Women and HIV

Herpes Zoster in HIV-Infected and HIV-Uninfected Women

Study Question(s): Is the risk of herpes zoster higher in HIV-infected women than in uninfected women, even in the era of highly active antiretroviral therapy (HAART)? Because herpes zoster occurs at all CD4 counts, the investigators hypothesized that HIV-infected women treated with HAART would continue to be at higher risk for developing zoster.

Study Participants: 1832 HIV-infected women and 489 HIV-uninfected women who were enrolled in the Women's Interagency HIV study at six sites across the country during October 1994 to November 1995.

Study Methods: Women underwent extensive interviews, physical examinations, and blood collection every 6 months for 7.5 years. During each interview, participants were asked if they had been diagnosed with herpes zoster in the past 6 months. Interviewers also ascertained self-reported HAART use.

Study Findings: The probability of reporting herpes zoster was higher among HIV infected women-across all ranges of CD4 counts-than among uninfected women. During the 7.5-year follow-up period, 18.4% of HIV-infected women experienced herpes zoster compared to only 1.4% of HIV-uninfected women. Among HIV-infected women, the incidence of herpes zoster was highest for women with the lowest CD4 counts. When compared to HIV-infected women with CD4 counts above 750, the risk of herpes zoster was doubled for women with CD4 counts of 350-399 and was tripled for women with CD4 counts less than 200. Higher HIV RNA level (viral load) was also associated with increased likelihood of reporting zoster. After adjusting for CD4 count and viral load, HAART use itself was not associated with the risk of herpes zoster. Among women who had initiated HAART during follow-up (68%), lower CD4 cell counts were associated with a greater chance of reporting herpes zoster. Viral load was not related to zoster risk in this group, likely due to the decrease in viral load levels with HAART.

Limitations: This study relied on self-report measures of herpes zoster that were not confirmed by medical records. Because HAART use was modeled on an intent-to-treat approach, the authors were not able to assess the potential impact of starting and stopping HAART on herpes zoster incidence. In addition, since the authors have no data on the clinical manifestations of or complications of herpes zoster in the cohort, they cannot make any inferences about the severity of herpes zoster in relation to CD4 count and the use of HAART.

Lessons Learned: This study found a strong relationship between incidence of herpes zoster and degree of immunosupression among HIV-infected women. However, even HIV-infected women with the highest count of CD4 cells were nine times more likely to develop herpes zoster than HIV-uninfected women, suggesting that HIV status on its own has a large impact on herpes zoster risk. Perhaps most notably, CD4 count affected incidence of herpes zoster independent of the initiation of HAART. Recent studies have shown that the initiation of HAART may increase risk for herpes zoster in the short term. However, this study found that the initiation of HAART neither increases nor decreases the risk of herpes zoster.

Source: Glesby MJ, Hoover DR, Tan T, Shi Q, Gao W, French AL, Maurer T, Young M, Dehovitz J, Ru J, Anastos K. Herpes Zoster in Women With and at Risk for HIV: Data from the Women's Interagency HIV Study. Journal of Acquired Immune Deficiency Syndromes, 2004 December: 37(5). 1604-1609.

Effect of Highly Active AntiRetroviral Therapy (HAART) in HIV-Infected Women

Study Question(s): What is the impact of HAART on anemia and what is the relationship between anemia and survival in HIV infected women?

Study Participants: 2056 HIV-infected women who where enrolled in the Women's Interagency HIV Study at six U.S. sites from October 1994 to November 1995. Most women were African American (56%) or Latina (23%), and 41% reported a history of injection drug use. The median age was 36 years.

Study Methods: During a 3.5 year follow-up period, women were seen every 6 months. At each visit, participants underwent a standardized history, physical examination, gynecologic examination, and blood tests. For this study, anemia was defined as hemoglobin less than 12 g/dL.

Study Findings: Over one-third of women (36.7%) were anemic at their baseline visit. Almost half (47%) of women without baseline anemia were anemic on at least one follow-up visit. Similar factors were independently associated with the inability to resolve anemia (for women with baseline anemia) and with the development of anemia over time (in women who were not anemic at baseline). These factors included low CD4 cell count (less than 200), high levels of HIV-1 RNA (more than or equal to 50,000 copies) and use of AZT. AIDS status was not related to the resolution of anemia but was associated with developing anemia. Women who used HAART, even for only six months, were more likely to resolve their anemia, while HAART use for at least 12 months protected against the development of anemia. Importantly, women who were anemic at any time were at a greater risk of dying.

Limitations: This study found only a weak, non-significant relationship between HAART use and better survival. This weak association was due to several factors. First, the number of women who had taken HAART therapy for 18 months was relatively small. Second, those who received HAART therapy early enough to have had it for 18 months were those individuals who had more advanced HIV at the time that HAART first became available.

Lessons Learned: This large, prospective study highlights the importance of identifying and treating anemia in HIV-infected women. Persistent or developing anemia was associated with decreased survival , although the mechanism is not known. The findings demonstrate that even short-term HAART use can help correct anemia while longer HAART use protects against developing anemia.

