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Aids and women: An international perspective Suzy H. Fletcher DNS
a
a
Department Graduate Nursing Studies , Indiana State University Published online: 14 Aug 2009.
To cite this article: Suzy H. Fletcher DNS (1990) Aids and women: An international perspective, Health Care for Women International, 11:1, 33-42, DOI: 10.1080/07399339009515873 To link to this article: http://dx.doi.org/10.1080/07399339009515873
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution,
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AIDS AND WOMEN: AN INTERNATIONAL PERSPECTIVE Suzy H. Fletcher, DNS
Downloaded by [UQ Library] at 13:24 31 October 2014
Department Graduate Nursing Studies, Indiana State University
This article focuses on HIV infection, HIV problems that are female specific (in the biological, psychological, and sociological spheres), a national and international perspective on HIV infection, and the challenges facing women as "women at risk for HIV infection," including childbearing and childrearing. The article discusses HIV infection in females worldwide, high risk categories (including behaviors, groups, and physiological indicators), physiological parameters of HIV infection in females, and health care challenges throughout the world. The framework for AIDS assessment, risk reduction, and intervention in women is the same as for other major health problems. However, we must first know the female specific HIV risks and "HIV disease course" and incorporate that knowledge in our assessment and intervention strategies.
"The House has approved landmark legislation to provide 1.2 billion dollars during the next three years for AIDS testing, counseling, and research programs.' The bill provides the first national policy for responding to AIDS . . . provides for strict guidelines for confidentiality of test results; provides monies to states for testing of individuals who engage in high risk behaviors (ex. prostitutes and intravenous drug users) and victims of sexual assaults; allows the continuation of the patient-physician confidentiality relationship; and provides for mental health counseling. (Getlin, 1988)
The author acknowledges the World Health Organization and Centers for Disease Control for their statistical information and slides used in preparation for this article. This article was originally presented to the Third International Congress on Women's Health Issues, Tampa, Florida, November 10, 1988.
Health Care for Women International, 11:33-42, 1990 Copyright © 1990 by Hemisphere Publishing Corporation
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Articles about AIDS such as this appear almost daily in newspapers across the United States. The practice of high-risk behaviors associated with HIV (human immunodeficiency virus) are increasingly a problem of women. In this article I will focus on HIV infection, HIV problems that are female specific, a national and international perspective on HTV infection, and the challenges facing women both as health care providers and as women at risk for HIV infection in this epidemic. Humor is one way we in the United States have of handling things we fear the most and understand the least. Humor is also a way of identifying myths and fears. In that context, I would like to share with you one of my favorite AIDS stories. It goes something like this: A man and a woman were having an affair. The affair had been going on for some time when the man said to the woman, "I'm sorry, but there is something I have to tell you—I'm married." A long silence ensued. "Oh, that," the woman responded, "I thought you were going to tell me you had AIDS, and I didn't want to get that again." This particular story enhances fears and ignorance and targets much of the misinformation we continue to have about AIDS in spite of our educational programs. These facts are: 1. AIDS can be transmitted from women to men; it is not just a disease of gay men or men alone. 2. AIDS can and does happen to married people. 3. AIDS does not go away: Once one becomes HTV positive, one remains HIV positive. 4. People do not always tell the truth about their personal lives on a first, or even a second or third, sexual encounter. Do not trust your sexual partner to be truthful about his past or current sexual or drug patterns. A recent United States survey reported that 67% of men who were asked about their sex lives said they did not tell the truth. The World Health Organization (WHO) and the Centers for Disease Control (CDC) provide slides that are shown world wide. AIDS A worldwide effort will stop it SIDA Un effort mondial le vaincra SIDA Un esfuerzo mundial lo vencer'a (WHO)
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BACKGROUND Across the world, the reported AIDS cases are seen as the tip of an iceberg of human immunodeficiency virus (HIV) that began perhaps 20 or more years ago. The rest of the iceberg consists of those persons who are infected but asymptomatic, those who are symptomatic but have not yet progressed to AIDS, and those with other reportable illnesses associated with AIDS. CDC's (1987) definition of AIDS is "a disabling or life-threatening illness caused by human immunodeficiency virus (HIV) characterized by HIV encephalopathy, HIV wasting syndrome, or certain diseases due to immunodeficiency in a person with laboratory evidence for HIV infection or without certain other causes of immunodeficiency." AIDS is not a disease, but a diagnostic category. The primary modes of transmission of the HIV virus are (a) sexual contact (heterosexual or homosexual); (b) exposure to contaminated blood, primarily through intravenous drug use but also through transfusions and accidental needle sticks1; and (c) perinatal-prepartum, intrapartum, and, possibly, postpartum exposure. AIDS INCIDENCE IN THE UNITED STATES There were about 80,000 reported AIDS cases in the United States as of October 1988, with estimates of HIV infection ranging from 1 million to 5 million (estimates are based on reports from both the CDC and the Hudson Institute). Of those AIDS cases diagnosed in 1981, 91% are dead. Of those diagnosed with AIDS in 1988, 24% are dead. It is predicted that 99% of those who become HIV positive will die within 10 to 12 years, barring the discovery of vaccines, cures, or adequate treatments, none of which we have currently. In the United States, 2% of persons with AIDS are under 19 years of age, 89% are between 20 and 49 years of age, and 10% are over 49. Minorities in the United States have been disproportionately affected by AIDS. A breakdown by racial-ethnic group shows 58% White, 26% Black, and 15% Hispanic. The primary AIDS patient
1 It can take from 6 weeks to 2 years for a person to test HIV positive after exposure to HIV; therefore, the blood supply in industrial countries is not totally protected. In developing countries, testing of the blood supply is limited or unavailable. It is important to note that HIV cannot be contracted through donating blood.
