Women and HIV

Partner Violence and Sexual Risk Behavior

Study Question: What is the relationship between intimate partner violence and sexual risk behavior?

Study Participants: This study examined a lower-income, community-based sample of Hispanic women reporting a current male sexual partner (N= 170). The participants were drawn from the Boston area, and were predominantly born outside the United States. Participants were all Spanish-speaking, between the ages of 18 and 35, and not fluent in English.

Study Methods: Recruitment was conducted through community outreach at housing projects, English as a Second Language classes, and HIV intervention program groups. Participants were categorized as either abused or not-abused using the Abusive Behavior Inventory. Participants' sexual risk levels were determined using the Safer Sex Assessment and the Condom Self-Efficacy Scale. Participants completed self-administered surveys at three 12-week time intervals that addressed issues of fear of partner response to safer sex negotiation, condom-use intent, partner control over condom use, and partner control over the sexual relationship. The surveys assessed relationships between safer sex intent and abusive relationship status.

Study Findings: About one-fifth of the sample reported male-perpetrated intimate partner violence in the past three months. Abused women were significantly more likely than not-abused women to report high STD/HIV risk, including sexual control by male partners, and male partner risk, including male infidelity. Intimate Partner Violence was not found to be significantly related to intent to use condoms and women reporting a recent history of intimate partner violence were actually significantly more likely than those not reporting such a history to report safer sex negotiation. However, abused women were more likely to report fear of verbal abuse or infidelity should they attempt to negotiate condom use. Surprisingly, fear of verbal abuse and fear of infidelity were not associated with safer sex negotiation.

Limitations: This study examined a specialized sample of lower-income, immigrant, heterosexual, Hispanic women who all reported inconsistent or no condom use. In addition, the study's reliance on female partners to assess male partner risk may create imprecise estimates of male partner risk.

Lessons Learned: In addition to the other health risks they pose, abusive male partners may place women at risk for HIV and other STDs. Providers working with populations at risk for HIV, should not neglect the significance of abusive relationships when taking patient histories and counseling patients about HIV risk factors.

Source: Raj, A., Silverman, G., Amaro, H. Abused women report greater male partner risk and gender-based risk for HIV: findings from a community-based study with Hispanic women. Aids Care, 2004, May; 16(4): 519-29

Depression and High Risk Behavior

Study Question: What is the relationship between depression and HIV risk behaviors in patients at a sexually transmitted disease clinic?

Study Participants: The sample was comprised of both male and female patients attending an STD clinic (N = 671). The mean age of participants was 30 and participant ages ranged from 18-58. The sample was almost entirely (96%) African American. Three-quarters (74%) of participants were single and 75% had some high school education or had graduated from high school. The sample included 351 women, on whom the rest of this summary is focused.

Study Methods: This study was a cross-sectional analysis, which employed computer-assisted self-interview assessments of depression (Beck Depression Inventory), sexual and drug-related behaviors (Risk Behavior Assessment), and overall health status (General Health Questionnaire). A subset of participants were evaluated through interviews, using the Structured Clinical Interview for DSM-IV.

Study Findings: Depressed women were much more likely than non-depressed women to have traded sex for drugs or money, to have had sex when using alcohol, cocaine, or heroin, and to have used cocaine or heroin. Depressed women were also much more likely to report having had a sex partner who used intravenous drugs. Contrary to expectation, depression was not independently related to unprotected sexual intercourse.

Study Limitations: The study's cross-sectional design precludes causal interpretation of associations between depression and risk behaviors.

Lessons Learned: This is one of the first studies to document an association between depression and HIV risk behaviors among STD clinic patients. If providers are able to identify and employ strategies to effectively intervene with depressed patients, they may be able to reduce the incidence of HIV risk behaviors.

Source: Hutton, H., Lykestos, C., Zenilman, J., Thompson, R., Erbelding, E. Depression and HIV risk behaviors among patients in a sexually transmitted Disease Clinic. The American Journal of Psychiatric, 2004 May; 161(5): 912-14

Testosterone Administration to Low-Weight HIV-infected Women

Study Question: How safe, tolerable, and effective is testosterone administration in HIV-positive women who are symptomatic, have reduced androgen levels, and are of low weight?

Study Participants: HIV-infected women (N = 57) with free testosterone levels less than the median of the reference range and weight less than 90% of ideal body weight. The mean age of the sample was 38. Over half (56%) of the participants were White, 18% were African American, 16% were Hispanic, and 10% were classified as other. Pregnant women were excluded from the study.

