An AIDS wake-up call: a documented case of female-to-female transmission raises a question: why are lesbians excluded from most HIV-prevention messages? (Health).

When a 20-year-old woman tested positive for HIV last year, her physicians were baffled. The woman had no history of injection-drug use, blood transfusions, body piercing, or heterosexual intercourse. It turned out that her bisexual female partner was HIV-positive and that her partner's physician had counseled her to use protection only with her male partners, since female-to-female transmission is considered so rare.

According to the February 1 issue of the influential journal Clinical Infectious Diseases, this is among the first documented cases of HIV transmission through female-to-female sex. Working together, researchers at two Pennsylvania hospitals matched the genotype of the HIV strain of the two women, which included six identical mutations that made it resistant to several anti-HIV medications.

With HIV-prevention efforts in the United States largely focused on male-to-male and male-to-female transmission, the report could become a wakeup call to public health officials and AIDS educators who have spent little time or resources reaching out to women who have sex with women.

"There are many, many lesbians who are being told they're not at risk for HIV," says Dawn Harbatkin, a board member of the Gay and Lesbian Medical Association and director of medicine at the Callen-Lorde Community Health Center in New York City. "Many women who have sex with women believe they have nothing to worry about. That's exactly the situation that facilitates new transmissions of HIV."

Adds Talata Reeves, director of women and family services at Gay Men's Health Crisis in New York City: "What's so striking about the Pennsylvania case is that the HIV-positive partner was advised by a physician to use protection only with male partners. It speaks to the mythology that women can't get HIV from their female partners, shared by doctors and the larger community alike."

The Clinical Infectious Diseases report speculates that the 20-year-old contracted HIV from her female partner of two years through vaginal bleeding. "Sexual practices included sharing of sex toys and oroanal and orogenital contact, which never occurred during menses but which was occasionally traumatic enough to draw blood," it states.

Standard HIV-prevention measures encourage women to use latex barriers, including condoms when sharing sex toys. "What's sad is that this infection could've been easily avoided," Reeves says. "Sex toys should of course be cleaned, have condoms put over them, or not used at all. We get calls from women all the time who want to know what's safe and what's not, so there clearly is a strong need for education."

Harbatkin says some women ignore entreaties not to eschew unprotected sex. "In my experience talking to our female clients, they are less likely to use barriers like dental dams," she says. "Some know it's theoretically possible to get HIV but figure the chance is so low, it's not worth bothering. That means that public health messages have not reached all groups of women equally."

Indeed, since female-to-female transmission is considered relatively rare, public health officials long have debated the extent to which scarce prevention resources should be allocated to outreach to lesbians. The federal Centers for Disease Control and Prevention, for instance, says very little about the risk of female-to-female transmission because there have been so few documented cases.

"At our health center the number of gay men who come in with new HIV, syphilis, or other sexually transmitted diseases is staggering," Harbatkin says. "We get many fewer lesbians, and those who test positive have generally had sex with men. So I can understand the temptation to put all our resources into preventing HIV among men who have sex with men. But we can also see the dangers of leaving anyone behind."

Reeves agrees. "Anyone who thinks that because there are few cases among lesbians we shouldn't be reaching out to them should talk to the woman in this report," she says. "She's only 20, and now she will be living with HIV for the rest of her life."