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groups are homosexual-bisexual men: 62%; intravenous drug abusers (TVDAs): 16%; homosexuals and IVDAs: 7%; heterosexuals: 4%; and transfusion recipients: 3%. When the first AIDS data were reported in 1982, the homosexual group comprised more than 90% of those affected. Current U. S. AIDS cases in women are reported as 3,301 IVDAs, 21 hemophiliacs or women with coagulation disorders, 1,881 heterosexuals, 694 transfusion recipients, and 485 undetermined (CDC, October, 1988). The male-to-female ratio for heterosexual transmission is about 1:3.5. There are 1,212 reported cases in children, most of them (78%) from parents at risk. The increase in children was greater than 100% over the 12 months ending in November 1988. Most children with AIDS are diagnosed by the time they are 18 months of age. When statistics are separated by sex, women are younger (20-35 years of age) than men (20-49 years of age) when diagnosed and tend to die younger and sooner after diagnosis. The routes of transmission are critically important in evaluating women at risk. Other than exclusively homosexual, non-drug user contact, women are at higher risk than are men for other modes of transmission. INTERNATIONAL AIDS INCIDENCE Internationally, we have a much different picture and also a much harder time making predictions or projections because of difficulties with surveillance and reporting of data. June and October 1988 WHO data suggest that between 5 and 10 million individuals are infected worldwide: an estimate that is extremely low if the United States estimates are accurate. In March 1988, WHO reported about 85,000 AIDS cases from 173 countries, with the Americas, Europe, and Africa reporting the most cases. Three patterns are emerging in AIDS worldwide. The first is the one found primarily in industrialized countries such as the United States, Western Europe, Mexico, and Canada. Pattern 1 began in the late 1970s, with HIV transmission primarily in the homosexual-bisexual male populations, with some spread in the drug abuser populations. The most reported cases are and continue to be men (10:1), although rates in women and children are increasing. As could be expected from routes of transmission, female and, therefore, pediatric cases are far fewer in Pattern 1 countries. In Pattern 1, the United States leads in incidence and deaths from HIV. Pattern 2 is found in Latin America and some parts of Africa and also began in the late 1970s. Transmission in these areas is primarily heterosexual, the male to female ratio being about 1:1. Because of the large numbers of women affected, perinatal transmission is high. Pattern 3 began in the early to
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mid 1980s in Eastern Europe, Northern Africa, Asia, and the Middle East. There are still few reported cases in these areas, and those have been primarily in persons who have traveled outside this region, with smaller numbers in all other risk categories (WHO, 1988). There are no studies reporting resistance, increased susceptibility, or increased dissemination ability due to race or other genetic characteristics. The United States leads in reported incidence and numbers of cases regardless of pattern. It is believed that the United States numbers may be higher due to more sophisticated surveillance and reporting. International figures are unavailable to separate men, women, and children for reporting purposes. Both national and international statistics show that HIV infection rates among women are increasing and that assessment for risk is vital to decrease the spread of the disease. HIGH-RISK CATEGORIES Behaviors I have developed the following series of categories for assessing risk for HIV infection. The first category is high-risk behaviors. These include (a) intravenous drug abuse, especially of heroin and crack (increased number of needle sticks increases chance of exposure), (b) having a gay or bisexual sexual partner, (c) getting tattoos (needles may be contaminated), (d) behavior resulting in imprisonment (the number of years spent in prison is positively correlated with HIV infection), (e) prostitution, (f) receptive anal intercourse, (g) sex with minors, (h) "sex addictions," (i) use of "sex" toys, (j) having multiple sexual partners (more than 10 per year). Of course, these categories are additive and many of the behaviors are seen in the same person. Not one of these behaviors "causes" HIV in the absence of exposure to the HIV virus. Groups The second category is that of high-risk groups. Many people have stopped talking about high-risk groups because of the sensitivity of those in the groups affected. However, we cannot effectively target education and treatment unless we know whom to target. Those included in highrisk groups in the United States share gender and racial, ethnic, and behavioral characteristics. They are 1. Minorities, especially Blacks and Hispanics, who live in poverty. The length of time from diagnosis to death is shorter for these groups. For example, within the United States, people diagnosed
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2. 3. 4.
