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New York/Virgin Islands AIDS Education and Training Center

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1 New York/Virgin Islands AIDS Education and Training Center
Women and HIV Tanya D.I. Zangaglia, MD New York/Virgin Islands AIDS Education and Training Center

2 AIDS In Adolescent and Adult Women, By Ethnicity, United States
57% 22% 20% 1% Cumulative Reported Cases through June 2000. HIV/AIDS Surveillance Report. Midyear edition, vol. 12, no.1

3 AIDS in Adolescent and Adult Women By Transmission Category, United States
41% 40% 41% 3% Cumulative Reported Cases through June 2000. HIV/AIDS Surveillance Report. Midyear edition, vol. 12, no.1

4 AIDS Cases Among Females, Cases by Age and Ethnicity
Number of Cases Age at Diagnosis Cumulative Reported Cases through June 2000. HIV/AIDS Surveillance Report. Midyear edition, vol. 12, no.1

5 In some developed countries such as the United States, the incidence of HIV/AIDS is now increasing at a faster rate among women than among men The majority (3/4) of women diagnosed with AIDS are women of color CDC, 7/95

6 Are Women more Biologically Vulnerable to HIV Infection?
Male to female transmission of HIV is anywhere from 2-4 times to 20 times as efficient as female to male transmission In semen there is a higher concentration of pathogens than in vaginal secretions There is greater ease with which pathogens can cross the mucous membranes lining the vagina and the cervix STDs in women are often asymptomatic: the presence of untreated STDs increases a woman’s vulnerability to HIV infection

7 Are Women more Biologically Vulnerable to HIV Infection?
Certain tradition physical practices can increase a woman’s susceptibility to HIV infection: Tattooing Blood letting Sacrification Female circumcision (FC)/Female genital mutilation (FGM)

8 Are Women more Socially Vulnerable to HIV Infection?
In most cultures and societies there is a significant power differential between men and women The terms of sexuality are determined by men Only males are expected to initiate relationships and female sexual assertiveness is stigmatized and/or punished The gender differential is compounded by the age differences – husbands are expected to be older than their wives In countries with high HIV infection rates men seek out younger and younger females on the grounds that younger women are less likely to be infected

9 Are Women more Socially Vulnerable to HIV Infection?
Specific social customs related to women’s sexual activity include: Arranged marriages Early age of female marriage The expectation that the brother of a man who dies will have sex with his widow Polygamy Non-monogamy Women cannot use condoms without men’s cooperation

10 The prevalence of HIV was more strongly associated with poverty than was infant mortality (infant mortality is a traditional public health indicator, and one sensitive to women’s societal status) Farmer, P. Infections and Inequalities: The Modern Plagues Berkeley: University of California; 1999

11 How do women become HIV infected?

12 Factors Increasing Susceptibility to HIV
Hormone levels In the second half of the menstrual cycle, the immune system is suppressed so that sperm will not be destroyed…therefore, during this period there is also an increased risk of HIV transmission Low estrogen levels make the vaginal mucosa thin and friable Breast-feeding, menopause, and malnutrition lower estrogen levels National Conference on Women and HIV, May 1997

13 Factors Increasing Susceptibility to HIV
Cervical Ectopy (CE) (exposed columnar epithelial cells) Is found in adolescents, during pregnancy, and after childbirth Hormonal contraceptives also contribute to CE such as OCPs, norplant and depo-provera In addition to the increased transmission of HIV, the presence of CE can allow for numerous other infections including gonorrhea and chlamydia

14 Factors Increasing Susceptibility to HIV
Inflammatory Responses Tissue swelling  Blood vessel permeability Irritation Local invasion by lymphocytes and macrophages Inflammatory Triggers Infections (yeast, bacteria, trichomonas) Mechanical trauma (penetration, douching, tampon use, pelvic exams, vaginal treatments)

15 Risk and Transmission Women at highest risk of HIV transmission are:
Young Poor Tend to live in urban areas In the United States, predominantly African American and Latino

16 Risk and Transmission Routes of infection include:
Heterosexual intercourse Intravenous (IV) drug use Transplantation of infected tissues Percutaneous puncture Vertical transmission

17 Risk and Transmission The risk of HIV infection through sexual intercourse increases if: Women’s partner is uncircumcised Partner has more advanced HIV disease (higher viral load in blood and/or semen) During anal intercourse During menses

18 Risk and Transmission The risk of HIV transmission increases when there are other genital infections: Gonorrhea Chlamydia Trichomoniasis Herpes Syphillis Chancroid

