 women, 52.9% HIV positive • median age 43 years • 53% with history of illicit drug use • 89% women of color

  16. HIV and Menopause (2) • Onset of menopause significantly differed: • 46 years [Interquartile Range (IQR) 39-49 years] for HIV+ women • 47 years [IQR 39-48 years] for HIV- women • Those with CD4+ counts <200 cells/mm3 had earliest onset (median age 42.5 years)

  17. HIV and Menopause (3) • No association between receipt of HAART and onset of menopause • Earlier onset of menopause combined with HIV disease contributes to risk of dyslipidemia and osteopenia

  18. AIDS Complications in Women (1) • AIDS complications unique to women: • recurrent vaginal candidiasis • severe pelvic inflammatory disease • cervical dysplasia • cervical cancer

  19. AIDS Complications in Women (2) • HIV+ women at higher risk of cervical dysplasia, a precursor to cervical cancer • Risk of cervical cancer associated with: • immune deficiency (declining CD4 counts and higher HIV RNA levels) • human papillomavirus (HPV) which occurs in more than 60% of women with HIV (Abularach & Anderson, 2005)

  20. HIV and Cervical Cancer (1) Cervical Cancer • Incidence is up to 9 times higher in HIV+ women • Presents at more advanced stages • Is less responsive to therapy

  21. HIV and Cervical Cancer (2) • CDC Pap screening recommendations: • Pap smear when first diagnosed, and again 6 months later; then once yearly for life • Women with cervical abnormalities or CD4 counts <200 cells/mm3 should be screened every 6 months for life

  22. HIV and Oral Symptoms • Studies have shown a significant relationship between high viral loadand both oral candidiasis and hairy leukoplakia (Greenspan et al, 2000; 2004; Patton et al., 2000) • Recurrence and incidence of candidiasis are reduced by HAART,and that recurrence is reduced independent of CD4 count and HIV RNA level • HAART does not reduce the incidence of hairy leukoplakia or oral warts in women (Greenspan et al., 2004

  23. HIV and Women: Studies (1) • The Women's Interagency HIV Study (WIHS) • established in 1993 • investigated the impact of HIV infection on women • recruited 2066 HIV-positive and 575 HIV-negative women from six sites in the U.S. • The Women and Infants Transmission Studies (WITS) • multi-site observational study established in 1989 • enrolled 2336 HIV-infected pregnant women and 1887 infants born to them

  24. HIV and Women: Studies (2) • 10 primary care sites in the HIV Research Network (HIVRN) (N=19,500)(Gebo et al., 2005) • HIV+ women less likely than HIV+ men to receive prescriptions for the most effective treatments for HIV infection

  25. HIV and Women: Studies (3) • Those less likely to receive clinically indicated ART: • <40 y.o.; women; African-Americans; IDUs; the uninsured or those with private insurance • Those more likely to receive clinically indicated ART: • older patients; men; Whites; Hispanics; those with risk factors other than IDU; those with Medicare coverage

  26. HIV and Women: Treatment (1) Recommendations for treatment of women of reproductive age: • Indications for initiation of therapy and goals of treatment are same as for other adults and adolescents • Avoid Efavirenz for the woman who wants to become pregnant or who does not use effective and consistent contraception Panel on Clinical Practices for Treatment of HIV Infection, 2008

  27. HIV and Women: Treatment (2) Recommendations for treatment of women of reproductive age: • For the woman who is pregnant, an additional goal of therapy is prevention of mother-to-child transmission, with a goal of viral suppression to <1,000 copies/mL • Selection of an ARV combination should consider known safety, efficacy, and pharmacokinetic data of each agent during pregnancy (Panel on Clinical Practices for Treatment of HIV Infection, 2008)

  28. Lipodystrophy Syndrome (1) • Metabolic and clinical features include: • insulin resistance • impaired glucose tolerance • type 2 diabetes • hypertriglyceridemia • hypercholesterolemia • increased free fatty acids (FFA) • decreased high density lipoprotein (HDL) • fat redistribution

  29. Lipodystrophy Syndrome (2) Factors that increase risk of lipodystrophy syndrome include: • increasing age • current use and total duration of antiretroviral therapy, including NRTIs and PIs, but not NNRTIs Carr, A. (2003). HIV lipodystrophy: risk factors, pathogenesis, diagnosis and management. AIDS, 17 (1), S141-S148.

  30. Lipodystrophy Syndrome (3) • Also associated with lipodystrophy are: • Gender • AIDS diagnosis • greater CD4 lymphocyte and HIV RNA responses to antiretroviral treatment • low body weight pre-therapy • elevated C-peptide and triglyceride levels after about 1 year of therapy • use of the dual PI combination ritonavir–saquinavir • use of thymidine analogues Carr, A. (2003). HIV lipodystrophy: risk factors, pathogenesis, diagnosis and management. AIDS, 17 (1), S141-S148.