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5. 6. 7.
8.
with AIDS in San Francisco are now living 18 to 24 months after diagnosis, whereas Haitian patients in Miami are living less than 6 months after diagnosis. Inner city dwellers. IVDAs. Adolescents and young adults. Many have more than 10 sexual partners per year. Gay and bisexual men and their partners. Children who are born to parents in any of the high-risk groups. Women who become pregnant by artificial insemination. The U.S. Congressional Office of Technology (1988) reported that only about half of all doctors performing artificial insemination test for HIV. Many, but not all, sperm banks test for HIV. Sex or drug-abuse partners of sicker HTV-infected persons. The sicker the HIV infected partner is, the greater the transmittability to others is.
Physiological Indicators A third category is that of high-risk physiological indicators. These can also be considered cofactors with HIV exposure. Who converts to HTV positive after exposure? What triggers conversion? What determines the time from exposure to conversion? What is the number or coexistence of cofactors that allow one person to become HTV positive and not others in the same circumstances after exposure? Who and under what circumstances does one convert to HTV positive after exposure? Since some people exposed never convert to HIV positive, what triggers conversion in the body? What triggers the immune system to fail? Some people convert in 6 weeks, many people may take as long as 2 years after exposure to conversion. The conversion rate explains why we do not have a totally safe blood supply. High-risk physiological indicators include 1. Lack of an adequate immune system, which increases the likelihood of getting AIDS after exposure. 2. Use of alcohol. 3. Use of recreational drugs. 4. Use of prescription drugs, especially tranquilizers and sleeping pills, which contributes to a decreased immune system response. 5. Increased age, which corresponds with a decrease in natural immunity. 6. A history of sexually transmitted disease, especially syphilis, herpes, genital ulcer disease, and chancroid. Any open wound with HIV exposure increases chance of contracting HIV.
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7. Tuberculosis. 8. A history of hepatitis B. 9. A history of immune deficiency hemophilia. The more severe the hemophilia, the more blood or blood products are received. Therefore, exposure to HIV is increased. 10. Multiple exposures to HTV. 11. Increased risk to women during menstruation because of the opening of the cervix during that time. Other risks include having a sexual partner from an identified highrisk area and being the victim of sexual abuse or rape. Women and children who are victims of sexual abuse and rape will increasingly be exposed to HIV. An additional correlation has been found in gay and bisexual men who exhibit compulsive behavior (many have poor immune systems when exposed to HIV because they are underweight, overexercised, undernourished, and, therefore, cannot withstand stress). AIDS IN WOMEN The proportion of female AIDS patients is growing in this country. A November 7, 1988, USA TODAY report indicated that at least 100,000 women in United States carry the AIDS virus, and for every five infected women, officials predict that one infected baby will be born. In November 1988 women accounted for 8% of the cases in the United States. Almost 30% of these women were infected through sex with men, half through sharing needles, and the remainder through transfusions. And over 80% are Black, Hispanic, or Haitian women. The categories outlined above provide the knowledge necessary for adequate assessment of women at risk for HIV. SPECIFIC HEALTH CARE AREAS There are three specific health care areas that affect women with HIV infection primarily. I will discuss these areas along with the challenges we face in providing care to these women. The first is respiratory infections. When women seek health care for respiratory problems, their risk for HIV is not being assessed. The serious respiratory problems that affect women with HIV infection are not being diagnosed and are undertreated until much later in the course of the disease. As a result, morbidity and mortality are much higher than they are for men with the same symptoms. The same is true for gynecological infections. Risk assessment for HIV infection is not being ascertained when women seek health care for
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gynecological problems. Gynecological problems in HIV-infected women include pain in the lower abdomen (chronic pelvic infection); vaginal, ovarian, and cervical abnormalities; candidiasis; ovarian abscesses; amenorrhea; menorrhagia; sexually transmitted diseases (especially syphilis, gonorrhea, and herpes); and vaginitis. Women are seldom assessed or tested for HIV infection when they come for treatment for these conditions. In fact, HTV infection is seldom suspected as a potential cause. We need to be acutely aware of HTV risks, evaluate HIV as a risk factor, and test for HTV if appropriate. The disease is often far advanced before treatment is initiated, which, in many cases, contributes to early mortality. The third most common health problem is by far the most controversial: women who are HIV infected and planning pregnancy, already pregnant, or seeking birth control or abortion. There is overwhelming evidence, in both national and international studies, that a pregnant woman who knows that she is HTV infected will seldom alter her decision to have the baby. The evidence is also overwhelming that she will not only have the baby, but will continue to have other babies. These studies only reinforce the complexity