SEPTEMBER 1998

NUMBER ONE

Listen Up Sisters

HIV infections continue to increase rapidly among women, who made up 22 percent of cases in the U.S. in 1997 and now make up 42 percent of cases worldwide. New HIV infections among women in hard-hit New York City, for example, now exceed new cases in gay men. Race and poverty are major factors, with 80 percent of HIV cases affecting urban, poor, African-American, and Latina women, especially young women who rely on Medicaid, have less access to health care, and are less likely to get the newest HIV drugs. Black and Latina women aged 45 to 62 are also contracting HIV more frequently through heterosexual sex.

Standard of Care: Women's health care should be integrated into HIV primary care, with frequent gynecological exams (Pap smears every six months, coloscopies for abnormal results), contraceptive counseling, and aggressive screening of STDs accompanied by prompt treatment and follow-up (a new report shows that STDs increase the risk of HIV transmission twofold to fivefold).

Specific Concerns: HIV-positive women face more gynecological problems as their immune systems weaken. These include menstrual irregularities, genital ulcers, STDs like herpes simplex, pelvic inflammatory disease, and permature menopause. In addition to the usual opportunistic infections, women are more likely to develop bacterial pneumonia, esophogeal candidiasis (often the first AIDS-defining illness), endocarditis, pulmonary TB, kidney failure, bacterial infections, and chronic vaginitis. Ongoing studies at Columbia University report that persistent infections of human papilloma virus (HPV) greatly increase the risk of cervical cancer among HIV-positive women. Unfortunately, HIV combination therapy does not appear to clear HPV or yeast infections, according to new reports.

Menstruation: Periods can affect an HIV-positive woman's health. Blood loss from heavy periods can lead to anemia, while irregular or absent periods may be a sign of systemic illness. HIV can also cause menstrual irregularities.

Pregnancy: There's no evidence that pregnancy or childbirth hasten the progression of HIV disease in developed countries. But pregnancy does alter immune function, and this should be carefully monitored. Since many women are exposed to the virus through IV drug use, treatment for drug addiction should be part of prenatal care for these women. Some researchers have suggested that spontaneous abortions may occur more frequently among HIV-positive women when transmission occurs during a pregnancy. Since pregnancy can affect absolute T-cell levels, viral-load tests may be a better measure of disease progression.

Maternal HIV Transmission: HIV can infect a fetus as early as eight weeks after conception. Studies show that 30-50 percent of infections occur in utero and 50-70 percent occur during labor. Delivery by cesarean section may lower the risk of HIV transmission at birth. Intensive prenatal care and case management are also important. An ongoing Women and Infants Trans-mission Study shows that women also infected with hepatitis C transmitted by needle sharing are more likely to pass HIV through perinatal transmission.

Ideally, HIV-positive women should delay antiviral therapy with existing drugs until 14 weeks after conception to avoid any risk of hurting the developing fetus. If you are already on therapy and get pregnant, talk to your doctor about the risks and benefits of continuing or temporarily stopping treatment. If you stop, all drugs should be stopped at the same time; when you begin again, start all the drugs at the same time to avoid HIV resistance. But beware: At Geneva, researchers said women already on HAART who get pregnant and discontinue treatment may run the risk of a viral rebound that could hurt the fetus.

Using HIV Drugs: A multicenter federal study called ACTG 076 found that aggressive use of AZT is safe and can decrease maternal HIV transmission by 70 percent. Anemia is the main side effect of AZT. Recently, short-course oral AZT was added as an option for lowering mother-to-child transmission among women in the developing world (see Box, page 20). A small University of Southern California study found that adding nevirapine to the mix appeared safe. But using other drugs may be more risky. In animal studies, Sustiva produced birth defects in three of 13 newborn monkeys; it should not be used by pregnant women. Hydroxyurea may also be dangerous for pregnant women, based on animal studies. At Geneva, there was also distrubing news of adverse effects among pregnant women using HAART (see "Newborn Drug Scare").

Pregnancy causes nausea, vomiting, and an increase in glucose, as do some HIV drugs. Consequently, doctors are hard-pressed to distinguish whether these symptoms are normal or caused by therapy. Among HIV drugs, only AZT and 3TC have been well-evaluated in pregnant women. Crixivan may temporarily elevate bilirublin levels in newborns and should be monitored carefully. For now, though, better pregnancy-drug safety data is badly needed.

Contraceptives: HIV-positive women are encouraged to use condoms and a water-based lubricant with male sexual partners. Intrauterine devices (IUDs) should be avoided, because they may increase the risk of pelvic inflammatory disease (PID) and HIV transmission by increasing the flow of menstrual blood. Some HIV drugs also interact with p450 liver-processed oral contraceptives such as estradiol. Nelfinavir and ritonavir lower levels of oral contraceptives, while Crixivan seems to have no effect. Consult your doctor for updates. Animal studies in female rhesus monkeys suggest that contraceptives such as Depo-Provera and Norplant may potentially increase the risk of getting SIV. Discuss this with your doctor.

Viral Load: New data suggests women may have significantly lower viral-load levels than men and that among women taking HIV combination therapy. HIV can be detected in the genital tract even when it is not detectable in plasma.

Antiviral Therapy: New federal guidelines recommend three-drug combination therapy for HIV-positive women, including pregnant women who meet the criteria (see "Uncle Sam Says"), but a lack of data regarding dosing, safety, HIV drug absorbtion, and drug tolerance in women persists. Women using Rescriptor had higher blood levels of the drug than men and appeared to take longer to clear the drug from their bodies in one well-known study.

If you're positive, talk to your doctor about proper nutrition, screening for STDs and hepatitis, monitoring vitamin and hormone levels, and the likely impact of new HIV drugs on oral contraceptives, menstruation, pregnancy, and side effects.

Lesbians Take Note MANY LESBIANS DON'T GET TESTED FOR HIV BECAUSE LESBIANS as a group are perceived to be at low risk. This reliance on categories rather than the real world of risky behaviors has created denial, say advocates. Many small-scale studies show that lesbians or bisexual women who use IV drugs or have sex with gay or bisexual men are at a particularly high risk for HIV. There are also women who don't identify as lesbian but have sex with other women, and women who use donor insemination. A recent study by Emory University researchers shows that HIV-positive women have actively reproducing HIV in their vaginal secretions that may be different HIV strains from those circulating in their blood. The data underscores the risk of HIV to lesbians and bisexual women. Other studies suggest that lesbians are at risk for STDs that may increase the risk of HIV transmission.