HIV & AIDS in Women

HIV & AIDS in Women

Reviewed By:
Joanne Poje Tomasulo, M.D., ACOG

Summary

Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) are names for different stages of the same viral infection that impairs a person’s immune system. This infection attacks the cells that coordinate a person’s immune response to foreign invaders and prevents the body from fighting off viruses, bacteria, fungi and parasites. Because of this failure of the immune system, there is an increased risk of developing certain forms of cancer, including cervical canceras well as numerous other diseases.

People become infected with the HIV virus through contact with certain types of body fluids from an infected individual. Once infected, the virus begins to quietly damage the immune system by invading helper T cells (CD4 lymphocytes), the white blood cells that coordinate the immune system. Eventually all people with HIV will go on to develop AIDS. However, it can take a decade or more before HIV develops into full-blown AIDS. Many of the available treatments, if initiated early enough, can help delay this progression.

The rate of HIV infection among women in the United States has increased in recent years, particularly among women of color. Most cases of HIV infection in women are the result of sexual contact with infected men, according to the U.S. Department of Health and Human Services. In addition, pregnant or breastfeeding women infected with HIV are at risk of passing the disease on to their children.

Though there is no cure for HIV and AIDS, treatments have become much more effective in controlling symptoms and suppressing disease progression in recent years. Today, people with AIDS can lengthen their lifespan and enhance their quality of life through a variety of medications. Most people in the United States and other developed nations have access to these drugs. In underdeveloped parts of the world, access is limited, and AIDS mortality rates remain high.

About HIV and AIDS

Human immunodeficiency virus (HIV) is the virus that causes acquired immune deficiency syndrome (AIDS), a chronic life-threatening condition that damages the cells of the immune system. This prevents the body from fighting off viruses, bacteria, fungi and parasites. People infected with HIV and AIDS are vulnerable to the damaging effects of many diseases, including infections and some types of cancer. There is no known cure for HIV or AIDS.

HIV and AIDS are part of the same disease, with HIV occurring in the early stages of the disorder and AIDS occurring in the later stages. The HIV virus spreads through a variety of body fluids, including:

  • Blood
  • Semen
  • Vaginal fluids
  • Breast milk
  • Body fluids handled by healthcare workers, including amniotic fluid

There are several strains of HIV. The most common strain is HIV-1, but a person can become infected with more than one strain. Soon after infection, the virus attacks the immune system and begins to multiply in the lymph nodes. HIV also gradually destroys helper T cells (CD4 lymphocytes), the white blood cells that coordinate the immune system.

Eventually, the disease progresses to the point where it becomes classified as AIDS. The Centers for Disease Control and Prevention (CDC) defines AIDS as the presence of HIV infection (having a positive test for the HIV virus) and any one of the following:

  • Development of an opportunistic infection. This is an infection that occurs when the immune system is impaired.

  • CD4 lymphocyte count of 200 or less. Normal counts range from 600 to 1,000.

Patients infected with HIV are susceptible to various viral, bacterial, fungal and parasitic infections. They are also more likely to develop certain cancers, including:

  • Kaposi’s sarcoma. A type of cancer that starts with purplish spots on the feet and legs and spreads from the skin to lymph nodes and internal organs.

  • Lymphoma. Malignant (cancerous) tumors that arise in the lymph nodes or in other lymphoid tissue.

  • Cervical cancer. Cancer of the cervix, the narrow lower end of the uterus.

Women and HIV and AIDS

In recent years, the rate of human immunodeficiency virus (HIV) infection among women worldwide has been increasing. By the end of 2005, approximately 17.3 million women were living with HIV/AIDS (acquired immune deficiency syndrome) worldwide, according to the World Health Organization (WHO). This figure represents nearly half the 38.6 million adults living with HIV/AIDS. Women make up a smaller percentage of HIV/AIDS patients in developed nations. The Centers for Disease Control and Prevention (CDC) estimates that nearly 956,666 Americans, including more than 182,822 females, were diagnosed with AIDS through 2005.

Most cases of HIV infection in women are the result of sexual contact with infected men, according to the U.S. Department of Health and Human Services (HHS). Use of needles tainted with the virus during intravenous drug use is the second most common method of transmission among women.

