HIV and Women

Almost fourteen years into the AIDS epidemic, many people still believe this fatal disease strikes only gay men and drug addicts. It is true that, initially, most cases were diagnosed in gay men and IV-drug abusers. But in the past few years the rate of new diagnoses among homosexual men has decreased and incidence is increasing rapidly among heterosexuals, especially heterosexual women. In fact, women infected through heterosexual contact are now the fastest-growing group among all HIV-infected persons nationwide. In New York City, AIDS has been the leading cause of death for women age 25-34 for several years, and it is now the leading cause of death nationwide for women in this age group. According to one estimate, AIDS will kill 3 million or more women and children worldwide in this last decade of the 20th century. Clearly, HIV/AIDS is not a "gay problem".

It's not who you are, it's what you do, that puts you at risk for HIV infection. And the primary behavior that increases your risk of HIV infection is engaging in unprotected sex. The homosexual community has become educated to this fact and has long been acting on this information. However, the message has not gotten through as well to heterosexuals.

Although medical science still doesn't fully understand HIV/AIDS, certain facts are definitely known. Most scientists believe that HIV (Human Immunodeficiency Virus) causes AIDS (Acquired Immunodeficiency Syndrome), a condition in which your body becomes incapable of fighting diseases and infections. These diseases and infections can kill you.

People infected with HIV usually look and feel healthy and so for years may not even know they are infected. Nevertheless, infected persons can infect others, even if they have no symptoms of illness. We know that there is an "incubation period", frequently as long as six months, between exposure to the virus and when it can first be detected in the blood. Only a blood test can determine whether someone is infected with HIV.

We know that the virus can enter your body through cuts, sores and mucous membranes, including the linings of the mouth, vagina and rectum. We know that the HIV virus is present in the blood of infected persons, the vaginal fluids of infected women and the semen of infected men. Therefore, engaging in unprotected sex -- sex in which semen enters the vagina, rectum or mouth -- with a man who cannot be 100 per cent sure he has never been exposed to the HIV virus will greatly increase your risk of infection. And we know that it is possible to become infected from even one sexual experience or one sharing of needles with someone who is infected.

Symptoms in Women

HIV infection manifests itself in women differently than it does in men. While both may experience symptoms such as swollen lymph nodes, low blood counts, pneumocystis carinii pneumonia (PCP) and other opportunistic infections, HIV-infected women can also experience chronic yeast infections, abnormal Pap smears, abnormal growth or development of the cervix (cervical dysplasia), genital warts and even cervical cancer. Of course, vaginal yeast infections and even abnormal Pap smears are not necessarily diagnostic of AIDS, but they are sometimes "markers" for the presence of HIV infection.

Yeast infections in HIV-positive women are resistant to therapy, and tend to recur. Pelvic inflammatory disease (PID), another sexually transmitted disease, is also seen frequently in HIV-positive women. It may be a marker of HIV disease, or may be a consequence of the general suppression of the immune system suffered by those infected with HIV.

Studies and Treatments

Almost all HIV patient studies to date have been done on homosexual men; women have been excluded from research trials because of possible side effects of medications on female reproductive organs and fetuses. However, as more cases are recognized in women, more questions are being raised. It is apparent now that clinical trials need to include women and take into account the unique effects of HIV infection in women. Some studies are now being done, but with the present dearth of such research, infected women and infected men are receiving essentially the same treatments.

Testing

If you have had unprotected sex since 1977, received a blood transfusion or blood products before 1985, or have shared drug needles or syringes, you should be tested. If your partner falls into any of these categories, he should be tested too. Sometimes it takes up to six months from the time of infection before antibodies to HIV can be detected in the blood, so even if you've both recently tested negative you should be tested again if your last unsafe experience was within the six-month period. And you should both be tested if you are thinking about becoming parents. HIV-infected mothers can pass their disease on to their unborn children -- about one-third of all babies born to infected mothers are themselves born infected. Your test provider or doctor can tell you about your options.

Finding out your HIV status is relatively simple. A small sample of blood is taken and tested for the presence of antibodies to the HIV virus. The test needs to be accompanied by professional counseling, both before taking the test and after receiving the results. Various tests can be used but you must be certain that the person performing the testing is board certified and uses a certified lab. The tests used today are nearly 100 per cent accurate in detecting antibodies to HIV in the blood of an infected person -- but all positive results (and of course all inconclusives) must be confirmed by a second test.

What is Safe?

It must be said that the best way to avoid HIV infection is to not have sex, or to have sex only with a partner who is not infected, who only has sex with you, and who does not "shoot" drugs or share needles and syringes.

