Clinical care issues for women living with HIV and AIDS in the United States

Pregnancy intentions among women living with HIV in the United States

BACKGROUND

The number of HIV-infected women giving birth in the United States is increasing. Research on pregnancy planning in HIV-infected women is limited.

METHODS

Between January 1 and December 30, 2012, pregnant women with a known HIV diagnosis before conception at 12 US urban medical centers completed a survey including the London Measure of Unplanned Pregnancy (LMUP) scale. We assessed predictors of LMUP category (unplanned/ambivalent versus planned pregnancy) using bivariate and multivariable analyses.

RESULTS

Overall, 172 women met inclusion criteria and completed a survey. Based on self-report using the LMUP scale, 23% women had an unplanned pregnancy, 58% were ambivalent, and 19% reported a planned pregnancy. Women were at lower risk for an unplanned or ambivalent pregnancy if they had previously given birth since their HIV diagnosis [adjusted relative risk (aRR) = 0.67, 95% confidence interval (CI): 0.47 to 0.94, P = 0.02], had seen a medical provider in the year before the index pregnancy (aRR = 0.60, 95% CI: 0.46 to 0.77, P < 0.01), or had a patient-initiated discussion of pregnancy intentions in the year before the index pregnancy (aRR = 0.63, 95% CI: 0.46 to 0.77, P < 0.01). Unplanned or ambivalent pregnancy was not associated with age, race/ethnicity, or educational level.

CONCLUSIONS

In this multisite US cohort, patient-initiated pregnancy counseling and being engaged in medical care before pregnancy were associated with a decreased probability of unplanned or ambivalent pregnancy. Interventions that promote healthcare engagement among HIV-infected women and integrate contraception and preconception counseling into routine HIV care may decrease the risk of unplanned pregnancy among HIV-infected women in the United States.

Self-Reported Preconception Care of HIV-Positive Women of Reproductive Potential: A Retrospective Study

OBJECTIVES

We determined the proportion and correlates of self-reported pregnancy planning discussions (that is preconception counseling) that HIV-positive women reported to their family physicians (FPs), HIV specialists, and obstetrician/gynecologists (OB/Gyns).

METHODS

In a cross-sectional substudy, HIV-positive women of reproductive potential were asked whether their care providers discussed pregnancy planning. Logistic regression was used to calculate odds ratios for the correlates of preconception counseling.

RESULTS

A total of 431 eligible participants (median age 38, interquartile range = 32-43) reported having discussion with a physician (92% FP, 96% HIV specialists, and 45% OB/Gyns). In all, 34%, 41%, and 38% had their pregnancy planning discussion with FP, HIV specialist, and Ob/Gyns, respectively; 51% overall. In the multivariable model, significant correlates of preconception counseling were age (P = .02), marital status (P < .01), number of years living in Canada (P < .001), and age of youngest child (P < .01).

CONCLUSIONS

Preconception care in our cohort was suboptimal. We recommend that counseling on healthy preconception should be part of routine HIV care.

Trends in injection drug use among pregnant women admitted into drug treatment: 1994-2006

OBJECTIVE

To describe trends in the regional and demographic characteristics of injection drug use (IDU) during pregnancy.

METHODS

Data were obtained from the Treatment Episode Data Set (TEDS), an administrative data set that captures admissions to federally funded treatment centers in the United States. Demographic and treatment-related measures were examined and compared between injection drug and noninjection drug admissions. The results were stratified by year of admission to assess trends over time.

RESULTS

From 1994 to 2006, there were 239,511 admissions of pregnant women, of whom 34,717 (14.4%) reported IDU. There was little change in the proportion of injecting from year to year. Compared with admissions of noninjecting pregnant women, a greater proportion of injection drug users were white (68.5 vs. 48.6%), reported heroin use (70.0% vs. 13.2%), and had no health insurance (48.2% vs. 40.2%). Over the time period, the proportion of injection drug users was seen to spread from the West to the South and Northeast for heroin and to the Midwest for amphetamines.

CONCLUSIONS

IDU among pregnant women in drug treatment remains a significant public health issue, especially among white women.