Virtually all people with HIV will go on to develop AIDS. However, it can take a decade or more before HIV develops into full-blown AIDS. The rate of HIV infections that develop into full-blown AIDS among women in the United States has seemingly reached a plateau after rising steadily in recent years. This is largely a result of more effective therapies that keep the virus at bay. However, younger women are increasingly being diagnosed with HIV infection. Women age 24 and younger accounted for 15 percent of the female HIV/AIDS cases reported to the CDC from 2001 through 2004.

In addition, rates of HIV infection among women of color have risen. According to HHS:

  • African-American and Hispanic/Latina women account for 81 percent of AIDS cases in women in the United States despite composing just one-fourth of the country’s female population.
  • More African-American women between the ages of 25 and 44 die from HIV/AIDS than from any other cause of death.

In 2004, HIV infection was the fifth leading cause of death among all women aged 35 to 44 years, and the sixth leading cause of death among all women aged 25 to 34 years, according to the CDC. The only diseases causing more deaths in women were cancer and heart disease.

In addition, women can pass the HIV infection on to their babies during pregnancy, delivery or breastfeeding. Precautions can be taken to help an expectant mother reduce the likelihood of passing HIV to her child. Because of this, there has recently been a change in the requirement of routine prenatal HIV testing in many places.

Finally, HIV can infect older women who are sexually active as easily as it infects younger women. Some older women may be less educated about HIV and AIDS and ways to prevent infection. In addition, some physicians may be more reluctant to discuss the issue with older women, or more likely to mistake HIV-related symptoms for routine signs of aging. For these reasons, older women must be involved in seeking out preventive care.

Potential causes of HIV and AIDS

Human immunodeficiency virus (HIV) infection attacks white blood cells known as CD4 lymphocytes, which coordinate the efforts of the immune system in attacking disease. Normally, white blood cells and antibodies attack and destroy foreign organisms (antigens) in the body. HIV attaches to CD4 lymphocytes and “hijacks” them by inserting its own genetic material into the cells and replicating itself.

Eventually, these copies of the virus enter the bloodstream and begin attacking other cells. When this occurs, the original CD4 lymphocyte that spawned the copy dies. The cycle repeats itself over and over, with more than 10 billion new HIV particles produced every day. The immune system reacts by trying to create vast quantities of new CD4 cells – as many as 2 billion new cells each day – but eventually finds itself overpowered by the virus.

As the virus continues to overwhelm the immune system, the number of CD4 cells in the body decreases. This results in severe immune deficiency, in which the body is left unable to fight off viruses and bacteria. The deficiency then becomes AIDS when the CD4 count is less than 200.

HIV can be transmitted in several ways, including:

  • Sexual contact. An infected person can transmit the virus to a sexual partner through semen or vaginal secretions that enter the partner’s body. A woman can be infected by either a man or a woman. Vaginal, anal and oral sex are all potential avenues of transmission. Shared sexual devices can also transmit the virus when the device is not disinfected or covered with a condom.

    The virus usually enters the body of a sexual partner through tiny tears in the vagina or rectum. The likelihood of transmission greatly increases in people who already have another sexually transmitted disease.

    Women should also be aware that the spermicide nonoxynol-9 may irritate the lining of the vagina, causing tears that can increase the risk of transmission.
  • Mother-to-child transmission. Women can transmit HIV to their children through pregnancy, delivery or breastfeeding. However, this risk declines significantly when mothers receive treatment for their HIV infection. In the United States, pregnant women are routinely screened for HIV infection. Those who test positive are prescribed anti-retroviral drugs.
  • Infected blood. HIV can be transmitted through blood and blood products used in blood transfusions. Blood products include whole blood, packed red blood cells, fresh-frozen plasma and platelets. People who received a blood transfusion between 1977 and April 1985 – especially those who received multiple transfusions, such as those with hemophilia (a disease characterized by delayed clotting of the blood) – had a higher risk for exposure to HIV than those who have received transfusions since. The U.S. blood supply has been screened for HIV since 1985, nearly eliminating the risk of contracting HIV through the blood supply since that time.
  • Tainted needles. HIV is easily transmitted through needles and syringes that have come into contact with infected blood, and then are used by someone who does not yet have the virus. Drug addicts who share intravenous drug paraphernalia are especially at risk for this method of transmission. Healthcare workers and others are also sometimes infected when they are accidentally stuck with a needle that has been in contact with an infected person.
  • Other methods. In rare cases, HIV may be transmitted through organ or tissue transplants or unsterile dental or surgical equipment. There also is a small chance of infection during open-mouth kissing if there are bleeding cuts or sores in the mouth present.

