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Researchers examine treatment issues for HIV-infected women

Use of highly active antiretroviral therapy (HAART) to treat infection with the human immunodeficiency virus (HIV) that causes AIDS has prolonged life and revolutionized patient care since its introduction in April 1996. Yet questions remain about who does and does not have access to the latest and most potent therapies. According to a recent study, women who are college-educated, not black, privately insured, and have no history of injection drug use are much more likely to receive HAART than other women.

A second study focused on evaluation and management of HIV infection in women. According to the author, the rate of newly diagnosed cases of AIDS in the United States is growing fastest among women who are infected with HIV primarily through heterosexual transmission. About 60 percent of these women are black and 18 percent are Hispanic. They usually are diagnosed when they seek medical attention for a gynecologic infection. The author uses a question and answer format to address treatment issues specific to HIV-infected women.

Both of these projects are from the Women's Interagency HIV Study (WIHS), which is funded through a cooperative agreement between the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality. The WIHS is a multicenter investigation of the natural history of HIV disease in women. The two studies are described here.

Cook, J.A., Cohen, M.H., Grey, D., and others. (2002, January). "Use of highly active antiretroviral therapy in a cohort of HIV-seropositive women." American Journal of Public Health 92(1), pp. 82-87.

The researchers analyzed antiretroviral medication use among 1,690 HIV-positive women beginning in 1994 (preceding HAART availability) at 6-month study visits until September 1998. The majority of the women were black or Hispanic, nearly half lived in poverty, and only 12 percent had private health coverage. Before HAART availability, women's likelihood of using any antiretroviral therapy was associated with clinical indicators such as CD4 cell count, viral load, and symptoms and behavioral factors such as drug and alcohol use and past participation in clinical trials.

After HAART became commercially available, other factors affected its use: a woman's race, educational level, insurance status, and past use of illicit drugs. Black women were about 20 percent less likely to report HAART use at any study visit after April 1996, as were women with a history of injection drug use or recent drug or alcohol use. On the other hand, women with some college education were significantly more likely to report HAART use, as were those with private health insurance and those who had previously participated in clinical drug studies. These findings held even after adjustment for clinical laboratory markers, CD4 count, and viral load.

The researchers note the need for special outreach and medical education efforts to help black women and those involved with drugs and alcohol make informed decisions about HAART use. Likewise, efforts are also needed to educate physicians about the vulnerability of disadvantaged women, whom they may view as unlikely to adhere to the complicated and expensive HAART regimens that require near-perfect adherence to be effective.

Levine, A.M. (2002, February). "Evaluation and management of HIV-infected women." Annals of Internal Medicine 136(3), pp. 228-242.

As this researcher notes, a gynecologic infection is the most common symptom that leads to initial medical evaluation and diagnosis of HIV infection in women. She recommends that doctors initially measure a woman's CD4 lymphocyte count (lower counts indicate a less competent immune system and more advanced disease) and HIV-1 RNA level (higher counts indicate more advanced disease) and conduct a gynecologic examination including a Pap smear. Decisions about beginning antiretroviral therapy depend on the patient's clinical diagnosis, willingness to adhere to treatment, and CD4 lymphocyte and HIV-1 RNA levels.

Levels of HIV-1 RNA may be somewhat lower in women than in men at the same CD4 count, whereas women have higher CD4 lymphocyte counts at the time of AIDS diagnosis. However, prospective trials have not yet indicated the need to change the threshold CD4 lymphocyte counts or HIV-RNA levels for initiation of therapy in women. The efficacy of antiretroviral therapy appears to be similar in men and women, although women are more likely to suffer from medication-related toxicities.

About 40 percent of women have abnormal Pap smears at baseline, and 58 percent are infected with human papillomavirus. The prevalence of both of these conditions increases with lower CD4 lymphocyte counts and higher HIV-1 RNA levels. Precursor lesions to cervical cancer may be effectively treated, but almost 50 percent recur within 1 year, mandating careful followup. Physicians should refer women for specialized gynecologic care and for issues related to HIV itself, since survival is prolonged in patients treated by doctors who are experienced in treating HIV. Finally, when HIV-infected women are provided the same access to care, they have similar prognoses as HIV-infected men, concludes the author.

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