By Jill Taylor
SAN DIEGO, CA -- April 20, 2007 -- The evolution of HIV infection in women is allowing the number of infections to increase, and special issues with regard to treating these patients were discussed here at Internal Medicine 2007 (IM), annual scientific meeting of the American College of Physicians (ACP).
"What we're seeing is a steady, slow increase in the number of cases and prevalence," said presenter Constance A. Benson, MD, professor of medicine, University of Colorado Health Sciences Center, Denver, Colorado, United States. "We've gone from what used to be only 20% of women who were being infected through heterosexual contact to now 80% of infections through heterosexual contact."
Dr. Benson reported that CDC analyses of data collected from 2,467 men and 1,309 women showed differences between the sexes with respect to HIV infection. Of particular interest, women tend to have lower viral loads than men do, with CD4+ levels > 500/mcL viral loads for women being 57% lower than for men; CD4+ levels 200-499/ mcL viral loads for women being 48% lower than in men; and CD4+ < 200/ mcL viral loads for women being 40% lower than for men.
For this reason, Dr. Benson said, there has been an ongoing concern that because women have lower viral loads, they may progress at a different rate from men, and perhaps should be treated differently than men. However, CDC analyses indicated that there is no difference in recommendations for initiation of antiretroviral therapy for women and men.
Most of the recommendations with respect to initiation of antiretroviral therapy, Dr. Benson discussed, have to do with CD4 counts as opposed to viral loads. "Viral load does add to prognostic capability and higher viral loads are associated with more rapid disease progression," she said. "But the converse of that is not necessarily true."
There is a concern in using nevirapine in the treatment of HIV in women due to liver toxicity. Dr. Benson reported that this occurs in 8% to 18% of women administered nevirapine and 2.5% to 11% of patients develop symptomatic hepatitis, usually in the first 4 to 18 weeks of treatment. Nevirapine has been associated with rapid hepatic failure in pregnant women and, therefore, should not be given to this population unless the benefits clearly outweigh the risks. There is increased risk in women with chronic hepatitis B or C virus, or steatosis, and in women with CD4+ T cell counts > 250/ mcL.
HIV is shed during the menstrual cycle, and there is a positive correlation between levels of progesterone and viral load. Women with HIV have a higher incidence of abnormal PAP smears, low- and high-grade squamous intraepithelial lesions, and cervical intraepithelial neoplasia compared to non-HIV infected women.
Dr. Benson discussed recommendations that women receive a full pelvic exam and PAP smear at the time of HIV diagnosis. If the PAP smear is normal, it should be repeated after 6 months.
"We can assume that the majority of women with HIV are sexually active, and they should therefore be tested for other sexually transmitted diseases," Dr. Benson said. "It is not unusual at all for us to diagnose -- at the same time we diagnose acute HIV infection -- syphilis, Chlamydia, gonorrhoea, or human papillomavirus."
[Presentation title: Infectious Disease Issues in Women. Session MTP 044 (No Abstract)]
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