1st International AIDS Society (IAS) Conference on HIV Pathogenesis and Treatment
July 7-11, 2001
Buenos Aires, Argentina
Access to Care for Women
Do women have access to highly active antiretroviral therapy (HAART) equal to that of men? Numerous studies over the years have demonstrated that women have not had the same access to antiretroviral therapy as men, even with the same indications. For example, in the early 1990s Stein and colleagues found that HIV-infected women with AIDS were 3 times less likely to receive zidovudine than were men, while Hellinger reported that women with HIV were statistically less likely to receive medical services than were men, including medications, hospital admissions, and outpatient visits.
Likewise, evaluating Medicaid data from Florida from the years 1992-1997, Anderson and colleagues found a consistent disparity among women and men in terms of receipt of antiretroviral agents. Of interest, Mocroft and colleagues examined the management of HIV disease among a population in Alberta, Ontario, Canada, where all healthcare, including physician visits, medications, and hospitalization, is provided by the state. Even in this study, conducted among 1403 patients (9% of whom were female), women were significantly less likely to start HAART (defined as at least 3 antiretrovirals taken consecutively), and were significantly less likely to start a protease inhibitor (PI)-containing HAART regimen.
These data would imply that the gender differences in receipt of antiretroviral agents extend from the beginning of the epidemic, when women were specifically excluded from entering trials of antiretroviral therapy, to the present time. Furthermore, the disparity in receipt of effective antiretroviral therapy seems to occur both in the United States and in other countries, and appears to be independent of financial considerations.[3,4]
This disparity in receipt of HAART between the genders apparently is continuing, despite recent publicity concerning the issue. Carten and colleagues from Cook County Hospital in Chicago, Illinois, reported gender differences in HIV-infected patients who were admitted to the inpatient HIV ward between January 1999 and September2000. In this study of 640 patients, including 175 women, 33% of women were receiving HAART at the time of admission vs 43% of the men (P = .002). Other characteristics of the men and women are summarized in Table 1.
Table 1. Selected Characteristics of HIV-Infected Patients at Cook County Hospital, Chicago, Illinois
|Mean age (years)||39||41||.003|
|Coinfection with HCV||49%||38%||.026|
|Mean CD4+ cell count||230||181||.027|
|Mean viral load||90,000||119,000||.10|
|At least 1 clinic visit within the past 6 months||62%||65%||NS|
Thus, despite the fact that men and women were equally likely to have attended clinic within the past 6 months, and despite the fact that the mean viral load was equivalent (and high) in both groups, women were statistically less likely to have received HAART from the same group of providers. Details of the hospital admissions among this patient group are shown in Table 2.
Table 2. Hospital Admissions Among HIV-Infected Patients at Cook County Hospital, Chicago, Illinois
|Average length of stay (days)||5.7||6.9|
|Skin condition (includes 38 cases of KS)||17%||24%|
|Congestive heart failure||4%||2.5%|
|Aspergillosis, histoplasmosis, or cryptococcosis||2%||4.5%|
With regard to cancers, 4% of women were admitted for this reason, including 4 with invasive cervical cancer, 2 with lung cancer, 1 with Kaposi's sarcoma (KS), 1 with lymphoma, and 1 with oropharyngeal cancer. A total of 10% of the men were admitted with a diagnosis of cancer, including KS in 38; lymphoma in 18; lung cancer in 8; oropharyngeal cancer in 4; and 1 each of testicular cancer, anal cancer, liver cancer, and bladder cancer.
Although approximately 50% of both women and men were admitted due to opportunistic infections, the statistically significant disparity in receipt of HAART might have played a role in their development among the women. It is clear from these data, then, that in the HAART era, women are still less likely to receive HAART, even when they have the same healthcare providers and similar HIV characteristics. We still have a long way to go in this area.
Effect of HAART on Bacterial Pneumonia
Does receipt of HAART alter the likelihood of bacterial pneumonia in HIV-infected women? In a group of 885 women followed for an average of 4.5 years, 336 episodes of bacterial pneumonia were diagnosed among 204 women, giving a crude rate of 9.4 cases per 100 person-years. Of interest, receipt of trimethoprim-sulfamethoxazole as prophylaxis against Pneumocystis carinii had no effect on preventing bacterial pneumonia. However, receipt of HAART decreased the risk of pneumonia by 50% after controlling for smoking, viral load, CD4+ cell count, and receipt of less than a high school education, each of which was independently associated with an increased risk of pneumonia. Thanks to Alexandria Levine, MD, and Medscape (www.medscape.org) for this report.