GMHC Treatment Issues 1997 Jul/Aug 1; 11(7/8): 2
Much of what is known today about HIV/AIDS was learned from
long-term natural history studies of gay men, such as the
Multicenter AIDS Cohort Study (MAC) and the San Francisco Gay
Men's Health Study. Current understanding of modes of
transmission, biologic cofactors, behavioral cofactors, acute
HIV infection, progression of HIV disease and case definitions
of AIDS were derived from these studies. Until recently, no
comparable long-term cohort studies had been conducted in
Globally, HIV is a disease acquired primarily via heterosexual
intercourse. Although the male cohort studies advanced the
overall understanding of HIV's behavior, they inevitably were
unable to frame or answer basic questions regarding gynecologic
manifestations of HIV infection, hormonal considerations in
women, or the mechanics and epidemiology of heterosexual,
female-to-female and perinatal transmission.
Critical to our current knowledge of the prevalence of HIV
infection in women are data obtained from population-based
studies of newborns that began in 1986. These studies, funded
by the CDC, used anonymous samplings of newborns as a surrogate
for uncovering the underlying HIV seroprevalence in women of
childbearing age (see pages 33-34 of this issue). These studies
established that women living in economically depressed, urban
centers throughout the U.S. had substantial seroprevalence of
HIV infection (from 2% to 6% of women). Reports by various
authors have tracked the epidemiologic status of women, an
early example being a publication (JAMA, 1987) authored by Mary
Guinan of the CDC, Epidemiology of AIDS in Women in the United
States. Early, small cohort studies in women have also
contributed to our knowledge base, particularly in the area of
gynecologic disease. Carpenter published data in 1991 regarding
200 HIV-positive women followed in Rhode Island. Substantial
data regarding abnormal Pap smear findings and risk for
dysplasia and cervical cancer in women have been published,
although treatment recommendations are lacking (see pages 10-18
of this issue). Investigation into the mechanics of
maternal-infant HIV transmission led to the intervention study
of use of zidovudine to reduce perinatal transmission (ACTG
At the present time, there are various ongoing, longitudinal,
natural history or heterosexual transmission studies of HIV in
women; for example, EVE, HATS, HERS, WIHS. Women enrolled in
these studies receive transportation, up to $80 payment per
visit, and other incentives. Still they often complain about
the long visits (four to five hours), the blood draws (9 to 10
tubes of blood), and the in-depth initial two-hour interviews
asking about everything from anal intercourse, sexual abuse,
and domestic violence to menstrual calendar data. What
knowledge do we expect to gain over the next five years, and
how will that knowledge be used to help women? At this interim
point, the following data is emerging from two large cohort
studies, WIHS and HERS. It is of enduring importance for
consumers, advocates and clinicians to continue to monitor and
provide critical input into these studies.
Women's Interagency HIV Study (WIHS)
WIHS is a longitudinal study of 2,080 HIV-positive women and
575 HIV-negative high-risk women enrolled between October 1994
and November 1995. There are WIHS collaborative sites in: the
Bronx/Manhattan; Brooklyn; Washington, D.C.; Chicago; San
Francisco/Bay Area; and Los Angeles/Southern California/Hawaii.
WIHS's objective is to investigate the spectrum of
AIDS-defining and other HIV-related conditions in women, the
predictors of genital infections and cervical disease, the
immunological and clinical correlates of disease progression,
risk behaviors, health care utilization, depression, domestic
violence and quality of life. To date, WIHS has published
substantial abstracted data from the entire cohort and from
subcohorts. Some highlights include:
* High prevalence of domestic violence and childhood sexual abuse in
* High prevalence of coinfection with Hepatitis C (40% of 269
women tested), with use of injection drugs the strongest
predictive behavior for this coinfection.
* 25% of the cohort reported ever having sex with a female
* HIV-positive women in the cohort have more comorbidity
(diabetes, high blood pressure, etc.) than the HIV-negative
women (25% vs. 18%).
* More acute genital tract infections in the HIV-negative
women; positive women had more chronic genital tract
* High prevalence of lower genital tract symptoms in the
positive women (itch, discharge, ulceration and vulvar pain)
even in the absence of identified infection.
* Amenorrhea linked to severe immune deficiency (13% of women
with CD4 counts below 50).
* Variability of HIV viral load in the genital tract.
* Close correlation between viral load in cervicovaginal
secretions and in plasma.
* 10% of the 533 HIV-positive women coinfected with another
retrovirus, HTLV-II, with injection drug use again being the
HIV Epidemiology Research Study (HERS)
HERS is a multicenter study of women with or at high risk for
HIV infection. Study sites are in Baltimore, the Bronx,
Detroit, and Providence, RI. HERS has conducted observational
and demographic research in the entire cohort (863 HIV-positive
and 430 HIV-negative women) as well as selected subcohort
studies. Some significant data thus far, include:
* Underutilization of anti-HIV therapy and opportunistic
* 28% of positive women reported having at least one family
member with HIV infection.
* 40% of women with or at high risk for HIV experienced
childhood sexual abuse.
* Longer persistence of human papillomavirus (HPV) in the
positive women, compared to the at-risk women.
* Oral and vaginal colonization of candidiasis associated with
low CD4 counts.
* Rare fluconazole resistance among oral and vaginal candida
* High prevalence of bacterial vaginosis (BV) in women with or
at risk for HIV.
* Women with female sex partners were 3 times more likely, and
women with male partners were 1.7 times more likely to have
BV than women without partners.