The Women for Positive Action faculty has developed a number of initiatives designed to raise awareness of the issues surrounding women living with HIV.

To download these tools please click on the links below.

  • Educational slide decks

    • Women and HIV testing

      The HIV epidemic in women is reviewed, highlighting continued the need for improved testing, treatment access and prevention of onward transmission. Initiatives to improve HIV testing and the practical implementation of guidelines are also discussed.

    • Women and clinical trials in HIV

      This slide kit reviews the factors behind the under-representation of women in clinical trials and the importance of enrolling and retaining women in HIV clinical trials.

    • HIV, conception, pregnancy and contraception

      This slide kit provides an overview of the importance of planning for the possibility of pregnancy for all women of child-bearing potential who are HIV positive or those who are HIV negative and in a relationship with an HIV-positive partner.

    • HIV and ageing

      The physical and emotional challenges associated with ageing in women living with HIV are discussed in this slide kit. Topics reviewed include the menopause, bonehealth and neurocognitive changes.

    • Stigma in women living with HIV

      This slide kit provides practical examples to combat against the stigma and discrimination which may be experienced by women living with HIV and discusses support for those who may wish to disclose their HIV status.

    • Emotional wellbeing of women living with HIV

      Information on the importance of issues relating to the emotional wellbeing of women living with HIV is provided. This includes aspects related to depression, stigmatization, trauma and emotional considerations in relation to pregnancy and the menopause.

    • Supporting the patient-healthcare professional relationship

      An overview of the importance of a positive, supportive relationship between women and their healthcare providers and recommendations on how to establish such a rapport.

    • Beliefs, spirituality and HIV: harnessing benefits and overcoming barriers

      This slide kit provides an overview of the impact of beliefs, spirituality and religion among women living with HIV.

    • HIV and Younger Women *NEW*

      This tool is designed to inspire community and healthcare representatives to tackle the evolving challenges and support the needs of girls living with HIV as they develop into young women.

  • News

    • Women for Positive Action celebrates International Women’s Day 2014 by launching new educational tool on ‘HIV and younger women’ *NEW*

       

      Women for Positive Action celebrates International Women’s Day 2014 by launching new educational tool on ‘HIV and younger women’

       

      Empowering those involved in HIV care to support girls as they develop into young women

       

      In conjunction with International Women’s Day (March 8, 2014), a practical and educational tool on the topic of young women living with HIV has been developed by Women for Positive Action (a global, multidisciplinary group of experts committed to addressing the specific concerns of women living with HIV).This tool is designed to inspire community and healthcare representatives to tackle the evolving challenges and support the needs of girls living with HIV as they develop into young women (available for download - http://bit.ly/1c9GpGV).

      “Young women aged 15-24 are particularly vulnerable to HIV, with infection rates twice as high as in young men. Unfortunately, gender inequalities, discrimination and lack of adequate targeted services often mean that these women fail to receive the services and support they need” explains Angelina Namiba, Project Manager for Positively UK and Women for Positive Action faculty member.

      In line with this year’s International Women’s Day theme of ‘Inspiring change’, Women for Positive Action faculty members, Lorraine Sherr, Mona Loutfy, Karine Lacombe and Angelina Namiba have designed the 'HIV and Young Women' tool to help motivate those caring for young women to look for new ways to assist them through their journey into adulthood and support them to lead full and productive lives. Emotional wellbeing, including depression, and anxiety, is just one of the challenges addressed. This can affect more than 60% of those with perinatally acquired HIV specifically, and 30–60% of women living with HIV overall1,2; however peer, parent and teacher support are associated with better emotional health outcomes.3 Other topics covered include sexual health and relationships as well as stigma and disclosure, with examples of how community-based initiatives and counselling approaches can support girls as they develop into young women and transition to adult care.

      “Young women born with HIV are surviving into adulthood and beyond and often have complex medical and psychological needs that should be managed appropriately to ensure ongoing participation of women in their own care and prevention of HIV transmission” explains Karine Lacombe, associate professor in the infectious and tropical diseases department of Saint-Antoine Hospital (AP-HP), France and Women for Positive Action faculty member. “Transition from paediatric to adult services, in particular, is a critical time for young women, and it is essential that the multi-disciplinary team support women to develop strong self-management and life skills in order to improve their outcomes”.

      Women for Positive Action are committed to exploring and addressing the challenges faced by women living with HIV and those involved in their care. For more information visit the website, www.womenforpositiveaction.org and keep up to date with Women for Positive Action activities through Twitter @WFPA_HIV.

      -   ENDS   -

      Notes to Editor

      Worldwide, over 60% of all young people (i.e. those aged 15-24 years) living with HIV are young women.4 Infection rates in this group are twice as high as in young men, and account for 22% of all new infections.5 However, with effective treatment many girls who acquired HIV perinatally are now living well into adulthood6 and those acquiring HIV in adulthood have a near normal life expectancy.7

      Visit www.womenforpositiveaction.org for further information about Women for Positive Action and ongoing projects. Women for Positive Action is an educational program funded by AbbVie. All content is independently generated by the Women for Positive Action faculty experts reflecting their knowledge and opinions.

      References

      1. Mellins CA et al. J Child Psychol Psychiatry 2009;50:1131-38

      2. Ickovics JR et al. JAMA 2001;285:1466-74

      3. Mellins CA, Malee KM. J Int AIDS Soc 2013;16:18593

      4. The Global AIDS Epidemic – Key Facts. UNAIDS, 2012

      5. World AIDS Day report 2011. UNAIDS

      6. Mofenson L & Cotton MF. J Int AIDS Soc 2013;16(1):18650.

      7. Hogg RS et al. IAS 2013, Abstract TUPE260

      For further information please contact the Women for Positive Action Secretariat:

      Email:           WFPA@litmus-mme.com

      Tel:              +44 (0)20 7632 1969

      Address:        Women for Positive Action, Program Secretariat, Litmus MME, 151 Shaftesbury Avenue, London WC2H 8AL, United Kingdom

      Twitter:          @WFPA_HIV 

    • Adhering to ART: The unique challenges faced by women living with HIV

      To mark Worlds AIDS Day (December 1, 2013), Women for Positive Action has released an article highlighting the specific challenges faced by women in maintaining adherence to antiretroviral therapy (ART). Given the World AIDS Day theme of "Getting to zero: zero new HIV infections. Zero discrimination. Zero AIDS related deaths", identifying and overcoming barriers to adherence is particularly pertinent to ensure optimal care for women living with HIV, with the ultimate goal of achieving "Zero AIDS related deaths".

      Background

      • ART has been shown to suppress plasma HIV RNA, contributing to substantial reductions in HIV-related morbidity and mortality among people receiving treatment.1,2 However, effective management of HIV disease requires high levels of ART adherence3,4
      • Sub-optimal adherence directly impacts HIV-related outcomes: it can detrimentally affect virological control and subsequently disease progression, as well as contribute to elevated rates of antiretroviral resistance3,4
      • Women comprise the fastest growing group of persons with AIDS: they are often diagnosed later in the disease, when ART is strongly indicated5
      • Numerous studies have found women living with HIV to be less adherent to ART than men6-10 and treatment discontinuation rates have also been reported to be higher in women.11
        • Although another study reported no significant gender-related differences, sub-analyses found outcomes to be worse in women than in men.12

      Why do many women struggle to achieve optimal adherence?

      • Women living with HIV face a number of challenges unique to their gender which may impact upon medication adherence, including: personal and emotional health factors; social factors, such as communication; and resource factors, such as medication and transport costs7,13
      • Women are often forced to make difficult choices between tending to their immediate needs, such as housing, caring for children and for sick family members, and adhering to their own medical treatment14
      • The rate of stigma and discrimination is reported to be higher among women living with HIV than in men and HIV-related stigma is associated with suboptimal ART adherence15-17
        • People experiencing high levels of stigma have over four times the odds of reporting poor access to care16, and have an increased number of missed ART doses18
        • Experiences of social rejection, disapproval, and discrimination related to HIV may heighten a woman’s sense of shame regarding their illness and can lead to a lack of motivation to maintain optimal health15
        • Stigma can lead to patients not taking their ART as directed by their healthcare provider, for fear of inadvertent illness disclosure15
          • In a US study in people living with HIV, taking medication in front of others was found to be a barrier to adherence in women, but not in men19
          • Women tend to hide their diagnosis more than their male counterparts, which may contribute to social isolation and hence increased likelihood of poor adherence5
        • Anticipated and internalised stigma are also associated with low levels of adherence20
      • Gender inequality has been reported to influence whether a woman is able to access services  and medications21,22
      • Some women are denied permission from their husbands or do not get the required financial support from their spouses to access HIV services regularly – often due to the husband’s fear of his own HIV status being disclosed21,22
      • Women unable to share their HIV status with their close family, and their need to comply with a strict treatment programme, miss out on getting support from family members, potentially compromising their ability to adhere successfully22
      • Severe depression places individuals at four times greater risk for non-adherence than minimal depression25
      • Women are more likely than men to discontinue ART due to symptoms such as rash, peripheral neuropathy, fatigue, weight loss and feelings of vertigo/dizziness28
      • Women are more likely to perceive body weight changes, particularly weight gain, and thus are more likely to cease treatment, whether or not there is any actual evidence of weight redistribution26,29
      • Anecdotally, women, more so than men, just do not like to take medication and will resist therapy because of the numerous pills, large size of the pills, complicated dosing schedules, or fear and mistrust about side effects5
      • In a study of people with alcohol problems who were also living with HIV, alcohol consumption was significantly and independently related to poor adherence30
      • In another study of current and former drug users, female gender, alongside ongoing alcohol and drug misuse were associated with poor ART adherence31
      • Women living with HIV have high rates of psychiatric disorders, including major depression and post-traumatic stress disorder, significant levels of psychological distress, and histories of extreme trauma.23 These problems are significant with regard to adherence, as women who present with mental health disorders often demonstrate poorer adherence to ART14,24
      • Women often report that motivation to take ART decreases once they have protected their children from contracting HIV and successfully weaned them35
      • When discussing ART and adherence, healthcare professionals have been shown to ask relatively few open questions, few questions that elicit patient opinions, values or preferences, and only rarely check patients’ understanding
      • Women may be given only a limited time to speak to their physician, or may feel that their views are not respected or understood
      • Young women, who are not used to taking medications, are being asked to be perfect pill takers for regimens fraught with potential side effects. In many cases difficulties with adherence are not entirely unexpected26,27
      • Alcohol and drug abuse can also contribute to worse adherence in women27
      • ART adherence is significantly lower in women who experience intimate partner violence (IPV) compared with women without IPV experiences32
      • Reaching adequate ART adherence levels is a challenge for women in pregnancy, and even more so during the postpartum period33,34
      • Physician-patient communication may also have an impact on ART adherence36,37
      • Several research studies have showed that adherence declines over time in people on long-term ART - even in those individuals who usually take their medications very successfully. This may happen in women who have lived for many years with the burden of having to swallow several pills a day, and is known as "pill fatigue" or "treatment fatigue"38
      • The Gender, Race And Clinical Experience (GRACE) study, which evaluated sex- and race-based differences in outcomes for those receiving  treatment with ART, found that the main reasons for non-adherence were, respectively, being the primary caregiver for children, unemployment, and transportation difficulties; all of which disproportionately affect women more that men39
      • Some evidence suggests that women metabolise ART differently than men and are at an increased risk of developing antiretroviral toxicities, and thus discontinuing treatment40

      How can we increase adherence to ART in women?