Study Methods: Participants were randomly assigned to receive either active testosterone transdermal delivery systems twice weekly or identical placebo patches. Randomization was stratified by weight at baseline. All investigators and patients were blinded to drug assignment. Participants were placed on a meat-free diet 3 days prior to all assessments. Baseline screenings consisted of urine collection and blood samples used to measure hormonal levels as well as CD4 counts and viral load. Subjects returned for monthly assessments, during the six-month longitudinal study. The assessments included physical examinations, blood tests, urine tests, muscle function assessment and caloric intake assessment.

Study Findings: Testosterone treatment resulted in significant increases in testosterone levels and was well-tolerated without adverse effects on immune function, lipid and glucose levels, liver function or body composition. A statistically non-significant trend of increased muscle mass (p=0.08) was observed among the treated patients. While strength decreased among many of the placebo-treated subjects, strength increased in most muscle groups of the treated subjects. Shoulder, elbow, and knee flexion as well as knee extension increased in testosterone treated subjects as compared with control.

Limitations: Though this is a longitudinal study, it was conducted over a relatively short period of time. Further research should be done to assess the optimal length of testosterone courses as well as the long-term effects of such treatment.

Lessons Learned: Transdermally-delivered testosterone may help prevent a decline in strength and muscle function in low-weight, HIV-infected women.

Source: Dolan, S., Wilkie, S., Aliabadi, N., Sullivan, M., Basgoz, N., Davis, B., Grinspoon, S. Effects of Testosterone Administration in Human Immunodeficiency Virus-infected Women with Low Weight. Archives of Internal Medicine, 2004 April; 164(8):897-904.

HIV-1 RNA Shedding and the Menstrual Cycle

Study Question: What is the association between hormone fluctuations during the menstrual cycle and HIV-1 RNA levels in vaginal and cervical secretions?

Study Participants: This study examined women (N = 17) who were HIV-1 seropositive, antiretroviral naïve, had regular menstrual cycles, had not used hormonal contraception or intrauterine device six months before the study, and had not undergone a hysterectomy.

Study Methods: Participants attended a series of daily clinic visits, beginning on the first or second day of menses and continuing until the start of the next menstrual cycle. Women were examined every day for the duration of one menstrual cycle. Endocervical and vaginal secretions were swabbed at every visit to test viral RNA levels in secretions. Daily urine samples were obtained to ascertain hormone levels and blood samples were obtained three times per week to measure other hormone levels. The study assessed the association between hormone levels and HIV-1 RNA levels in vaginal and cervical secretions.

Study Findings: There was a significant association between serum virus load, detection of HIV-1 infected cells in vaginal secretions, presence of menses at examination, and increased HIV-1 RNA levels in vaginal secretions. No significant association was found between the number of days from the woman's luteinizing hormone (LH) surge and the virus levels in her vaginal secretions. By contrast to vaginal secretions, after menses, cervical HIV-1 hormone levels appeared to decrease gradually until the LH surge and then gradually increase before the start of the next menses. Thus, a cyclical pattern of virus shedding emerged, where virus shedding was at a minimum at the LH surge and increased during the luteal phase of menstrual cycle.

Limitations: This study had a notably small sample size. In addition, HIV-1 RNA was only detected in 70% of vaginal samples, which may impede the study's ability to detect significant associations between hormone levels and virus levels in vaginal secretions.

Lessons Learned: There may be more risk of transmission of HIV-1 at certain times during the menstrual cycle. Providers should make HIV-infected women aware of this potential increase in risk of transmission and emphasize prevention of transmission.

Source: Benki, S., Mostad, S., Richardson, B., Mandaliya, K., Kreiss, J., Overbaugh, J. Cyclic Shedding of HIV-1 RNA in Cervical Secretions during the Menstrual Cycle. Journal of Infectious Disease. 2004, June: 189(12):2192-201.

HIV Risk among Women Sex Workers

Study Question: Does homelessness contribute to the sexual risk taking behavior among a sample of women who are already engaging in high-risk behaviors? What are some potential barriers to HIV/AIDS risk reduction, and to developing specific strategies for intervening with the target population?

Study Participants: 485 homeless and non-homeless women sex workers in Miami, Florida, US, for whom HIV and hepatitis test results were available. To meet the inclusion criteria, women had to be between the ages of 18-49 (mean = 37), have traded sex for money or drugs at least three times in the past 30 days, and have used heroin and/or cocaine three or more times a week in the past 30 days. 41.6% reported they considered themselves to be homeless, and both homeless and non-homeless groups were primarily African-American, followed by white and Latina.

