Sexually Transmitted Infections

Women and HIV/AIDS

HIV is the human immunodeficiency virus, which can lead to acquired immune deficiency syndrome, or AIDS. HIV damages a person’s body by destroying specific blood cells, called CD4+ T cells, which are crucial to helping the body fight diseases.

In the United States, women and adolescent girls now account for 27 percent of annual new HIV infections, up from 7 percent in 1985.⁴⁰ This translates to more than 278,000 women and adolescent girls living with the infection.⁴¹ Women and girls of color—especially African- American women—are disproportionately affected compared with white women.

The HIV prevalence rate for African- American women (1,122.4 per 100,000) is nearly four times the rate for Hispanic/Latina women (263 per 100,000) and nearly eighteen times the rate for white women (62.7 per 100,000).⁴² Approximately one in thirty African- American women will be diagnosed with HIV at some point (as will approximately one in sixteen African-American men).⁴³ Relatively fewer cases have been diagnosed among Asian, American Indian/Alaska Native, and Native Hawaiian/other Pacific Islander females.

Among women diagnosed with AIDS in the United States in 2008, 77 percent of African- American women, 75 percent of Hispanic/ Latina women, and 65 percent of white women became infected through heterosexual contact.

Transmission

Two conditions must be met for HIV to pass from one person to another.

• The virus must be present in sufficient quantity. Five bodily fluids—blood, pre-ejaculate (pre-cum), semen, vaginal fluid, and breast milk—can carry enough virus to cause infection. Saliva, tears, sweat, urine, feces, and vomit (unless they are mixed with blood) do not ordinarily contain enough virus to cause infection.
  
  
• The virus must have a way to get into the bloodstream. HIV can enter a body through the mucous membranes that line the vagina and rectum; directly into the blood from a shared IV‑drug or tattoo needle; through the skin via any open cut, wound, or scratch; through the mucous membranes in the eyes and the nose; and through the opening of a man’s penis. Oral sex, rimming, fisting, fingering, and deep kissing are considered lower-risk activities for HIV transmission than penis-in-vagina and penis-in-rectum sex, unless blood is involved.

The virus can enter mucous membranes more easily if there are tiny cuts, inflammation, or open sores due to another STI or a vaginal infection. Therefore, your risk of becoming HIV infected or potentially infecting a partner is increased if you or your partner has other STIs that are untreated, or if you have untreated vaginitis or bacterial vaginosis (BV), a condition in which there is an imbalance of bacteria in the vagina.

Practicing safer sex is important even when both partners are HIV-positive. Unprotected sex among HIV+ partners can lead to mixing or exchanging viral strains, so one partner may spread resistant viruses to the other. Protection from other STIs is important as well. Barrier methods such as condoms and dental dams are recommended, as appropriate, for every sexual encounter. If one partner is infected and the other is not, using a barrier method can prevent infection of the uninfected partner. (For more information and guidelines on practices to prevent HIV transmission, see Chapter 10, “Safer Sex.”)

HIV can also be transmitted by sharing drug needles with an infected user. If you are considering getting a tattoo or a piercing, make sure that you find out what steps are in place at the facility for sterilizing needles between clients.

Pregnancy and Childbirth

HIV can pass from mother to fetus (this is called vertical transmission) during pregnancy and childbirth. If you want to have a child and think you might have been exposed to HIV, get tested before you become pregnant.

In the early days of the HIV infection, women were often discouraged from becoming pregnant, owing to the 30 percent chance of HIV being transmitted to the child before or during birth and the likelihood that the child would be without a parent in the near future. That is no longer the case in the United States. Early testing, rapid testing at the time of labor and delivery, effective antiretroviral medication, and cesarean sections for women with high viral loads have contributed to reducing the rate of transmission from mother to baby to under 2 percent in the United States and other industrialized nations.⁴⁴

Since HIV can pass to the infant through breast milk, the CDC advises against HIV+ women breastfeeding if they live in the United readily available and can be safely prepared. In areas where there is limited access to formula and to clean water, some experts believe that the benefits to the baby of exclusive breastfeeding outweigh potential risks of HIV transmission.⁴⁶ Researchers are currently investigating whether certain types of antiretroviral therapy may help prevent transmission in cases where breastfeeding is necessary.

