FREE ESSAY ON WOMEN AND AIDS

WOMEN AND AIDS

Understanding the Issues of Women and HIV/AIDS
Rachel Seldin,
Colgate University, Hamilton NY 13346
ABTRACT:
Infection with the human immunodeficiency virus (HIV) had emerged as a major health
problem for women in the United States. Family physicians can play an important role in
the detection and care of HIV-infected women. The epidemiology and natural history of HIV
infection in women were reviewed. HIV infection is now a leading cause of morbidity and
mortality among young women in the United States, particularly women of racial and ethnic
minorities. Most cases of acquired immunodeficiency syndrome (AIDS) in women occur as a
result of injection-drug use or heterosexual transmission. Based on limited information,
women and men appear to have similar AIDS-defining conditions. Gynecological problems are
common n HIV-infected women. Pregnancy does not seem to be affected by early HIV
infection, but women with advanced disease might be at increased risk for obstetric
complications. More women need to be included in natural history studies and clinical
drug trials. Early awareness of HIV infection and better access to health care services
are required to improve the treatment and survival of HIV-infected women. 
KEYWORDS: Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV),
Pregnancy, Zidovudine (AZT), Vaginal Candidasis, Transmission Methods of HIV/AIDS,
Perinatal Transmission, Women and HIV
INTRODUCTION:
Acquired Immunodeficiency Syndrome (AIDS) has been declared 'the public health threat of
the century'  (1 cited in 2). The US Surgeon General has designated it as the nation's
number one health priority (2). AIDS is a disease that affects the immune system. The
term immunodeficiency refers to the inability of the immune system to function properly,
thus making the individual susceptible to a variety of infections not typically found in
a healthy immune system (3). A syndrome is a group of symptoms or illnesses originating
from one cause. The main agent causing AIDS is a retrovirus known as Human
Immunodeficiency Virus (HIV). HIV is the agent of a sexually transmitted disease that can
also be contracted through blood transfusions or IV drug use; the disease can also be
passed on to a fetus during pregnancy. When people are infected with HIV, they are not
necessarily also infected with AIDS. A person is not infected with AIDS until HIV reduces
immune function to a certain level or when one or more serious illnesses related to HIV
occurs. (4) 
Everyone is at risk of contracting the HIV virus, although women with HIV/AIDS face more
difficulties living with this disease than do men. HIV/AIDS women are of special interest
because they are the major source of infection of infants. Not only do they have to think
about the effects on their own lives, but also they must think about their infants if
they choose to conceive. In my paper, I will review the ways in which HIV/AIDS affects
women differently than men, through clinical issues and gynecological manifestations. I
will also discuss the virus itself and issues concerning HIV positive women who are
planning to conceive.
WHAT IS AIDS?
In early 1983, a team at the Pasteur Institute in Paris, France led by Dr. Luc Montagnier
first announced the discovery of HIV (5). They originally named it LAV, or
lymphadenopathy-associated virus. However, it was not until the American team, led by Dr.
Robert Gallo, called the virus HTLV-3 or human T-cell lymphotrophic virus that both teams
collaborated and simplified it to just HIV (5). 
HIV can cause a range of conditions, of which AIDS is the worst. For example, it can lead
to persistent swelling of the lymph nodes (5). Other people may have more serious
symptoms but still show no sign of AIDS. This condition is known as AIDS related-complex
( ARC) (5). Some of the symptoms of ARC include swollen glands, severe or chronic
diarrhea, severe fatigue, rapid unexplained weight loss, drenching night sweats, fevers,
and yeast infections, Although it can be serious, ARC is not fatal (5). 
The cause of AIDS is not fully understood. There are other factors are involved in the
development of AIDS. Once a person tests positive to HIV, alcohol or drug use, poor
nutrition, high stress levels, frequent exposure to other disease (especially sexually
transmitted disease), have all been suggested to increase the risk of developing full
blown AIDS (5). 
HIV transmission can be tracked accurately. However, anxiety surrounds AIDS because its
transmission from one person to another is not fully understood. Many people believe that
it is possible to get AIDS through, normal everyday contact with an infected person. This
is not the case. The majority of the people infected with HIV have contracted it through
sexual intercourse with an infected person (5). Bodily fluids such as blood, semen, and
vaginal secretions all may contain the virus. Using a condom can decrease the risk of
contacting the HIV virus during intercourse with an infected partner. Another method of
infection is through blood transfusion during surgery. A person may receive untested,
infected blood, therefore containing the disease. Through mid 1992, 2% of HIV infected
adults and 12% of HIV infected children were infected with HIV via blood transfusion
(15). However, the ELISA (enzyme linked immunosorbent assay) test was developed to screen
the nation's blood supply before used during transfusion procedures (15). Sharing needles
during IV drug use is yet another method of contracting HIV. Infected users pass the
needle back and forth increasing the risk of spreading HIV. Finally, another method of
transmitting this disease is from mother to infant during pregnancy. Infants may be
infected with HIV while in the womb or possibly at birth if the mother is infected (5).
