Caring for women living with HIV: gaps in the evidence.

INTRODUCTION: In 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. METHODS: Using 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. RESULTS: This 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. CONCLUSIONS: Based 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.

A review of reproductive health research, guidelines and related gaps for women living with HIV.

The study of pregnancy and motherhood in women living with HIV (WLWH) has concentrated on the health of the unborn baby and the prevention of mother-to-child transmission, whereas consideration of the broader aspects of women's reproductive health has been largely overlooked. The rights of WLWH with respect to their reproductive health should be exactly the same as non-HIV-positive women, however, inequalities exist due to discrimination and also because the treatment guidelines used in the care of women are often based on insufficient evidence. The purpose of this article is to review the available literature on reproductive health issues for WLWH and to identify gaps requiring further investigation. Our review indicates that further research is warranted into a number of aspects of reproductive health among WLWH. Currently, access to the relevant reproductive health resources and services, such as advice on contraception and fertility services, for WLWH is far from optimal in many developed countries and most developing countries. More data are needed on the most appropriate family planning options with the consideration of drug interactions between contraceptives and antiretroviral therapy and the risk of HIV transmission. Also, more research is needed to improve understanding of the maternal health challenges facing WLWH. Similarly, our understanding of the impact of HIV on the physical and emotional health of pregnant women and new mothers is far from complete. Answering these questions and countering these inequalities will help to ensure the reproductive health and child-bearing intentions of WLWH become an integral part of HIV medicine.

Preexposure prophylaxis and timed intercourse for HIV-discordant couples willing to conceive a child.

Many HIV-discordant couples express a strong wish to conceive a child. Insemination with processed semen is offered to these couples in many countries. Given the very low level of transmission risk during fully suppressive antiretroviral therapy, we offered timed intercourse combined with preexposure prophylaxis to further reduce the transmission risk. In 53 cases, natural conception was attempted using the proposed method. Pregnancy rates were high and reached a plateau of 75% after six cycles. Advanced age in the female partner was a predictor for infertility in these couples.

Consultations of HIV-infected women who wish to become pregnant.

PURPOSE: The aim of this study was to determine the impact and outcome of consultations of HIV-infected women if a pregnancy is planned. METHODS: This study was performed retrospectively based on patient's records of HIV-infected women with the desire to become pregnant between 2000 and 2008. Relevant data regarding HIV infection, obstetrical history, diagnostic procedures and medical interventions related to conception, as well as pregnancy outcomes, were evaluated. RESULTS: A total of 57 HIV-infected women (and their partner) were included; 38% (n = 22) of the couples showed a reduced fertility and 24 women (42%) became pregnant once or several times during the study period. Conception resulted from unprotected intercourse (n = 11), self-insemination (n = 10), assisted insemination (n = 2) or in vitro fertilization (n = 1). The outcome of all pregnancies was: 26 live births, 1 intrauterine fetal demise (38 weeks), 1 miscarriage, 1 cervical pregnancy and 1 legal abortion. No horizontal transmission occurred in serodiscordant couples. Seven (12%) women were lost to follow-up, 12 couples (21%) abandoned the attempt to get pregnant, and 14 couples (25%) reported an ongoing wish for a child. CONCLUSIONS: In this group of HIV-affected couples, we showed a high rate of reduced fertility. In our study, consultations and interventions led to a pregnancy rate of 42% without horizontal transmission of HIV.

Women Living with HIV Does Sex and Gender Matter? A Current Literature Review.

BACKGROUND: As women are more susceptible to heterosexual HIV infection than men, it is predicted that the percentage of women amongst people living with HIV will continue to grow worldwide. This has not only impact on preventive and reproductive issues, but also on treatment of women with HIV. - METHODS: Abstracts from the 9 superset th Conference on Retroviruses and Opportunistic Infections in Seattle and the XIV World AIDS Conference in Barcelona in 2002 have been reviewed for this article, complemented by further internet-search. - RESULTS: Increased time was dedicated to sex and gender aspects in major conferences. Sex-mediated differences in viral replication tend to disappear within the first five to six years of HIV-infection. Providing adequate medical care, women do respond equally well or even better to antiretroviral treatment and do not progress faster than men to AIDS. Gaps in our knowledge on efficacy, side effects, and pharmacocinetics of antiretrovirals and psychosocial factors promoting adherence to treatment in women have been identified. - CONCLUSIONS: If women die faster of AIDS, it is a matter of gender, but not sex. Providing access to treatment, psychosocial and behavioural aspects of adherence are mediated as a function of gender. Missing data on side effects and pharmacokinetic profiles of various treatments in women may be explained by the lack of regulatory requirements for statistically meaningful participation of women and sex-specific analysis as licensing criteria for drug approval. Involvement of women s community advisory boards (CABs) in the design of future studies may help to gather knowledge for recommendations in the treatment of women living with HIV.