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Women and HIV/AIDS: Treatment Issues
Key Issues:
Women must be included in more drug studies.
Pharmaceutical companies and the medical community must remove barriers preventing women from joining drug studies. Governments must remove the social and economic barriers preventing women from gaining access to treatment. Women need greater social and economic support if they are to receive effective treatment.
Women must be encouraged to get tested for HIV, and HIV-positive women must be closely monitored for all gynecological and hormonal changes.
Lack of scientific research makes fighting HIV in women more difficult. Gender-specific studies on side effects of drugs needs to be investigated in greater depth. It may be necessary to develop drug guidelines that deal specifically with the physiology of women. Side effects reported by HIV-positive women must be taken seriously and studied in greater depth.
General HIV Treatment Information
There is no cure for HIV/AIDS. New anti-HIV drugs allow some HIV-positive people to live a longer, have a better quality of life, but these drugs are not a cure. Not everyone can tolerate these therapies: some drugs cause liver damage and others life-altering side effects. Drug therapy is complex and demanding, and prescribed instructions must be followed closely: pills must be taken at the same time every day, several times a day; some drugs must be taken on an empty stomach, others on a full stomach. The sheer number of pills and difficulty swallowing them makes following instructions difficult. However, failure to do so can decrease overall health, and the effectiveness of these drugs. Many social and economic barriers interfere with effective therapy: poverty, discrimination, intimidation, and lack of access to treatment information contribute to this. New drugs offer hope, but there are still unanswered questions about their long -term effectiveness and their long- term effects on the body.
Classes of Drugs
Four classes of drugs (called antivirals) are currently used to fight HIV/AIDS. Each is designed to fight the virus at specific stages of its life cycle. The first class is nucleoside reverse transcriptase (called “nukes”or NRTIs), and the second is called non-nucleoside reverse transcriptase inhibitors (called “non nukes” or NNRTIs). Both classes attack the virus at the same stage in its life cycle (before it reproduces itself) but do so in different ways. The third class of drugs is called protease inhibitors, which stop (inhibit) the protein that makes the virus fully mature. These drugs work at the final stage of the virus’s life cycle, once it has already infected a person’s cell.
The fourth, and most recent class of drugs is called fusion inhibitors. The drugs stop the virus from entering the T-cell. There is currently only one drug in this class available, and it is only used for “salvage” or third-line therapy. This drug must be injected.
Therapies
Combination therapy is the prevailing treatment method: it consists of using more than one drug from the various classes of drugs at the same time (in combination). Using drugs from the NRTIs, NNRTIs, and protease inhibitors in combination attacks the life cycle of the virus simultaneously and at different stages of viral reproduction. The goal of combination therapy is to disrupt the life cycle of HIV. For those who have not had success on combination therapy, the fourth class of dugs is added.
Highly Active Antiretroviral Therapy (HAART) is a recent therapy that is producing remarkable results in some HIV-positive people. Three, and sometimes four drugs are used simultaneously, usually a protease inhibitor is included. The goal of HAART is to reduce the viral load (the number of viruses in the blood). A reduced viral load is considered beneficial because it suggests virus reproduction has slowed. Slowing viral reproduction, theoretically, allows the body’s immune system to become stronger and more able to fight HIV/AIDS.
Microbicides are chemicals that kill or neutralize HIV and other sexually transmitted infections (STIs). They can be formulated in a number of ways: gels, creams, suppositories, sponges or films, similar to products used with diaphragms. These substances are still being studied, but no such substance is yet available. These substances can theoretically reduce the possible risk of reinfection from a different strain of HIV. It may be possible for an HIV-positive woman to be reinfected by a different strain if her partner is also HIV-positive and they have unprotected sex. Microbicides may also prevent an HIV-positive woman from developing a drug- resistant strain of HIV if her HIV-positive partner is using a different combination of anti- HIV drugs. If HIV becomes resistant to a drug from one class, it is possible to become resistant to all other drugs from that class. When this happens, treatment options for women are limited.
Complementary or Alternative Medicine (CAM) are non-western treatment options used by some HIV-positive persons. Many Aboriginal and non-western cultures have their own healing traditions such as herbal remedies. There is an important distinction between complementary and alternative therapies: complementary therapies are used in conjunction with western medicine, while alternative treatments are used on their own. Some complementary and alternative therapies can be used together and may include massage and yoga for stress reduction; vitamin supplements; healthy eating; and regular exercise. Some studies suggest that women are more likely than men to use CAM, perhaps because they feel more comfortable with such remedies. Women in higher income and educational groups tend to use CAM because they have greater access to information and more money to spend on such therapies.