Study Methods: As members of the targeted population, active sex workers recruited study participants using their "insider status" to help build the trust and confidence necessary for successful outreach and recruitment. Eligible participants were given urine tests for cocaine and opiates. Subjects were then interviewed, and subsequently assigned at random to one of two alternative HIV and hepatitis prevention interventions, either a Sex Worker Focused Intervention (developed specifically for this study), or the Revised National Institute on Drug Abuse (NIDA) Standard Intervention. Topics included HIV disease, transmission routes, risk behaviors, risks associated with crack or cocaine use, unsafe sexual practices and rehearsal of male and female condom use. Testing was also provided for HIV and hepatitis A, B and C on a voluntary basis.

Study Findings: 41.6% of the subjects reported that they considered themselves to be homeless, though only one-fourth of these women considered themselves homeless due to the precarious nature of their living arrangements. Demographic information did not significantly differ among homeless and non-homeless women. Drug-involved, homeless, women sex workers were at a significantly greater risk for HIV infection. Although both homeless and non-homeless women had lengthy sex work histories, and substantial numbers of lifetime partners, current patterns of sexual risk suggested that as homelessness further increased women's economic vulnerability, their susceptibility to engage in risky behaviors also increased. Self-reports of the past month of sexual activity indicated that homeless women sex workers engaged in significantly more vaginal sex acts (44.3 versus 28.0), more unprotected vaginal sex acts (15.4 versus 8.7), more oral sex acts (32.2 versus 21.4) and more sex acts while under the influence of drugs and/or alcohol (47.1 versus 28.6). HIV seropositivity rates did not differ by homelessness, but overall, African-American sex workers were almost two times more likely than sex workers of other race/ethnic groups to test positive for HIV.

Limitations: The sampling procedure was not a random design. Recruitment was localized, weakening the ability to generalize the findings to all communities of sex workers. Further, though controversial, the exclusive use of self-report measures was combined with assurances of confidentiality and the use of specially trained peers as staff in the present study.

Lessons Learned: The importance of integrating HIV prevention initiatives into community-based organizations serving the homeless is highlighted in this study. One possible approach to this continuing cycle of homelessness and increased risk is the development and implementation of specialized HIV/AIDS interventions combined with intensive outreach into the homeless sex worker community for the purposes of increasing their willingness to participate in intervention programs, establishing referral linkages to substance abuse treatment facilities, and reducing barriers to accessing treatment and other community services.

Source: Surratt, H.L., Inciardi, J.A. HIV risk, seropositivity and predictors of infection among homeless and non-homeless women sex workers in Miami, Florida, USA. AIDS CARE, 2004 Jul; 16(5): 594-604.

Drug Use and HIV Progression in Women

Study Question: Do HIV-infected women who use injection drugs (IDU) progress more rapidly to AIDS than non-IDU HIV-infected women?

Study Participants: 639 HIV-infected women enrolled in the HIV Epidemiological Research Study (HERS) group were followed for a mean of 7.25 years. 402 participants (62.9%) were African American. At baseline, 333 (52.1%) self-reported injection drug use as their major HIV-risk behavior, and 306 (47.9%) reported sexual contact as their primary risk behavior. At baseline, 11.4% of the entire study population reported daily injection, and 14.0% reported injecting less than daily.

Study Methods: Women enrolled in the HERS group underwent interviews, physical exam, CD4 count and HIV viral load at baseline and at 6 month intervals. Participants were considered to have AIDS after developing an AIDS-defining clinical condition or if CD4 count < 200 cells/mm³ or CD4% <14. At the end of the study, participants were re-categorized according to the frequency of injection drug use during the follow-up period. 124 participants who identified IDU as their primary risk category reported no injection behavior during the follow-up period, and 18 women who reported sexual contact as the primary risk category had engaged in intravenous drug use during the study. The new categories included: women who never injected drugs (n=250), women who injected drugs but not during the follow-up period (n=164), and women who actively injected during the follow-up period (n=225). These three groups were assessed for differences in progression to AIDS.

Study Findings: 299 women (46.8%) progressed to AIDS during the follow-up period. There was no significant difference in length of time until AIDS diagnosis among the three populations. Women who reported no injection drug use during the last 6-month period showed no difference in time to AIDS from the population who injected daily or the population who injected less than daily. Women in drug treatment programs had a slower progression to AIDS compared to women who were not in drug treatment programs. The death rate was 8% among women who never injected, 24% among former IDUs, and 19% among current IDUs.

Limitations: Poor information was available on the use of antiretroviral drugs and HAART, but available information suggests that adherence to ARV regimens was low. The effect of IDU on HIV progression may have been confounded by other factors involved in the treatment of HIV.

Lessons Learned: The authors write that the results, in agreement with earlier studies on the topic, suggest no direct association between injection drug use and progression of HIV disease. Women in drug treatment programs exhibited slower progression to AIDS, but that suggests that drug treatment and social support systems may be more important in HIV disease progression than injection drug use itself.