WOMEN AND THE HIV ILLNESS:
HIV/AIDS was first identified in the United States among gay and bisexual men, and for
the first decade of the epidemic, the disease was primarily associated with homosexuality
and intravenous drug use in men (6). In recent years, there has been a growing
realization that HIV/AIDS is spreading rapidly among women, and rates of HIV infection in
women may eventually mirror those in the global epidemic (6). Approximately 61,4000 women
had been diagnosed with AIDS in the United States as of December 1994 (7). In the last
decade, the proportion of AIDS cases in women has nearly tripled (7). In 1985, there was
a 7%increase of AIDS cases among women, which grew to almost 20% in 1996 (8). Of that
total number of cases reported among women, the proportion attributable to heterosexual
contact also increased (9). In 1994, AIDS cases in women attributable to transmission via
heterosexual contact surpassed the number attributable to transmission via injection drug
use; however, sexual contact with a man who injects drugs accounts for the majority of
heterosexual acquired AIDS cases (9). AIDS is the fourth leading cause of death in women
ages 25-44 years in the United States (9), and is the leading cause of death among
African-American women in the same age group (10). Yet women remain understudied and
overlooked. The lack of research specific to women leaves health care providers
unprepared to recognized and respond to women's symptoms or experiences and uninformed
about their health needs (11). As a result, women are diagnosed at later stages of
clinical deterioration and receive fewer health care services to help them survive the
illnesses associated with AIDS (11). Therefore, women die sooner from AIDS than men do.
Clinical Manifestations:
A recent surveillance study has indicated that from 1995 to 1996 there has been a 23%
decrease in the number of deaths from AIDS (6). There has also been a 6% decrease in the
number of HIV-infected individuals diagnosed with AIDS (6). The decrease in AIDS-related
morbidity and mortality are attributed to the improvements in the medical care, as well
as the increased availability of therapies. However, these decreasing trends do not
concern women infected with HIV and AIDS. During this same time, women with AIDS-related
illnesses increased by 2% with only a 10% decrease in the numbers of AIDS related death
(6). The differences reported for women are due to the increasing AIDS cases in women and
the lack of drug therapies specific to women (6).
In 1982, the Center for Disease Control and Prevention (CDC) developed a case definition
of AIDS based on a list of related diseases and lab evidence for or against HIV infection
(12). Over the years, this definition has been modified and used for epidemiological
studies and clinical assessments, which frequently tied it to the provisions of certain
health and social services (12). In 1993, the CDC expanded the case definition for AIDS
in adolescents and adults when they added invasive cervical cancer to the list of
AIDS-related diseases (6 12). Although women develop recurrent and resistant
gynecological problems as a consequence of HIV infection, they do not meet the CDC
criteria for an AIDS diagnosis (12). Hence, without this diagnosis, many women are unable
to receive health benefits and services available to those with an official AIDS
diagnosis (12). Further data that show that women with AIDS do not survive as long after
diagnosis as men and, once diagnosed, become sick faster and die sooner than men with
AIDS (12). Some studies suggest this be attributed to gender differences or to delay
diagnosis of women, inferior access to health care and poor utilization of service (12).
Utilization of the prescribed drug therapies may affect the course of HIV/AIDS in women.
Evidence suggests that a number of HIV-infected women are reluctant to take
antiretroviral drugs because of concerns about their effectiveness and side effects, as
well as beliefs that drugs are experimental (6). Many women have negative views of
available drug therapies because of the lack of relationship between them and their
health care provider's (6). Consequently, women decide against taking the drugs to help
their HIV infection. These clinical manifestations underscore the immediate need for more
aggressive study of HIV infection in women. With more extensive research and clinical
care, women living with the infection may be able to avoid further AIDS-related illnesses
and women without the disease may be able to reduce their risk of infection.
Gynecologic Manifestations:
Until recently, AIDS diagnoses have excluded the serious gynecologic manifestations of
HIV that have been identified in women for some time (7). Most of the illnesses
associated with HIV are found in uninfected women, but occur less frequently, or severity
(10). Although the CDC has only recognized cervical cancer in the case definition of
AIDS, providers must be alert to the other female-specific conditions that their patients
might encounter (12). 
Candidasis:
Vaginal Candidasis has been described as one of the earliest manifestations of
immunosuppression in women (12). Refactory Candidasis may be an early warning of HIV
infection (7,12). In an early study, 24% of women had chronic refactory Vaginal
Candidasis as a complaint (7). As the illness progresses, the vaginal infection may move
to esophageal and tracheal involvement, and ultimately to the stomach in some very severe
cases (12). Candida infection of the esophagus has been reported as the most frequent
AIDS-defining symptoms in early studies of HIV-positive women (12). It is so common
because of the frequent use of antibiotic (13). However, this illness usually responds
well to the conventional treatment in women with early HIV infection, but advanced
therapy may be called for in a more severe case (13). 
