Caring for women living with HIV: gaps in the evidence

Abstract

IntroductionIn the management of HIV, women and men generally undergo the same treatment pathway, with gender differences being given limited consideration. This is in spite of accumulating evidence that there are a number of potential differences between women and men which may affect response to treatment, pharmacokinetics, toxicities and coping. There are also notable psychological, behavioural, social and structural factors that may have a unique impact on women living with HIV (WLWH). Despite our increasing knowledge of HIV and advances in treatment, there are significant gaps in the data relating specifically to women. One of the factors contributing to this situation is the under-representation of women in all aspects of HIV clinical research. Furthermore, there are clinical issues unique to women, including gynaecologic and breast diseases, menopause-related factors, contraception and other topics related to women's and sexual health.MethodsUsing scoping review methodology, articles from the literature from 1980 to 2012 were identified using appropriate MeSH headings reflecting the clinical status of WLWH, particularly in the areas of clinical management, sexual health, emotional wellbeing and treatment access. Titles and abstracts were scanned to determine whether they were relevant to non-reproductive health in WLWH, and papers meeting inclusion criteria were reviewed.ResultsThis review summarizes our current knowledge of the clinical status of WLWH, particularly in the areas of clinical management, sexual health, emotional wellbeing and treatment access. It suggests that there are a number of gender differences in disease and treatment outcomes, and distinct women-specific issues, such as menopause and co-morbidities, that pose significant challenges to the care of WLWH.ConclusionsBased on a review of this evidence, outstanding questions and areas where further studies are required to determine gender differences in the efficacy and safety of treatment and other clinical and psychological issues specifically affecting WLWH have been identified. Well-controlled and adequately powered clinical studies are essential to help provide answers to these questions and to contribute to activities aimed at improving the health and wellbeing of WLWH.

Out of focus: tailoring the cascade of care to the needs of women living with HIV

“…As highlighted in this review, there are a number of unmet needs faced by WLWH, both in terms of offer and uptake of HIV testing and in terms of linkage to care after HIV testing, that appear to be exacerbated by the impact of social and stigma issues . More research is needed into what prevents women from accepting HIV testing and what encourages them to accept it.…”

“…Importantly, stigma and discrimination are reported among WLWH more frequently than in men living with HIV, and may contribute to the lack of or delay to HIV testing among women . Women may especially fear disclosure if found to be HIV positive, more so if they come from communities with significant gender power inequities; they may have fears about HIV in general and choose not to be tested .…”

“…Women appear to be at particular risk for certain ART‐related drug toxicities and adverse events (AEs), and this may impact their cascade of care and treatment outcomes. The increased drug toxicities and AEs experienced by WLWH were previously summarized in another review . Long‐term follow‐up data from the FIRST (Flexible Initial Retrovirus Suppressive Therapies) trial of initial ART regimens (PI, NNRTI or PI + NNRTI‐based combinations) suggest that WLWH have a more than twofold higher risk of treatment‐related anaemia than do men living with HIV [HR 2.34; 95% confidence interval (CI) 1.09–4.99] .…”

“…Gender-specific factors can also impact on the clinical care of WLWH post-diagnosisaffecting access to and retention in care, management, and the likelihood of achieving and maintaining viral suppression on ART (Table 1) [12,[17][18][19][20][21][22]. In addition to female-specific challenges around reproductive considerations, pregnancy and menopause, women differ from men in body composition and pharmacokinetic (PK) parameters.…”

Contraceptive Choice and Use of Dual Protection Among Women Living with HIV in Canada: Priorities for Integrated Care

“…Uncertainty about optimal contraceptive choice for women with HIV contributes to high rates of unintended pregnancy, which has consequences for women's health, as well as for their partners and children . In Canada, an estimated 56–61% of all pregnancies among women with HIV are unintended, a proportion that is notably higher than that among the general population of Canadian women (30%) and the most recent global estimate (40%) …”