Many economically disadvantaged HIV-positive women in need of anti-HIV therapy are not accessing it, according to a US study published in the August 15th edition of the Journal of Acquired Immune Deficiency Syndromes. However, investigators also found that although a substantial number of women were experiencing significant immune damage, AIDS-defining opportunistic infections were rare.
The HERS study followed 648 women who were HIV-positive, but AIDS-free at baseline, from 1993 to 2001. The overwhelming majority of women were from none-white racial backgrounds, with 62.5% being African American and 15.6% Latina. Just under three-quarters of women had a monthly income below $1,000. Drug use was very common, with 62% of women reporting heroin use, and 30.6% crack or cocaine use.
At baseline mean CD4 cell count was 509 cells/mm3, and 29.5% of women had a viral load below 500 copies/mL, and 79.3% a viral load below 5,000 copies/mL. There was a high prevalence of other viral diseases, with 56.4% of women coinfected with hepatitis B, 59% with hepatitis C, 67% with herpes simplex 2, and 94.7% with cytomegalovirus.
The five years of the study provided over 2,300 person years of follow-up and during this time CD4 cell counts fell below 200 cells/mm3 in 46.1% of women. Although this is technically enough to diagnose AIDS, only 20 women developed an AIDS-defining opportunistic infection, meaning that only 10.7% of women with at least one CD4 cell count below 200 cells/mm3 developed an opportunistic infection.
At baseline, 30% of women were taking antiretroviral therapy, and by the end of 1999, 40.8% of women who had ever had a CD4 cell count below 500 cells/mm3 or a viral load above 30,000 copies/mL were on HAART, 27.9% were on antiretroviral therapy but not HAART, and 31.3% were taking no anti-HIV treatment.
Eighty percent of women who had a baseline CD4 cell count between 200 and 349 cells/mm3 experienced a fall in their CD4 cell count to below 200 cells/mm3, compared to less than a quarter of women with a CD4 cell count above 500 cells/mm3. Higher baseline viral load was also strongly associated with disease progression.
Investigators also found that an income below $1,000 a month (p=0.05), being African-American (p=0.10) and living in Detroit or Baltimore were associated with more rapid progression. Women with a low body mass index tended to progress more quickly than with higher body mass index.
Women with a CD4 cell count above 500 cells/mm3 and anaemia tended to progress more quickly than women with higher CD4 cell counts who were not anaemic (p=0.04), but this was not the case for women with CD4 cell counts below 500 cells/mm3. Being coinfected with hepatitis C was also associated with more rapid HIV progression in women with CD4 cell counts above 500 cells/mm3 (p=0.64).
The investigators note, “in this cohort of primarily poor and nonwhite HIV-positive women, more than 1/3 who had CD4 cell counts below 350 cell/mm3 remained HAART naïve, despite guidelines suggesting they would benefit from therapy.”
However, few women in the study experienced opportunistic infections, even though 58% of individuals had at least one CD4 cell count below 200 cells/mm3. Prophylaxis for PCP is insufficient to explain this as only 46% of women with severe immune damage were taking drugs to prevent this opportunistic infection developing.
Older women and African-Americans were more likely to experience disease progression. The investigators note that the role of age on HIV disease progression has been highlighted by earlier studies. Regarding racial differences, they note that genetic differences have been hypothesised as a possible cause, as have detrimental health-seeking behaviour patterns. The association of anaemia and body mass index with HIV progression has also been noted in earlier studies.
Commenting on the different rates of CD4 cell loss seen in different US cities, the investigators suggest that this could be related to access to specialist HIV care, as women who received their care from an HIV specialist were twice as likely to be treated with HAART.
The investigators conclude that their study demonstrates that, “innovative programs are needed to facilitate disenfranchised women’s access to appropriate clinical services to optimize the benefits of HAART.”
Further information on this website
HIV-positive women have increased risk of abnormal cervical cells; HAART no benefit - news story on earlier published data from the HERS study
American HIV-positive women have high prevalence of other chronic viral infections - news story on earlier published data from the HERS study
HAART not a risk factor for anaemia, but AZT, low CD4 counts are, and prognosis remains poor - news story on anaemia studies presented to the IAS conference in July 2003
Mayer KH et al. Clinical and immunological progression in HIV-infected US women before and after the introduction of highly active antiretroviral therapy. JAIDS 33: 614 – 624, 2003.