Care of the human immunodeficiency virus-infected menopausal woman

Women with HIV transitioning through menopause: Insights from the Swiss HIV Cohort Study (SHCS)

Objectives

We aimed to assess prevalence and age at menopause, identify factors associated with early menopause and explore the provision and utilization of healthcare in women living with HIV in Switzerland.

Methods

This was a retrospective Swiss HIV Cohort Study analysis from January 2010 to December 2018. Descriptive statistics to characterise the population and menopause onset. Logistic regression analysis to identify risk factors for early menopause.

Results

Of all women in the SHCS, the proportion of postmenopausal women tripled from 11.5% (n = 274) in 2010 to 36.1% (n = 961) in 2018. The median age at menopause was 50 years. Early menopause (< 45 years) occurred in 115 (10.2%) women and premature ovarian insufficiency (POI) (< 40 years) in 23 (2%) women. Early menopause was associated with black ethnicity (52.2% vs. 21.6%, p < 0.001), but not with HIV acquisition mode, CDC stage, viral suppression, CD4 cell count, hepatitis C, smoking or active drug use. While 92% of the postmenopausal women underwent a gynaecological examination during the 36 months before menopause documentation, only 27% received a bone mineral density measurement within 36 months after the last bleed and 11% were on hormone replacement therapy at the time of menopause documentation.

Conclusions

The median age of women living with HIV at menopause is around 2 years lower than that reported for HIV‐negative women in Switzerland. HIV care providers need to adapt their services to the requirements of the increasing number of women living with HIV transitioning through menopause. They should be able to recognize menopause‐associated symptoms and improve access to bone mineral density measurement as well as hormone replacement therapy.

Attitudes toward Menopause in HIV-Infected Cambodian Women

(1) Background: Attitudes toward menopause are believed to play a potential role in the experience of menopause, including its perceived severity. However, the studies available on the perspectives of women living with human immunodeficiency virus (HIV) on menopause in Cambodia are very limited. This study aimed to evaluate the attitudes toward menopause of Cambodian women living with HIV. (2) Methods: A cross-sectional study was conducted among 189 women using a questionnaire titled Attitude toward Menopause Scale and socio-demographics. (3) Results: The study analysis showed that the participants had slightly negative attitudes toward menopause with the mean attitude score of 86.81 ± 10.79 (Range 35–140). Postmenopausal women displayed more positive attitudes than premenopausal women. Older age, higher education, and a non-drinking habit were independently associated with a positive attitude toward menopause. (4) Conclusions: The results suggest the need for a multidisciplinary team of health care experts that would address the special needs of this population marked by the menopausal transition.

Using Best-Worst Scaling to Determine the Most Burdensome Menopausal Symptoms in Cambodian Women Living With HIV

ABSTRACT

As persons living with HIV live longer, it is important to understand the symptoms experienced by menopausal women living with HIV (WLWH). This study used best-worst scaling (BWS) to determine the menopausal symptoms that are most burdensome for Cambodian WLWH. Participants were asked to rate a list of menopausal symptoms in terms of the most and least burdensome in their lives via BWS. The final analysis included 183 participants, 67 of whom were premenopausal, 47 perimenopausal, and 69 postmenopausal women. Physical and mental exhaustion (mean best-worst score = 319) was rated as the most burdensome symptom, and hot flushes and sweating were the least burdensome (mean best-worst score = -181). The BWS provides information on priorities for the distribution of health care resources. Understanding how Cambodian WLWH prioritize burdensome menopausal symptoms is crucial for choosing the most contextually sensitive method to provide health care services and interventions.

Special Topics in the Care of Older People with HIV

PURPOSE OF REVIEW

Antiretroviral therapy has enabled many people with HIV to live long lives with their infection, but the literature suggests that long term survivors are developing comorbidities and aging-related syndromes at earlier ages than their non-infected counterparts. In addition, there is evidence or sex-based differences in comorbidity risk.

RECENT FINDINGS

How to best care for people aging with HIV is not known, but the tools of comprehensive geriatric assessment can identify people at risk for decline. Newer antiretroviral therapies offer promise of fewer side effects and drug interactions. We will also discuss special needs of women aging with HIV.

