HIV, AIDS and Women's Health

By Dr. Liji Thomas, MDReviewed by Danielle Ellis, B.Sc.

Prevalence in women
Risk factors
Women at risk
HIV-related problems in women
References 
Further reading

The human immunodeficiency virus (HIV) is a retrovirus that, if left untreated, progresses to a life-threatening and ultimately fatal condition called acquired immunodeficiency syndrome (AIDS). This results from the virus targeting the CD4 T lymphocytes, responsible for specific cell-mediated immunologic defenses against opportunistic pathogenic bacteria, fungi, and viruses.

In the absence of curative treatment for HIV infection, the current recommendation is lifelong treatment with antiretroviral therapy (ART), which has brought the life expectancy of properly treated HIV-positive individuals on par with those of HIV-negative individuals.

However, given that most new cases arise because of unprotected sex with an infected partner, emphasis must be laid on avoiding casual sex encounters. Not only will this expose one to physical, mental and emotional pain and illness, but it will also reduce one's quality of life.

Prevalence in women

In the USA, about a fifth of newly diagnosed HIV cases are among cisgender women. Over 40% of transgender women are HIV-positive. Overall, about 20% of American HIV patients are female.

Black women are affected the most in both groups, making up 57% of newly infected cases in the former. Almost two-thirds of HIV-positive transgender women are Black, and over a third are Hispanic or Latina.

The risk of HIV infection is least for women who have only one sexual partner. Barring this, women must use condoms or pre-exposure or post-exposure prophylaxis (PrEP and PEP, respectively).

Risk factors

Risk factors for HIV infection include:

• Unprotected intercourse: The most common route is by intercourse with an HIV-positive man. There are several factors responsible for this, including:
  • the larger vaginal area compared to the area of the penis,
  • the longer contact time with semen in the vagina,
  • the higher concentration of HIV in semen, coupled with the larger volume of seminal secretions
  • the presence of STIs, or other infections, increases mucosal vulnerability to the virus.
• The second most common transmission route is using illegal drugs by self or a partner.
• Having intercourse in return for money or drugs or with someone who does this
• Using drugs or drinking before or during sex
• HIV-positive partner: Infection risk is especially high in early HIV, with half of all transmission in the USA happening during this period.
• Bisexual partner
• Having a sexually transmitted infection (STI)

Women at risk

Women are two to four times more likely to be infected with HIV by unprotected sex than men. However, they often lack the power to insist on condom use by their partners and may not even know about the benefit of this practice. Younger women are at higher risk because of their immature reproductive system.

Women over 50 are still at risk because they and their doctors may not consider HIV a possibility when they become symptomatic, may not use condoms because of the low chances of pregnancy, but may have more fragile and drier vaginal mucosa, which is more easily damaged during intercourse, making HIV transmission more likely with an infected partner.

Women are likely to be stigmatized, shunned, excluded, and even violently rejected by family, friends, society, and the medical system if they disclose their HIV status. Many women are helpless because of their lack of education and employable skills, fear for their children's future, and financial dependence. 

The forced secrecy prevents their seeking treatment and thus jeopardizes their health and lives.

Women may also get it from other women who have sex with an HIV-positive partner or if either partner uses HIV-positive semen for conception. Sharing needles with an HIV-positive individual, sharing sex toys, or having contact with menstrual blood from HIV-positive women, also promotes HIV transmission.

HIV-related problems in women

HIV affects females in some unique ways that are unique. For instance, HIV can cause issues during childbirth, most notably vertical transmission to the fetus; gynecological issues, including a higher risk of cervical cancer; cardiovascular disease (CVD); adverse effects and drug interactions; and problems as women grow older.

Gynecological problems in women living with HIV (WLWH)

STIs and other infections

HIV is associated with a higher risk of sexually transmitted infections (STIs), such as genital herpes, chancroid, and pelvic inflammatory disease. Both frequency and severity are likely greater in these cases if the woman has more than one sexual partner. Screening and treating such infections is important for her health and minimizing HIV transmission to her partners.

Vaginal candidiasis is more common and resistant to treatment in WLWH, often recurring four or more times a year.

Bacterial vaginosis (BV), when the normal vaginal flora is replaced by other bacterial pathogens, is also more frequently observed in WLWH and may be refractory to standard treatment.