      • Women participating in specially designed interventions  are significantly more likely to achieve 95% adherence and viral load suppression compared to those who don’t41 and there is evidence to suggest that interventions should be gender appropriate29
      • The likelihood of successful ART adherence is optimised when there can be a certain openness and acceptance of a woman’s HIV status, allowing them to negotiate support from significant others, and fit ART into their daily schedule, free from fear and stigma42
        • Women should be supported to disclose their HIV status to long-term partners 43,44
        • Women should be encouraged to seek out community based support groups in their area, to access supporting resources and meet others who may be in a similar situation45
      • HIV guidelines now offer advice on monitoring and improving adherence to ART44-47 suggesting a number of traditional and more novel interventions that can be employed successfully, including:46-49
      • Dose-time reminder alarms e.g. mobile phone text messaging
      • Simplification of dosing schedules and reduction of pill burden
      • Pill boxes, medication planners, calendars
      • Peer support
      • Improved patient-physician communication
      • Patient education and counselling interventions – one-on-one and group
      • Substance abuse therapy
      • Given the strong association between poor adherence and mental health and alcohol and drug use, integration of mental health, substance abuse and medical care services may also be an important strategy for promoting medication adherence in women living with HIV
      • Further research is urgently needed to investigate the reasons underlying treatment non-adherence and discontinuation in women living with HIV and to optimise interventions to address them

      Women for Positive Action Comment

      Adriana Ammassari, HIV physician, National Institute for Infectious Diseases, Italy: “Correct medication adherence is the main element for translating evidence-based medicine into health outcomes relevant to the individual and the general population. Particularly in the treatment of HIV, sub-optimal antiretroviral intake may lead to virological failure, drug resistance, increased morbidity and mortality, onward HIV transmission, and increased health care costs. Women in general, as well as those living with HIV, are more likely than men to be non-adherent to prescribed medications. The reason for this gender-specific vulnerability is multi-factorial, and resides in patient, treatment, and health care-associated factors. Systematic adherence assessment in clinical practice, open and non-judgemental discussion, psychological support, and stigma-lowering actions are essential for implementation of concrete and effective adherence intervention strategies. Women living with HIV need to be specifically supported in health care delivery systems and are of utmost importance for achieving a change in public opinion regarding HIV-infection, because of their key role in families and society.”

      Mariana Mardarescu, HIV physician, Institutul Matei Bals, Romania, “Adherence has acquired a new significance in the context of the HIV/ AIDS epidemic, especially in achieving the World AIDS Day goal of, ‘Getting to zero: zero new HIV infections. Zero discrimination. Zero AIDS related deaths.’ Where possible, women living with HIV should be entered on to an adherence program; specific to the cultural, emotional and practical needs of the patient. The Women for Positive Action mini-lecture at EACS 2011, titled, ‘East Meets West: Management of Women Living with HIV, emphasised the importance of recognising cultural differences in providing effective HIV care in Central and Eastern Europe (the presentation can be downloaded from the Women for Positive Action website). Discussions in this area should always play a part in providing a comprehensive view on the challenge of antiretroviral adherence in women living with HIV.”        

      Annette Piecha, HIV advocate, Germany, “We urgently need to enhance the dialogue between healthcare professionals and women living with HIV. It is important that women are counselled on how to manage their disease, including any anxieties they may have surrounding their treatment. Depression is common in women living with HIV and this leads to an increased risk of antiretroviral non adherence. In fact, research has shown that adherence is six times higher in women when they are in good mental health.”

      References

      1. Hogg et al. JAMA. 2001; 286(20), 2568–77
      2. Egger et al. Lancet. 2002; 360(9327), 119–29
      3. Paterson et al. Ann Intern Med. 2000; 133(1), 21–30
      4. Deeks SG. Lancet. 2003; 362(9400), 2002–11
      5. Holstad et al. Online Journal of Issues in Nursing. January 31, 2006. Available at: http://www.medscape.com/viewarticle/528308_1
      6. Puskas et al. Curr HIV/AIDS. 2011; 8, 277–87
      7. de Fatima Bonolo et al. Clinics (Sao Paulo). 2013; 68, 612–20
      8. Krummenacher et al. Int J Clin Pharm. 2012; 34, 426–31
      9. Hanif et al. BMC Public Health. 2013; 13, 574
      10. O'Neil et al. J Int Assoc Physicians AIDS Care (Chic). 2012; 11(2), 134–41
      11. Barber et al. Antivir Ther. 2011; 16, 805–14
      12. Soon et al. AIDS Patient Care STDS. 2012; 26, 444–53
      13. Holstad et al. AIDS Behav. 2011; 15, 885–96
      14. Mellins et al. AIDS Patient Care STDS. 2003; 17, 407–16
      15. Vanable et al. AIDS Behav. 2006; 10, 473–82
      16. Sayles et al. J Gen Intern Med. 2009; 24, 1101–8
      17. Zhang Y et al. Gender and Ethnicity Differences in HIV-related Stigma. Presented at the 1st International Workshop on HIV & Women, Washington DC, 2011. Abstract P_28
      18. Dlamini et al. AIDS Patient Care STDS. 2009; 23, 377–87
      19. Sayles et al. J Womens Health (Larchmt). 2006; 15, 173–81
      20. Gari et al. BMC Health Serv Res. 2013; 13, 198
      21. Lubega et al. Patient Prefer Adherence. 2013; 22, 447–54
      22. Skovdal et al. J Int AIDS Soc. 2011; 14, 29
      23. Springer et al. AIDS Behav. 2012; 16, 2119–43
      24. Whetten et al. PLoS One. 2013;8, e74771
      25. Sarna et al. Indian Journal of Medical Research. 2008; 127, 28–36
      26. Plankey et al. AIDS Behav. 2009; 13, 53–9
      27. Berg et al. J Gen Intern Med. 2004; 19, 1111–7
      28. Kempf et al. JAIDS. 2009; 52, 336–41
      29. Santos et al. AIDS. 2005; 19 Suppl 4, S14–21
      30. Parsons et al. J Health Psychol. 2007;12, 357–70
      31. Arnsten et al. J Gen Intern Med. 2002; 17, 377–81
      32. Nachega et al. AIDS. 2012; 26, 2039–52
      33. Trimble et al. J Assoc Nurses AIDS Care. 2013; 24, 331–40
      34. Vitalis D. Int J STD AIDS.2013; 24, 427–32
      35. Ngarina et al. BMC Public Health. 2013; 13, 450 [Epub ahead of print]
      36. Laws et al. AIDS Behav. 2013; 17, 148–59
      37. Johnson et al. AIDS Patient Care STDS. 2006; 20, 258–68
      38. Nischal et al. Indian J Dermatol Venereol Leprol. 2005; 71(5), 316–20
      39. Squires K et al. AIDS Patient Care STDS. 2013; 27(6), 352–62
      40. Ofotokun et al. Gend Med. 2007; 4(2), 106-19
      41. Simoni et al. JAIDS. 2006; 43, supplement 1, S23–S35
      42. Dahab et al. BMC Public Health. 2008; 8, 1–6
      43. Stirratt et al. AIDS and Behavior. 2006; 10, 483–93
      44. Remien et al. AIDS. 2005; 19, 807–14
      45. Malcolm et al. AIDS Care. 2003; 15(2), 251–61
      46. Thompson et al. Ann Intern Med. 2012; 156, 817–33
      47. European AIDS Clinical Society (EACS) Guidelines Version 6.1, November 2012
      48. http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/30
      49. Deglise et al. J Telemed Telecare. 2012; 18, 273–81
    • Challenges facing women living with HCV and HIV coinfection: Why are women still being overlooked?

      Women living with HIV are almost twice as likely as HIV-negative women to acquire hepatitis C (HCV)1, which is a major cause of non-AIDS-related deaths in this population.2 Despite advances in the management of HCV, women are continually under-represented in clinical studies in this area. As treatment guidelines are informed by clinical trials, a shortage of women impacts on the appropriateness of subsequent care. This article summarises the challenges of HCV coinfection in women living with HIV and highlights the need for greater inclusion of women in clinical trials.

      Background

      • Chronic hepatitis C virus (HCV) infection is a blood-borne infection that primarily affects the liver, with potential complications including chronic liver inflammation, liver cirrhosis and liver cancer3
      • After acute infection with HCV, 15-45% of people clear the virus naturally from their blood during the acute stage, whilst the rest develop chronic HCV4
      • There is wide variation in the way that people living with HCV experience the disease:
        • Acute HCV can remain unsymptomatic in many patients – others can experience flu-like symptoms
        • Some people with chronic HCV never experience complications, whilst about a third of people may develop serious liver disease over years or decades4
      • Worldwide, approximately 15%–30% of people living with HIV are coinfected with HCV5, with higher rates of up to 95% in intravenous drug users (IVDUs)6
        • The risk of contracting HCV through sexual transmission is extremely low
        • However, in recent years an active epidemic in men who have sex with men (MSM) with highly risky sexual behaviour has been identify in several cities in the USA, Canada and Europe; which may have implications for onwards transmission to women7
      • Areas of higher prevalence include Africa and Asia, where transmission is primarily from contaminated injections given during mass treatment or vaccination campaigns8

      What does HCV coinfection mean for women living with HIV?