Signs and symptoms of HIV and AIDS

Initially, human immunodeficiency virus (HIV) may exhibit few symptoms other than a brief illness that resembles the flu. This usually occurs two to six weeks after becoming infected, and includes:

  • Fever
  • Headache
  • Sore throat
  • Swollen lymph nodes
  • Rash

Because its symptoms are similar to the flu, many people do not realize they have been infected with HIV. Nonetheless, people who are infected are able to transmit the virus to others, even when symptoms are not apparent.

Once the virus enters a person’s body, it begins to multiply and destroy immune cells. In some cases, a person may remain symptom-free for nearly a decade while this damage occurs. Eventually, symptoms will begin to appear, such as:

  • Mild infections
  • Swollen lymph nodes
  • Diarrhea
  • Weight loss
  • Fever
  • Cough and shortness of breath

Ten years or more after the initial infection, the last phase of HIV begins, and more serious symptoms start to appear. These are the result of severe damage to the immune system and may include:

  • Soaking night sweats
  • Shaking chills or fever higher than 100 Fahrenheit (38 Celsius) for several weeks
  • Dry cough and shortness of breath
  • Chronic diarrhea
  • Persistent white spots or unusual lesions on the tongue or in the mouth
  • Blurred and distorted vision
  • Weight loss
  • Persistent, unexplained fatigue
  • Muscle and joint pain
  • Swelling of lymph nodes for more than three months
  • Persistent headaches

HIV infection can be passed from a mother to her child in pregnancy, delivery or through breastfeeding. Children with HIV may have difficulty gaining weight and may not grow normally. As the infection damages the immune system, these children may experience delays in mental and physical development. Children may also have severe forms of common childhood illnesses, such as:

  • Ear infections (otitis media)
  • Pneumonia (inflammatory infection of the lungs)

Related conditions to HIV and AIDS infection

Women infected with HIV are susceptible to several conditions that may be more difficult to treat because of the infection. These include the following:

  • Vaginal infections, including:
    • Yeast infection
    • Bacterial vaginosis

  • Sexually transmitted diseases, including:

    • Chlamydia
    • Gonorrhea
    • Human papillomavirus (HPV)
    • Trichomoniasis

  • Pelvic inflammatory disease (PID).

  • Menstrual cycle changes, including:
    • Amenorrhea (absence of menstrual periods)

    • Dysfunctional uterine bleeding (heavy or constant bleeding)

Women are also susceptible to conditions that affect any person infected with HIV. These are a result of the damage that HIV inflicts upon a patient’s immune system. Such disorders include:

  • Bacterial infections:
    • Bacterial pneumonia. Among the most common infections occurring in people living with HIV and AIDS (acquired immune deficiency syndrome), it can be caused by dozens of types of bacteria. Bacterial pneumonia develops on its own or after a person has had an upper respiratory infection such as a cold or the flu.

    • Mycobacterium avium complex (MAC). An infection caused by a group of bacteria collectively known as mycobacterium avium complex. In many cases, MAC causes an infection of the respiratory tract. But patients with advanced HIV infection and CD4 lymphocyte counts of less than 50 may develop a systemic infection of almost any internal organ, including the bone marrow, liver or spleen. Symptoms of MAC include night sweats, weight loss, stomach pain and diarrhea.

    • Tuberculosis (TB). This infection is the leading cause of death among people living with AIDS in developing countries. Patients with HIV are more susceptible to TB, and TB increases the rate of AIDS virus replication.

    • Salmonellosis. A bacterial infection that stems from contaminated food or water. Symptoms include severe diarrhea, fever, chills, abdominal pain and vomiting. Salmonellosis is far more common in people who are HIV-positive.

    • Bacillary angiomatosis. An infection that appears as purplish to bright red patches on the skin. It often resembles Kaposi’s sarcoma (a type of cancer) and is rarely seen in people who do not have HIV.