Changes in menstrual function

Variations in periods may accompany HIV, with increased or decreased bleeding during menstruation, missed periods, or increased premenstrual syndrome symptoms.

Cervical cancer

The risk of cervical cancer is higher in WLWH, almost always linked to human papillomavirus (HPV) infection caused by high-risk serotypes 16 and 18. Regular Pap smears and vaccination against HPV are advisable in WLWH.

Importantly, cervical cancer also defines acute immunodeficiency syndrome (AIDS), marking the woman's transition to full-blown AIDS.

ART-related issues

HIV can be controlled completely with lifelong antiretroviral therapy (ART. However, some ART drugs, like nevirapine and ritonavir, can cause liver damage, skin rashes, nausea, and vomiting. ART can also promote metabolic alterations causing fat accumulation throughout the body, sometimes causing acute pancreatitis.

ART could also interact with other drugs the patient takes, whether prescribed or over the counter.

Age-related issues

As WLWH live longer, they may have a higher age-related risk of diabetes, cancer, arthritis, and CVD. Menopause may be earlier or its symptoms more severe. Postmenopausal CD4 T cell counts may fall due to reduced estrogen levels, increasing susceptibility to infection.

Heart disease related to HIV is a major cause of death in this group, even those on effective treatment. WLWH have threefold the risk of a heart attack as women without HIV.

Pregnancy and birth control

Fertility in WLWH is reduced by up to 40%, though the mechanism remains unclear. It could be due to HIV-induced premature ovarian failure. Still, this is more likely due to coexisting tuberculosis and other infections affecting the pelvic organs, coupled with risky behavior that increases STI risk.

WLWH needto change their HIV medications if they become or are planning to become pregnant. In addition, they will have to be careful to avoid infecting their partner if the latter is HIV-negative.

Vertical transmission is always a possibility, but the use of ART during the whole of pregnancy, along with its administration to the neonate for the first six weeks of life, can reduce this risk to 1%, provided breastfeeding is also avoided to prevent transmission of the virus to the baby through this route. A surgical mode of delivery may be recommended depending on the latest viral load reported in the mother.

Interruption of ART during pregnancy may occur for various reasons, including drug toxicity, acute maternal illness, hyperemesis of pregnancy refractory to standard treatment, or elective surgeries. This can lead to an increase in the viral load, possibly allowing disease progression and reduced immunity.

In turn, this may allow vertical transmission to the fetus, as reported in one study where third-trimester discontinuation of ART for six weeks led to vertical transmission in almost a fifth of pregnancies, for an almost 50-fold increase in the odds of transmission.

This requires counseling about multiple aspects of pregnancy and postpartum care, including mode of delivery, infant feeding, contraception, and infant testing and prophylaxis – both pre- and post-exposure. Again, smoking, drug and alcohol use and STIs are risk factors for vertical transmission. Mothers should be encouraged to stop using such substances and be screened for STIs to initiate appropriate treatment.

For WLWH on birth control, HIV ART may reduce the efficacy of hormonal contraception, and condoms remain the only way to avoid transmitting the virus, as well as STDs, to one's partner.

References

• HIV and Women's Health Issues. Retrieved from https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/womens-health-issues. Accessed on September 28, 2022.
• HIV: Protecting the Health of All Women. (2022). Retrieved from https://www.hiv.gov/blog/hiv-protecting-health-all-women. Accessed on September 28, 2022.
• Women and HIV (2021). Retrieved from https://www.womenshealth.gov/hiv-and-aids/women-and-hiv#7. Accessed on September 28, 2022.
• HIV and Specific Populations: HIV and Women. (2021). Retrieved from https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-and-women. Accessed on September 28, 2022.
• Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States. Retrieved from https://clinicalinfo.hiv.gov/en/guidelines/perinatal/overview. Accessed on September 28, 2022.
• Tannenbaum, I. (1992). The impact of HIV on women: gynecology, pregnancy, and family planning considerations. SIECUS Report. Available at https://pubmed.ncbi.nlm.nih.gov/12317731/.
• Paudel, V. et al. (2015). Women living with HIV/AIDS (WLHA), battling stigma, discrimination and denial and the role of support groups as a coping strategy: a review of literature. Reproductive Health. https://doi.org/10.1186/s12978-015-0032-9. https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-015-0032-9#citeas

Further Reading

• All HIV Content
• The Economic Impacts of AIDS
• Recent Advancements in Treating HIV