      • Non-IVDU women living with HIV are almost twice as likely as HIV negative women to acquire HCV via sexual transmission1
      • People living with HIV and HCV coinfection are at more than three times the risk of liver disease and liver failure,2 and up to nine times the risk of liver-related death from HCV compared to those living with HIV alone9
        • HCV infection progresses to cirrhosis more than 3 times faster in those living with HIV and HCV coinfection compared to those living with HCV alone (6.9 years vs. 23.2 years)10
      • Whether HCV has a negative impact on the disease progression of HIV continues to be debated, with recent studies producing conflicting results11-15
      • Compared to people living with HIV alone, people coinfected with HCV and HIV have been shown to:
        • Start HAART at a later stage16
        • Have a higher risk of cardiovascular, cerebrovascular and kidney disease17
        • Have a higher risk of bone fractures;18 a risk which is already high in women living with HIV
      • There are a number of differences between men and women in the course of the disease and its treatment
        • Women are twice as likely as men to spontaneously clear HCV without treatment, although further research is needed in HIV coinfected populations18
        • In women, the onset of menopause is correlated with the progression of liver disease, exposing women living with HIV and those coinfected with HCV, to a sudden and rapid worsening of their liver condition19
        • Women may experience certain side-effects of HCV treatment more frequently or more severely than men, making them more likely to require dose modification or stop treatment20
        • Men living with HIV and HCV coinfection have been reported to have a higher response to HAART (CD4 cell response) than co-infected women21
      • In pregnant women living with HIV and HCV coinfection the incidence of HCV transmission from mother to infant is increased compared to women living with HCV alone, with transmission rates between 10% and 20%22-25
        • Maternal HIV/HCV coinfection may also increase the risk of perinatal transmission of HIV25
      • Effective treatment that permanently clears HCV (a sustained virological response [SVR]) can improve liver fibrosis, reduce incidence of liver cancer, reduce mortality27,28, and has the potential to reduce disease transmission29
        • Around 37% of patients living with HIV and HCV coinfection achieve a SVR with pegylated interferon and ribavirin treatment30
        • Promising new HCV therapies are becoming available or are under investigation, but there is uncertainty about how these should be used in women living with HIV
      • Emotional factors associated with living with HCV and HIV coinfection also need to be considered, including willingness and decision to test, treatment adherence and mental wellbeing31,32
        • Few studies exist in this area and many are in populations who are also IVDUs, which suggests that complex models of provision, support and understanding are needed

      Current standard of care

      • Regular screening for HCV is recommended for all women living with HIV. This should be promoted and encouraged, as early diagnosis and treatment has a high response rate33
      • Although early ART initiation is recommended to reduce the rate of liver disease progression, the most effective way to decrease HCV-related morbidity and mortality in coinfection is to achieve HCV viral eradication
      • The current standard-of-care treatments for HCV in most cases are the immune-boosting drugs interferon and pegylated-interferon33-35
        • Although effective, current standard of care treatments can be associated with potentially severe side-effects, including depression, anaemia and severe flu-like symptoms
        • Many women face multiple roles on a daily basis (e.g. balancing work and family commitments), however, the burden of side-effects, such as depression and fatigue, can upset this balance, with many women requiring counselling and emotional and practical support before and during HCV treatment36
      • Where available, HCV protease inhibitor based therapy with either boceprevir or telaprevir is now the new standard of treatment in HCV genotype 1 infection in people living with HIV35
      • Numerous guidelines are available providing recommendations for the management of HCV coinfection in people living with HCV.33-35 However, these are non-specific to gender and typically based on data extrapolated from predominantly male clinical trials; guidance for men may not translate to guidance for women
      • Guidelines are available specifically for pregnant women with HIV/HCV coinfection. Unfortunately little data exists on the optimal management of pregnant women living with HIV and HCV coinfection, and currently available anti-HCV treatments are not recommended during pregnancy due to their teratogenicity37,38

      Women remain underrepresented in clinical trials

      • Guidance offered by the NIH Office of Research on Women’s Health states:39
        • ‘If sex differences have been shown to affect the course or impact of a treatment in early phases of research, then subsequent studies can be designed so that application of the treatment will benefit both men and women’
      • Despite evidence suggesting sex differences in both disease progression and treatment response to HCV, women remain underrepresented in these new HCV studies
        • In the majority of clinical trials of novel direct-acting antiviral agents for HCV presented at the EASL (European Association for the Study of the Liver) International Liver Congress 2013, female enrolment was lower than men (at least 60% of participants were male)40

      Key Points

      • Many women who live with HIV also live with HCV, which more than triples the risk for liver disease, liver failure, and liver-related death from HCV2
      • Studies have shown that women living with HIV may experience a different HCV disease course than men and may experience more side effects than men on the current standard of care treatment for HCV18-21
      • There is limited research evidence that specifically addresses the treatment, care and support needs and gaps for HIV/HCV coinfected women, and it is therefore crucial to address this deficit in order to develop relevant structures and guidelines for care

      References

      1. Frederick et al. AIDS Patient Care STDS. 2009; 23: 915-23
      2. http://www.cdc.gov/hepatitis/Populations/PDFs/HIVandHep-FactSheet.pdf. Accessed on 3 September 2013
      3. Salmon-Ceron et al. J Hepatol. 2009; 50: 736-45
      4. Thomas & Seeff. Clin Liver Dis 2005; 9(3): 383-98
      5. Andreoni et al. Eur Rev Med Pharmacol Sci. 2012; 16, 1473-83
      6. Mast et al. J Infect Dis. 2005; 192(11): 1880-9
      7. Bradshaw et al. Curr Opin Infect Dis. 2013; 26(1): 66-72
      8. Bouare et al. World J Hepatol. 2013; 5(4): 196-205
      9. Rockstroh et al. J Hepatol. 2013; 59: 213-20
      10. Soto et al. J Hepatol. 1997; 26: 1-5
      11. Chen et al. Clin Infect Dis. 2009; 49: 1605-15
      12. d’Arminio Monforte et al. Clin Infect Dis. 2009; 49(4): 612-22
      13. Kovacs et al. J Infect Dis. 2010; 201: 823-34
      14. Karim et al. AIDS. 2013; 27: 1473-81
      15. Kuniholm et al. PLoS ONE. 2013; 8(4): e61973
      16. French et al. Clin Infect Dis. 2004; 39(3): 402-10
      17. Operskalski et al. Curr HIV/AIDS Rep. 2011; 8: 12-22
      18. Grebely et al. Hepatology. 2013 Aug 2. Epub ahead of print
      19. Nasta. Acta Biomed. 2011; 82(2): 115-23
      20. Bhattacharya et al. J Acquir Immune Defic Syndr. 2010; 55: 170-5
      21. Palepu et al. Drug and Alcohol Dependence. 2006; 84(2): 188-94
      22. Tovo et al. Clin Infect Dis. 1997; 25(5): 1121-4
      23. Gibb et al. Lancet. 2000; 356(9233): 904-7
      24. Mast et al. J Infect Dis. 2005; 192(11): 1880-9
      25. Alter. J Hepatol. 2006; 44(1 Suppl): S6-9
      26. Hershow et al. J Infect Dis. 1997; 176(2): 414-20
      27. Singal et al. Clin Gastroenterol Hepatol. 2010; 8(3): 280-8
      28. Limketkai et al. JAMA. 2012; 308(4): 370-8
      29. Durier et al. PLoSONE 2012; 7(4): e34548
      30. Iorio et al. Cochrane Database Syst Rev. 2010; 1: CD004888
      31. McLaren et al. Can J Gastroenterol. 2008; 22(2): 133-7
      32. Ogawa et al. Subst Use Misuse. 2009; 44(7): 915-33
      33. http://aidsinfo.nih.gov/contentfiles/lvguidelines/glchunk/glchunk_26.pdf. Accessed on 3 September 2013
      34. Brook et al. HIV Med. 2010; 11: 1-30
      35. http://www.europeanaidsclinicalsociety.org/images/stories/EACS-Pdf/EacsGuidelines-v6.1-2edition.pdf. Accessed on 3 September 2013
      36. http://www.hcvadvocate.org/hepatitis/factsheets_pdf/Wm_treatment.pdf. Accessed on 24 September 2013
      37. http://aidsinfo.nih.gov/contentfiles/lvguidelines/perinatalgl.pdf. Accessed on 3 September 2013
      38. http://www.bhiva.org/documents/Guidelines/Pregnancy/Pregnancy_Guidelines_for_Consultation120125.pdf. Accessed 3 September 2013
      39. http://orwh.od.nih.gov/research/strategicplan/ORWH_StrategicPlan2020_Vol1.pdf. Accessed 3 September 2013
      40. http://www.natap.org/2013/EASL/EASL_106.htm. Accessed 3 September 2013

       

    • Pre-exposure prophylaxis (PrEP) for prevention of HIV transmission: The VOICE trial

      Pre-Exposure Prophylaxis (PrEP) involves the use of antiretroviral medications to reduce the risk of HIV infection. VOICE (Vaginal and Oral Interventions to Control the Epidemic) is a major HIV trial assessing three different PrEP treatments in preventing transmission of HIV in predominately young and unmarried African women. The final results from VOICE were presented at the Conference on Retroviruses and Opportunistic Infections (CROI),
      held in Atlanta earlier this year.1

      Background2

      • VOICE began in September 2009 and enrolled over 5,000 predominately young and unmarried women in Uganda, South Africa and Zimbabwe. Follow-up of all participants was completed in August 2012
      • The women were randomised to receive one of three different treatments and the safety and efficacy of each was assessed:
        • Oral tenofovir
        • Oral tenofovir/emtricitabine (TDF/FTC)
        • Tenofovir 1% gel
      • As with other HIV prevention trials, all participants in VOICE received ongoing HIV risk reduction counselling, condoms, and diagnosis and treatment of sexually transmitted infections throughout their participation

      What were the findings of the study?2

      • None of the treatments proved to be statistically more effective than placebo among the women enrolled in the trial
      • Unfortunately, most participants did not use the treatments daily as was recommended
      • As adherence was low across all study groups, it was not possible to evaluate efficacy, even among women who appeared to use the study treatments consistently
      • No safety concerns were identified

      How can further analysis of the VOICE study help support the care of women living with HIV?

      • Two ongoing behavioural studies, VOICE C and VOICE D, hope to explain why adherence to treatment was so low2
        • VOICE C aims to identify specific factors within a participant’s household, social group or broader community, that can influence her willingness or ability to correctly and consistently follow a PrEP regimen
        • VOICE D aims to explore the participants personal views regarding risk perception and PrEP adherence
      • Another study, examining of the levels of active PrEP medication in the body, is also planned to provide a greater insight into the relationship between treatment use and efficacy, particularly for tenofovir gel2
      • The viral load in vaginal fluid usually mirrors the plasma viral load, however this isn’t always the case; antiretroviral drugs may not always reduce the viral load in the female genital tract to the same degree as the bloodstream3
      • Significantly, a previously published study of TDF/FTC levels in mucosal tissues found higher drug concentrations in the rectal mucosa, compared with vaginal and cervical tissue4

      What other studies are examining the use of PrEP for HIV prevention in women?

