HIV/AIDS: An Update ________________________________________________________________________
Clinical Manifestations Many symptoms and signs of acute HIV infection and non- specific manifestations, such as fevers, weight loss, and fatigue, are the same for women and men. Because past research has either excluded women altogether or included only small cohorts of women, it has been difficult to determine gender differences in the clinical course of HIV disease. In general, studies have not shown significant differences in response to ART based on sex. However, limited data show that pharma- cokinetics for some ART drugs may differ between men and women, possibly due to variations in factors such as body weight, plasma volume, gastric emptying time, plasma protein levels, cytochrome P450 activity, drug transporter function, and excretion activity [35]. Gender-specific manifestations of HIV disease include irregu- lar menstruation, recurrent vulvovaginal candidiasis, human papillomavirus (HPV)-related cervical dysplasia (abnormal, precancerous cell growth), and cervical cancer. HIV-infected women have a higher prevalence of HPV infection, a higher risk of progression from infection to disease, and an increased risk of invasive cervical cancer and other HPV-related cancers than non-infected women [54]. Research indicates that ART does not significantly decrease the incidence of HPV-related cancers. As such, the American College of Obstetricians and Gynecologists recommends that women with HIV should have cervical cytology screening twice in the first year after diagnosis and annually thereafter [55]. Prognosis and Treatment Considerations Studies have shown that women with HIV have a poorer prognosis than men, with poorer access to or use of healthcare resources (later diagnosis), domestic violence, homelessness, and lack of community support all potential factors that may contribute to the seemingly higher mortality rate for HIV- infected women [64]. There are some unique clinical and therapeutic issues to con- sider when caring for women with HIV, and care providers should consult the updated guidelines. Considerations for
resistant to rifamycins with or without other antimycobacterial agents, the preferred therapy is 14 days of pretomanid plus linezolid plus moxifloxacin plus bedaquiline daily, followed by 24 weeks of pretomanid plus linezolid plus moxifloxacin daily, and bedaquiline three times per week; moxifloxacin should be omitted if resistant to fluoroquinolones. Alternative therapy for drug-resistant TB consists of an individualized regimen based on drug susceptibility test results and clinical and microbio- logical responses, and includes at least five active drugs, with close consultation with experienced specialists. Duration of treatment is 6 to 24 months depending on clinical and/or bacteriologic response to therapy [50]. Optimal management of HIV-related tuberculosis is complex, involving decisions around duration of therapy, timing of ART, and support services to assure adherence to observed therapy and regular follow-up care. Healthcare professionals should consult the guidelines to ensure use of the most effective management strategies for patients with tuberculosis and HIV, while concurrently promoting optimal ART for these patients. Special considerations apply to children and pregnant women with HIV-related tuberculosis.
HIV INFECTION IN SPECIAL POPULATIONS
WOMEN LIVING WITH HIV INFECTION Globally, women make up 53% of all individuals living with HIV. In the United States in 2022, there were more than 1.2 million individuals living with HIV, including 268,800 (22%) who were women. Women accounted for nearly 7,000 (19%) newly diagnosed cases in 2022, and within that group, it was reported that 83% were attributed to heterosexual sex, 17% to injection drug use, and 1% to other causes. The risk for acquisition of HIV and the factors that may affect seroconver- sion in women are areas of research, but it is clear that, in the absence of protective measures, women are much more likely to become infected with HIV through heterosexual sex (i.e., vaginal or anal receptive sex) than men. The overall incidence rate for women with a diagnosis of HIV in the United States remained unchanged between 2018 and 2022 [9]. HIV/AIDS is no longer a leading cause of death in women overall in the United States, but it remains the ninth leading cause of death in Black women 25 to 34 years of age. Women of color have been disproportionately affected by HIV/AIDS, with Black women accounting for 50% of new HIV diagnoses among women in the United States while representing only 13% of the female population. In comparison, White women accounted for 24% and Hispanic/Latina women accounted for 20% of HIV diagnoses. Black women also have the highest rates of HIV-related deaths among women with HIV, account- ing for 57% in 2022, compared with 20% for White women and 15% for Hispanic/Latina women [53].
ART in women living with HIV include [35]: • Some ART drugs may have significant
pharmacokinetic interactions with hormonal contraceptives and hormone replacement therapy. • Women, and Black women in particular, are susceptible to ART-associated weight gain after initiating or changing an ART compared with men, a difference reported across all classes of ART. • Postmenopausal risks of osteopenia, osteoporosis, and fractures are exacerbated by HIV and some ART agents.
51
MDCT2026
Powered by FlippingBook