Clinical:Case Study: Women and HIV Part I - Diagnosis and initial considerations

Original materials created in June 2000 by Suzanne Eidson-Ton, M.D.

“Women and HIV” is a complex and expansive topic involving public health, social justice issues, and the latest in biomedical research. This case is the first in a two-part series designed to touch on some of the important issues to consider when caring for a woman with HIV/AIDS. “Women and HIV” is not designed to provide comprehensive data, but perhaps more importantly, to acknowledge the complexity of HIV in women and the wide-reaching effects of the virus on every body system, and the patient’s experience of life. Many of us likely comanage such patients with infectious disease specialists or other physicians who care for a larger number of women with HIV/AIDS. For this reason, an overview rather than details will be useful. For support, recommendations, and information, the resources are listed below can be consulted. Again, this is simply a place at which to start

History

AD is a 38 yo G2P0 white woman, who has been my patient for many years. She is generally healthy, and she comes only for her annual exams. This visit she reports 2 months of amenorrhea. She has recently begun a new romantic relationship with a man she has known for years. They have been engaging in unprotected vaginal intercourse for about 4 months. She hopes this isn’t menopause because she has always wanted to have a child.

PMHx: No major illnesses or surgeries. No domestic violence. Chlamydia as a teenager which was treated, never recurring or resulting in PID

SocHx: AD lives alone. A few close friends, and her mother and sister live near by. Ten pack-year smoking hx. No alcohol but remote history of IVDU 20y ago. HIV and hepatitis C negative 5y ago. Of note, her current partner is a friend from 20y ago, who she believes is also clean, although for how long she is unsure. AD is heterosexual, with a total of 3 lifetime partners, but unsure of her partner’s sexual history in terms of infections, number of partners, or experiences with men. AD is fairly certain that she is his only current partner. They used condoms for contraception for “a while,” but stopped four months ago as they would both like a child at this point in their lives and “if it happens, it happens.”

Exam: Well-developed, well-nourished woman appearing her stated age. No lymphadenopathy. Exam is normal except for an asymptomatic vaginal yeast infection.

Studies

UPT is negative. CBC is significant for mild anemia with HCT of 34.1 % (36-48) and a normal MCV. Voluntary HIV test is positive (HIV+), Hep C and B are negative. RPR is nonreactive. Pap smear shows atypical squamous cells of unknown significance (ASCUS).

Discussion

Twenty percent of HIV+ individuals in the US are women (worldwide=40%), and they are the most rapidly growing group. AIDS is now the leading cause of death for women 25-44 years old in urban areas of the US. AD is somewhat unusual in her demographics. She is Anglo, and has fairly good social and economic support. A disproportionate number of women who contract HIV in this country are socially and economically disadvantaged, as well as being members of minority communities (African-American and Latina). ^[1] This may be related to relative access to power (both economic and social) within our society. AD’s case illustrates several important points regarding HIV in US women.

Transmission The most common means of HIV transmission to women is through heterosexual contact. The most recent statistics show that the majority of heterosexual contact leading to the acquisition of HIV in women occurs from HIV-positive men whose risk status is unknown. This underscores the use of condoms as paramount in protection of women from transmission of the virus. Negotiating condom use is problematic, however, in the face of culturally sanctioned male-dominance in relationships. Female condoms, and other methods that women can control, may be better alternatives to recommend to patients for prevention. The second most frequent mode of transmission is IVDU. Transmission from transfusion or other blood products is a small percentage (<1%).

Heterosexual transmission of HIV differs between men and women. First, heterosexual transmission from men to women is more efficient than from women to men. Contributing factors are the greater surface area of women’s vagina and cervix compared to the male urethra, and more viral particles noted in semen than in cervical secretions. Because younger women have a higher degree of cervical ectopy, with more exposure of the cervical transition zone, a woman may have varying susceptibility depending on her age. Younger women may also have more difficulty negotiating safer sex, especially with often older partners. Questions have been raised, although without conclusive data, about the role of certain contraceptives in the transmission of HIV, including oral contraceptive pills and nonoxynol-9.

HIV transmission among women who have sex with women has been difficult to characterize due to a variety of factors, including provider misconceptions, and lack of knowledge, with assumptions and homophobia no doubt playing a large part. Woman to woman transmission has been reported and is likely proportional to the degree of vaginal/mucosal trauma during sexual interaction. Other factors associated with HIV infection in same-sex couples is prior intercourse with men, IVDU, and use of unscreened semen for conception (i.e. from sources other than a sperm bank).

HIV Infection and Domestic Violence (DV) Current public health policy encourages partner notification to protect those at risk for HIV infection. Many providers believe, however, that the possibility of emotional and/or physical abuse, or abandonment must be considered when counseling women to disclose. Comprehensive data with respect to prevalence of domestic violence in relationship to HIV infection and disclosure are just now being accumulated, but providers have a plethora of anecdotal evidence. It is prudent to assume that domestic violence is at least as severe in HIV-infected women as in the general population.

For providers engaged in the diagnosis and treatment of women with HIV, encouragement to disclose must be balanced with screening and interventions for DV. Certain recommendations have been made, including:

• screening all HIV-infected women for domestic violence
• when the risk of DV is ascertained, patients should be counseled regarding such risk, and information regarding community, medical and legal services be made available
• in a case with risk of DV, provider should insure that a safety plan is in place before counseling disclosure. ^[2]

As more data are collected about prevalence and treatment of domestic violence in women with HIV/ AIDS, recommendations will likely evolve, and include more specifics. (“Women and HIV, Part II” continues next month with discussion of opportunistic infections and comorbidities, HIV and pregnancy, and Dr. Eidson- Ton’s plan for AD)

References

1. ↑ Newman, MD. “Women and HIV: The New Face of the Epidemic.” UCSF AIDS Program at SFGH. Medical Grand Rounds, January 25, 2000. Published at http://HIVInSite.ucsf.edu/topics/women/ 2098.45ef.html “New Developments in HIV Care for Women.”
2. ↑ Rothenberg, KH, et. al. Domestic violence and partner notification: Implications for treatment and counseling of women with HIV. JAMWA, 1995;50:87-93

Resources

1. HIV Warmline (Consultations for Providers): (800) 933-3413

2. WORLD (Women Organized to Respond to Life Threatening Diseases): phone (510) 658-6930, fax (510) 601-9746

3. http://HIVInSite