      • At present, there are three ongoing Phase III HIV prevention trials specifically focused on women:
        • The Follow-on African Consortium for Tenofovir Studies (FACTS) is examining the safety and efficacy of 1% tenofovir gel in preventing HIV-negative women from acquiring HIV and herpes simplex virus (HSV)5
        • A Study to Prevent Infection with a Ring for Extended Use (ASPIRE) is being run by the Microbicide Trials Network and is evaluating HIV prevention in HIV-negative women through the use of a vaginal ring that slowly releases dapivirine to cells inside the vagina throughout the one-month period that it’s worn6
        • The Ring Study, a sister trial to ASPIRE, is being run by the International Partnership for Microbicides. It is also evaluating the use of a dapivirine vaginal ring in HIV-negative women. Both studies will potentially offer women a discreet, long-acting preventative treatment option7
      • The efficacy of PrEP has previously been investigated in a number of published studies
      • The first study of PrEP in humans, the iPrEx trial, found that the acquisition of HIV in HIV-negative men who have sex with men was reduced by 44% in those who took a daily dose of TDF/FTC, compared with those given a placebo8
      • FEM-PrEP, a trial of TDF/FTC based PrEP in 1,951 HIV-negative women, was halted early after it was concluded that treatment was highly unlikely to show a significant protective effect against HIV infection9
      • The TDF2 study found that TDF/FTC reduced the risk of acquiring HIV in a HIV-negative heterosexual study population (which included 557 women) by around 63 percent10
      • The CAPRISA 004 study compared 1% tenofovir gel with a placebo gel in a study population of 900 HIV-negative women. Results showed that 1% tenofovir gel was 39% more effective than placebo in reducing the risk of acquiring HIV11

      Key points

      • Results from VOICE suggest that the treatments that are long acting and require minimal daily adherence may be a more suitable HIV prevention option for young and unmarried African women
      • Ongoing behavioural studies should shed light on why women in the VOICE trial failed to adhere to treatment and inform ways in which women can be better supported in following pre-exposure prophylaxis regimens in the future

      What do these study results mean for women living with HIV?

      • The studies are consistent in showing that PrEP can be effective if used appropriately and if adherence is maintained
      • There is no reason to believe that, biologically, women should respond differently to prevention with antiretrovirals unless the pharmacokinetics of the drugs are somehow different than in men
      • Whilst this cannot be proven in the studies presented so far, it would appear that adherence is the main barrier to effective use in women
      • Whatever the reasons, it is clear that PrEP in its current form is not optimal for women and newer strategies need to be developed, that are safe, efficacious, and acceptable
      • Young sexually active women, who want to consider the use of PrEP to prevent acquisition of HIV, need to discuss these discrepant results with their physicians in order to make informed personal decisions
      • The factors impacting on adherence in women should be investigated in future studies to support with the development on female-specific interventions

      References

      1. Marrazzo et al. 20th Conference on Retroviruses and Opportunistic Infections. March 3-6, 2013. Atlanta. Abstract 26LB.
      2. Microbicide Trials Network. VOICE (MTN-003). Available at: http://www.mtnstopshiv.org/news/studies/mtn003. Date accessed June 2013.
      3. NAM AIDSmap. Viral load in vaginal fluid. Available at: http://www.aidsmap.com/Viral-load-in-vaginal-fluid/page/1322891/. Date accessed June 2013.
      4. Patterson et al. Sci Transl Med. 2011; 3(112):112re4.
      5. FACTS Consortium. Available at: http://www.facts-consortium.co.za/
      6. Microbicide Trials Network. ASPIRE (MTN-020). Available at: http://www.mtnstopshiv.org/news/studies/mtn020. Date accessed June 2013.
      7. International Partnership for Microbicides. The Ring Study. Available at: http://www.ipmglobal.org/the-ring-study. Date accessed June 2013.
      8. Grant et al. N Engl J Med. 2010; 363(27):2587–99.
      9. Van Damme et al. N Engl J Med. 2012; 367(5):411–22.
      10. Thigpen et al. AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, 2011. Rome. Abstract WELBC01. 2011.
      11. Karim et al. Science. 2010; 329(5996):1168–74.
    • Intimate partner violence and HIV

      Intimate partner violence (IPV) is a major public health problem around the world.
      Studies have shown that women living with HIV are at a greater risk of IPV compared with the general population.1 As a result, there is a growing body of research examining the link between HIV and IPV; a summary of which is presented in this article.

      Background

      • The World Health Organisation defines IPV as any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship. Such behaviour includes:2
        • Acts of physical aggression - such as slapping, hitting, kicking and beating
        • Psychological abuse - such as intimidation, constant belittling and humiliating
        • Forced intercourse and other forms of sexual coercion
        • Various controlling behaviours - such as isolating a person from their family and friends, monitoring their movements, and restricting their access to information or assistance
      • According to recent data, IPV affects 30-60% of women worldwide and has significant consequences for mental, physical and sexual health3,4
      • For women living with HIV, there appears to be a much higher prevalence of IPV compared with the general population
        • A US-based study found 27% of women living with HIV had experienced IPV in the past year4, compared with 1.4% of women in the general population6
        • In a study of women reporting for routine antenatal care in South Africa, those who reported a history of IPV were 53% more likely to test positive for HIV7
        • A Tanzanian study found that women under 30, who were seeking voluntary counselling/testing for HIV, were around 10 times more likely to be HIV positive if they reported IPV8
      • IPV has a detrimental effect on HIV disease progression and has a significant impact on patient engagement with care9

      What links IPV to HIV?

      • IPV has been associated with both positive HIV status and an increased risk of contracting HIV in the first instance. The reasons behind this point towards a combination of psychological, cultural and environmental factors:10
        • Women may be forced into sex or be sexually abused by their HIV positive partner
        • Women in violent relationships may not feel able to discuss safer sex behaviours (such as barrier contraception) with their partner
        • In a controlling relationship, women may be coerced to engage in risky behaviours such as sex work or intravenous drug use
        • Women living with HIV may be the target of violence resulting from the disclosure of their status to an abusive partner
      • IPV is also associated with poor medication adherence:
        • Women who experience extreme forms of violence from their partner (e.g. using a weapon) were less likely to be adherent to their medication compared with women in non-violent relationships11
        • The Woman’s Interagency HIV study identified a history of IPV as a risk factor for poor medication adherence12

      Tackling IPV in women living with HIV

      • Currently, few initiatives specifically address violence against women living with HIV, focusing instead on interventions designed to change ‘risk behaviour’, or to achieve public health goals of reducing HIV transmission13
      • Nonetheless, a number of studies have identified the need for better IPV screening as a systematic and integral part of managing women living with HIV:
        • Illangasekare et al. noted the correlation between IPV and missed gynaecological appointments and/or depressive symptoms, which should prompt further screening for IPV5
        • Kendall et al. recommended identifying and addressing past and current gender-based violence during pre- and post-HIV test counselling14
        • Ezeanochie et al. and Ntaganira et al. concluded that IPV may act as a barrier to projects aimed at preventing mother-to-child transmission and recommend that screening be incorporated into such programs15,16

      Future strategies

      • All health services, including those focused on women living with HIV, provide an important entry point for identifying and responding to women who experience IPV
        • Cross-training those working on HIV counselling and those working on domestic violence may be an effective strategy to raise awareness among healthcare providers17
        • Couple testing and counselling followed by mediated disclosure may be a way of reducing tensions between partners and the potentially adverse consequences for women18
        • Developing a ‘safe place’ where women feel able to talk freely, without feeling like they will be judged or experience negative consequences19
      • Targeted educational programmes, similar to those that have been implemented in South Africa, are a useful way of dispelling gender and sexual norms (and stigmatisation) which often underlie violence against women living with HIV20,21

      Key Points

      • Women living with HIV are at a greater risk for IPV compared with the general population
      • IPV has a significant impact on the engagement, adherence and success of HIV treatment
      • The issue of IPV in women living with HIV is currently poorly addressed and a greater awareness of the issues involved is necessary amongst both patients and healthcare providers
      • An improved understanding of how to best identify and support women living with HIV who are affected by IPV, e.g. through screening, survey-questionnaires, social work, peer groups; is crucial to develop relevant structures and guidelines for care

      References

      1. Dunkle and Decker. Am J Reprod Immunol. 2013; 69(S1):20-6
      2. Krug et al. World Health Organization. 2002
      3. Ellsberg et al. Lancet. 2008; 371:1165-72
      4. Garcia-Moreno et al. Lancet. 2006; 368:1260-9
      5. Illangasekare et al. Women's Health Issues. 2012; 22(6):e563-9
      6. Breiding et al. AJPM. 2008; 34:112-8
      7. Dunkle et al. Lancet. 2004; 363:1415-21
      8. Maman et al. Am J Public Health. 2002; 92:1331-7
      9. Schafer et al. AIDS Patient Care. STDS 2012; 26(6):356-65
      10. Gielen et al. Trauma Violence Abuse. 2007; 8(2):178-98
      11. Lopez et al. AIDS Educ Prev. 2010; 22:61-68
      12. Jones et al. Women’s Health Issues. 2010; 20:335-42
      13. Hale and Vazquez. Violence Against Women Living With HIV: A Background Paper. DVCN & ICW Global. 2011; 1-46
      14. Kendall et al. J Assoc Nurses AIDS Care. 2012; 23(5):377-87
      15. Ezeanochie et al. Acta Obstet Gynecol Scand. 2011; 90(5):535-9
      16. Ntaganira et al. BMC Women's Health. 2008; 8:1-7
      17. WHO Department of Gender, Women and Health, Global Coalition on Women and AIDS. Information Bulletin Series, 2004; No. 1
      18. World Health Organization (WHO). Gender dimensions of HIV status disclosure to sexual partners. 2003
      19. Lang. Women, Interpersonal Violence (IPV) & HIV. AIDS Connecticut. Available at: http://www.aids-ct.org/powerpoint/hiv_women.ppt. Accessed April 2013
      20. Guedes A. Addressing gender-based violence from the reproductive health/HIV sector.
        IGWG. 2004
      21. Welbourn A. Stepping Stones. Strategies for Hope. Oxford 1995.
    • International Women's Day 2013 - Women for Positive Action commentary

      “On International Women's day we need to pause and reflect on the urgent challenges, needs and achievements in the struggle of women globally to fight HIV infection.

      Women are affected by the virus and this year has shown a spotlight on the neglect and various lags in provision for women. Yet at the same time, many of the new initiatives resonate with women and hold out future hope and promise. The UNAIDS policy of virtual elimination of paediatric HIV infection directly affects women in terms of HIV testing, treatment and inclusion in services. The WHO’s B+ option permits a focus on the health of the mother as well as their children. This option allows for the roll-out of treatment beginning in the antenatal clinic and continuing for life. Also recognition of women in relationships has triggered a more family-based approach to HIV treatment prevention and care and this is in harmony with the needs of women.

      As women age with HIV infection and as treatment ensures longer life, the challenges of growing older with HIV come to the fore. The gender agenda resonates for women with HIV. They need to be included in clinical trials; global data needs to be disaggregated by gender to understand female specific issues and findings.  It is no longer good enough to extrapolate findings from men and apply them to treatment decisions for women.