of pregnancy. In some countries, women are being tested during pregnancy but not given the results until after the baby is born. If HTV positive, it is felt that an undue burden will be experienced by the woman. Obviously, women are not given a choice of pregnancy termination in this situation. The chances of an HIV-infected woman having an infected baby are about 50%. Children born to women who are HIV infected have problems from the start, which are related to the problems of their parents. These can include poverty, compromised immune systems, intravenous drug abuse, poor nutritional status during pregnancy, lack of prenatal care, homelessness, unemployment, complicated deliveries, and poor follow-up care. In fact, many of these children never leave the hospital with their parents but instead grow up in foster care or hospitals because their mothers are first unable to care for them and die then as a result of their own illness. The challenges for us in women's health care and for the women with HIV infection are many. Symbols of life—semen, blood, and birth—are now symbols of death that affect all of us as women. Women are concerned about the use of mandatory HIV testing and its results as they are related to childbearing. Questions must be raised: If a women is HTV positive and knows it, will the health care system interfere with her pregnancy? If she is already pregnant, will the health care system force abortion, force sterilization after delivery, or provide adequate health care? And what about the woman who is HTV positive and chooses to have an abortion? The possibilities for discrimination are very real. Other challenges facing women include: (a) prostitutes who are HTV positive and the
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legal implications of their prostitution; (b) women having children who are HIV positive or who have AIDS while the mothers are themselves dying; and (c) the burdens many women faced before being HIV positive, including poverty; lack of education; lack of prenatal care; lack of child care; and inadequate nutrition, housing, and employment; (d) access to health care that provides adequate risk assessment, testing, and follow-up care, including prenatal care, which is vital to early diagnosis and intervention in women; (e) women who are typically in their childbearing years during the course of the disease and are seen as bad if they pass on the disease to a child; (f) the fact that HTV changes family organizational structure, lifestyle, and health care; (g) the challenge of testing: whom to test and under what circumstances and how to counsel (testing should be voluntary and with informed consent; counseling should be culturally sensitive); (h) adequate treatment for women with HIV-related infections and problems; (i) the multigenerational aspects of HIV, which has now affected two generations; (j) care for "children at risk" from conception until death; (k) the fact that women are sometimes seen only as "vectors" for HIV transmission from men to men (through prostitution) and to children (perinatally) and their own needs are not considered; and (1) the fact that a disproportionate number of women infected with HTV are Black, Hispanic or Haitian in the United States and are members of minority groups worldwide. Also, in most countries, women are economically deprived, undereducated, and have the poorest health care. The framework for AIDS assessment, risk reduction, and intervention is the same as for any other health problem. However, we must first become aware of the risks for women and incorporate them into our health care system. AIDS is predicted to become the second leading cause of death in the United States for 25- to 49-year-olds by the year 1991. A number of obstacles thwart effective education to prevent AIDS in the United States. These include the biological basis and social complexity of the behaviors that must be changed, disagreement about the propriety of educational messages to prevent AIDS, uncertainty about the degree of risk to the majority of Americans, and dual messages of reassurance and alarm from responsible officials. Long-term protection of an individual from infection requires extreme changes in risk-taking behavior. (Fineberg, 1988, p. 596) The obstacles and solutions outlined by Fineberg are appropriate worldwide, not just in the United States. AIDS A worldwide effort will stop it SIDA Un effort mondial le vaincra
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SIDA Un esfuerzo mundial lo vencer'a —World Health Organizaiton
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REFERENCES Centers for Disease Control (1988, October 24). AIDS weekly surveillance report. Centers for Disease Control (1987). Morbidity and Mortality Weekly Report, 30.1S. Fineberg, H. V. (1988). Education to prevent AIDS: Prospects and obstacles. Science, 239, 592-596. Fourth International Conference on AIDS. (1988, June). (Books 1 and 2, Final Program). Stockholm, Sweden. Getlin, J. (1988, September). Landmark AIDS bill approved by house. St. Petersburg Florida Times, p. 1A. Institute of Medicine (1988). Confronting AIDS: Update 1988. Washington, DC: National Academy Press. Lechtblan, E. (1988, August). Insemination raises concern over AIDS. Indianapolis Star, p. 4. Painter, K. (1988, November). Women's risk of AIDS on upswing. USA Today, p. D1. Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic. (1988). Washington, DC: U. S. Government Printing Office. Scientific American. (1988). Vol. 259, No. 4 (entire issue). Third International Conference on AIDS. (1987, June). (Final Program). Washington, DC. World Health Organization (1988, October 24). Update AIDS cases reported to global program on AIDs. Geneva: Author.