Health needs of HIV-infected women in the United States: insights from the women living positive survey

The objective of this study was to describe attitudes, opinions, and perceived health needs of HIV-infected women in the United States. In this cross-sectional study, women were invited to participate in the Women Living Positive survey, a structured interview instrument with 45 questions. Collected data were deidentified and the margin of error was calculated as four percentage points. Incoming toll-free phone interviews were conducted from December 21, 2006, through March 14, 2007 among subjects recruited from a U.S. national network of AIDS counseling centers. Seven hundred HIV-infected women (43% African American, 28.5% Hispanic, 28.5% Caucasian; median age, 42.5 years) receiving combination antiretroviral therapy for 3 years or more replied to recruitment flyers. Overall, 55% of survey participants had never discussed gender-specific HIV treatment issues with their HIV care providers. Of the 45% who did discuss these issues, almost all (96%) were satisfied. On average, one-third of the women had seen three or more providers since beginning HIV treatment; 43% indicated they had switched providers because of communication issues. Among women who had been or were pregnant at the time of the survey (n=159), more than half (57%) had not had pre-pregnancy discussions with their HIV provider about the most appropriate HIV regimens for women attempting to become pregnant. Significant communication gaps exist between HIV-infected women and their providers when discussing gender-specific treatment issues. These data highlight a need for U.S. health care providers to incorporate discussion of gender-specific issues, including preconception and reproductive counseling, into management strategies for HIV-infected women.

Time for gender mainstreaming in editorial policies

The HIV epidemic has been continuously growing among women, and in some parts of the world, HIV-infected women outnumber men. Women's greater vulnerability to HIV, both biologically and socially, influences their health risk and health outcome. This disparity between sexes has been established for other diseases, for example, autoimmune diseases, malignancies and cardiovascular diseases. Differences in drug effects and treatment outcomes have also been demonstrated. Despite proven sex and gender differences, women continue to be underrepresented in clinical trials, and the absence of gender analyses in published literature is striking. There is a growing advocacy for consideration of women in research, in particular in the HIV field, and gender mainstreaming of policies is increasingly called for. However, these efforts have not translated into improved reporting of sex-disaggregated data and provision of gender analysis in published literature; science editors, as well as publishers, lag behind in this effort.Instructions for authors issued by journals contain many guidelines for good standards of reporting, and a policy on sex-disaggregated data and gender analysis should not be amiss here. It is time for editors and publishers to demonstrate leadership in changing the paradigm in the world of scientific publication. We encourage authors, peer reviewers and fellow editors to lend their support by taking necessary measures to substantially improve reporting of gender analysis. Editors' associations could play an essential role in facilitating a transition to improved standard editorial policies.

A magic bullet for the “African” mother? Neo-Imperial reproductive futurism and the pharmaceutical “solution” to the HIV/AIDS Crisis

On the basis of a close reading of popular and medical texts which address a debate over the ethics of clinical drug trials funded by the United States and designed mainly for sub-Saharan Africa, I argue that international public health discourse about infant HIV infection in that region reflects and legitimates a neo-imperialist, anti-reproductive justice ideology. Participants share a fetal-centered logic that US-funded biomedicine must shoulder the burden of rescuing sub-Saharan Africa from itself by using the bodies of HIV-positive pregnant women to transmit biomedicine's magic bullet—antiretroviral drugs—to the next generation. The survival of the fetus, disguised as the well-being of the HIV-positive woman and accomplished by the magic of biomedical research, becomes the survival of a region otherwise doomed by its present state of economic, political, and medical incapacity. This version of what queer theorist Lee Edelman (2004, No Future: Queer Theory and the Death Drive) calls “reproductive futurism” redounds to the benefit of the more explicitly women-hating and nationalist ideologies of still-powerful right-wing movements against reproductive and sexual rights.

Development of proteinuria or elevated serum creatinine and mortality in HIV-infected women

BACKGROUND

Data on the incidence and prognostic significance of renal dysfunction in HIV disease are limited.

OBJECTIVE

To determine the incidence of proteinuria and elevated serum creatinine in HIV-positive and HIV-negative women and to determine whether these abnormalities are predictors of mortality or associated with causes of death listed on the death certificate in HIV-positive women.