      Updated information forms a key starting point and the Women for Positive Action initiative has summarised a number of key issues for women in materials available on the website (http://www.womenforpositiveaction.org). In these constrained economic times the gender agenda has never been more important.  As life expectancy extends, quality of life becomes paramount.”

      Lorraine Sherr, Professor of Clinical and Health Psychology, UK, on behalf of the Women for Positive Action faculty

      For more information on Women for Positive Action, please click here to view a poster developed and presented by members of the Women for Positive Action faculty at the 3rd International Workshop on HIV & Women in Toronto, Canada.

    • World AIDS Day Press Release December 1, 2012

      Women for Positive Action highlight ongoing need for more research into gender differences in HIV outcomes
      To mark Worlds AIDS Day (December 1, 2012), Women for Positive Action has released a commentary highlighting the shortage of women in HIV clinical trials (currently only ~20%) and discussing recent scientific papers reporting gender-related differences in virologic and clinical outcomes with combination antiretroviral therapy. The commentary, available at: www.womenforpositiveaction.org, emphasises the need to collect gender-specific data in HIV research so that clinical decisions regarding therapy can be guided appropriately.

      Sharon Walmsley, HIV Physician, Canada and faculty member of Women for Positive Action explains “Extrapolation from data derived from male participants in clinical trials to females is not appropriate, and it is poor science. Only with data on the specific effects (both positive and negative) of interventions in women will we have the knowledge to apply to women’s care and optimise future outcomes. It is no longer enough to simply report on gender distribution - researchers need to consider gender in the planning and analysis stages of clinical trials.” The commentary, developed by Sharon Walmsley, Mona Loutfy, Lorraine Sherr, Karine Lacombe and Ophelia Haanyama Ørum on behalf of Women for Positive Action provides further expert opinion on the implications of the lack of data focussing specifically on women living with HIV.

      “Many of the studies we have reviewed indicate that women may fare worse with regard to HIV outcomes. This may be as a result of biological, behavioural, pharmacological and social differences between women and men” added Annette Piecha, member of the German Therapy Activists Network DCAB HIV and the European AIDS Treatment Group. “Understanding the specific effect of the disease and treatment is a key step in improving the lives of women and working towards bridging gender inequalities in HIV.”

      Women for Positive Action is a coalition of healthcare professionals, community representatives and women living with HIV from across Europe, Canada, Latin America and South Africa established to explore and address the issues faced by women living with HIV and those involved in their care. For more information visit the website www.womenforpositiveaction.org.

      ---- ENDS ----

      Notes to Editors
      Although women represent 50% of people living with HIV globally and are one of the fastest growing population groups at risk for HIV infection, relatively little research has looked at women-specific issues, and women only account for about 20% of participants in clinical trials of HIV to date. As part of its mission Women for Positive Action aims to raise awareness around recent and ongoing studies that focus on women. Visit the multilingual website http://www.womenforpositiveaction.org for further information about Women for Positive Action and ongoing projects; alternatively please also follow us on Twitter @WFPA_HIV. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories.

        References
      1. UNAIDS Report. Global HIV/AIDS Response 2011. Available at: http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20111130_UA_Report_en.pdf
      2. Soon GG et al. (2012) Meta-analysis of gender differences in efficacy outcomes for HIV-positive subjects in randomized controlled clinical trials of antiretroviral therapy (2000-2008). AIDS Patient Care STDS; 26(8): 444-53

      For further information please contact the Women for Positive Action secretariat:
      Email: WFPA@litmus-mme.com
      Twitter: @WFPA_HIV
      Tel: +44 (0) 20 7632 1969
      Address: Women for Positive Action, Program Secretariat, Litmus MME, 151 Shaftesbury Avenue, London WC2H 8AL, United Kingdom

    • Understanding gender differences in HIV to help improve the care of women living with HIV

      Mona Loutfy, Lorraine Sherr, Karine Lacombe, Ophelia Haanyama Ørum and Sharon Walmsley on behalf of Women for Positive Action

      Worldwide, women are one of the fastest growing population groups at risk for HIV acquisition; however gender-specific HIV research is limited. In support of the World AIDS Day theme of "Getting to zero: zero new HIV infections. Zero discrimination. Zero AIDS related deaths" Women for Positive Action aim to highlight the need for additional research into gender-specific outcomes and care issues to increase our ability to meet the goal of ‘getting to zero’.

      A key to getting to zero is the effective use of antiretroviral therapy (ART) in both management and prevention strategies, and for women in particular for the prevention of mother-to-child transmission. Over the past year, a number of sub analyses of randomised controlled studies have reported gender differences in virologic outcomes to different ART combinations, and other studies have investigated potential contributing factors for these differences.

      The Women for Positive Action faculty feel that evaluating this research and implementing the findings is of importance to all those involved in the care of women living with HIV. Below they have summarised findings from these studies, in addition to providing their perspective on the subject of gender-based research.

      Literature assessment of gender differences in virologic and clinical outcomes of ART

      As women become increasingly affected by the HIV epidemic, a better understanding of gender-related differences in short and long term virologic outcomes in response to effective ART and associated factors is essential for the development of targeted interventions for women. Recent analysis of some of the newer ART studies have shown gender differences in virologic and clinical outcomes, with women faring worse in a large number of these. However, the results are largely inconclusive, and the reasons for the difference unclear, stressing the need for further research in this area.

      Kwakwa et al (2012) conducted a literature search to identify randomised controlled trials that reported virologic suppression / virologic failure rates for both men and women on ART. They found that, over a 16-year period, only 14 studies published efficacy results for women compared with men. The investigators then went on to conduct a meta-analysis of seven of the randomised controlled trials that reported outcomes in a consistent manner, and found that women were 28% less likely to achieve virologic suppression <50 copies/mL compared to men.1

      Similarly, Soon et al (2012) conducted a systematic review of gender-related ART efficacy data, using the FDA Division of Antiviral Products (DAVP) database. Although ARTs were equally efficacious in men and women on average, based on 20 subgroup analyses with respect to age, region, and ethnicity, the study reported that more treatment naïve Caucasian males achieved HIV RNA <50 copies/mL compared to treatment-naïve Caucasian females. Likewise, more treatment-experienced males in North America achieved HIV RNA <50 copies/mL compared to treatment experienced females in North America.2

      Cornell et al (2012) evaluated gender differences in survival among 46,201 adults starting ART in eight ART programs in South Africa between 2002 and 2009.3 Although virologic suppression was similar by gender, women had slightly better immunological response than men, perhaps reflecting lesser degrees of immunosuppression at ART initiation. HIV-positive men had higher mortality on ART than women, which may in part be related to differences in mortality between men and women in the general South African population. Similarly, another South African cohort study showed women to have a better long term immune response to ART. The authors suggest that the reasons for the gender effect may in part be due to differences in health-seeking and adherence behaviour in this region.4

      In another study, conducted in Denmark, the investigators aimed to assess the impact of gender on the risk of AIDS defining illnesses (ADI) and death in people living with HIV. The authors reported that although gender had no major impact on progression to AIDS or mortality, there were significant gender differences in the risk of ADIs, with women presenting more often with tuberculosis but less often with AIDS-defining cancers compared to men.5

      Why might there be gender differences in outcomes?

      Up until recently, most data suggested that the virologic and clinical responses to ART did not vary by gender whereas the newer studies as cited above suggest there may be differences. What is unclear is whether these differences are true and if so do they truly relate to a biologic difference in response to ART or do they more likely reflect behavioural- and adherence-related issues. Some of the potential factors that may contribute towards reported gender differences are suggested below.6

      • Women may have different pharmacokinetics, thus impacting drug concentration
      • There may be gender differences in the susceptibility of women to toxicities resulting in adverse events which may impact tolerability and adherence
      • Women often start ART in the context of a pregnancy and this may impact on the viral response related to adherence, or to the lesser immunosuppression
      • Women often leave studies for personal reasons, not specifically related to the study treatment, thus the reported gender differences may relate to their busy lives and conflicting demands. Women for Positive Action have previously published a paper suggesting strategies to overcome the barriers to the retention of women in clinical trials7

      Recent studies have also looked at potential gender differences in emotional wellbeing and HIV-related stigma, and the potential impact this may have on ART adherence and outcomes. In the majority of studies:

      • women reported higher levels of stress, depression, anxiety and PTSD and reduced health-related quality of life8-12
      • significant levels of gender-related stigma were observed among women13-15
      • women were found to be less adherent to ART than men,16 particularly women with depressive disorders.17

      Women for Positive Action comment

      Although late in the day, it is never too late to emphasise the need for gender-specific data and gender awareness in the research agenda. Extrapolation from male data to females is not only unfair, it is poor science. Firstly, studies need to include more women; in 2012 Soon et al reported that women only represented approximately 20% of the subjects in randomised controlled trials submitted to the FDA from 2000 to 2008, and that during this period an overall decrease in the percentage of women enrolled in HIV trials was seen.2 Studies also need to analyse the data by gender to give clear insight into female-specific needs and outcomes. This must start at the planning stages where an inclusive protocol is set up and studies are powered to examine gender differences. It is not enough anymore to simply report on gender distribution – analyses need to go further. If there truly are virologic, immunologic or clinical gender differences in response to ART these need to be better understood so that the optimal treatment choices can be made for women.

      Women for Positive Action has previously addressed the shortage of women living with HIV in clinical trials7 and is currently working to provide an expanded publication on gender differences in HIV. This view is also supported by AmfAR, The Foundation for AIDS Research, which, in January 2012, called for greater focus on sex differences in HIV/AIDS research and policy.18 Likewise, the importance of analyses by gender has been recognised by the US FDA, who are now required to report annually on the extent to which clinical trial participation and safety and efficacy data reported by sex are included in new drug applications.19

      Leaders in medicine, research, public health and communities can work together to improve the lives of women living with HIV, but only with specific data on the effects of interventions in women will we have the knowledge to apply to women’s care to improve outcomes in the future. Women living with HIV should discuss the potential of participating in clinical trials and how they can contribute to a better understanding of the gender issues.

      About Women for Positive Action

      Women for Positive Action is a global initiative established in response to the need to address specific concerns of women living and working with HIV. The group is made up of healthcare professionals, women living with HIV, and community group representatives from across Canada, Europe, Latin America and South Africa.

      Women for Positive Action aims to empower, educate and support women with HIV and the professionals and community advocates/leaders involved in their treatment. The group explores issues facing women with HIV and provides meaningful education-based support to respond to these needs and to contribute towards an enhanced quality of life for women with HIV. For further information, and to freely download educational resources please visit www.womenforpositiveaction.org or follow us on Twitter at @WFPA_HIV. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories.