Women with HIV-positive male partners who want to bear children have several options. Some fertility clinics use special sperm-washing techniques that can remove viral particles, allowing the couple to conceive an HIV-negative baby. Other couples choose to conceive using donor insemination from an HIV-negative donor. If you would like to become pregnant and you have an HIV-positive partner, consult with a fertility expert to learn more.

Possible Signs and Symptoms

People with HIV often experience a flulike illness four to six weeks after the actual time of infection. This illness, recognized as acute HIV infection, corresponds to the seroconversion of the HIV antibody from negative to positive. Symptoms that occur at this time can include fever, swollen glands, rash, sore throat, muscle aches, fatigue, or outbreaks of herpes zoster or aseptic meningitis. The symptoms are often experienced as a bad cold or flu. Once seroconversion has occurred, most patients feel entirely healthy and may have no further symptoms of HIV infection for years. During this period, however, people can transmit the virus to others through unsafe sex or by sharing needles.

Screening and Diagnosis

The Centers for Disease Control advise routine voluntary HIV screening for all persons thirteen to sixty-four years old—adults, adolescents, and pregnant women—as a normal part of medical practice, similar to screening for other treatable conditions, in all health-care settings.

The guidelines indicate that blood tests should be repeated at least annually for everyone likely to be at high risk for HIV, including injection drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, men who have sex with men, and people who have had (or whose sex partners have had) more than one sex partner since their most recent HIV test.

If you are starting a new sexual relationship, it’s a good idea for both you and your partner to get tested prior to having sex. If you or a partner has multiple sex partners (or you have reason to think this is the case), consider an annual HIV test. If you are pregnant, the test should be part of your prenatal medical screening. If you go for testing and treatment of another STI, consider including a HIV test.

See “HIV Testing,” p. 306, for more information on when and where to get tested. Support groups and counselors are available at some testing sites to help you with testing decisions.

Course of HIV/AIDS

HIV attacks T cells (CD4 lymphocytes), which are central to a healthy immune system. If HIV is untreated, immune function eventually begins to break down. If T cell levels go below 200/mm, symptoms of AIDS start to appear. These include weight loss, fatigue, swollen glands (lumps in the neck, armpits, or groin), and skin rashes. Night sweats, fevers, thrush (an oral yeast infection), headaches, diarrhea, and loss of appetite can also occur.

Opportunistic infections—such as pneumocystis pneumonia (PCP), Kaposi’s sarcoma (a cancer-causing virus), cytomegalovirus, esophageal candidiasis, or lymphoma—often occur when the immune system has been severely damaged by HIV.

Women with HIV often have unique complications. Recurrent vaginal yeast infections, chronic pelvic inflammatory disease, frequently recurring or disseminated genital herpes, or progression of human papillomavirus (HPV) infection can occur—and may indicate that HIV infection has progressed to AIDS.

Treatment

Antiretroviral therapies (ART) may allow people to live with HIV for decades, possibly for a normal life span. The goal of ART is to reduce the amount of HIV in the blood to undetectable levels. Achieving this usually allows the T cell levels to rise, sometimes back to normal levels, enabling the body to resist opportunistic infections. ART used to require taking multiple pills in multiple doses, but now it is sometimes as simple as taking one pill once a day. The increasing effectiveness of HIV treatment has dramatically reduced death rates and improved quality of life, and HIV is now often a manageable longterm illness. In addition, people who take their ART very consistently, without missing doses, are far less likely to pass HIV to a partner.⁴⁷

Treatment can be challenging, however. While many people experience initial side effects of the medications, including nausea or diarrhea, some have long-lasting side effects such as fatigue, bone loss, and fat redistribution. Some of the medications have been associated with diabetes and liver disease, and some may interfere with treatments for other conditions. It is important to make sure your HIV medicines are compatible with other medications you are taking, as well as with birth control pills. Tell your health-care providers all the medications you’re taking to ensure you are prescribed the right medications at the right doses.