HIV/AIDS in Women
Physiologically women are at greater risk of contracting HIV and other sexually transmitted infections (STIs) because they have a larger surface area of mucosa (wet surfaces) exposed to their partners’ semen, and semen remains in women several hours after sex. STIs make women more vulnerable to HIV infection because STIs can weaken the mucosal membrane, or even produce genital ulcers, which provide easier access for HIV. Frequently women do not experience symptoms of STIs, and if left untreated the body is more vulnerable to HIV/AIDS.
Some studies suggest that HIV/AIDS may be different in women than men. The rate at which the disease progresses is also different in women; accepted predictors of disease progression (such as viral loads) are not always accurate predictors for women. A man and woman may have the same low viral load yet the progress of the disease may continue at a faster rate in the woman. More studies are needed to understand how and why this is so.
Some HIV-positive women experience menstrual irregularities such as changes in length of cycles, breakthrough bleeding and the volume of blood. Evidence suggests that advanced immune deficiency (T-cell count < 200) affects menstrual cycles, and many women are more likely to have cycles lasting more than 40 days.
Women and Treatment
Too little is known about anti-HIV drugs and female physiology. What remains unknown is how much of a drug is absorbed, and at what point a drug produces toxicity in women. Biological factors such as hormonal levels that vary according to monthly cycles, pregnancy, and menopause, may influence drug absorption, and anti-HIV drug interaction with other medication taken by women, specifically with birth control pills and hormone replacement therapy (HRT).
Barriers to Treatment
Women tend to receive HIV-positive test results later in the course of the disease (often finding out during pregnancy) because many doctors, and women, still believe women are at low risk of contracting HIV. Women are therefore discouraged from receiving early detection and treatment, receiving both can maintain health over a longer period of time. Discrimination against women and failure by the medical community to understand the disease in women also prevent women from receiving effective treatment. Many HIV-positive women feel intimidated by doctors and may not ask as many questions as their HIV-positive male coutnerparts.
Barriers to Clinical Trials
Despite increasing rates of HIV among women, they are woefully under-represented in clinical trials, which require a substantial time commitment, and may result in unpaid time away from work. Pharmaceutical companies and hospitals do not provide child-care services or compensatory money, making it difficult for women to participate in studies. Taking time off work may raise disclosure issues, as some women may not want to disclose their HIV status to employers. Women are often excluded from drug trials because of their biological potential for pregnancy. Many women lack support in the home, which can hinder their ability to participate in studies.
Poverty is another barrier to treatment because anti-HIV drugs are very expensive. Women earn less than men; many women work part time, and are often excluded from health plans; many mothers place the financial needs of their children and families above their own. Complementary and alternative therapies are typically not covered by provincial health plans, placing such therapies out of reach for many women.
Side Effects and Women
Many HIV-positive men and women experience a range of side effects, such as nausea, fever, anemia, diarrhea, and fatigue. But women experience side effects that are not seen in men, and some that affect women differently than men. Lipodystrophy (changes in body shape) syndrome is indicated by a redistribution of body fat such as the loss of fat in the legs and arms, and accumulation around the abdomen, in the face, and between the shoulders (“buffalo hump”). Women may be more at risk for this side effect. They are more likely to have fat accumulation, particularly in the abdomen and breasts. Some women using HAART report that their breasts become enlarged, red and painful, although studies have found that once the drug is discontinued, their breasts may return to normal. Women are more likely to get other side effects such as skin rashes, thrush, hepatic steatosis (fatty liver), lactic acidosis (increase in lactic acid) and osteoporosis than men.
Opportunistic infections (OIs) are bacterial, viral and fungal infections that take advantage of weakened immune systems. There are many types of OIs, but for HIV-positive women gynecological OIs cause several illnesses, such as: increased rates of vaginal infections, pelvic inflammatory disease (PID), and genital warts (HPV). Studies show that HIV-positive women are more likely to be infected by more than one type of HPV, and this virus is more aggressive in HIV-positive women. HPV has been linked to cervical cancer. Many drugs are available to treat OIs, but cervical cancer, and its treatment, is particularly serious for HIV-positive women because cancer treatments weaken the immune system, further compromising an HIV-positive women’s health. Furthermore, cervical cancer is an AIDS defining diagnosis; it means that HIV-positive women have developed AIDS.
Barriers to Drug Adherence
As with barriers to treatment, social and economic factors prevent HIV-positive women from keeping to a drug regimen. However, women are faced with an additional burden: as traditional family care givers, they give much of their time and energy taking care of others. Skipping medications, or taking drugs later than recommended, can reduce the overall level of health in HIV-positive women.
Information for this fact sheet was provided by:
The Community AIDS Treatment Information Exchange (CATIE). For more information contact CATIE at 1-800-263-1638.
The Canadian Treatment Advocates Council (CTAC). For more information contact CTAC at (416) 422-2179 or 410-6538.
