(Replaces Committee Opinion No. 414, August 2008)
ABSTRACT: In the United States, most new cases of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) occur among women of color (primarily African American and Hispanic women). Most women of color acquire the disease from heterosexual contact, often from a partner who has undisclosed risk factors for HIV infection. Safe sex practices, especially consistent condom use, must be emphasized for all women, including women of color. A combination of testing, education, and brief behavioral interventions can help reduce the rate of HIV infection and its complications among women of color. In addition, biomedical interventions such as early treatment of patients infected with HIV and pre-exposure antiretroviral prophylaxis of high-risk individuals offer promise for future reductions in infections.
Early in the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) epidemic, HIV/AIDS was rarely diagnosed in women, but women now account for an increasing proportion of new HIV/AIDS diagnoses. In 1985, women represented 8% of HIV/AIDS cases, but by 2010, women accounted for 21% of new cases (1, 2). According to a Centers for Disease Control and Prevention (CDC) report, HIV/AIDS is defined as HIV infection with or without AIDS. Heterosexual contact was the source of 86% of these new infections (1). Many women are unaware of their male partners’ risk factors for HIV infection (such as unprotected sex with multiple partners, sex with men, or injection drug use). Of great concern is the number of young women with HIV infection and AIDS. In 2009, 23% of new diagnoses of HIV/AIDS were in girls in the 13–19-year-old age group, and 19% of new diagnoses were in women in the 20–24-year-old age group (3). More than 90% of new HIV/AIDS cases in women younger than 25 years are from heterosexual transmission (3). Of women with AIDS, 60% received the diagnosis before age 45 years, suggesting that many were infected as adolescents (1). In older women, there also is an increase in HIV diagnoses. Between 1999 and 2004, the number of women with newly diagnosed HIV infections from heterosexual activity increased by 4.8% per year among women aged 40–49 years, by 6.8% per year among women aged 50–59 years, and by 4.1% per year among women older than 60 years (4). There are many reasons why women infected with HIV may have difficulty obtaining health care, including lack of financial resources and health insurance, lack of transportation, and the added responsibility of caring for others, especially children. Lack of access to effective therapy has been associated with an increase in the mortality rate (5).
Women of Color
Most new cases of HIV infection among women in the United States occur in women of color (1). The rate of AIDS diagnosis for African American and Hispanic women is disproportionate to this population. African American and Hispanic women represent 25% of all U.S. women; however, the two groups accounted for 80% of the estimated total of new HIV diagnoses in women in 2010 (1). Among African American women, the rate of HIV/AIDS diagnosis is 15 times the rate for white women and more than four times the rate for Hispanic women (6). Hispanic women are infected more than four times the rate of white women (6). Current estimates are that 1 in 32 African American women and 1 in 106 Hispanic women will acquire HIV infection in their lifetimes, compared with 1 in 562 white women (7). Mortality rates in women of color remain very high with African American women accounting for 65% of deaths among women infected with HIV in the United States (1). The death rate from HIV infection among African American women was higher than for all other groups, both male and female, except for African American men.
There are many factors associated with the increased risk of HIV infection among women of color. Among African American and Hispanic women living with HIV/AIDS, the most common exposure was high-risk heterosexual contact (1). The higher prevalence of HIV infection in the African American community makes women in that community more likely to be exposed to HIV. African American men who have sex with men have the highest incidence and prevalence of HIV among any ethnic or behavioral risk group in the United States (8). Among men who have sex with men, African American men are more likely than European-American men to also have sex with women and are less likely to disclose their behavior to friends and partners, putting women at risk (9). Poverty and economic uncertainty may make it more difficult for women to feel empowered to negotiate condom use and other safe sex practices (10). In addition, among African American women, increased rates of other genital infections, including gonorrhea, chlamydia, syphilis, bacterial vaginosis, and trichomoniasis, may increase susceptibility to HIV infection (8, 11, 12). Racially associated differences in allele frequencies of genes that influence susceptibility to and progression of HIV infection may increase the risk of HIV infection in African American women (13). High rates of incarceration in the African American community disrupt stable partnerships and promote high-risk concurrent partnerships (14). Among Hispanic women, traditional gender roles hinder open communication of safe sex practices with male partners (15). Hispanic men and women are disproportionately likely to face serious socioeconomic barriers, including lack of education, unemployment, inadequate health insurance, and limited access to health care, which can increase the risk of HIV infection (15). Language also can be a barrier for this population, thus, culturally and linguistically focused interventions are warranted (15).
Interventions for Women of Color
Multiple interventions at the individual, group, and community level have been assessed and found to be associated with types of behavior that prevent HIV infection and skills such as condom use and partner communication (16). Gender-tailored and culturally appropriate interventions are important and can reduce risk-taking behavior and rates of sexually transmitted infections (STIs) among adolescents of color (17–20). Behavioral interventions targeting adult women of color also are crucial to decrease rates of morbidity and mortality from HIV and AIDS. In a randomized controlled trial that tested the efficacy of HIV and STI risk-reduction interventions for African American women in primary care settings, it was found that brief single-session, one-on-one interventions, or group skill-building interventions may reduce behavior associated with HIV and STI risk, such as unprotected sex, and also may reduce rates of STI morbidity (21). In multiple studies, it has been shown that brief behavioral interventions, including personalized risk assessment, training in negotiation skills, and identification of specific targets for behavioral change, can increase rates of condom use and decrease rates of acquisition of STIs compared with education alone among women of color (21–24). These findings suggest that targeted and focused programs can be effective among women of color. The CDC maintains an ongoing compendium of individual, group, and community level behavioral interventions rated on the level of evidence of effectiveness for reducing the risk of HIV infection, increasing the rate of HIV testing, and optimizing care for individuals with HIV in various high-risk groups, including women of color (16). In addition, the CDC provides support and technical assistance to health departments and community-based organizations to provide effective interventions for women of color and other groups.
