Women and HIV: Same Treatment, Different Care
October 21, 2015
Women with HIV should receive not only the same antiretroviral therapy (ART) as men, but also clinical care tailored to their specific risk factors and health care goals, according to Kathleen Squires, M.D., director of the Division of Infectious Diseases at Thomas Jefferson University.
Squires, speaking at IDWeek 2015 in San Diego, California, explained that while medication guidelines are the same for both genders, treatment for women with HIV should also include wraparound clinical services such as gynecological care, abuse counseling and menopause management. She also emphasized that more basic scientific research is needed to understand the slight differences in viral load relative to CD4+ cell count in women compared to men, and that more clinical research is needed that includes a greater proportion of women as trial volunteers.
Treating women with HIV requires a sophisticated understanding of the risk factors and challenges they face, Squires said. She noted that the recent and alarming uptick in infection rates among young men in the U.S. might lead some clinicians to become complacent about issues specific to HIV in women.
Since 1985, there has been a threefold increase in infection rates among women in the U.S. Squires described three female patients she has treated within the last two months. All three women had strikingly similar stories. Despite their lack of condom use with relatively new partners, these women "were not really cognizant that they were at risk" for HIV, Squires said.
Squires relayed this anecdote to drive home her main point: The medical community needs to focus more on HIV in women, and especially women of color. HIV has disproportionally affected black women, Squires stressed. By 2013, black women made up only 13% of the female population in the United States, but 63% of the total cases of female HIV diagnosis, she said.
It is important to understand that women have different risk factors compared to other groups, Squires explained. HIV risk is correlated to rates of childhood sexual abuse and adult physical assault. Domestic abuse and violence is also correlated with risk of HIV, or actual HIV in women, she said.
Antiretroviral Therapy in Women
The U.S. Food and Drug Administration (FDA) has recognized that women are underrepresented in clinical trials. In order to tease out the safety and efficacy of HIV regimens in women, the FDA conducted a meta-analysis of registration trials. The bottom line, Squires said, is that the meta-analysis showed no major differences between men and women in their responses to treatment.
However, the pharmaceutical company Gilead Sciences recently conducted a trial of antiretroviral therapy exclusively in women. This study, called the Women AntiretroViral Efficacy and Safety study (WAVES), compared two HIV treatment regimens and found that women taking elvitegravir/cobicistat/emtricitabine/tenofovir (Stribild) had better viral suppression and fewer side effects than women taking ritonavir (Norvir)-boosted atazanavir (Reyataz) plus tenofovir/emtricitabine (Truvada).
These results appear to differ from Gilead's mostly male clinical trial, which was used to support Stribild's approval. The WAVES study hinted that an all-female group might respond to antiretroviral therapy slightly differently than an all-male group.
Absent meaningful head-to-head data, formal treatment guidelines will likely remain the same for men and women. Nevertheless, complications of highly active antiretroviral therapy are different in men and women, Squires pointed out. For women, complications can include increased risk of pancreatitis, rash, fat accumulation and breast enlargement. Also, women have greater risk of triglyceride increases, hepatic steatosis, lactic acidosis and bone mineral density decreases.
Counseling and Pregnancy
HIV treatment in women requires close collaboration with an OB-GYN practice, Squires said. Ideally, clinicians should try to offer "one-stop shopping" rather than ask patients to visit a number of different providers, she added.
Contraceptive counseling is mandatory when treating any newly diagnosed female HIV patient, Squires said. If a woman choses oral contraceptives, her clinician needs to be aware of the risk of drug-drug interactions.
According to Squires, too many HIV clinicians neglect pregnancy counseling with their patients. "If you don't ask your patient what her goals are, you're not going to be able to help her reach those goals," she said. If an HIV positive woman does want to become pregnant, she needs to understand the importance of achieving viral suppression first, Squires said.
"Management of pregnant women [with HIV] is complex and requires a multidisciplinary approach," said Squires. There is limited clinical data available on the best ART regimen for pregnant women because pregnant women are excluded from clinical trials. Boosted protease inhibitors are usually prescribed during pregnancy, but there have been a number of studies correlating boosted PIs with lower birth rate or early labor.
"Nobody has suggested we shouldn't be using these regimens," Squires said, but she advised audience members to "keep your eye on the literature."
Providers also need to keep clinical care in mind after a woman gives birth. Squires noted that women need to be monitored for postpartum depression and counseled about the risks of breast-feeding.
According to the World Health Organization, today almost half of HIV-infected people around the world are women. Squires emphasized that, even if women are no longer a minority of the HIV-infected population, their care nevertheless requires a multifaceted approach.
Sony Salzman is a freelance journalist reporting on health care and medicine, who has won awards in both narrative writing and radio journalism. Follow Salzman on Twitter: @sonysalz.
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This article was provided by TheBodyPRO. It is a part of the publication IDWeek 2015.
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