19 Primary Gynecological Concerns in HIV Positive Women
Cervical Cancer Human Papilloma Virus (HPV, Genital Warts) Pelvic Inflammatory Disease

20 Human Papilloma Virus Signs and Symptoms
Genital warts can often be felt if external HPV linked to cancers of anus, penis, vagina, cervix Treatment Aldera – Cryosurgery Podophyllin – Laser, then monitor as Alferon-N HPV can recur Imiquimod topical cream – 5-FU

21 Cervical Cancer Signs and Symptoms
Cervical lesions and cellular abnormalities caused by sexually transmitted virus: HPV, HSV Detection: Abnormal Pap smear Confirmation: Colposcopy Treatment Early State Cancer: Cryosurgery, scraping and cone biopsy Invasive Cancer: Chemotherapy, radiation, hysterectomy, lymphremoral Experimental: Topical 5-fluorouracil for high grade dysplasia

22 Pelvic Inflammatory Disease
Signs and Symptoms Vaginal discharge – Pain Internal ulcers – Ectopic pregnancy Link to chlamydia Screening and early detection is crucial Treatment Ceftriaxone plus tetracycline Ceftriaxone or doxycycline Ceftriaxone or erythromycin (if patient pregnant and allergic)

23 HIV/AIDS in Correctional Institutions in the United States
The prevalence of AIDS among prisoners in the U.S. is five times that of the general population In 1997, an estimated 8,900 inmates had AIDS and 35-47,000 were infected with HIV In 1996, those released from prisons and jails included 17% of the total number of Americans with AIDS that year 1st National HIV Prevention Conference, CDC, 8/99

24 HIV/AIDS in Correctional Institutions in the United States
In 1996, those released from prisons and jails included 17% of the total number of Americans with AIDS that year The total prison population is less than 2 million on any given day 7.75 million people are released from jails and prisons in a single year

25 HIV/AIDS in Correctional Institutions in the United States
The rate of HIV transmission in prison is unknown, but is estimated to be less than 1% each year (less than 1% can translate to large numbers of cases because of the size of the prison population High rates of other STDs such as syphilis, gonorrhea and chlamydia add fuel to the continuing epidemic of HIV

26 HIV/AIDS in Correctional Institutions in the United States
Women entering prison between 1996 and 1999 had high rates of syphilis, gonorrhea and chlamydia Women entering prison during this period had syphilis in the range of 3% to 22% 10% of state and federal prisons and 5% of city and county jails offer comprehensive HIV prevention programs for inmates

27 HIV/AIDS in Correctional Institutions in the United States
In 1997, an estimated 300,000 prisoners had hepatitis C, a prevalence 9 times that of the general population Although 90% of prisons and jails say they make the newer combinations of anti-HIV drugs available, it is not necessarily to all inmates

28 The Real Context of Women’s Risk
Personal Responsibility Work Opportunity and Reconciliation Act (PRWORA) 1996 welfare legislation Has had a negative impact on the reproductive health of women Has changed the social conditions of women Imposition of work requirements Diminished access to healthcare Wise, P. Assessing the Effects of Welfare Reform Policies on Reproductive and Infant Health Am. J. Public Health 1999; 89;

29 The Real Context of Women’s Risk
Social policy that reduces a women’s autonomy Reduces a woman’s potential to contribute Increases a woman’s rate of HIV infection Increases the incidence of AIDS Gollub, E. Human Rights is a US Problem, Too: The Case of Women and HIV Am. J. Public Health; 1999; 89;

30 The Real Context of Women’s Risk
Women and Autonomy Lack of this autonomy increases: The rate of HIV infection Increases the incidence of AIDS by decreasing women’s access to and time for effective HIV therapy The number of women who are abused Gollub, E. Human Rights is a US Problem, Too: The Case of Women and HIV Am. J. Public Health; 1999; 89;

31 The Real Context of Women’s Risk
Women and Autonomy Education, job training, employment and free child care increase a woman’s autonomy Such autonomy allows a woman to leave a risky or harmful relationship, to enter drug treatment or to insist on the use of condoms Gollub, E. Human Rights is a US Problem, Too: The Case of Women and HIV Am. J. Public Health; 1999; 89;

32 HIV and Aging People older than 50, represent about 10% of those infected with HIV In 1983, there were 4,856 persons over 50 with HIV In 1998, there were 69,257 persons over 50 with HIV With AIDS death rates decreasing and infected people living longer, people over 50 living with HIV will mushroom David Blatt, MD, Illinois Masonic Medical Center of Chicago, Director of HIV Program

33 Older Women and HIV Women are more likely to be college educated, professional, religious Intravenous drug use less likely the identified mode of transmission Usually in monogamous relationships