In addition to behavioral interventions to decrease the risk of HIV infection and transmission, several promising biomedical developments suggest a new avenue of prevention. An international randomized trial of early treatment of individuals with HIV showed a 96% reduction in transmission to heterosexual partners when antiretroviral therapy was started while the CD4+ lymphocyte count was between 350–550 cells/microliter compared with waiting until the CD4+ cell count decreased to less than 250 cells/microliter (25). This study emphasizes the importance of testing to allow early identification of infected individuals in order to offer antiretrovirals to preserve their own health and to minimize the risk of partner transmission. Several studies of pre-exposure prophylaxis with antiretrovirals for individuals without HIV also have been reported but results have been mixed. The Pre-exposure Prophylaxis Initiative showed a 44% reduction in incident HIV infections among men who had sex with men who were randomized to daily oral tenofovir and emtricitabine compared with placebo (26). In a study of discordant heterosexual couples in Kenya and Uganda, among HIV-1–negative partners, there was a relative reduction of 67% with tenofovir and 75% with tenofovir and emtricitabine (27). In Botswana, a study of HIV-negative, heterosexual men and women who received daily pre-exposure prophylaxis with tenofovir and emtricitabine or placebo, showed the efficacy of tenofovir and emtricitabine to be 62.2% (28). However, the Pre-exposure Prophylaxis for Women study, which studied the use of oral tenofovir and emtricitabine, and the oral tenofovir arm of the Vaginal and Oral Interventions to Control the Epidemic (VOICE) study, which enrolled high-risk women who were not infected with HIV, were both stopped early because of futility. No benefit was found for the use of antiretrovirals compared with placebo in preventing infection (29, 30). The oral tenofovir and emtricitabine arm of the VOICE study is continuing. Similarly, two large studies of tenofovir vaginal gel for HIV prevention in women have had conflicting results; the Centre for the AIDS Programme of Research in South Africa 004 study showed a 39% reduction in infection risk with pericoital use compared with placebo, whereas the VOICE study found no benefit with daily tenofovir gel use compared with placebo (31, 32). Guidelines for use of oral pre-exposure prophylaxis in men who have sex with men have been developed (33), but given conflicting results, no such guidelines are available for women. Until groups of women likely to benefit from oral pre-exposure prophylaxis are delineated, health care providers should focus on behavioral interventions and counsel women to have their partners tested for HIV.
All women can be affected by HIV/AIDS, but women of color are acquiring the disease at higher rates than other groups. Most are acquiring the disease from heterosexual contact, often from a partner who has undisclosed risk factors for HIV infection. Prevention and early recognition are critical, but women of color are not maximally benefiting from these two interventions. The American College of Obstetricians and Gynecologists recommends routine HIV screening for women aged 19–64 years and targeted screening for women with risk factors outside of that age range (eg, sexually active adolescents younger than 19 years) (34). Ideally, opt-out HIV screening should be performed, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care, unless the patient declines testing (35) (see Resources). Obstetrician–gynecologists should be aware of and comply with legal requirements regarding HIV testing in their jurisdictions. The National HIV/AIDS Clinicians’ Consultation Center at the University of California–San Francisco maintains an online compendium of state HIV testing laws (see Resources). Several additional approaches can reduce the rate of HIV infection in women of color and optimize health:
- Women whose confirmatory testing yields positive results and, therefore, are infected with HIV should receive or be referred for appropriate clinical and supportive care. Early recognition allows initiation of optimal care and medication, when indicated, as well as education to prevent transmission.
- Safe sex practices, especially consistent condom use, must be emphasized for all women, particularly for women of color. Patients should be asked the reason they are not using condoms to assess whether the patient feels safe negotiating condom use (see Resources). Multiple studies have shown that behavioral interventions can increase rates of condom use, reduce risk-taking behavior, and decrease rates of acquisition of STIs. Most interventions are designed to be provided by nurses or peer educators and often are available through local health departments or community organizations.
- Health care providers are urged to identify resources in their communities for training of office staff in risk reduction interventions for women of color or for referral of women to these programs. A combination of testing, education, and brief behavioral interventions can help reduce the rate of HIV infection and its complications among women of color.
The following list is for information purposes only. Referral to these sources and web sites does not imply the endorsement of the American College of Obstetricians and Gynecologists. This list is not meant to be comprehensive. The exclusion of a source or web site does not reflect the quality of that source or web site. Please note that web sites are subject to change without notice.
The National HIV/AIDS Clinicians’ Consultation Center. A University of California San Francisco/San Francisco General Hospital-based AIDS Education & Training Centers clinical resource for health care professionals. Available at: www.nccc.ucsf.edu/. Retrieved June 26, 2012.
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