Natural history

The natural history of HIV in women is similar to that found in men. Primary infection seems to manifest in the same way. At one time, it was thought that women experienced a faster progression to AIDS and death, but later investigations indicated that disease progression and survival rates are equivalent given the same access to quality health care and treatment.

Because many early studies noted that women who had similar CD4 cell counts to men had consistently lower viral loads, the international AIDS Clinical Trials Group PEARL study team explored this by collecting data on over 1500 men and women from the US and eight resource-limited countries in diverse geographic areas. All participants had CD4 counts less than 300 cells/mm3 before starting antiretroviral therapy.

The study team found significant gender differences in the clinical, immunological, and virological characteristics of participants, concluding that female gender was independently associated with lower viral load. This was attributed to inherent biological differences.1 

Generally, after adjusting for CD4 cell count, median viral load in men and women is similar at five years post seroconversion. Recommendations for initiating antiretroviral therapy are the same for men and women. 

Women with HIV infection often present in clinic with gynaecologic problems. In general, these conditions are more frequent, severe, and difficult to treat than when found in women who are not HIV-positive.

Amenorrhoea and other menstrual disorders are more commonly found in HIV-positive women. It is not known if this is a result of HIV infection, HIV-related immunosuppression, antiretroviral therapies, or viral load. 

Research done over the past 15 years suggests that fertility may be reduced in women with HIV infection. A Ugandan study found an overall age-adjusted fertility rate of 0.74 as compared to HIV-negative women. Another study identified lower rates of conception and increased rates of pregnancy loss amongst HIV-positive women.2,3

There are indications that natural menopause may occur earlier in HIV-positive women than it does in the general population. A French study found that the median age of menopause onset was 46 in the study cohort versus 50 in the general population. Aside from immunosuppression, African ethnicity and injecting drug use were both significant predictors of early menopause.4

In a US study looking at whether antiretroviral response differed according to menopausal status, researchers concluded that antiretroviral-naive women could expect immunologic and virologic response to therapy regardless of menopause status.5

References

  1. Grinsztejn B et al. Gender-associated differences in pre-ART plasma HIV-1 RNA in diverse areas of the world vary by CD4+ cell count 15th Conference on Retroviruses and Opportunistic Infections, Boston, abstract 672, 2008
  2. Carpenter LM et al. Estimates of the impact of HIV infection on fertility in a rural Ugandan population cohort. Health Trans Rev 7 (suppl 2):113-126, 1997
  3. Gray RH et al. Population-based study of fertility in women with HIV-1 infection in Uganda. Lancet 351(9096): 98-103, 1998
  4. de Pommerol M et al. Menopause and HIV: age at onset and associated factors, ANRS CO3 Aquitaine Cohort. Fifth IAS Conference on HIV Pathogenesis, Treatment, and Prevention, Cape Town, abstract CDB009, 2009
  5. Patterson K et al. Treatment responses in antiretroviral treatment-naive premenopausal and postmenopausal HIV-1-infected women: an analysis from AIDS Clinical Trials Group Studies. Clin Inf Dis 49(3): 473-476, 2009
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