  • Viral infections:
    • Human papillomavirus (HPV). Among the most common causes of Sexually transmitted diseases, HPV can cause genital warts and other lesions. People with HIV are susceptible to infection with HPV and are more prone to recurrent infections. In women, HPV infection increases the risk of cervical cancer. Infection with HPV and HIV further increases a woman’s risk of aggressive cervical cancer. About half of all women with HPV have no symptoms.

      Women who are HIV-positive or have unprotected sex with more than one partner should have an annual Pap smear exam to check for cervical cancer.

    • Cytomegalovirus (CMV). Common herpes virus transmitted in body fluids such as saliva, blood, urine, semen and breast milk, and from mother to fetus during pregnancy. A healthy immune system inactivates the virus, and it remains dormant in the body. But diseases such as HIV that weaken the immune system can activate the virus, causing damage to the eyes, digestive tract, lungs or other organs.

    • Viral hepatitis. Viral infection of the liver that manifests as yellowing of the skin and the whites (sclera) of the eyes (jaundice), fatigue, nausea, abdominal pain, loss of appetite and diarrhea. Patients who are HIV-positive and also have hepatitis may see their HIV infection progress more rapidly. They also are more likely to develop liver toxicity from their medication.

    • Herpes simplex virus (HSV). The virus that causes genital herpes. It is usually transmitted during unprotected anal or vaginal sex. Symptoms include pain or irritated skin in the genital area that progresses to sores that ooze and bleed on the genitals, buttocks and anus. These sores heal and then reappear later. People who have HIV are more likely to experience severe skin infections than those who do not have HIV.

    • Progressive multifocal leukoencephalopathy (PML). A serious brain infection caused by the human polyomavirus JCV. Symptoms may include speech problems, weakness on one side of the body, loss of vision in one eye or numbness in one arm or leg.

  • Fungal infections:
    • Candidiasis. A common HIV-related infection that causes inflammation and a thick white coating on the mucous membranes of the mouth, tongue (thrush), esophagus (Candida esophagitis) or vagina (yeast infection).

    • Cryptococcal meningitis. Meningitis is an inflammation of the membranes and fluid surrounding the brain and spinal cord (meninges). Cryptococcal meningitis is caused by a fungus found in soil and is the most common central nervous system infection associated with HIV. It is rarely seen in non-HIV patients in the United States.

  • Parasitic infections:
    • Pneumocystis carinii pneumonia (PCP). The most common opportunistic infection that occurs with AIDS in the United States, it attacks the lungs and makes it difficult for patients to breathe. Symptoms include a persistent cough, fever and trouble breathing.

    • Toxoplasmosis. The most common cause of brain lesions in people with advanced HIV infection. Toxoplasmosis is caused by the Toxoplasma gondii parasite. House cats are primarily responsible for spreading this parasite, which passes through their stool. Women who are infected with the parasite can pass the infection on to their babies. Toxoplasmosis often leads to encephalitis, an infection of the brain. Signs and symptoms may include disorientation, seizures and difficulty walking or speaking.

    • Cryptosporidiosis. Infection caused by an intestinal parasite commonly found in animals. People who have AIDS often experience severe, chronic diarrhea after being infected with this parasite.

  • Cancers:
    • Kaposi’s sarcoma. The most common cancer found in HIV-positive people. This tumor of the blood vessel walls is rare in people not infected with HIV. It usually appears as pink, red or purple lesions on the skin or in the mouth. In individuals with darker skin, the lesions may look dark brown or black.

    • Cervical cancer. Cancer of the cervix, the narrow outer end of the uterus.

    • Non-Hodgkin’s lymphoma. Cancer that begins in the lymphocytes of the bone marrow, lymph nodes, spleen, digestive tract and skin. Symptoms include a painless swelling of the lymph nodes in the neck, armpit or groin.

  • Wasting syndrome. For years, wasting syndrome was common in HIV-infected people. It causes them to lose at least 10 percent of their body weight while suffering with diarrhea, chronic weakness and fever. Aggressive treatment regimens have reduced, but not eliminated, the incidence of this syndrome.