Health Care for Women International Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcw20
Aids and women: An international perspective Suzy H. Fletcher DNS
a
a
Department Graduate Nursing Studies , Indiana State University Published online: 14 Aug 2009.
To cite this article: Suzy H. Fletcher DNS (1990) Aids and women: An international perspective, Health Care for Women International, 11:1, 33-42, DOI: 10.1080/07399339009515873 To link to this article: http://dx.doi.org/10.1080/07399339009515873
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution,
Downloaded by [UQ Library] at 13:24 31 October 2014
reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
AIDS AND WOMEN: AN INTERNATIONAL PERSPECTIVE Suzy H. Fletcher, DNS
Downloaded by [UQ Library] at 13:24 31 October 2014
Department Graduate Nursing Studies, Indiana State University
This article focuses on HIV infection, HIV problems that are female specific (in the biological, psychological, and sociological spheres), a national and international perspective on HIV infection, and the challenges facing women as "women at risk for HIV infection," including childbearing and childrearing. The article discusses HIV infection in females worldwide, high risk categories (including behaviors, groups, and physiological indicators), physiological parameters of HIV infection in females, and health care challenges throughout the world. The framework for AIDS assessment, risk reduction, and intervention in women is the same as for other major health problems. However, we must first know the female specific HIV risks and "HIV disease course" and incorporate that knowledge in our assessment and intervention strategies.
"The House has approved landmark legislation to provide 1.2 billion dollars during the next three years for AIDS testing, counseling, and research programs.' The bill provides the first national policy for responding to AIDS . . . provides for strict guidelines for confidentiality of test results; provides monies to states for testing of individuals who engage in high risk behaviors (ex. prostitutes and intravenous drug users) and victims of sexual assaults; allows the continuation of the patient-physician confidentiality relationship; and provides for mental health counseling. (Getlin, 1988)
The author acknowledges the World Health Organization and Centers for Disease Control for their statistical information and slides used in preparation for this article. This article was originally presented to the Third International Congress on Women's Health Issues, Tampa, Florida, November 10, 1988.
Health Care for Women International, 11:33-42, 1990 Copyright © 1990 by Hemisphere Publishing Corporation
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Articles about AIDS such as this appear almost daily in newspapers across the United States. The practice of high-risk behaviors associated with HIV (human immunodeficiency virus) are increasingly a problem of women. In this article I will focus on HIV infection, HIV problems that are female specific, a national and international perspective on HTV infection, and the challenges facing women both as health care providers and as women at risk for HIV infection in this epidemic. Humor is one way we in the United States have of handling things we fear the most and understand the least. Humor is also a way of identifying myths and fears. In that context, I would like to share with you one of my favorite AIDS stories. It goes something like this: A man and a woman were having an affair. The affair had been going on for some time when the man said to the woman, "I'm sorry, but there is something I have to tell you—I'm married." A long silence ensued. "Oh, that," the woman responded, "I thought you were going to tell me you had AIDS, and I didn't want to get that again." This particular story enhances fears and ignorance and targets much of the misinformation we continue to have about AIDS in spite of our educational programs. These facts are: 1. AIDS can be transmitted from women to men; it is not just a disease of gay men or men alone. 2. AIDS can and does happen to married people. 3. AIDS does not go away: Once one becomes HTV positive, one remains HIV positive. 4. People do not always tell the truth about their personal lives on a first, or even a second or third, sexual encounter. Do not trust your sexual partner to be truthful about his past or current sexual or drug patterns. A recent United States survey reported that 67% of men who were asked about their sex lives said they did not tell the truth. The World Health Organization (WHO) and the Centers for Disease Control (CDC) provide slides that are shown world wide. AIDS A worldwide effort will stop it SIDA Un effort mondial le vaincra SIDA Un esfuerzo mundial lo vencer'a (WHO)
AIDS and Women
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BACKGROUND Across the world, the reported AIDS cases are seen as the tip of an iceberg of human immunodeficiency virus (HIV) that began perhaps 20 or more years ago. The rest of the iceberg consists of those persons who are infected but asymptomatic, those who are symptomatic but have not yet progressed to AIDS, and those with other reportable illnesses associated with AIDS. CDC's (1987) definition of AIDS is "a disabling or life-threatening illness caused by human immunodeficiency virus (HIV) characterized by HIV encephalopathy, HIV wasting syndrome, or certain diseases due to immunodeficiency in a person with laboratory evidence for HIV infection or without certain other causes of immunodeficiency." AIDS is not a disease, but a diagnostic category. The primary modes of transmission of the HIV virus are (a) sexual contact (heterosexual or homosexual); (b) exposure to contaminated blood, primarily through intravenous drug use but also through transfusions and accidental needle sticks1; and (c) perinatal-prepartum, intrapartum, and, possibly, postpartum exposure. AIDS INCIDENCE IN THE UNITED STATES There were about 80,000 reported AIDS cases in the United States as of October 1988, with estimates of HIV infection ranging from 1 million to 5 million (estimates are based on reports from both the CDC and the Hudson Institute). Of those AIDS cases diagnosed in 1981, 91% are dead. Of those diagnosed with AIDS in 1988, 24% are dead. It is predicted that 99% of those who become HIV positive will die within 10 to 12 years, barring the discovery of vaccines, cures, or adequate treatments, none of which we have currently. In the United States, 2% of persons with AIDS are under 19 years of age, 89% are between 20 and 49 years of age, and 10% are over 49. Minorities in the United States have been disproportionately affected by AIDS. A breakdown by racial-ethnic group shows 58% White, 26% Black, and 15% Hispanic. The primary AIDS patient
1 It can take from 6 weeks to 2 years for a person to test HIV positive after exposure to HIV; therefore, the blood supply in industrial countries is not totally protected. In developing countries, testing of the blood supply is limited or unavailable. It is important to note that HIV cannot be contracted through donating blood.