SUMMARY

People with HIV and their providers are often unprepared to confront issues of aging, and each clinical program must develop methods to assess older patient and manage age-related complications and syndromes.

Severe menopausal symptoms associated with reduced adherence to antiretroviral therapy among perimenopausal and menopausal women living with HIV in Metro Vancouver

OBJECTIVES

Although more women living with HIV (WLWH) are entering midlife, the experiences of perimenopausal and menopausal WLWH, including the effects of menopausal symptoms severity, remain understudied. This study longitudinally investigated the correlates of antiretroviral therapy (ART) adherence among perimenopausal and menopausal WLWH from Metro Vancouver.

METHODS

Analyses drew on longitudinal data (2014-2017) from Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment, an ongoing community-based cohort of WLWH, aged 14+, from Metro Vancouver, Canada. At baseline and biannually, participants completed an interviewer-administered questionnaire. Bivariate and multivariable logistic regression with generalized estimating equations were used to identify the correlates of self-reported <95% ART adherence.

RESULTS

The sample included 109 perimenopausal and menopausal WLWH (233 observations), with a median age of 49 years (IQR 44-53). Whereas most (68.8%) participants experienced menopausal symptoms, only 17% had received treatment (eg, antidepressants, hormone therapy) at baseline. In multivariable analysis, severe menopausal symptoms (adjusted odds ratio [AOR] 1.03, 95% confidence interval [CI] 1.00-1.06), injection drug use (AOR 2.86, 95% CI 1.44-5.55), and physical/sexual violence (AOR 2.33, 95% CI 1.02-5.26) independently and positively correlated with <95% adherence.

CONCLUSIONS

These findings suggest that menopausal symptoms may undermine ART adherence, with overlapping vulnerabilities such as injection drug use and sexual/physical violence further exacerbating poor ART adherence. Women-centred, trauma-informed care approaches to detect menopause and treat menopausal symptoms are urgently needed. Such approaches should holistically address the intersecting barriers to adherence and link WLWH to peripheral health and social services, including trauma counseling and evidence-based harm reduction services.

Menopausal symptoms and associated factors in women living with HIV in Cambodia

This study investigated the prevalence and severity of menopausal symptoms and associated factors among women living with HIV in Cambodia. Menopause Rating Scale (MRS) assessed the menopausal symptoms, and SPSS Version 20.0 analyzed the data. The three most dominant symptoms, which were also rated the top three "severe" symptoms, were psychological: physical and mental exhaustion (91.5%), irritability (84.1%), and depressive mood (83.6%). The highest incidence was among the perimenopausal women. Severity of symptoms was associated with personal income, abortion, and intake of calcium supplements. Health-care professionals need to provide appropriate individualized interventions to maintain the social, emotional, and overall well-being of menopausal women living with HIV.

Clinical Characteristics and Outcomes Among Older Women with HIV

OBJECTIVES

To inform the development of HIV care strategies for older women with HIV infection, an understudied group, we compared the psychosocial, behavioral, and clinical characteristics of HIV-positive women aged ≥50 (older women) with those aged 18-49 (younger women).

METHODS

We examined factors among HIV-positive women in care using data from the 2009 through 2013 cycles of a nationally representative sample of HIV-positive adults in care (Medical Monitoring Project). We compared psychosocial, clinical, and behavioral factors among women aged ≥50 years at interview versus those aged <50 years. We calculated weighted frequency estimates and performed logistic regression to compute adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) for the comparison of characteristics among women aged ≥50 versus <50 years.

RESULTS

Of 22,145 participants, 6186 were women; 40.7% (CI 39.1-42.3) were ≥50 years, and 32.7% of older women reported being sexually active. Compared with women <50 years, women aged ≥50 years were more likely to be dose adherent (aPR = 1.19; CI 1.07-1.33), prescribed antiretroviral therapy and have sustained viral load suppression (aPR = 1.03; CI 1.00-1.18), and were less likely to report any depression (aPR = 0.92; CI 0.86-0.99), to report condomless sex with a negative or unknown partner if sexually active (aPR = 0.56; CI 0.48-0.67), and to have received HIV/sexually transmitted infection (STI) prevention counseling from a healthcare provider (aPR = 0.82; CI 0.76-0.88).

