Physician's Weekly Article - Considering Gender Differences in HIV

       Women are increasingly being infected with HIV, but clinicians can better manage this patient population by considering the unique issues they face with regard to diagnosis and treatment.

      HIV has long been considered a disease restricted to homosexual men and injection drug users, but research has shown that heterosexual women account for more than 25% of all new HIV and AIDS diagnoses in the United States. This figure represents a significant increase from the 7% new diagnosis rate observed in 1985. “Although homosexual activity is still a major reason for transmission of the infection, the most common way women contract the infection is through heterosexual activity,” says Kathleen E. Squires, MD. “HIV is now appearing in women of all ages, but most often among those of reproductive age. Despite these climbing rates among women, many doctors still talk about HIV as if it’s a male disease.”

      A survey of 700 HIV-positive women in the U.S. revealed that the stigma associated with HIV is particularly substantial among women (Table 1). More than half of HIV-positive women felt that they could have children if they received the appropriate medical information and support, but just as many believed that society strongly urges them not to have children. Only four in 10 respondents recognized that they should discuss pregnancy plans with their doctor well before getting pregnant. Additionally, more than half of respondents said their providers never discussed how treatments for the disease affect women differently than men.

      Wanted: Open Dialogue

      “Misconceptions among physicians and providers regarding gender and HIV are a significant concern,” Dr. Squires says. “For example, infected women—particularly those in monogamous relationships—may not be tested promptly, which can delay an HIV diagnosis. Even when women present with symptoms of HIV, physicians often won’t think to administer an HIV test, and women won’t ask for one. For physicians, it’s important to move away from the notion that HIV only affects certain kinds of women. The bottom line is that if a woman is sexually active, she should be considered for HIV testing. The communication lines need to open so that the social stigma associated with the infection can be overcome.”

      Discuss Pregnancy Plans

      Dr. Squires says that women who are diagnosed with HIV report that doctors often fail to discuss issues like pregnancy and contraception with them (Table 2). “The CDC now recommends that all pregnant women—regardless of risk-factor status—be offered HIV testing. If other common risk factors are present, then more frequent testing may be required. Although women who are newly diagnosed with HIV are not typically planning to get pregnant in the near future, providers must remember that these feelings can change over time.”

      Studies have shown that the risk of transmitting HIV from mother to baby can reach less than 1% with aggressive treatment and good prenatal care. “By bringing up the topic of pregnancy early and revisiting it throughout treatment, physicians can help ensure that their patients will make the necessary changes to minimize their chances of passing the infection to their fetus,” says Dr. Squires. “When assessing women with HIV who are of childbearing age, there should be a full discussion about the management of their reproductive potential, their hopes and aspirations, and whether or not they need to be on medication. If and when treatment is initiated, it’s important to follow current guidelines and consider drug-drug interactions between antiretroviral therapy and other medications—including oral contraceptives—when selecting treatment regimens.”

      Gender-Specific HIV Therapy Side Effects

      Many clinicians do not talk with their patients about gender-specific side effects of some HIV medications, says Dr. Squires. “Many people with HIV don’t start medication as soon as the diagnosis is made because there are risks and benefits for existing therapies. However, women planning to get pregnant in the near future can consider starting therapy early to help control viral replication. The goal is to get the viral load as low as possible to decrease the risk of HIV transmission to the fetus.”

      More information about gender differences in HIV continues to surface, and Dr. Squires says it is important to discuss all drug options and associated side effects with women so that they make informed choices. “Women need to be told about HIV medications that can lower the effectiveness of oral contraceptives. They also should understand that the risk of lipodystrophy—either fat wasting or fat accumulation—and lactic acidosis is higher in women taking some antiretroviral regimens. The key is to recognize warning signs of these potential complications and to discuss them with patients so that they know what to expect.”

      Kathleen E. Squires, MD, has indicated to Physician’s Weekly that she has received grant/research support from Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Koronis, Merck, Schering-Plough, and Tibotec. She has also been on the scientific advisory board for Abbott, Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Koronis, Merck, Pfizer, Schering-Plough, Tibotec, and Tobira, and has been a consultant at Merck.