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HIV Infection in Women in the United States Status at the Millennium

Shannon L. Hader, MD, MPH; Dawn K. Smith, MD, MPH, MS; Janet S. Moore, PhD; Scott D. Holmberg, MD, MPH
JAMA. 2001;285(9):1186-1192. doi:10.1001/jama.285.9.1186.
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Context During the past decade, knowledge of human immunodeficiency virus (HIV) infection in women has expanded considerably but may not be easily accessible for use in understanding and prioritizing the clinical needs of HIV-infected women.

Objectives To perform a comprehensive review of epidemiologic, clinical, psychosocial, and behavioral information about HIV in women, and to recommend an agenda for future activities.

Data Sources A computerized search, using MEDLINE and AIDSline, of published literature was conducted; journal articles from January 1981 through July 2000 and scientific conference presentations from January 1999 through July 2000 were retrieved and reviewed for content; article reference lists were used to identify additional articles and presentations of interest.

Study Selection Data from surveillance and prospective cohort studies with at least 20 HIV-infected women and appropriate comparison groups were preferentially included.

Data Extraction Included studies of historical importance and subsequent refined analyses of topics covered therein; these and studies with more current data were given preference. Four studies involving fewer than 20 women were included; 2 studies were of men only.

Data Synthesis Women account for an increasing percentage of all acquired immunodeficiency syndrome (AIDS) cases, from 6.7% (1819/27 140 cases) in 1986 to 18% (119 810/724 656 cases) in 1999. By the end of 1998, of all newly reported AIDS cases among women, proportionally more were in the South (41%), among black women (61%), and from heterosexual transmission (38%). Of note, increasingly more women have no identified or reported risk, about half or more of whom are estimated to be infected heterosexually. It is estimated that a total of at least 54% of women newly reported with AIDS in 1998 acquired HIV through heterosexual sex, including women in the no identified or reported risk category estimated to have been infected heterosexually, meeting the surveillance heterosexual risk definition. Natural history, progression, survival, and HIV-associated illnesses—except for those of the reproductive tract—thus far appear to be similar in HIV-infected women and men. Although antiretroviral therapy has proven to be highly effective in improving HIV-related morbidity and mortality rates, women may be less likely than men to use these therapies. Drug use, high-risk sex behaviors, depression, and unmet social needs interfere with women's use of available HIV prevention and treatment resources.

Conclusions Continued research on HIV pathogenesis and treatment is needed; however, emphasis should also be placed on using existing knowledge to improve the clinical care of women by enhancing use of available services and including greater use of antiretroviral therapy options, treating depression and drug use, facilitating educational efforts, and providing social support for HIV-infected women.

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Figure. New Acquired Immunodeficiency Syndrome (AIDS) Cases in Adolescent and Adult Women in the United States, by Region, Race/Ethnicity, and Risk Category, 1988-1998
Graphic Jump Location
Asterisk indicates that other racial/ethnic minorities made up less than 1% of reported AIDS cases each year. Dagger indicates that about half or more of these women are estimated to be infected heterosexually and an additional unknown number may be infected through heterosexual contact with a person not known to be infected or of high risk.12 Double dagger refers to the total heterosexually transmitted cases, based on estimated values calculated as the sum of all heterosexual and an assumption of 50% of no identified/reported risk cases reported, based on a multisite validation study of AIDS cases reported from 1992 through 1995.12 It does not include persons who likely acquired HIV through heterosexual sex but do not meet the surveillance heterosexual risk definition, which is sex with a person known to be HIV-infected or of high risk. Intervals between 1988 and 1998 were selected to be approximately equidistant except that 1993 was included because of the change in AIDS case definition in that year. These data were calculated using the AIDS Public Information Data Set13 and HIV/AIDS Surveillance Reports.14



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