Clinical aspects of HIV infection in women

Epidemic (human immunodeficiency virus-related) Kaposi's sarcoma in West African women

BACKGROUND

Most patients infected with human immunodeficiency virus (HIV) experience skin disease at some stage of their illness, either as a presenting feature or as a later manifestation. Different dermatoses may coexist during the course of the infection, and the unusual nature of the skin lesions can make an accurate diagnosis difficult. Kaposi's sarcoma is one of the acquired immunodeficiency syndrome (AIDS)-defining skin diseases and may coexist with other lesions in AIDS patients. Kaposi's sarcoma is caused by human herpesvirus 8 (HHV8), which is mainly transmitted through male homosexual behavior, and is less common in women than in men.

METHODS

The clinical, histopathologic, and therapeutic aspects of AIDS-related Kaposi's sarcoma in three women (age, 18-34 years) who presented to the dermatology clinic of the University of Nigeria Teaching Hospital, Enugu, Nigeria, were studied over 18 months, beginning in August and September 1998.

RESULTS

At presentation, the condition of the three patients was generally poor, with severe anemia and extensive dark-brown papules, plaques, and nodules. Mucosal involvement was extensive. Generalized lymphadenopathy was found in two patients, one of whom had extensive coexisting dermatophytosis. All three women were in stage III/IV of the disease at the time of initial presentation. Death occurred within days in one and within 7-8 months in two.

CONCLUSIONS

Because these female patients with epidemic Kaposi's sarcoma lived in an almost entirely heterosexual population, the mode of contamination with HHV8 was obscure. The course of the disease was pervasive, aggressive, and devastating.

Differential predictors of emotional distress in HIV-infected men and women

Changes in the AIDS epidemic in many areas of the United States require information about the experience of the growing segment of women afflicted. This study compared patterns of emotional distress between men and women with symptomatic HIV and examined potential predictors of different levels of vulnerability. A sample of 126 low socioeconomic men and women seeking care from HIV treatment centers was surveyed using measures of physical and psychological well-being. Women had more HIV symptoms, poorer functioning, and greater disruptions in physical and psychosocial well-being. Physical health status and optimism were primary predictors of emotional distress in both men and women. More than 50% of men and women had scores indicative of clinical anxiety. Approximately 1 out of 10 had clinically relevant scores for depression. Gender differences may provide potentially useful information for tailoring assessment interventions for emotional distress in people infected with HIV.

A study of sex differences in presentation for care of HIV

The current study examines sex differences in 183 male and 141 female patients presenting for care of HIV disease at an inner city hospital infectious disease clinic. Females (43%) were found to be less likely to have a history of illicit drug use (relative risk = .77, p < .01) and more likely to have become infected heterosexually (relative risk = 2.38, p < .01). However, a significant number of women reported both intravenous drug use (IVDU) and heterosexual exposure to an IVDU partner which complicates the analysis of the risk factors. Women sought testing because they knew that their sexual partners were HIV-positive (relative risk = 2.88, p < .01) Median CD4 counts at entry were significantly different (females = 340, males = 246; p < .01). Women were less likely to contract tuberculosis, the only infection which presented with a sex difference (relative risk = .38, p < .01) and to have previously had an AIDS defining infection (relative risk = .37, p < .01). Women took longer to progress to AIDS (42 vs. 19 months; p < .05). Survival of patients with AIDS was 51 months for females and 54 for males (p > 0.9). It did appear that the effect of a lower CD4 cell count on risk for death was magnified in patients who acquired their disease through heterosexual transmission. Women presented with higher CD4 counts, were more aware of their risk factors and fared better, with respect to progression to AIDS, than the men. The study underscored the impact of heterosexual transmission of the virus in women as well as the affect of this risk factor on disease progression. Hopefully, this information will initiate further studies on sex differences which will guide interventions and policy development.

Women with HIV: living with symptoms

This exploratory study used a semistructured interview to describe women's experiences coping with HIV-symptoms, their descriptors of their worst and best days, and their attempts to control symptoms. A convenience sample of 44 women, largely women of color, of lower socioeconomic status, unemployed, seeking treatment in one of six outpatient clinics in Los Angeles, were interviewed. Fatigue, the most frequently reported worst symptom, was present in 98% of these women. Feeling physically sick and having negative mood were mentioned most often in descriptions of worst days; being active, feeling physically healthy, and having positive mood were descriptors of best days. Of the total, 59% used rest/sleep to control symptoms, and this often was used in conjunction with healthy diet. The results of this study reveal aspects of women's day-to-day experiences with HIV-related symptoms.

Endocrinologic complications of HIV infection

A variety of endocrine disorders occur in HIV-infected patients. The abnormalities may be a consequence of HIV infection, or may result from opportunistic infections, associated malignancies, illness-associated cytokine production, or use of therapeutic agents. Observations and controversies concerning adrenal, gonadal, thyroidal, and metabolic abnormalities are discussed. Heightened awareness of problems that might otherwise be overlooked will permit timely diagnosis and treatment of identified problems, which will enhance and potentially prolong the lives of people infected with HIV.

Focused review: physiatric management of HIV-related disability

Since 1981, the epidemic of acquired immunodeficiency syndrome (AIDS), due to infection with human immunodeficiency virus (HIV), has grown and challenged health care providers in the United States. Although the total number of AIDS cases diagnosed each year appears to be reaching a plateau, cases attributable to heterosexual transmission are rising. With improved treatment, survival of persons with HIV infection is expected to increase; this change suggests that the prevalence of HIV-related physical disability will also increase. This article outlines the pathophysiology and systemic manifestations of HIV infection. The more common neuromuscular and neurological complications at each stage of the disease are presented, and appropriate rehabilitation interventions are discussed. The indications for aerobic exercise in persons with HIV infection and the approach to disability management in pediatric HIV infection are presented. Psychosocial considerations related to access to rehabilitations services, discrimination on the basis of HIV infection or membership in HIV risk behavior groups, and vocational rehabilitation are discussed. The review concludes that rehabilitation interventions in persons with HIV infection are based on functional deficits, rather than disease processes, suggesting that a general physiatric fund of knowledge should be adequate to manage most HIV disability.

Preconception counseling for the primary care physician

All health care providers that interact with women of childbearing age should understand the potential benefits of preconception counseling and to approach the evaluation in a thorough manner during routine health maintenance visits. With the increased number of patients enrolled in managed care programs, health maintenance visits provide the unique opportunity to educate women contemplating pregnancy regarding the potential influences of their lifestyle and health status on the future pregnancy. It is becoming increasingly apparent that interventions made during the preconception period are just as crucial as the subsequent 9 months of prenatal care to achieve an optimal maternal-fetal outcome. Some guidelines for the preconception evaluation have been provided, and the implications of chronic medical illness on pregnancy have been discussed.