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groups are homosexual-bisexual men: 62%; intravenous drug abusers (TVDAs): 16%; homosexuals and IVDAs: 7%; heterosexuals: 4%; and transfusion recipients: 3%. When the first AIDS data were reported in 1982, the homosexual group comprised more than 90% of those affected. Current U. S. AIDS cases in women are reported as 3,301 IVDAs, 21 hemophiliacs or women with coagulation disorders, 1,881 heterosexuals, 694 transfusion recipients, and 485 undetermined (CDC, October, 1988). The male-to-female ratio for heterosexual transmission is about 1:3.5. There are 1,212 reported cases in children, most of them (78%) from parents at risk. The increase in children was greater than 100% over the 12 months ending in November 1988. Most children with AIDS are diagnosed by the time they are 18 months of age. When statistics are separated by sex, women are younger (20-35 years of age) than men (20-49 years of age) when diagnosed and tend to die younger and sooner after diagnosis. The routes of transmission are critically important in evaluating women at risk. Other than exclusively homosexual, non-drug user contact, women are at higher risk than are men for other modes of transmission. INTERNATIONAL AIDS INCIDENCE Internationally, we have a much different picture and also a much harder time making predictions or projections because of difficulties with surveillance and reporting of data. June and October 1988 WHO data suggest that between 5 and 10 million individuals are infected worldwide: an estimate that is extremely low if the United States estimates are accurate. In March 1988, WHO reported about 85,000 AIDS cases from 173 countries, with the Americas, Europe, and Africa reporting the most cases. Three patterns are emerging in AIDS worldwide. The first is the one found primarily in industrialized countries such as the United States, Western Europe, Mexico, and Canada. Pattern 1 began in the late 1970s, with HIV transmission primarily in the homosexual-bisexual male populations, with some spread in the drug abuser populations. The most reported cases are and continue to be men (10:1), although rates in women and children are increasing. As could be expected from routes of transmission, female and, therefore, pediatric cases are far fewer in Pattern 1 countries. In Pattern 1, the United States leads in incidence and deaths from HIV. Pattern 2 is found in Latin America and some parts of Africa and also began in the late 1970s. Transmission in these areas is primarily heterosexual, the male to female ratio being about 1:1. Because of the large numbers of women affected, perinatal transmission is high. Pattern 3 began in the early to
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mid 1980s in Eastern Europe, Northern Africa, Asia, and the Middle East. There are still few reported cases in these areas, and those have been primarily in persons who have traveled outside this region, with smaller numbers in all other risk categories (WHO, 1988). There are no studies reporting resistance, increased susceptibility, or increased dissemination ability due to race or other genetic characteristics. The United States leads in reported incidence and numbers of cases regardless of pattern. It is believed that the United States numbers may be higher due to more sophisticated surveillance and reporting. International figures are unavailable to separate men, women, and children for reporting purposes. Both national and international statistics show that HIV infection rates among women are increasing and that assessment for risk is vital to decrease the spread of the disease. HIGH-RISK CATEGORIES Behaviors I have developed the following series of categories for assessing risk for HIV infection. The first category is high-risk behaviors. These include (a) intravenous drug abuse, especially of heroin and crack (increased number of needle sticks increases chance of exposure), (b) having a gay or bisexual sexual partner, (c) getting tattoos (needles may be contaminated), (d) behavior resulting in imprisonment (the number of years spent in prison is positively correlated with HIV infection), (e) prostitution, (f) receptive anal intercourse, (g) sex with minors, (h) "sex addictions," (i) use of "sex" toys, (j) having multiple sexual partners (more than 10 per year). Of course, these categories are additive and many of the behaviors are seen in the same person. Not one of these behaviors "causes" HIV in the absence of exposure to the HIV virus. Groups The second category is that of high-risk groups. Many people have stopped talking about high-risk groups because of the sensitivity of those in the groups affected. However, we cannot effectively target education and treatment unless we know whom to target. Those included in highrisk groups in the United States share gender and racial, ethnic, and behavioral characteristics. They are 1. Minorities, especially Blacks and Hispanics, who live in poverty. The length of time from diagnosis to death is shorter for these groups. For example, within the United States, people diagnosed
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2. 3. 4.