Source: Rompalo, A.M., Shah, N., Margolick, J.B., Farzadegan, H., Arnsten, J., Schuman, P., Rich, J.D., Gardner, L.I., Smith, D.K., Vlahov, D for the HIV Epidemiology Research Study (HERS) Group. Evaluation of possible effects of continued drug use on HIV progression among women. International Journal of STD & AIDS, 2004 May; 15: 322-327.

Relationship between Smoking and Human Papillomavirus Infections in HIV-Infected and -Uninfected Women

Study Question: What is the effect of smoking on the natural history of human papillomavirus (HPV) infection?

Study Participants: 1797 HIV-seropositive women and 496 HIV sero-negative women who were part of the Women's Interagency HIV Study (WIHS) and were tested for HPV at five visits between October 1994 and January 1998.

Study Methods: At the initial visit women were asked about their lifetime smoking history. At each visit women were asked about current smoking, were interviewed, had a physical exam, and had specimens collected, including one for HPV DNA testing. Women with HIV were asked about current antiretroviral (ARV) therapy. Statistical analysis looked at the high-risk and low-risk HPV type, HIV status, and whether the patient was smoking.

Study Findings: Women who did not have HIV were significantly more likely to be smokers. HIV-infected women were 3.9 times as likely to have a prevalent HPV infection at the first visit. HIV-infected women were 3.13 times more likely to acquire an HPV infection during the study. Smoking was significantly associated with the incidence of HPV among women with HIV infection. Women with HIV with high viral loads were more likely to acquire HPV infection, while women with high CD4+ counts were less likely. The study found that women with HIV infection when compared to uninfected women were more likely to have persistent HPV infection. Women who smoked consistently were more likely than those who did not to have persistent HPV infection.

Limitations: The study did not use an objective measure of smoking. They did not assess whether some women might be at less risk from smoking because of genetics. They could not tell whether HPV infections that were found during the study were new infections or reactivated ones. Each of these limitations would lead to an underestimate of the effects of smoking on HPV.

Lessons Learned: Persistent HPV infection has been linked to cervical cancer. HIV infection and immunosuppression play important roles in changing the natural history of HPV infection. This study found that among women with HIV, smoking is associated with significantly higher incidence and prevalence of HPV. Smoking during HIV infection may alter the natural history of HPV infection and increase the risk of cervical disease.

Source: Minkoff, H., Feldman, J.G., Strickler, H.D., Watts, H., Bacon, M.C., Levine, A., Palefsky, J.M., Burk, R., Cohen, M.H., and Anastos, K. 2004. Relationship between smoking and human papillomavirus infections in HIV-infected and -uninfected women. Journal of Infectious Disease. 189, 1821-1828.

Total Lymphocyte Count, Hemoglobin, an Delayed-Type Hypersensitivity as Predictors of Death and AIDS Illness in HIV-1 infected Women Receiving Highly Active Antiretroviral Therapy

Study Question: Does total lymphocyte count (TLC), hemoglobin, and delayed-type hypersensitivity response (DTH) measured prior to the initiation of highly active antiretroviral therapy (HAART) predict clinical response to HAART?

Study Participants: 873 women who were enrolled in the Women's Interagency HIV Study (WIHS) who began HAART after July 1995 and for whom laboratory and testing data were available were enrolled in this retrospective analysis.

Study Methods: The study analyzed data collected on each woman before she began HAART therapy including hemoglobin, total lymphocyte count (TLC-white blood cells), delayed-type hypersensitivity response (DTH), and CD4+ cell count. The study examined the statistical relationships between these factors and the occurrence of a new clinical AIDS defining illness or death after HAART was started.

Study Findings: The study found that a low TLC (<850cell/µL or <1250), CD4+ cells <200, anergy to DTH testing, hemoglobin <10.6, and a pre-HAART report of an AIDS-defining illness were independently associated with both death and diagnosis with a new AIDS-defining illness.

Limitations: The study was not randomized but included all women in the WIHS study who met the criteria.

Lessons Learned: The authors concluded that pre-HAART hemoglobin level, TLC, anergy to DTH testing, and clinical disease predicted AIDS-defining illness and death after HAART was started. These findings support the use of TLC to guide decision-making for starting HAART.

Source: Anastos, K., Shi, Q., French, A., Levine, A., Greenblatt, R.M., Williams, C., et al. 2004. Total lymphocyte count, hemoglobin, and delayed-type hypersensitivity as predictors of death and AIDS-related illness in HIV-1 infected women receiving highly active antiretroviral therapy. JAIDS, 35, 383-392.