  31. Lipodystrophy Syndrome (4) In a study of 2258 patients, women were twice as likely as men to have lipodystrophy Morphologic AlterationWomenMen Fat loss only 9.3% 12.2% Fat accumulation only 10.1% 7.7% Both fat loss & accumulation 22.4% 9.7% Galli M, Veglia F, Angarano G, et al. Correlation between gender and morphologic alterations in treated HIV patients. Program and abstracts of The 1st IAS Conference on HIV Pathogenesis and Treatment; July 8-11, 2001; Buenos Aires, Argentina. Abstract 505

  32. Lipodystrophy Syndrome (5) Morphologic changes of lipodystrophy syndrome vary by gender: Women tend to experience fat accumulation in the abdomen and breasts Men tend to experience fat depletion from the face and extremities

  33. Contraception (1) • WIHS study- effects of hormonal contraceptives on HIV RNA and CD4 counts (Cejtin et al., 2003) • 1721 women 50 y.o. or less, not menopausal • controlled for CD4 count, tobacco use, age, race, ART use, and a history of AIDS-defining illnesses • No effect on viral load; small increase in CD4 count, not clinically significant

  34. Contraception (2) • WIHS study- effects of hormonal contraceptives on effectiveness of HAART (Chu et al., 2005) • 77 hormonal contraceptive users matched with non-users on age, race, and pre-HAART CD4 count and viral load • Followed from point of HAART initiation • No effect on CD4+ cell count and viral load responses to HAART

  35. Contraception (3) • Hormonal contraceptives can interact with ARVs and cause any of the following: • decreased contraceptive effectiveness • increased concentrations of the ARV • decreased concentrations of the ARV e.g. Fos-Amprenavir should not be co-administered with hormonal contraceptives • Amprenavir increases blood levels of both estrogen and progestin • oral contraceptives decrease Amprenavir levels

  36. Contraception (4) • Copper IUDs • are associated with increased menstrual flow and duration • May contributing to HIV transmission risk • May contribute to anemia in HIV+ women

  37. Stigma • Stigma of HIV disease has several negative consequences • secrecy and unwillingness to disclose serostatus • fear of being identified as HIV positive • isolation • reduced access to care • difficulties with medication adherence • unwillingness to seek social support (Carr & Gramling, 2004)

  38. Social Support (1) • Social support includes the provision of • Emotional support • esteem • affiliation • Instrumental support • financial • housing • Informational support • advice • information

  39. Social Support (2) • Women with HIV receive less social support than demographically similar women • Social support decreases as symptoms of HIV increase (Hough et al., 2003; Klein et al., 2000) • Social support reduces psychological distress and is a critical element in effective coping with HIV (Hough et al., 2005)

  40. Social Support: INSPIRE Study (1) • Baseline data of INSPIRE (Interventions for Seropositive Injectors-Research and Evaluation) study (Knowlton et al., 2006) • Examined role of social support in facilitating effective HAART use in 446 IDUs • 34% female, 69% Black, 26% homeless, median age 43 years

  41. Social Support: INSPIRE Study (2) • Adjusted odds of undetectable viral load (UVL) 3X higher in those with • high social support • stable housing • CD4 > 200 • Adjusted odds of achieving UVL almost 60% higher (AOR = 1.57) in those reporting better patient-provider communication

  42. Social Support: INSPIRE Study (3) • Interventions to facilitate effective HAART use in IDUs should promote • social support functioning • patient-provider communication • stable housing • drug abuse treatment (Knowlton et al., 2006)

  43. Social Support • Study of social support in 147 poor, young (M=36 y.o., SD=7) urban, African American (87%) mothers with HIV (Hough et al. 2005) • 47% of primary support network, who provided the most salient support, were children • few friends, and almost no health care providers were reported as sources of social support

  44. Social Support: Assessment • Scale to assess social support in HIV+ women and abused women is the Interpersonal Support Evaluation List (ISEL) (Cohen et al., 1985) • Scale available at http://www.psy.cmu.edu/~scohen/ISEL.html

  45. Social Support: Study of Unsupportive Social Interactions (1) • Presence of friends, family, significant others is not necessarily supportive • Unsupportive social interactions may be detrimental • Study of relationship-specific unsupportive social interactions and depression in 146 HIV+ women (Scrimshaw, 2003)

  46. Social Support: Study of Unsupportive Social Interactions (2) • 28% asymptomatic, 29% symptomatic, 43% with AIDS • Mean age 35.6 years (SD D 5.6) • African American (33%), Puerto Rican (34%), White (33%) • Incomes: 36% < $10,000; 48% $10,000 and $19,999; 26% $20,000+ • 70% married or steady partner • 73% mothers • 55% IVDUs

  47. Social Support: Study of Unsupportive Social Interactions (3) • Unsupportive social interactions from family • direct negative effect on depressive symptoms • Unsupportive interactions from a lover/ spouse and friends • interactive effect on depression • independently predicted high levels of depressive symptoms (Scrimshaw, 2003)

  48. Social Support: Study of Unsupportive Social Interactions (4) • Number of HIV-related physical symptoms significantly associated with more unsupportive social interactions from all three sources: • family • lover/spouse • friends (Scrimshaw, 2003)

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