CONCLUSIONS

These data suggest that older women in HIV care have more favorable outcomes in some clinical areas, but may warrant increased HIV/STI prevention counseling from their care providers, especially if sexually active.

Practice Bulletin No. 167: Gynecologic Care for Women and Adolescents With Human Immunodeficiency Virus

In the United States in 2013, there were an estimated 226,000 women and adolescents living with human immunodeficiency virus (HIV) infection (1). Women with HIV are living longer, healthier lives, so the need for routine and problem-focused gynecologic care has increased. The purpose of this document is to educate clinicians about basic health screening and care, family planning, prepregnancy care, and managing common gynecologic problems for women and adolescents who are infected with HIV. For information on screening guidelines, refer to the American College of Obstetricians and Gynecologists' Committee Opinion No. 596, Routine Human Immunodeficiency Virus Screening (2).

Perspectives on menopause and women with HIV

Since the implementation of effective combination antiretroviral therapy, HIV infection has been transformed from a life-threatening condition into a chronic disease. As people with HIV are living longer, aging and its associated manifestations have become key priorities as part of HIV care. For women with HIV, menopause is an important part of aging to consider. Women currently represent more than one half of HIV-positive individuals worldwide. Given the vast proportion of women living with HIV who are, and will be, transitioning through age-related life events, the interaction between HIV infection and menopause must be addressed by clinicians and researchers. Menopause is a major clinical event that is universally experienced by women, but affects each individual woman uniquely. This transitional time in women's lives has various clinical implications including physical and psychological symptoms, and accelerated development and progression of other age-related comorbidities, particularly cardiovascular disease, neurocognitive dysfunction, and bone mineral disease; all of which are potentially heightened by HIV or its treatment. Furthermore, within the context of HIV, there are the additional considerations of HIV acquisition and transmission risk, progression of infection, changes in antiretroviral pharmacokinetics, response, and toxicities. These menopausal manifestations and complications must be managed concurrently with HIV, while keeping in mind the potential influence of menopause on the prognosis of HIV infection itself. This results in additional complexity for clinicians caring for women living with HIV, and highlights the shifting paradigm in HIV care that must accompany this aging and evolving population.

Predictors of early menopause in HIV-infected women: a prospective cohort study

OBJECTIVE

This study sought to investigate the age at natural menopause and its predictors in a cohort of human immunodeficiency virus (HIV)-infected women in Rio de Janeiro, Brazil.

STUDY DESIGN

HIV-infected women ≥30 years of age were included. Menopause was defined as having ≥1 year since the last menstrual period. Early age at natural menopause was defined as the onset of menopause at ≤45 years of age. Multivariate Cox proportional hazards analysis was applied.

RESULTS

A total of 667 women were included, and the median age at baseline was 34.9 years (interquartile range, 30.9-40.5 years). In all, 507 (76%) women were premenopausal, and 160 (24%) reached menopause during the observational period; of these, 36 of 160 (27%) had early menopause. The median age at natural menopause was 48 years (interquartile range, 45-50 years). Menarche at <11 years of age (hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.23-3.37), cigarette smoking during the observational period (HR, 1.59; 95% CI, 1.08-2.33), chronic hepatitis C virus (HCV) infection (HR, 2.53; 95% CI, 1.27-5.07), and CD4 count <50 cells/mm(3) (HR, 3.07; 95% CI, 1.07-8.80) were significantly associated with an earlier age at natural menopause. The magnitudes of the effects of menarche at <11 years of age (HR, 2.7; 95% CI, 1.23-5.94), cigarette smoking during the observational period (HR, 3.00; 95% CI, 1.39-6.45), chronic HCV infection (HR, 6.26; 95% CI, 2.12-18.52), and CD4 count <50 cells/mm(3) (HR, 6.64; 95% CI, 1.91-23.20) were much higher and significantly associated with early natural menopause.