      References

      1. Kwakwa H et al. Gender Differences in Virologic Outcomes in a Meta-Analysis of Randomized Controlled Clinical Trials in HIV-1-Infected Patients on Antiretroviral Therapy – ‘Women 28% Less Likely to Achieve <50 c/ml’. XIX International AIDS Conference, July 22-27, 2012. Washington DC, USA
      2. Soon GG et al. Meta-analysis of gender differences in efficacy outcomes for HIV-positive subjects in randomized controlled clinical trials of antiretroviral therapy (2000-2008). AIDS Patient Care STDS 2012;26:444-53.
      3. Cornell et al. Gender Differences in Survival among Adult Patients Starting Antiretroviral Therapy in South Africa: A Multicentre Cohort Study. PloS One 2012;0:e1001304
      4. Maman D et al. Gender differences in immune reconstitution: a multicentric cohort analysis in sub-Saharan Africa. PLoS One 2012;7:e31078.
      5. Thorsteinsson K et al. Impact of gender on the risk of AIDS-defining illnesses and mortality in Danish HIV-1-infected patients: A nationwide cohort study. Scand J Infect Dis 2012;44:766-75.
      6. Floridia M et al. Gender differences in the treatment of HIV infection. Pharmacological research : the official journal of the Italian Pharmacological Society. 2008;58:173-82. Epub 2008/08/19.
      7. d'Arminio Monforte A et al. Better mind the gap: addressing the shortage of HIV-positive women in clinical trials. AIDS 2010;24:1091-4.
      8. Oppong Asante K. Social support and the psychological wellbeing of people living with HIV/AIDS in Ghana. Afr J Psychiatry (Johannesburg) 2012;15:340-5.
      9. Sherr L et al. Gender and mental health aspects of living with HIV disease and its longer-term outcomes for UK heterosexual patients. Women Health 2012;52:214-33.
      10. Bayón C et al. Prevalence of Depressive and Other Central Nervous System Symptoms in HIV-Infected Patients Treated with HAART in Spain. J Int Assoc Physicians AIDS Care (Chic) 2012;11:321-8.
      11. Tran BX et al. Gender differences in quality of life outcomes of HIV/AIDS treatment in the latent feminization of HIV epidemics in Vietnam. AIDS Care 2012;24:1187-96.
      12. Pereira M et al. Gender and age differences in quality of life and the impact of psychopathological symptoms among HIV-infected patients. AIDS Behav 2011;15:1857-69.
      13. Blackstock OJ et al. HIV Providers' Perceptions of and Attitudes Toward Female Versus Male Patients. AIDS Patient Care STDS 2012;26:582-8.
      14. Jiméez J et al. Levels of felt stigma among a group of people with HIV in Puerto Rico. P R Health Sci J 2012;31:64-70.
      15. Logie CH et al. HIV, gender, race, sexual orientation, and sex work: a qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Medicine 2011;8:e1001124.
      16. Puskas CM et al. Women and vulnerability to HAART non-adherence: a literature review of treatment adherence by gender from 2000 to 2011. Curr HIV/AIDS Rep 2011;8:277-87.
      17. Nakimuli-Mpungu E et al. Lifetime depressive disorders and adherence to anti-retroviral therapy in HIV-infected Ugandan adults: A case-control study. J Affect Disord 2012 [Epub]
      18. The Foundation for AIDS research and policy. Available at: http://www.amfar.org/On_the_Hill/Events/amfAR_Meeting_Calls_for_Greater_Focus_on_Sex_Differences_in_HIV/AIDS_Research_and_Policy/
      19. Food and Drug Administration (FDA) Safety and Innovation Act (FDASIA) 2012. Clinical trials reporting by sex, race and ethnicity passes congress. Available at: http://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm131731.htm
    • Involving male partners improves HIV testing during pregnancy

      Whilst it's recognised that male partners play a key role in influencing increased testing and treatment of HIV in women, robust research in the area is lacking.1,2 During the recent AIDS 2012 conference however, a number of studies were presented which highlighted the benefits of including male partners in programs to prevent vertical transmission of HIV. A summary of recent research carried out in the area is presented in this article.

      Introduction

      • Fathers play a key role in various stages and phases of family functioning, from relationship formation to contraception, family planning, pregnancy and support, and parenting3
      • People living with HIV often see having children as an important part of their lives. For men, fertility, status and lineage considerations all contribute to their desire to have a family4
      • WHO Prevention of Mother-to-Child Transmission (PMTCT) strategic vision 2010-2015 highlighted the importance of male partners in PMTCT services (e.g. couples counselling, partner testing)5

      Rationale for Male Partner Involvement

      • Numerous studies have shown that HIV testing and prevention of horizontal and vertical transmission during pregnancy, requires communication and support within the couple6,7
      • A major factor that prevents women in Sub-Saharan Africa from accepting HIV testing is the need to seek consent from their partner8
        • A Ugandan study found that women were almost six times more likely to get tested if they felt their husband would approve9
      • The successful uptake of services designed to prevent vertical transmission in pregnant women is heavily influenced by patient fears, such as: disclosure of HIV status, lack of male partner support, fear of violence or abandonment, and stigmatisation10-12
        • In Sub-Saharan Africa, the position of women in society increases their vulnerability to HIV by restricting their ability to discuss contraception, sexual exclusivity and higher risk sexual behaviours13,14
      • Male partner involvement enhances female experience; improving adherence to antiretrovirals and infant feeding decisions.15 Furthermore, it is important that men themselves are provided with sufficient care and intervention to help respond to HIV infection, treatment access and ensure maintenance of a healthy ongoing life so that they can be available to provide support as a parent.1 Other types of interventions e.g. to prevent intimate partner violence and help improve partner relationships may also be beneficial

      Barriers to Male Partner Involvement

      • Support and care are seen as the female role within the family.16 As a result, female reproductive health is often not considered a male responsibility, thus limiting male involvement in prevention of vertical transmission17
      • Often men work long hours to support their family meaning they have no time to attend clinics with their partner.18 In addition, while clinics are available for those with limited reach and access to services, these are often held at times and locations that may not be easily accessible by users, further limiting the opportunities for male involvement
      • Some healthcare systems discourage men from attending their partner’s consultations and health examinations, meaning they don’t hear information first hand10,19
      • Many women feel embarrassed about raising the issue of sexual health with their partners20

      Increasing Male Partner Involvement

      • To date, the majority of studies aimed at increasing male partner involvement have been based in Africa:
        • In a South African based study by Mohlala et al. it was reported that providing pregnant women with a written invitation for partners to attend HIV counselling and testing led to an increase in male participation in antenatal care21
        • In Tanzania, the ACQUIRE Project has worked since 2008 to improve the involvement of men in antenatal care services in Iringa, the region with the country's highest HIV prevalence (16%). Interventions include partner invitation letters, posters encouraging male attendance, prioritising women accompanied by partners, improving couple counselling rooms, training caregivers on couple counselling for vertical transmission, and engaging villages to develop local strategies. A study which analysed data collected from 354 facilities before and after the introduction of ACQUIRE interventions, found that the number of male partners tested annually for HIV increased from 1,746 at baseline to 22,623 three years later. During this time, 50% of all partners underwent testing, compared with only 7% prior to initiation of the program22
        • The Elizabeth Glaser Pediatric AIDS Foundation initiated a program to train antenatal care providers on the importance of 'male friendly' services and male participation in the prevention of vertical transmission. Following the intervention, testing in the 40 Tanzanian clinics which took part in the scheme rose from 10% to 43% and the proportion of women living with HIV enrolled into care and treatment increased from 22% to 57%. Additionally, the proportion of ARV prophylaxis for HIV-exposed infants rose from 35% to 41% and the proportion of infants tested increased from 28% to 39%23
        • In a study conducted in Uganda, interventions such as distribution of educational DVDs, face-to face meetings and educational dance and drama shows were used to enhance awareness of PMTCT of HIV among men. Following the interventions, there was a 6% increase in the number of male partners who took part in counselling and a 16% increase in the number of men who agreed to be tested24
      • A recent UK-based study, the ‘Healthy Fathers Project’, assessed whether men attending routine antenatal ultrasound screenings would accept opportunistic screening for sexually transmitted infections, with 35% of partners agreeing to be tested25

      Key Points

      • Male partners can play a key role in the health and wellbeing of the family unit. However, economic and cultural factors play a large role in preventing male involvement in female reproductive health
      • Constructive engagement with men, through healthcare professional training, educational programs, counselling and encouraging local strategies, may be effective tools in involving men in the reproductive care of their partner, thus encouraging testing and preventing vertical transmission of HIV

      References

      1. Sherr L. J Int AIDS Soc 2010, 13(2):S4
      2. Kalembo FW et al. Open J Prev Med 2012, 2(1):35-42
      3. Sherr L and Croome N. J Int AIDS Soc 2012, 15(S2):173
      4. Antle BJ et al. Soc Work 2001, 46(2):159-169
      5. WHO. PMTCT strategic vision 2010-2015.February 2010. Available at: http://www.who.int/hiv/pub/mtct/strategic_vision.pdf
      6. Chama CM et al. J ObstetGynaecol 2004, 24:266-269
      7. Baiden F et al. AIDS Care 2005, 17:648-657
      8. Bolu OO et al. Am J Obs Gyn, 2007, S83-S89
      9. Bajunirwe, F & Muzoora, M. AIDS Res Ther 2007, 2:10
      10. Byamugisha R et al. Reprod Health 2010, 7:12
      11. Van Lettow M et al. BMC Public Health 2011, 11:426
      12. Brou H et al. PLoS Med, 2007, 4:12
      13. Gupta GR. BMJ 2002, 324:183-184
      14. Peacock D et al. JAIDS 2009, 51(S3):S119-S125
      15. Msuya SE et al. AIDS Care 2008, 20:700-709
      16. Peacock D. Men as partners: Promoting men’s involvement in care and support activities for people living with HIV/AIDS. United Nations Development Programme (UNDP) Proceedings of Expert Group Meeting on “The Role of Men and Boys in Achieving GenderEquality”, Brasilia, 21-24 October 2003
      17. FHI360. Involving Male Partners in PMTCT and Antenatal Services. Available at: http://www.fhi360.org/en/CountryProfiles/Tanzania/res_Men_in_PMTCT_Services.htm
      18. Aarnio P et al. AIDS, 2010, 12:21
      19. Larsson EC et al. BMC Public Health 2010, 10:769
      20. Pulerwitz J et al. Pub Health Rep 2010, 125:282-292
      21. Mohlala BK et al. AIDS 2011, 31;25(12):1535-1541
      22. Kikumbih N et al. 19th International AIDS Conference, 2012, Washington DC, Abstract THAC0103
      23. Mtambalike TI et al. 19th International AIDS Conference, 2012, Washington DC, Abstract MOPE567
      24. Ugba EA. 19th International AIDS Conference, 2012, Washington DC, Abstract MOPE705
      25. Dhairyawan R et al. Sex Transm Infect 2012; 88(3):184-186
    • Women for Positive Action at the Women’s Networking Zone, XIX International AIDS Conference, Washington DC

      Women for Positive Action was delighted to partner with the Women’s Networking Zone at the XIX International AIDS Conference. The Women’s Networking Zone was a community-built forum held within the Global Village at the International AIDS Conference and was open to the public. The area provided a place where community members, advocates, researchers, service providers, and decision-makers could meet to share experiences, skills, and knowledge to promote optimal outcomes for women living with HIV.