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5. 6. 7.
8.
with AIDS in San Francisco are now living 18 to 24 months after diagnosis, whereas Haitian patients in Miami are living less than 6 months after diagnosis. Inner city dwellers. IVDAs. Adolescents and young adults. Many have more than 10 sexual partners per year. Gay and bisexual men and their partners. Children who are born to parents in any of the high-risk groups. Women who become pregnant by artificial insemination. The U.S. Congressional Office of Technology (1988) reported that only about half of all doctors performing artificial insemination test for HIV. Many, but not all, sperm banks test for HIV. Sex or drug-abuse partners of sicker HTV-infected persons. The sicker the HIV infected partner is, the greater the transmittability to others is.
Physiological Indicators A third category is that of high-risk physiological indicators. These can also be considered cofactors with HIV exposure. Who converts to HTV positive after exposure? What triggers conversion? What determines the time from exposure to conversion? What is the number or coexistence of cofactors that allow one person to become HTV positive and not others in the same circumstances after exposure? Who and under what circumstances does one convert to HTV positive after exposure? Since some people exposed never convert to HIV positive, what triggers conversion in the body? What triggers the immune system to fail? Some people convert in 6 weeks, many people may take as long as 2 years after exposure to conversion. The conversion rate explains why we do not have a totally safe blood supply. High-risk physiological indicators include 1. Lack of an adequate immune system, which increases the likelihood of getting AIDS after exposure. 2. Use of alcohol. 3. Use of recreational drugs. 4. Use of prescription drugs, especially tranquilizers and sleeping pills, which contributes to a decreased immune system response. 5. Increased age, which corresponds with a decrease in natural immunity. 6. A history of sexually transmitted disease, especially syphilis, herpes, genital ulcer disease, and chancroid. Any open wound with HIV exposure increases chance of contracting HIV.
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7. Tuberculosis. 8. A history of hepatitis B. 9. A history of immune deficiency hemophilia. The more severe the hemophilia, the more blood or blood products are received. Therefore, exposure to HIV is increased. 10. Multiple exposures to HTV. 11. Increased risk to women during menstruation because of the opening of the cervix during that time. Other risks include having a sexual partner from an identified highrisk area and being the victim of sexual abuse or rape. Women and children who are victims of sexual abuse and rape will increasingly be exposed to HIV. An additional correlation has been found in gay and bisexual men who exhibit compulsive behavior (many have poor immune systems when exposed to HIV because they are underweight, overexercised, undernourished, and, therefore, cannot withstand stress). AIDS IN WOMEN The proportion of female AIDS patients is growing in this country. A November 7, 1988, USA TODAY report indicated that at least 100,000 women in United States carry the AIDS virus, and for every five infected women, officials predict that one infected baby will be born. In November 1988 women accounted for 8% of the cases in the United States. Almost 30% of these women were infected through sex with men, half through sharing needles, and the remainder through transfusions. And over 80% are Black, Hispanic, or Haitian women. The categories outlined above provide the knowledge necessary for adequate assessment of women at risk for HIV. SPECIFIC HEALTH CARE AREAS There are three specific health care areas that affect women with HIV infection primarily. I will discuss these areas along with the challenges we face in providing care to these women. The first is respiratory infections. When women seek health care for respiratory problems, their risk for HIV is not being assessed. The serious respiratory problems that affect women with HIV infection are not being diagnosed and are undertreated until much later in the course of the disease. As a result, morbidity and mortality are much higher than they are for men with the same symptoms. The same is true for gynecological infections. Risk assessment for HIV infection is not being ascertained when women seek health care for
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gynecological problems. Gynecological problems in HIV-infected women include pain in the lower abdomen (chronic pelvic infection); vaginal, ovarian, and cervical abnormalities; candidiasis; ovarian abscesses; amenorrhea; menorrhagia; sexually transmitted diseases (especially syphilis, gonorrhea, and herpes); and vaginitis. Women are seldom assessed or tested for HIV infection when they come for treatment for these conditions. In fact, HTV infection is seldom suspected as a potential cause. We need to be acutely aware of HTV risks, evaluate HIV as a risk factor, and test for HTV if appropriate. The disease is often far advanced before treatment is initiated, which, in many cases, contributes to early mortality. The third most common health problem is by far the most controversial: women who are HIV infected and planning pregnancy, already pregnant, or seeking birth control or abortion. There is overwhelming evidence, in both national and international studies, that a pregnant woman who knows that she is HTV infected will seldom alter her decision to have the baby. The evidence is also overwhelming that she will not only have the baby, but will continue to have other babies. These studies only reinforce the complexity