Diagnosis methods for HIV and AIDS

Human immunodeficiency virus (HIV) is diagnosed through a blood test that reveals the presence of antibodies to the virus in the bloodstream. Generally, it takes between six and 12 weeks following infection before these antibodies develop. In rare cases, it can take up to six months before these antibodies show up in blood tests.

For years, the enzyme-linked immunosorbent assay (ELISA) was the standard blood test used to detect HIV. Patients who tested positive would receive a second ELISA test to ensure that the positive reading was accurate. If this test also came back positive, the patient would be given a Western blot test to check for the presence of HIV proteins. The blot test was used to ensure that non-HIV antibodies were not causing a false-positive reading.

However, this testing took up to two weeks before results were ready. As a result, tests were developed that provide results in as little as 20 minutes. Both of these types of tests look for HIV antibodies, one through a finger prick of blood and the other through analysis of secretions collected by a pad from the mouth. If either of these tests produces a positive result, a blood test will be needed to confirm the diagnosis.

At present, the Food and Drug Administration (FDA) has approved just one test available for home use. The Home Access HIV test (marketed by Home Access Health) allows a patient to mail in a drop of blood before calling a toll-free number to receive the results in three to seven business days. The test is considered to be as accurate as a clinical test. Patients are identified by a code number that comes with the kit to ensure privacy. If the test comes back positive, the patient is referred to medical or social services.

Patients who test positive will have their blood checked for the amount of virus in the bloodstream, which is known as viral load. This can help a physician to predict the probable progression of the disease and to formulate the appropriate treatment plan.

Sexual partners should be notified of the diagnosis so they may seek medical testing and treatment. Intravenous drug users should also notify anyone with whom they may have shared a needle with. Some health clinics provide anonymous partner notification systems, which notify people that they may have been exposed to HIV, without informing them of who reported their names or when the exposure occurred.

Treatment options for HIV and AIDS

For many years, there was no effective treatment for human immunodeficiency virus (HIV) or AIDS (acquired immune deficiency syndrome). However, people who contract HIV today can use a variety of medications that can substantially improve their condition and quality of life. However, none of these drugs cure HIV or AIDS, some have substantial side effects and many are expensive.

Treatment aims to reduce the amount of virus in the blood to very low or even nondetectable levels. In most cases, a combination of three or more drugs – sometimes referred to as a “drug cocktail” – is used to achieve this effect, which suppresses – but does not eliminate – the virus. This suppression of the viral load will then slow down the progression to AIDS.

The main treatment for HIV and AIDS is use of anti-retroviral drugs. These are medications that inhibit the growth and replication of HIV. Such drugs include:

  • Nucleoside analogue reverse transcriptase inhibitors (NRTIs). The first anti-retroviral drugs to be developed, they help keep an HIV enzyme (a protein produced by cells that acts as a catalyst in specific biochemical reactions) called reverse transcriptase from replicating.
  • Protease inhibitors (PIs). Interrupt HIV replication by interfering with an enzyme known as HIV protease. Protease inhibitors cause HIV particles in the body to become structurally disorganized and noninfectious.
  • Non-nucleoside reverse transcriptase inhibitors (NNRTIs). Bind directly to the enzyme reverse transcriptase.
  • Nucleotide reverse transcriptase inhibitors (NtRTIs). Also interfere with the replication of reverse transcriptase and prevent the virus from inserting its genetic material into cells. NtRTIs act more quickly than NRTIs do.
  • Fusion inhibitors. New drugs that appear effective against even the most drug-resistant forms of HIV. Fusion inhibitors prevent the membrane of an HIV-infected cell from fusing with the membrane surrounding healthy cells.

In certain cases, a physician may choose to change a patient’s treatment regimen. This often occurs when a patient’s drug regimen is not working well enough. Treatment changes may also be made when side effects make it difficult to take certain drugs (drug toxicity).

Since 1989, increasingly effective HIV/AIDS therapy – including a decade of highly active anti-retroviral drugs – has provided three million years of extended life to patients with AIDS in the United States, according to the National Institute of Allergy and Infectious Diseases (NIAID).