      Members of our international faculty led three interactive workshop sessions providing positive support and recommendations on how women can deal with a selection of challenges faced following a diagnosis of HIV. The faculty presented challenges from both the perspective of a women living with HIV and a healthcare professional, demonstrating the importance of a strong partnership in responding to women’s needs.

      The audience provided very positive feedback on the sessions and engaged in some interesting discussions about their own experiences as a woman either living with HIV or providing support to positive women. Please click below to access the slide presentations from each session.

      Getting the most from the therapeutic relationship with your healthcare professional

      Angelina Namiba (UK) and Lorraine Sherr (UK)

      Turning the tide in the care of women living with HIV
      Angelina Namiba (UK) and Ophelia Haanyama Ørum (Sweden)

      Emotional wellbeing in women living with HIV
      Ophelia Haanyama Ørum (Sweden) and Ulrike Sonnenberg-Schwan (Germany)

      Please also visit our Resource Centre where additional educational slide presentations on the topics discussed at the Women’s Networking Zone are available and information on ongoing projects can be accessed.

    • Turning the tide in the care of women living with HIV: A WFPA satellite symposium at AIDS 2012

      On Monday 23rd July Women for Positive Action held an interactive satellite symposium entitled Turning the tide in the care of women living with HIV, a session focussed on supporting the care and management of women living with HIV throughout their different life stages. The symposium involved panel discussions around the audience response to a series of questions on the clinical management of two women cared for by members of the Women for Positive Action faculty: one younger and one older woman living with HIV.

      Disclosure, pregnancy and ante-natal care, emotional health and cardiovascular and bone fracture risk were some of the many issues discussed. Dr Sharon Walmsley (HIV Physician, Canada) chaired, with case presentations led by Professors Fiona Mulcahy (HIV Physician, Ireland) and Margaret Johnson (HIV Physician, UK). The expert panel providing their diverse views included women living with HIV and HIV clinicians: Adriana Ammassari (HIV Physician, Italy); Ophelia Haanyama Ørum (Community Representative, Sweden); Mona Loutfy (HIV Physician, Canada); Angelina Namiba (Community Representative, UK) and Lorraine Sherr (Psychologist, UK).

      The panel highlighted that a number of factors need to be considered in diagnosing and managing HIV in women. These factors change over the course of her lifespan and should be considered in the context of her life. For further details, please see a synopsis of each case study below and download the PowerPoint presentation and results of the audience voting questions here

      Introduction and welcome – Sharon Walmsley
      Sharon Walmsley opened the symposium, highlighting that the aims of the session were to give insights into practical advice to help improve the lives of women living with HIV in addition to raising awareness of what is known and unknown about specific issues in HIV for women.

      Younger women with HIV: A bright future – Fiona Mulcahy
      Fiona Mulcahy, presented the first case study investigating the challenges facing younger women living with HIV. Mary Anne is a 23 year old migrant from West Africa, who initially attends the clinic for STD screening. She is diagnosed HIV positive (CD4 count of 380/mm3 and viral load of 68,000 copies/ml) and initiated on a HAART regimen. She has psychological symptoms including poor sleeping, panic attacks and mood swings. When asked how they would manage her psychological symptoms, 31% of the audience suggested referring her to a psychologist for further assessment, 28% chose to talk her through her diagnosis and provide suggestions for coping with HIV, while 20% opted to refer her for peer support. In the panel discussion, HIV psychologist Lorraine Sherr explained that women in this situation need support to cope with their diagnosis and are good candidates for further psychological investigation in addition to peer support. Angelina Namiba, HIV peer support expert, stressed that giving the woman the option to discuss her situation with peers who have had similar experiences helps provide reassurance and practical support.

      Mary Anne is not ready to contemplate having children and 60% of the audience recommended condoms as the best contraceptive option for someone in her situation. Mona Loutfy, expert on HIV pregnancy planning, stressed that family planning is a very important conversation between a woman and her physician and should take into account the individual woman’s situation and specific life stage as well as potential interactions with HAART treatment. Mona routinely recommends dual contraception including condom and a hormonal-based method, as while condoms are very effective at preventing transmission of HIV and other STIs they are only 85% effective at preventing pregnancy.

      Nine months later, Mary Anne has disclosed her HIV status to her partner, who is supportive, and the couple now decide that they would like to start a family. The audience were asked to provide their opinion on a selection of conception methods. Fiona confirmed that unprotected sexual intercourse around the time of ovulation was the option used in this case, and is commonly used in Ireland and the UK. While Mona discusses all the options with her patients, in Canada self-insemination is the recommended method as this is the only route with zero transmission. However, patients often opt for one of the other methods and the panel agreed that it is an individual-based approach taking into account each woman’s unique situation.

      Mary Anne went on to have a successful pregnancy. She continues taking her HIV medication and her emotional wellbeing is being monitored on an ongoing basis. Click here for further information on this case study.

      A new age for women with HIV: Living life and growing older – Margaret Johnson
      Margaret Johnson presented the case of A.N., a 52 year old woman divorced with 2 children, who was admitted to hospital with non-specific interstitial pneumonitis and was eventually diagnosed HIV positive. Following a case review Margaret’s team established that there had been several missed opportunities for diagnosis at times when A.N. presented to her primary care physician over the previous years.

      Given the history of missed opportunities, the panel agreed that it is important to consider HIV in those individuals who do not belong to, or are not perceived as being in traditional HIV risk groups. In fact, rates of late diagnosis in the UK are high, and approximately 51% of heterosexual women over 50 years old are diagnosed late in the course of HIV infection.

      Margaret asked the audience where they thought that HIV testing should be prioritised. As HIV-positive women, Ophelia Haanyama Ørum and Angelina discussed that if home testing came with the assurance that services could be accessed immediately then it may be more useful. However they would not favour this option for a woman such as A.N., who does have a support network in place and could be put in a very vulnerable, stressful and frightening position on discovering her status alone. The panel agreed that testing in the other situations suggested are all priorities if progress is to be made in diagnosing more women earlier in the course of their HIV.

      Margaret went on to highlight that it is important to monitor for a range of co-morbidities in those who have HIV and are growing older. These include cardiovascular disease, renal function, cancer, bone mineral density and neurocognitive function. The audience agreed that in terms of optimal next steps in care for the present case she should undergo emotional wellbeing assessment (39%) followed by screening for co-morbidities. Lorraine Sherr recommended a stepwise approach to emotional care using peer support and cognitive behavioural therapy. This may help the woman respond to side effects of both treatment and HIV, which we know can have a negative impact on emotions.

      Dual energy x-ray absorptiometry (DEXA) results revealed that A.N. needed treatment for osteoporosis. Based on the audience vote, 46% would prescribe calcium, vitamin D and a bis-phosphonate; 36% would prescribe calcium and vitamin D; 7% change her ART regimen; 9% would encourage an exercise routine and 2% would not do any of the above. The panel agreed that an exercise routine should be encouraged at all stages of care. In this case Adriana Ammassari would refer A.N. to a rheumatologist but in general she would recommend screening earlier for vitamin D status and integrating treatment as appropriate.

      A.N. went on to complete a course of cognitive behavioural therapy and is now attending a support group. She has disclosed to her ex-husband and children, but disclosure to colleagues and other family and friends is an ongoing process. She is being monitored on an continual basis for development of co-morbidities. Please assess further information on this case study here

    • Trans-Sylvanian International Women’s Meeting , Romania, January 2012

      Women for Positive Action faculty members Dr Sharon Walmsley and Professor Margaret Johnson delivered presentations at the Trans-Sylvanian International Women’s Meeting that took place in Romania in January 2012. The meeting discussed the clinical challenges facing women living with HIV and examined how their needs differ in the UK and across Eastern Europe.

      Margaret Johnson’s presentation ‘Management of HIV Infection in Women reviews the treatment options and issues affecting women living with HIV in the UK. Sharon Walmsley’s presentation Prevention, fertility, contraception and pregnancy’  explores the specific needs of women living with HIV using a clinical case study to illustrate best practice.

    • Press Release March 8, 2012 Practical tool to support women living with HIV who face stigma and discrimination

      To mark International Women’s Day (IWD) (March 8, 2012), Women for Positive Action has launched a practical and educational tool to empower women living with HIV to deal with the challenges of stigma and discrimination.
      Women for Positive Action is a coalition of healthcare professionals, community representatives and women living with HIV from across Europe, Canada and Latin America. This stigma and discrimination resource has been designed for use in both the community and clinical settings and is available now for download here

      Research shows that women are more likely to be affected by HIV-related stigma and discrimination compared with men1, which may lead to depression, poor medication adherence and risky behaviour2. “The isolation caused by stigma and discrimination relating to HIV can have significant implications for a woman’s physical and emotional health” explains Dr Adriana Ammassari, Clinical Researcher in Infectious Diseases at the National Institute for Infectious Diseases, Italy “The theme of IWD 2012 is ‘Connecting Girls, and Inspiring Futures’ - by developing this tool we hope that we can help women to access the right support and care to achieve better outcomes for themselves and their families.”

      In addition to providing examples of the ways in which women living with HIV can be supported to combat stigma and discrimination this tool also discusses disclosure of HIV status and suggests ways to support women who wish to take this step. “Disclosure of HIV status can have positive benefits for an individual, their family and the community by reducing depression and anxiety and encouraging access to HIV support and care services. However, disclosure is not a decision which should be taken lightly. It is a process which should only be undertaken when the woman feels fully supported and when it becomes appropriate at the various stages of life.” Annette Piecha member of the German Therapy Activists Network DCAB HIV and the European AIDS Treatment Group explains.

      Women for Positive Action is committed to exploring and addressing the issues faced by women living with HIV and those involved in their care. For more information visit the website www.womenforpositiveaction.org.

      - ENDS -

      Note to Editors

      It is estimated that around 3,000 women and girls contract HIV each day, and the latest global estimate of women living with HIV (WLWH) in 2009 was approximately 17 million3. Women make up about 50% of HIV cases and a higher proportion of new diagnoses compared with men. This means that the share of HIV infection among women is increasing in several countries. Young women in sub-Saharan Africa, aged 15-24, are eight times more likely than men to be diagnosed with HIV3. The most common mode of infection is by heterosexual transmission and most women living with HIV are of childbearing age. Furthermore, women with HIV are more likely to present at a later stage of HIV infection than men. Visit www.womenforpositiveaction.org for further information about Women for Positive Action and ongoing projects. Women for Positive Action is supported by a grant from Abbott.