If you don't know for certain that your partner is not infected, you must use latex condoms for all instances of penetration -- vaginal, anal and oral, every time, start to finish. Latex condoms are impermeable to the virus (lambskin condoms are not) and so their use affords some protection, but they're not foolproof. They can be defective or tear; they can come off. Or they can simply be put on too late -- semen or pre-cum seeps out of the penis prior to ejaculation, so to be most effective, the condom should be put on during foreplay. Incidentally, condoms should also be used with any sex toys that you share with anyone else.

Use a spermicide with the condom for added protection -- the spermicide nonoxynol-9, used in "Lifestyle" condoms, has been shown to kill the HIV virus in laboratory tests. Spermicides are found in contraceptive foams, some lubricants, and some lubricated condoms. Never use spermicide alone instead of a condom.

A closed-mouth kiss (when there are no sores or cuts on the lips) is safe, even with someone who is infected. Very small traces of the virus have been found in the saliva of some infected people, so it is possible -- though, most scientists believe, not very likely -- that open-mouth kissing with someone who is infected may spread the disease, especially if either of you has any cuts or sores on the mouth of lips.

In order to infect you, the HIV virus must be carried by an infected partner's blood or semen into your body -- through cuts, sores or mucous membranes such as those lining your mouth, vagina and rectum, or by direct injection as in drug use. This means that activities in which such transmission does not occur are safe, even with someone who is (or might be) infected. These activities include hugging, touching, cuddling and massage, and kissing as discussed above. Mutual masturbation is usually safe, so long as neither person has any broken skin on the hands or genitals; however, some specialists suggest that condoms or latex gloves be used. The use of sex toys is usually safe so long as they are not shared.

HIV is not spread through everyday social activity or casual contact. It is not spread through air or water. And you can't get HIV from handshakes, coughs or sneezes, sweat or tears, eating utensils or food, insect bites, swimming pools or toilet seats.

A Woman's Responsibility...

We all know that it is usually the woman who is forced to take the responsibility for contraception and other sex-related health concerns in a relationship. It's always been important, but it's even more important now. Quite simply, it's almost impossible to be sure that your partner is not infected. As we have said, there is a "window" -- sometimes up to six months -- between the time of infection and the time when antibodies to HIV can be detected in the blood. So even if he tests negative, if your partner has recently had unprotected sex or shared needles or syringes, he may be infected.

You need to talk with your partner about HIV and about safer sex practices; try to have this talk before you're in a sexual situation or mood, so that passion won't cloud your thinking. And you must be willing to say no when your partner asks you to do something unsafe. Women need to, and can, take responsibility for protecting their own health.

In 1992, more people in the United States died from AIDS than died in 8 years of the Vietnam war. Nationwide, more than 100 people become HIV-infected each day, and there is one AIDS death every 12 minutes. These numbers must be turned around. As of right now, HIV/AIDS cannot be cured -- but it can be prevented. Learn all you can about how, and then don't just sit on the information -- use it.

If You Are Thinking About Testing:

You can get tested for HIV infection by your doctor (or through his or her referral), at independent labs and clinics, and (in New York and elsewhere) through the Department of Health. The actual test itself requires a small sample of your blood and is no more painful or dangerous than any other blood test. You have a right to complete privacy during the office visit and to absolute confidentiality regarding your results.

The test provider is required by law to obtain in writing your legal informed consent to be tested. Laws vary from state to state. In New York, the law provides for either confidential or anonymous testing. If you choose anonymous testing, you will not have to provide any identifying information; instead, you'll be given a number or code name so that only you can find out your own test results. If you choose confidential testing, your results will become part of your medical record, which is available to others only with your written consent (with only a very few, very specific exceptions).

All positive (and all inconclusive) results need to be confirmed by a second test. In New York, this confirmatory testing is mandatory and is called the Western Blot. Your test provider should never charge your for confirmatory testing.

Fear and worry are common feelings for those being tested, and counseling can alleviate those feelings by helping you clearly understand what your test results mean. Make sure that you receive counseling both before and after the test. You should be told about the limitations of the test, its voluntary nature, the significance of the different possible results and the possible consequences should you divulge your results to others. You should look for a test provider who is willing to discuss all your concerns in a spirit of openness and respect, who is supportive throughout the testing process, and who can offer continuing care based on your specific situation.

By Marc Gossin, R.P.A. & Sandra Lombardo, M.D.

Sandra Lombardo, M.D., is board certified in Internal Medicine, Hematology and Oncology. She has a private practice in New York City and is an attending physician at Lenox Hill Hospital. Marc Gossin is a Registered Physician Assistant with experience in internal medicine, obstetrics and gynecology. He is the administrative director of Always Your Choice medical office. His specialty is HIV, all Sexually Transmitted Diseases and Primary Care medicine.