CONCLUSION

Early natural menopause was frequent among the HIV-infected women. In addition to menarche and cigarette smoking, which are menopausal factors among women in general, HIV-related immunodeficiency and chronic HCV were additional predictors for an earlier age at natural menopause. Adequate management of HIV in women is critical, as early onset of menopause has been associated with increased morbidity and mortality.

Primary care of women aging with HIV

Women are living longer with HIV infection, but their life expectancy remains shorter than for women in the general population. How best to manage the multiple comorbidities and polypharmacy that are common in individuals wtih HIV has not been studied. This article explores areas where the primary care of women with HIV may differ from that of aging women in the general population. We also discuss aspects of care that may not commonly be considered in those under the age of 65, specifically multimorbidity and polypharmacy. Incorporating a gerontologic approach in the care of these women may optimize outcomes until research provides more definitive answers for how best to collaborate with women with HIV in order to provide them with optimal care.

Absence of effect of menopause status at initiation of first-line antiretroviral therapy on immunologic or virologic responses: a cohort study from Rio de Janeiro, Brazil

OBJECTIVE

To compare the effectiveness of first-line combination antiretroviral therapy (cART) between premenopausal and postmenopausal women.

METHODS

ART-naïve women initiating cART between January 2000/June 2010 at the Instituto de Pesquisa Clínica Evandro Chagas Cohort were studied. Women were defined as postmenopausal after 12 consecutive months of amenorrhea. CD4 cell counts and HIV-1 RNA viral load (VL) measurements were compared between pre- and postmenopausal at 6, 12 and 24 months after cART initiation. Women who modified/discontinued a drug class or died due to an AIDS defining illness were classified as ART-failures. Variables were compared using Wilcoxon test, χ2 or Fisher's exact test. The odds of cART effectiveness (VL<400 copies/mL and/or no need to change cART) were compared using logistic regression. Linear model was used to access relationship between CD4 change and menopause.

RESULTS

Among 383 women, 328 (85%) were premenopausal and 55 (15%) postmenopausal. Median pre cART CD4 counts were 231 and 208 cells/mm(3) (p = 0.14) in pre- and postmenopausal women, respectively. No difference in the median pre cART VL was found (both 4.8 copies/mL). Median CD4 changes were similar at 6 and 12 months. At 24 months after cART initiation, CD4 changes among postmenopausal women were significantly lower among premenopausal women (p = 0.01). When the analysis was restricted to women with VL<400 copies/mL, no statistical difference was observed. Overall, 63.7% achieved cART effectiveness at 24 months without differences between groups at 6, 12 and 24 months.

CONCLUSION

Menopause status at the time of first-line cART initiation does not impact CD4 cell changes at 24 months among women with a virologic response. No relationship between menopause status and virologic response was observed.

HIV and Menopause: A Systematic Review of the Effects of HIV Infection on Age at Menopause and the Effects of Menopause on Response to Antiretroviral Therapy

More than half of persons living with HIV infection in the United States (U.S.) will be ≥50 years of age by 2020, including postmenopausal women. We conducted a systematic literature review about the effects of (1) HIV infection on age at menopause and (2) menopause on antiretroviral therapy (ART) response, in order to inform optimal treatment strategies for menopausal women living with HIV infection. We used the Ovid Medline database from 1980 to 2012. We included studies that focused on HIV-infected persons, included postmenopausal women, and reported outcome data for either age at menopause or response to ART across menopause. We identified six original research articles for age at menopause and five for response to ART across menopause. Our review revealed that current data were conflicting and inconclusive; more rigorous studies are needed. Disentangling the effects of menopause requires well-designed studies with adequate numbers of HIV-infected and HIV-uninfected women, especially disproportionately affected women of color. Future studies should follow women from premenopause through menopause, use both surveys and laboratory measurements for menopause diagnoses, and control for confounders related to normal aging processes, in order to inform optimal clinical management for menopausal women living with HIV.