Source: Berhane, K., Karim, R., Cohen, MH., Masri-Lavine, L., Young, M., Anastos, K., Augenbraun, M., Watts, DH., and Levine, AM. Impact of Highly Active Antiretroviral Therapy on Anemia and Relationship Between Anemia and Survival in a Large Cohort of HIV-Infected Women: Women's Interagency HIV Study. Journal of Acquired Immune Deficiency Syndrome., 2004 October; 37(2).1245-1252.

Maternal-Child Separation among HIV-Infected Mothers

Study Question(s): What is the prevalence of and factors associated with the separation of HIV-infected mothers from their children?

Study Participants: Participants were part of a larger longitudinal cohort of HIV-infected women followed by the Family Advocacy, Care and Education Services (FACES) of Children's Hospital in New Orleans. This study was based on routine data collected from July 1, 2001 through March 20, 2003 on 236 HIV-infected women ranging in age from 14 to 58 years. All participants had one or more child under the age of 18, for a total of 586 children.

Study Methods: Women were interviewed at the study intake and every three months thereafter. Information obtained during the intake and follow up interviews included relationships in current household, whether or not the child was living at home, and HIV status of children. At each interview, self-report data included information about substance use, negative affects of substance use on life, and treatment for substance use or abuse.

Study Findings: 82 children (14%) were not living with their mother at baseline. The 3-month period prevalence of maternal-child separation ranged between 12.7% and 21.2% over the course of the follow up. The final analysis shows that older children, children with mothers who had less experience with FACES, children with mothers who used illegal drugs and/or alcohol, and children with mothers who had mental health problems were more likely to be separated from their mother. Children whose mothers had permanent residence were less likely to be separated from their mothers.

Limitations: The women in this study were part of a convenience sample who were receiving some HIV care and may not be representative of the general population of women with HIV. It seems likely that HIV-infected women who are not receiving care are at a greater disadvantage and may have higher rates of separation from their children. In addition, data was based on self-report. Participants may not have been honest, for example, about drug use due to concerns about illegality.

Lessons Learned: This study suggests that maternal-child separation was highest for mothers who use illegal drugs and/or alcohol, have suffered from mental health problems, or who do not have permanent housing. The findings highlight the importance of alcohol and drug abuse treatment and mental health services as well as housing assistance to prevent maternal-child separation among women with HIV infection.

Source: Theall, KP., Mitchell, C., Ludwick, M., Brown, B., and Kissinger, P. Factors associated with maternal-child separation among HIV-infected mothers. AIDS Patient Care and STDS. 2004 September; 18(9). 509-19.

The Use of Complementary and Alternative Medicine in HIV Treatment

Study Question(s): What is the association between the uses of complementary and alternative medicine (CAM) and HIV clinical disease indicators?

Study Participants: 391 HIV-positive women ranging in age from 18 to 50 years old. Participants were recruited through the NIH-funded study, "Women Involved in Life Learning from Other Women" (WiLLOW). Most of the participants were African-American (84%), single (86%) and had a household income less than $10,000 per year (70%).

Study Methods: Assessment of CAM use included in the WiLLOW baseline questionnaire included herbal and natural medicines, vitamins, dietary and nutritional regimens, religious healing, body work such as massage and acupuncture, and psychic healing. HIV clinical disease variables included CD4 cell count, viral load, CDC categories, Karnofsky scores, and number of infections experienced at or within 3 months of baseline. Statistical analyses examined relationships between CAM use and clinical disease, sociodemographic, and other disease-related variables.

Study Findings: 59% of women reported CAM use, with vitamins being the most commonly used CAM (36%). About 16% of women reported using herbs, 22% used dietary supplements, 27% engaged in religious healing, 10% practiced bodywork, and 1% used some type of psychic healing. Women who reported more CAM use tended to be older, better-educated, without insurance coverage, and living with HIV for a longer period of time as compared to those who did not report CAM use. The only clinical disease indicator that associated with CAM use was a higher number of infections (3 or more). Women who used vitamins had significantly higher education levels, higher incomes, and longer disease durations than those who did not use vitamins. Women who used vitamins had a lower viral load levels and a higher number of infections.

Limitations: The design of this study shows only correlation but not causality between CAM use and clinical disease status. Follow-up longitudinal studies and randomized clinical trials are needed to confirm these results.

Lessons Learned: Most studies on CAM use and HIV-positive individuals have focused on either white men or white men and women. This study stands out because it is the first of its kind to be done on a group of primarily African-American women. The results are consistent with past studies on CAM use in HIV-positive individuals. Most notably, vitamins have been the CAM more often associated with disease indicators. Indeed, in this study vitamin use was shown to be significantly associated with lower levels of viral load. However, it important to note that people who are likely to take vitamins may also be likely to engage in better health-taking practices such as eating healthier and getting more sleep. It is also important to note that useful CAM practices (such as taking vitamins) are more common among white, better-educated, and higher income individuals. Healthcare providers should make a point of educating all patients about the health benefits of CAM practices such as taking vitamins.

Source: Mikhail, S., Diclemente, R., Person, S., Davies, S., Elliott, E., Wingood, G., and Jolly, PE. Association of Complementary and Alternative Medicines With HIV Clinical Disease Among a Cohort of Women Living With HIV/AIDS. Journal of Acquired Immune Deficiency Syndrome, 2004 November; 37(3). 1415-1422.