HIV and AIDS in women: a different story.

(This article is based on an interview with Eileen Stretch. Eileen is on staff at NF Formulas, and a fourth-year student at the National College of Naturopathic Medicine. Her report "Tge clinical manifestations of HIV infection in women" appeared in a recent issue of the Journal of Naturopathic Medicine.)

Women constitute the group being diagnosed for HIV at the fastest growing rate in the United States. Women are twice as likely as men to die the month they are diagnosed. 10.5% of the total number of cases of AIDS have been found in women. 34% of women with AIDS have acquired it from heterosexual contact. Only 21% of these acquired their HIV from IV drug use. 65% of the women who have died from complications of HIV infection were never diagnosed as having AIDS. This is because their symptoms didn't meet the Center for Disease Control definition of AIDS. Currently, AIDS diagnosis is based on specific opportunistic infections. For example, an HIV infected man who develops Kaposi's sarcoma will then be considered to have AIDS. But HIV infected women tend to develop different infections than men. They die as a result of HIV infection but aren't given the diagnosis of AIDS. The CDC intends to change its criteria for AIDS diagnosis to more accurately reflect the course of the disease in women, but this change has been postponed until after the national election, for political reasons. Once the definition is changed, many more women will be officially noted as having AIDS. The future definition will be based on the presence of HIV antibodies accompanied by fewer than 200 CD4 cells per ml. Thus, regardless of the type of infections that develop, an HIV seropositive person with a severely depressed immune system will be diagnosed as having developed AIDS.

The first signs of HIV infection in women are usually gynecological. The most common symptom and the likeliest to occur first is a vaginal yeast infections show up 6 months to 3 years before any other symptoms, and are resistant to treatment. It may be the only symptom even when T cells have dropped to fewer than 100 per ml. (Normal T cell levels are 700 to 1100.)

Virtually all studies of HIV-infected people have been done on men. Little is known about the effect of treatments or the course of the illness in women. Infected women have a higher incidence than do HIV negative women of a number of gynecological diseases, including syphilis, herpes, chancroid, PID and genital warts caused by Human Papilloma Virus (HPV). Partly because of the 400% increase of HPV in HIV infected women, they have 8 to 11 times the usual rate of cervical dysplasia and cervical cancer. HPV is usually invisible to the naked eye and although the cervix is the most common site of infection, these women will usually have normal Pap smear results.

Women and Risk

We can no longer view women as being less likely to be seropositive if they aren't in an identified risk group. In a 1991 study of seropositive women, 70% were currently in stable, monogamous relationships. Risk assessment of behavior will miss 20 to 40% of infected women. These women probably acquired HIV from unprotected intercourse with one man and were unaware of his risk factors. A woman's risk of acquiring HIV is actually greater if she is in a monogamous relationship with a seropositive man (who may be part of the large group that is unaware of their HIV status) than if she is in the "risk group" of women who have multiple sex partners. Tragically, two studies were done that showed that 98 to 99% of men will lie about their risk factors to a prospective sexual partner if they think that knowledge of their risk factors will interfere with their ability to have sex with that person. A man is 20 times more likely to infect a woman with HIV than vice versa. One of the many contributing factors is that seminal fluid may contain much higher concentrations of the virus than that found in blood.

HIV and Pregnancy

80% of women diagnosed with AIDS are of childbearing age. More than 5000 infected women give birth each year. In one study in Great Britain, 46% of those who tested positive prenatally had been unaware until then that they were infected. While seropositive men lose an average of 0.5 to 1 percent of their T cells per month, seropositive women lose 2 percent of their T cells each month of pregnancy. Asymptomatic seropositive women with [greater than] 200 T cells had no difference in rates of fertility or pregnancy outcomes, and do not appear to have "higher risk" pregnancies or births. According to several studies, knowledge of testing positive for HIV has little or no effect on a woman's decision whether or not to have an abortion.

Transmission rates to newborns range from 13% to 40%, depending on the study. The exact mode of transmission is unknown. While the virus has been detected in embryos as early as 16 weeks after conception, researchers believe that transmission usually occurs prior to or during birth. Type of delivery (vaginal or cesarean) seems to make little or no difference in transmission, but use of scalp electrodes, episiotomy, forceps or vacuum extractors seem to raise the rates somewhat, perhaps because of increased exposure to maternal blood.

All babies of infected mothers are HIV seropositive at birth, due to the presence of the mother's antibodies in the child's blood. Which children are truly infected and will subsequently develop AIDS cannot be determined at birth. Studies now show that the virus itself can be detected in infants if they are tested as early as 4 to 9 weeks postpartum, and the differentiation can then be made between seropositive and HIV infected babies. It is believed that HIV can be transmitted through breastmilk. HIV has been detected in breastmilk and colostrum and infants who are exclusively bottle-fed have a lower rate of transmission. Even so, HIV infected babies do better if they've been breastfed. Because of this, third world countries with high rates of AIDS but even higher rates of malnourishment and infant mortality recommend that all babies be breastfed.