Prevention methods for HIV and AIDS

Although great progress has been made in treating human immunodeficiency virus (HIV) and AIDS (acquired immune deficiency syndrome), the best way to battle infection is to prevent it from occurring in the first place. The following steps can be taken to reduce the risk of contracting HIV. These include:

  • Practicing safe sex. Women should not engage in unprotected sex unless they are certain that their partner does not have HIV. Latex or polyurethane condoms are the best protection – aside from abstinence – from HIV. Lambskin condoms do not protect against HIV. Also, women should use only water-based lubricants during protected sex, as oil-based lubricants can weaken condoms. Dental dams, which are made of medical-grade latex, should be used during oral sex. Using a new latex or polyurethane condom for each sexual encounter can reduce – but not eliminate – this risk.

    Female condoms can also help block the spread of HIV and other sexually transmitted diseases (STDs), but are not as effective as male condoms. Birth control devices such as birth control pills, diaphragms, injections of medroxyprogesterone acetate and contraceptive implants will not protect a woman from getting HIV.
  • Condoms can also protect against contracting other STDs including syphilis, herpes, chlamydia, gonorrhea or bacterial vaginosis. A person infected with an STD is at greater risk for contracting HIV. Use of condoms can reduce – but not eliminate – the risk of contracting STDs.

  • Exercising caution when using blood supplies in foreign countries. Though the blood supply is screened in the United States, this is not the case in all countries. People who have blood transfusions in another country should be tested for HIV upon their return to the United States.

  • Scheduling regular gynecological exams. Women should have a yearly Pap smear and those who engage in anal sex should also have regular tests for anal cancer.

  • Not douching. Douching removes some of the normal bacteria that protect the vagina from infections, including HIV.

  • Not sharing needles during intravenous drug use. The safest behavior for drug addicts is to seek help for their addiction. However, those who continue to use drugs should not share needles with other addicts. Sharing a needle with an HIV-infected addict dramatically increases the risk of contracting HIV.

Pregnant women who are diagnosed with HIV should seek immediate treatment for the virus. The use of a drug called zidovudine (ZDV) can substantially decrease a mother’s risk of passing the virus on to her baby, a condition known as perinatal transmission. The American College of Obstetricians and Gynecologists also recommends that women infected with HIV discuss with their physician the option of having an elective Caesarean section, in which the baby is delivered through an abdominal incision instead of vaginally. Studies show that such methods of delivery, coupled with use of ZDV, can substantially reduce the risk of transmission of the virus to a newborn.

In addition, most physicians follow the recommendations of the United States Public Health Service (USPHS), which state that women who have HIV or AIDS should use formula instead of breast milk when feeding their babies.

It is also important to note that HIV patients should use HIV prevention methods even when their partner is also infected. These steps are necessary because people can carry different strains of the virus, and different strains can operate differently in the body or be resistant to different anti-HIV medications.

Ongoing research regarding HIV and AIDS

Clinical trials are under way to test several drugs designed to treat human immunodeficiency virus (HIV) and AIDS (acquired immune deficiency syndrome), or infections related to the virus. One medication attacks HIV in the last stages of its life cycle, and another prevents the virus from entering healthy cells.

Clinical trials are also being conducted to test dozens of potential AIDS vaccines, although experts generally do not expect an effective vaccine to be available for many years.

Researchers also are making promising strides in the hope of protecting women from HIV. Scientists are developing a topically applied drug called a microbicide (an agent that destroys microbes) that kills the HIV virus and other sexually transmitted diseases during sex while also protecting vaginal and rectal tissue. Microbicides could be available by 2010, according to reports by the United Nations. 

Questions for your doctor about HIV and AIDS

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions related to human immunodeficiency virus (HIV) and AIDS (acquired immune deficiency syndrome):

  1. How will I be tested for HIV?
  2. How long will I have to wait for test results?
  3. How can I reduce my risk of becoming infected?
  4. If I test positive for the virus, how will I be treated?
  5. How soon will I see improvement from the treatment?
  6. Can anything be done to keep HIV from becoming full-blown AIDS?
  7. How can I prevent AIDS from being transmitted to my sexual partner?
  8. How can I prevent AIDS from being transmitted to my unborn child?
  9. If I have AIDS, should I avoid breastfeeding my baby?
  10. If I have AIDS, what should I do to stay as healthy as possible?
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