of pregnancy. In some countries, women are being tested during pregnancy but not given the results until after the baby is born. If HTV positive, it is felt that an undue burden will be experienced by the woman. Obviously, women are not given a choice of pregnancy termination in this situation. The chances of an HIV-infected woman having an infected baby are about 50%. Children born to women who are HIV infected have problems from the start, which are related to the problems of their parents. These can include poverty, compromised immune systems, intravenous drug abuse, poor nutritional status during pregnancy, lack of prenatal care, homelessness, unemployment, complicated deliveries, and poor follow-up care. In fact, many of these children never leave the hospital with their parents but instead grow up in foster care or hospitals because their mothers are first unable to care for them and die then as a result of their own illness. The challenges for us in women's health care and for the women with HIV infection are many. Symbols of life—semen, blood, and birth—are now symbols of death that affect all of us as women. Women are concerned about the use of mandatory HIV testing and its results as they are related to childbearing. Questions must be raised: If a women is HTV positive and knows it, will the health care system interfere with her pregnancy? If she is already pregnant, will the health care system force abortion, force sterilization after delivery, or provide adequate health care? And what about the woman who is HTV positive and chooses to have an abortion? The possibilities for discrimination are very real. Other challenges facing women include: (a) prostitutes who are HTV positive and the
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legal implications of their prostitution; (b) women having children who are HIV positive or who have AIDS while the mothers are themselves dying; and (c) the burdens many women faced before being HIV positive, including poverty; lack of education; lack of prenatal care; lack of child care; and inadequate nutrition, housing, and employment; (d) access to health care that provides adequate risk assessment, testing, and follow-up care, including prenatal care, which is vital to early diagnosis and intervention in women; (e) women who are typically in their childbearing years during the course of the disease and are seen as bad if they pass on the disease to a child; (f) the fact that HTV changes family organizational structure, lifestyle, and health care; (g) the challenge of testing: whom to test and under what circumstances and how to counsel (testing should be voluntary and with informed consent; counseling should be culturally sensitive); (h) adequate treatment for women with HIV-related infections and problems; (i) the multigenerational aspects of HIV, which has now affected two generations; (j) care for "children at risk" from conception until death; (k) the fact that women are sometimes seen only as "vectors" for HIV transmission from men to men (through prostitution) and to children (perinatally) and their own needs are not considered; and (1) the fact that a disproportionate number of women infected with HTV are Black, Hispanic or Haitian in the United States and are members of minority groups worldwide. Also, in most countries, women are economically deprived, undereducated, and have the poorest health care. The framework for AIDS assessment, risk reduction, and intervention is the same as for any other health problem. However, we must first become aware of the risks for women and incorporate them into our health care system. AIDS is predicted to become the second leading cause of death in the United States for 25- to 49-year-olds by the year 1991. A number of obstacles thwart effective education to prevent AIDS in the United States. These include the biological basis and social complexity of the behaviors that must be changed, disagreement about the propriety of educational messages to prevent AIDS, uncertainty about the degree of risk to the majority of Americans, and dual messages of reassurance and alarm from responsible officials. Long-term protection of an individual from infection requires extreme changes in risk-taking behavior. (Fineberg, 1988, p. 596) The obstacles and solutions outlined by Fineberg are appropriate worldwide, not just in the United States. AIDS A worldwide effort will stop it SIDA Un effort mondial le vaincra
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SIDA Un esfuerzo mundial lo vencer'a —World Health Organizaiton
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REFERENCES Centers for Disease Control (1988, October 24). AIDS weekly surveillance report. Centers for Disease Control (1987). Morbidity and Mortality Weekly Report, 30.1S. Fineberg, H. V. (1988). Education to prevent AIDS: Prospects and obstacles. Science, 239, 592-596. Fourth International Conference on AIDS. (1988, June). (Books 1 and 2, Final Program). Stockholm, Sweden. Getlin, J. (1988, September). Landmark AIDS bill approved by house. St. Petersburg Florida Times, p. 1A. Institute of Medicine (1988). Confronting AIDS: Update 1988. Washington, DC: National Academy Press. Lechtblan, E. (1988, August). Insemination raises concern over AIDS. Indianapolis Star, p. 4. Painter, K. (1988, November). Women's risk of AIDS on upswing. USA Today, p. D1. Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic. (1988). Washington, DC: U. S. Government Printing Office. Scientific American. (1988). Vol. 259, No. 4 (entire issue). Third International Conference on AIDS. (1987, June). (Final Program). Washington, DC. World Health Organization (1988, October 24). Update AIDS cases reported to global program on AIDs. Geneva: Author.