Herpes Simplex Virus Infection (HSV or genital herpes):
Genital herpes simplex infection is dominant in women infected with the HIV virus (7,12).
The genital lesions associated with HSV may be an opportunity for the entry of the virus
(12). Thus, lesions that last longer than one month should be looked at and tested for
HIV infection (7). HSV is sometimes unresponsive to therapy (10) and can be an
AIDS-defining condition and require long-term suppressive therapy (7).
Pelvic Inflammatory Disease (PID):
Several studies have found a high rate of HIV infection among women with pelvic
inflammatory disease (13). Whether HIV is a cofactor or simply a sign for increased risk
of infection has yet to be established. One study showed that HIV infected women with
pelvic inflammatory disease are less likely to have a white-cell count great than 10,000
(13), which puts a patient at much higher risk for infection. Recommended treatment, is
to be hospitalization and treatment with intravenous antibiotics (7,12,13).
Further study is needed in many aspects of gynecologic disease in women with HIV. If the
epidemic of the female infections is to be reduced, health care providers must receive
education about these life-threatening diseases.
PREGNANCY AND HIV:
Because most HIV infected women are of childbearing age, considerable research has been
conducted on pregnancy-related issues. There is a 25% to 35% risk of perinatal
transmission (13), with an estimated 50 to 80 percent of infections occurring late in
pregnancy or during birth (10). HIV may be transmitted when maternal blood enters the
fetal circulation, or by mucus exposure to the virus during labor and delivery (10). 
Risks of perinatal transmission are increased if the mother has an advanced case of the
HIV disease, large amounts of HIV in her blood stream, or few immune system cells, CD4+ T
cells, which are the main targets of HIV (10). Other factors that may increase the risk
of transmission are maternal drug use, severe inflammation of fetal membranes, or a
prolonged period between membrane rupture and delivery (10,13,14). In one study, HIV
infected women who gave birth more than four hours after their fetal membranes were
ruptured were twice as likely to transmit the HIV virus to the infant as compared to
women who gave birth within that four hour period (10). In the same study, HIV infected
women who used heroin or crack/cocaine during pregnancy were also twice as likely to
transmit HIV to their babies than were women infected with the virus who were not
injecting drugs. 
Another risk of transmission is from a nursing mother to her infant (5,10,14). A recent
analysis suggested that breast-feeding introduces an additional risk of HIV transmission
of about 14% (10). In one case, an uninfected women who received a Cesarean section
needed a blood transfusion due to the massive amounts of lost blood. The baby boy was
breast fed, and it was later found that the blood that was given to the women was
contaminated with HIV. The mother and baby were both tested and both found to carry the
antibodies of HIV. The mother was apparently infected with the disease after delivery.
Hence, the baby could have only been infected through breast feeding (5). For this
reason, women who are infected with HIV are recommended to stay way from breast-feeding,
despite the slight chance of infection (5,10,14). 
To prevent transmission of HIV to infants, Zidovudine (AZT) (10,13,15) and prophylaxis
are recommended for pregnant women (13). There is limited knowledge with AZT. However, it
is known that it crosses the placenta and can be detected in fetal tissue and amniotic
fluids (13). When AZT is given shortly before therapeutic abortion of delivery, serum
amounts in the newborn are similar to those in the mother; thus reducing the risk of
maternal-infant transmission by two thirds (10). AZT is still being studied and
perfected. With further advances, AZT may be able to reduce the risk of transmission to
an undetectable amount, giving HIV infected women a less stressful decision when deciding
whether or not to continue with their pregnancy.
CONCLUSION:
More women are becoming infected with HIV. With earlier testing and treatment, women can
live with HIV as long as men can. However, in a male-dominated medical establishment,
women's health issues are often ignored (16). Some women go straight to their deaths,
while others are diagnosed after it is too late (16). Women need to know more about how
they can be infected, and should get tested for HIV if they think that there is any
chance that they have been exposed to the virus. This is especially true for pregnant
women. Not only are they endangering their own lives, they may be putting an unborn child
at risk for a disease that might have been avoidable.
If the cycle of female infection is to be broken, health workers must be able to provide
appropriate education, counseling and care to women (16). If women are to receive optimal
AIDS health care, research must be done specifically to target women (16). In the
meantime, people's fears and ignorance about HIV and AIDS must end by increasing the
education of the affects of HIV on women. Until the understanding of AIDS as it relates
to women becomes clear enough to health care workers, women will still suffer from the
rising AIDS epidemic.
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