34 Older Women and HIV Concurrent illnesses lead to concerns regarding drug-drug interactions HIV tends not be the center of these women’s lives Lack of programs, resources and support to help women in this age category

35 Confounding Signs and Symptoms of HIV in Aging Communities
PCP looks like bacterial pneumonia, bronchitis, CHF Early HIV symptoms such as fatigue and weight loss dismissed as a normal part of aging

36 Older Women at Higher Risk for HIV
Menopause causes vaginal tissues to become thinner and more susceptible to tearing during sex This tearing increases susceptibility Robert N. Butler, MD, Professor Geriatrics, Mt. Sinai Medical Center, NYC

37 HIV and Aging People older than 50 are 1/6 as likely as younger adults to use condoms during sex and 1/5 as likely to be tested Hence, there is expected to be a rise in STD cases among the elderly

38 In a study of 200 HIV-infected women, 42% were asymptomatic during 4 years of follow-up
Carpenter, CCJ HIV in North American Women: Experience with 200 Cases and Review of the Literature. Medicine: 1991; 70:

39 Ten Most Common Initial Manifestations of HIV Infections in Women
Candida infections: thrush, esophagitis, recurrent vaginitis Constitutional symptoms: Weight loss Night sweats Chronic fever (> 30 days) Diarrhea (> 30 days)

40 Ten Most Common Initial Manifestations of HIV Infections in Women
Persistent, generalized lymphadenopathy Cytopenia: anemia, leukopenia, thrombocytopenia Pneumocystis carinii pneumonia Kaposi’s sarcoma (predominately in men) Sexually transmitted diseases

41 Ten Most Common Initial Manifestations of HIV Infections in Women
Neurologic syndromes: Dementia Memory loss Mental slowing Peripheral neuropathy Bacterial infections: Pneumococcal pneumonia Hong Kong influenza type B Tuberculosis

42 The Most Common AIDS-Defining Conditions in Women
Invasive cervical cancer Esophageal candidiasis Pneumocystis carinii pneumonia Chronic mucocutaneous herpes simplex

43 Vaginal Microbicides Studies of topical microbicides (TM) are still in the early stages TMs may have the potential to protect women against HIV and other STDs Only preliminary data is currently available regarding the efficacy of these products Currently there are 60 products being studied as potential microbicides

44 Vaginal Microbicides PRO-2000 Gel
In vitro studies have shown that the compound blocks infection with a broad variety of HIV strains and is active against HSV-1, HSV-2, human CMV, chlamydia trachomatis and neisseria gonorrhoeae Postulates its MOA: Binds tightly to the HIV envelope and prevents HIV from getting into human cells Albert Profy, PhD., Procept, Inc. Biotechnology Company, Cambridge, MA

45 Vaginal Microbicides In animals, the gel prevented the transmission of genital herpes in mice and in rhesus monkeys it reduced vaginal transmission of a hybrid immunodeficiency virus that had the envelope of human HIV and the core of the SIV The product was safe and well tolerated in early clinical studies Currently expanded phase I studies are occurring health sexually active women and HIV-positive women in the United States and South Africa Albert Profy, PhD., Procept, Inc. Biotechnology Company, Cambridge, MA

46 Vaginal Microbicides Hydrogen peroxide-producing Lactobacilli
Gelatin suppository found to be safe and acceptable in early clinical studies. May be a way to “increase natural resistance” to HIV and other STDs Bacilli prevent the outgrowth of “bystander organisms” in the vagina that leads to bacterial vaginosis (BV). The presence of BV may increase the risk of HIV A phase III clinical trial evaluating its effectiveness in preventing BV in sexually active women ins being planned National Institute of Allergy and Infectious Diseases

47 Vaginal Microbicides Savvy
Vaginal gel contains glyminox, a synthetic molecule that is a spermicide Also being studied as a contraceptive In vitro data indicate that it has activity against chlamydia and gonococus, antiviral activity including inhibition of HIV replication and antifungal activity Mouse data show that the active ingredient inhibits transmission of chlamydia and genital herpes Biosyn, Inc., Philadelphia, PA

48 Vaginal Microbicides PC-515
Not viricidal but adheres to some viral cells, preventing them from attaching to cell walls In vitro shown to block HIV infection, and ahs protected mice from herpes simplex virus type 2 (HSV-2) infection Found to be easy to use and passed initial safety tests in an early trial of women in five countries, including the U.S. Forms a gel at high temperatures in women Contains carrageenan, a sulfated polysaccharide derived from seaweed that is used in food, cosmetics and pharmaceutical products Population Council


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