DESIGN

The incidence of proteinuria or elevated serum creatinine and mortality was assessed in a cohort of 885 HIV-positive women and 425 at-risk HIV-negative women.

SETTING

Women from the general community or HIV care clinics in four urban locations in the United States.

OUTCOME MEASURES

Creatinine of >or=1.4 mg/dL, proteinuria 2 or more, or both. Deaths confirmed by a death certificate (92%) or medical record/community report (8%).

RESULTS

At baseline, 64 (7.2%) HIV-positive women and 10 (2.4%) HIV-negative women had proteinuria or elevated creatinine. An additional 128 (14%) HIV-positive women and 18 (4%) HIV-negative women developed these abnormalities over the next (mean) 21 months. Relative hazards of mortality were significantly increased (adjusted relative hazard = 2.5; 95% confidence interval: 1.9-3.3), and there were more renal causes recorded on death certificates (24/92 (26%) vs. 3/127 (2.7%), p<.0001) in HIV-infected women with, compared with those without these renal abnormalities.

CONCLUSIONS

Proteinuria, elevated serum creatinine, or both frequently occurred in these HIV-infected women. These renal abnormalities in HIV-infected women are associated with an increased risk of death after controlling for other risk factors and with an increased likelihood of having renal causes listed on the death certificate. The recognition and management of proteinuria and elevated serum creatinine should be a priority for HIV-infected persons.

Adherence to antiretroviral therapy among women with HIV infection

OBJECTIVE

The overall objective of this secondary analysis was to examine self-reported adherence to antiretroviral therapy in a sample of women with HIV.

DESIGN

The primary study used survey methodology.

SETTING

The setting included a university-based HIV/AIDS clinic in southwestern Pennsylvania and a community-based HIV/AIDS clinic in eastern Pennsylvania.

PARTICIPANTS

Sixty-one women infected with HIV who were taking protease inhibitors.

MAIN OUTCOME MEASURE

Self-reported adherence was based on responses to two questions: whether the person had missed a dose of her medications within the past 24 hours, and how many pills the person had taken on time as scheduled (none, very few, a few, about half, most, nearly all, all of them).

RESULTS

Adherence ranged from 60% to 75%. Two thirds (65.6%) of the sample thought that their medications were helping them; three fifths (57.4%) thought that it was dangerous to miss a dose of their medications.

CONCLUSIONS

Adherence in this sample was less than perfect, suggesting the need to develop, implement, and test interventions to promote better adherence to antiretroviral medication regimens among women with HIV.

A brief sexual barrier intervention for women living with AIDS: acceptability, use, and ethnicity

Interventions aimed at reducing sexual transmission of human immunodeficiency virus/sexually transmitted diseases (HIV/STDs) have focused primarily on male condom use among seronegative men and women. However, female-controlled sexual barriers (female condoms and vaginal microbicides) offer women living with acquired immunodeficiency syndrome (AIDS) alternative methods to protect themselves and others from disease transmission. A pilot behavioral intervention was conducted to increase sexual barrier use and enhance and assess factors related to acceptability. Participants (N = 178) were drawn from the Stress Management and Relaxation Training with Expressive Supportive Therapy (SMART/EST) Women's Project, a multisite phase III clinical trial for women living with AIDS (Miami, FL; New York City, NY; Newark, NJ). Intervention participants (n = 89) were matched for age and ethnicity with control condition participants (n = 89). Women were African American (52%), Haitian (15%), Hispanic (19%), Caucasian (10%), and other ethnicities (4%). The intervention condition received barrier products (male and female condoms and spermicides based on nonoxynol-9 in the form of vaginal gel, film, and suppositories) during three sessions held over 3 months. Data on barrier use and acceptability were analyzed at baseline and 3 and 9 months postintervention. Use of N-9 spermicides on a trial basis increased significantly by 3 months in the intervention conditions (22%-51%, P <.05). Cultural differences in acceptability were greatest between Haitian women and women in other ethnic groups. Exposure to this pilot behavioral intervention was associated with increased acceptability and use of chemical barriers without decreased use of male condoms.