Taking ART consistently, as prescribed, is crucial. It is important to find a medical regimen that you are able to follow and tolerate. HIV mutates very quickly and can become resistant to an antiviral drug if too many doses are skipped or missed. If you don’t take the drugs consistently, you may develop HIV strains that are drug-resistant, and you may not be able to use the drugs later in the course of the illness.

Not every person with HIV needs to be on medication; the decision is influenced by factors such as viral load and CD4 count. Current guidelines recommend antiretroviral therapy for those with T cell counts less than 500/mm.⁴⁸ Talk to your health-care provider about how to decide. Everyone who wants ART should have access to it, regardless of gender, socioeconomic or educational status, housing status, or drug use.

To complement the highly effective antiretroviral medications, some people with HIV and AIDS use acupuncture and Chinese herbs, meditation, yoga, massage, and many other holistic approaches to healing.⁴⁹ Some people find that these help reduce the side effects of the medications, bolster the immune system, and help cope with the stresses of illness.

Some AIDS service organizations, hospitals, and clinics provide alternative therapies regardless of an individual’s ability to pay. The AIDS Care Project of Boston, for example, draws on federal and local public-health funding to offer acupuncture and traditional East Asian medicine at low or no cost in communities where HIV is prevalent.⁵⁰ If you have health insurance, some complementary treatments may be covered. (For more information, see “Complementary and Alternative Therapies,” p. 674.)

HIV treatments are constantly evolving. For more information, see The National Women’s Health Information Center’s section on women and HIV/AIDS.

Excerpted from the 2011 edition of Our Bodies, Ourselves. © 2011, Boston Women's Health Book Collective.

40. H. I. Hall et al., “Estimation of HIV Incidence in the U.S.,” Journal of the American Medical Association 300 (2008): 520–29.
41. Centers for Disease Control and Prevention, “Racial/ Ethnic Disparities in Self-Rated Health Status Among Adults with and Without Disabilities—United States, 2004–2006,” Morbidity and Mortality Weekly Report 57, no. 39 (October 3, 2008): 1069–73, cdc.gov/mmwr/PDF/wk/mm5739.pdf.
42. Ibid.
43. Centers for Disease Control and Prevention, “HIV Among African Americans,” cdc.gov/hiv/topics/aa/index.htm.
44. D. J. Jamieson, “Cesarean Delivery for HIV-Infected Women: Recommendations and Controversies,” American Journal of Obstetrics & Gynecology 173 (September 1973): S96–100.
45. Robert M. Grant et al., “Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men,” New England Journal of Medicine 363 (2010): 2587–99.
46. “Health Benefits of Breastfeeding in Children Born to HIV-Infected Mothers,” in HIV Transmission Through Breastfeeding: A Review of Available Evidence, 2007 update, p. 21, whqlibdoc.who.int/publications/2008/9789241596596_eng.pdf.
47. K. Kayitenkore et al., “The Impact of ART on HIV Transmission Among HIV Serodiscordant Couples,” program and abstracts of the XVI International AIDS Conference, 2006, Abstract MOKC101.
48. Department of Health and Human Services, AIDS Adult and Adolescent Treatment Guidelines, AIDSinfo.nih.gov/Guidelines.
49. R. Palmer, “Use of Complementary Therapies to Treat Patients with HIV/AIDS,” Nursing Standard 22, no. 50
(2008): 35–41.
50. AIDS Care Project, part of Pathways to Wellness, is a public-health clinic for complementary therapies and HIV, pathwaysboston.org/specialty/aidscare.html.