      References

      1. Zhang Y et al. (2009) Gender and Ethnicity Differences in HIV-related Stigma. Presented at the 1st International Workshop on HIV & Women, Washington DC, 2011. Abstract P_28
      2. Whetten K et al. Trauma, mental health, distrust and stigma among HIV-positive persons: Implications for effective care. Psychosom Med 2008;70:531-8
      3. UNAIDS. (2010). UNAIDS report on the global AIDS epidemic. Retrieved from http://www.unaids.org/globalreport/documents/20101123_GlobalReport_full_en.pdf

      For further information please contact the Women for Positive Action secretariat:

      Email: WFPA@litmus-mme.com
      Tel: +44 (0)20 7632 1969
      Address: Women for Positive Action, Program Secretariat, Litmus MME, 151 Shaftesbury Avenue, London WC2H 8AL, United Kingdom

    • Prevention strategies for the sexual transmission of HIV: A focus on women

      Teresa Branco, Margaret Johnson, Karine Lacombe, Anne-Mette Lebech, Mona Loutfy, Angelina Namiba, Maria Jesús Pérez Elías and Sharon Walmsley on behalf of Women for Positive Action.

      Women are one of the fastest growing population groups at risk for HIV infection, however research among this group is limited. Women for Positive Action aims to highlight the need for enhanced inclusion of women’s needs into HIV research and care.

      A number of recent and ongoing studies are focussed on investigating the challenges facing women living with HIV and the healthcare professionals involved in their care, as well as women who have a partner with HIV. The Women for Positive Action faculty feel that this research is of importance to all those involved in the care of women living with HIV and have summarised findings from these studies, in addition to providing their perspective of the impact of these findings.

      Antiretroviral treatment to prevent the sexual transmission of HIV: Findings from the HPTN 052 study

      Topical pre-exposure prophylaxis (PrEP) for prevention of HIV transmission

      Oral pre-exposure prophylaxis (PrEP) for prevention of HIV transmission

      Use of hormonal contraceptives and risk of HIV transmission

      Sexual transmission of HIV: Questions for consideration

       

      Antiretroviral treatment to prevent the sexual transmission of HIV: Findings from the HPTN 052 study

      The HPTN 052 study1 investigated if the risk of transmitting HIV to sexual partners can be reduced through the earlier initiation of oral antiretroviral therapy. The study assessed HIV transmission in 1,763 serodiscordant couples (one partner HIV positive, the other one negative) across 13 sites in nine countries. HIV-positive partners with CD4 cell counts of 350-550/mm3 were randomised to receive either immediate antiretroviral therapy or delayed therapy (defined as CD4 count declining to <250/mm3 or development of an AIDS-defining illness). Half of the HIV-positive participants were women.

      Over the follow-up period (median 1.7 years), there were 28 linked transmissions to the HIV-negative partner in those who delayed therapy compared to one transmission in the group who started antiretroviral therapy immediately. This represented a highly statistically significant reduction in the risk of transmission of 96% (p<0.001). The majority of transmissions (60%) were estimated to have occurred when the partner with HIV had a higher CD4 cell count (>350/mm3).

      Statistical analysis showed that a higher viral load at the beginning of the study was the strongest predictor of transmission in both groups (those who delayed therapy and those who began treatment immediately). Furthermore, study participants who stated that they used condoms consistently were reported to be at a reduced risk for HIV transmission.

      Couples who reported 100% condom use at study entry had a 67% lower risk of HIV transmission than couples who reported less than 100% condom use. However, the study findings show that the protective effect of antiretroviral therapy was independent of condom use.

      Women for Positive Action comment
      This study has important implications for the prevention of HIV transmission and for the counselling of HIV serodiscordant couples on the risk of sexual transmission of HIV. If one partner is HIV-positive, early initiation of therapy should be considered, not only to stabilise their own health but to prevent transmission to their partner. This appears to be particularly important with higher viral loads in the HIV-positive partner. In this study, only one transmission occurred in the early treatment group, and that one transmission occurred after 3 months of the HIV-positive partner having started antiretroviral therapy, again, highlighting the very low risk of HIV transmission when the HIV-positive partner is taking combination antiretroviral therapy.

       

      Topical pre-exposure prophylaxis (PrEP) for prevention of HIV transmission

      The topical administration of antiretroviral drugs for pre-exposure prophylaxis (PrEP) (where antiretroviral drugs are used to reduce the likelihood of contracting HIV by protecting an individual prior to possible HIV exposure) has been a key area for research recently and to date there are a number of studies ongoing.

      Initial research into the use of microbicide-containing antiretrovirals looked at 1% tenofovir gel in human cervical tissue samples, and provided pre-clinical support for the effectiveness of topical antiretroviral therapies against HIV infection.2 However, in early human studies the first generation of topical microbicides using gel formulations showed either no benefit or an increased risk of infection in women. This may have been related to irritation to the genital mucosa.

      The Centre for the AIDS Program of Research in South Africa (CAPRISA) 004 trial3, published in 2010, studied the effectiveness and safety of 1% tenofovir gel for the prevention of HIV infection in South African women. CAPRISA was the first study to demonstrate a positive effect on HIV transmission. When used intravaginally both before and after sex, 1% tenofovir gel reduced the incidence of HIV infection among women by 39% overall and by up to 54% in highly adherent subjects (i.e. those with >80% adherence). Approximately a 51% reduction in herpes simplex virus type 2 (HSV-2) was also observed. Despite an adherence support program and high gel acceptability, about 40% of the women in this study had <50% gel adherence, with declining rates of adherence observed over the course of the study.

      The VOICE (Vaginal and Oral Interventions to Control the Epidemic) study (also known as MTN-003)4 is an ongoing, safety and effectiveness study comparing daily use of 1% tenofovir gel, oral tenofovir and oral emtricitabine/tenofovir for the prevention of HIV infection in women. The study, which began in September 2009, has enrolled 5,029 sexually active HIV-negative women at sites in Zimbabwe, Uganda and South Africa. In September 2011 the tenofovir arm of the study was terminated by the Data and Safety Monitoring Board because it had already answered the research question that oral tenofovir tablets were no more effective in preventing HIV than placebo tablets. In November 2011 the study group using the 1% tenofovir gel daily was discontinued as the gel was shown to be no more effective than placebo. The study arm containing oral emtricitabine/tenofovir will continue and results are expected by 2013.

      The Follow-on African Consortium for Tenofovir Studies 001 (FACTS 001) trial is another study in the field, which has recently began recruitment. This is a large scale, placebo-controlled trial to test the safety and effectiveness of vaginal tenofovir gel used before and after sex to protect women against HIV infection and also against HSV-2. The FACTS 002 study is designed to test the safety and acceptability of tenofovir gel in 16- and 17-year-old South African women. Implementation of the strategy of PrEP in the clinical setting will be dependent upon the results of ongoing clinical trials. However, with regard to assessing the feasibility and effectiveness of providing tenofovir gel in a clinic setting, the three-year CAPRISA 008 study, which follows on from CAPRISA 004, will begin to provide information about implementation, demonstrating how the gel can be provided and monitored as part of family planning services.

      Looking to the future, new microbicides are already in development. Dapivirine, an NNRTI, is in Phase I or I/II development in Europe and Africa either alone or in combination with the CCR5 antagonist maraviroc, in gel or vaginal ring form. Other antiretrovirals such as integrase inhibitors have been used in exploratory studies and raltegravir has been shown to prevent vaginal transmission of simian HIV (found in monkeys) even when applied three hours after viral exposure in macaques, which could mean that microbicides could also be used as post exposure prophylaxis.

      Women for Positive Action comment
      As a PrEP strategy, topical administration of antiretrovirals is an attractive option. Higher genital or rectal epithelium levels of the drug and potentially less toxicity associated with low systemic absorption are some of the possible advantages of the method. Furthermore, as the method depends on women using it themselves this may also lead to enhanced uptake. However, implementation of this strategy awaits the findings from a number of ongoing studies and will need to take into account the nature of the epidemic and other prevention methods such as behavioural interventions.

      The CAPRISA 004 study has demonstrated the use of topical PrEP as an effective means of reducing transmission of HIV infection to women. However, the results need to be explored further at different dosage and delivery methods. They would also have to be adapted to consider diverse populations and sexual habits. Further data is needed on efficacy and safety in younger women, in pregnancy and breastfeeding, and in other settings. In the long term, toxicities and social and behavioural changes may follow. Hopefully, some of these knowledge gaps will be answered by ongoing studies including the FACTS 1 and 2 studies.

      Newer microbides delivered in longer acting formulations are under investigation and may improve on effectiveness, but again further data are necessary. PrEP strategies will also have to be balanced against recent ‘test and treat’ approaches to prevention of transmission but are certainly an important part of the fight against HIV infection.

       

      Oral pre-exposure prophylaxis (PrEP) for prevention of HIV transmission

      Recent research has focussed on the role of antiretrovirals as a preventive option for transmission of HIV; both as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP). In animal models, both tenofovir and emtricitabine were shown to be protective when animals were challenged with HIV virus and a combination of drugs may lead to increased protection.5

      Based on animal models5-8, and observational studies9, the Centers for Disease Control and Prevention (CDC) developed HIV prevention guidelines for occupational, non-occupational and high-risk exposure to HIV.10,11 One of the limitations of PEP is that efficacy is based upon the proximity between contact with the HIV virus and starting treatment. To date a number of studies have investigated the effectiveness of oral PrEP.

      It has been reported that PrEP is effective for slowing the spread of HIV in men who have sex with men however studies in women are limited. A phase II trial of tenofovir for PrEP among women in Ghana, Cameroon and Nigeria indicated, that the approach was safe, but could not assess the effectiveness due to the small number of infections seen during the study which was prematurely halted.12 The FEM-PrEP study of oral PrEP in women compared a once-daily dose of oral emtricitabine/tenofovir with placebo. The study was conducted at four sites across Africa where a high prevalence of HIV was reported.13 FEM-PrEP was prematurely stopped when the Independent Data Monitoring Committee advised that the study would be unable to demonstrate effectiveness of emtricitabine/tenofovir in preventing HIV infection. As of the 18 February 2011 the study had enrolled 1,951 participants and a total of 56 new infections were reported (equal numbers in both arms). Family Health International (FHI) which was responsible for implementation of the FEM-PrEP clinical trial along with research groups in Africa, decided to initiate orderly closure of the study.14 Thus, collection of primary end-point data continued to August 2011 with the final analysis scheduled for the end of 2011.

      The VOICE (Vaginal and Oral Interventions to Control the Epidemic) study4 is comparing daily use of oral emtricitabine/tenofovir, oral tenofovir and 1% tenofovir-based vaginal gel for safety and effectiveness in preventing male to female HIV transmission. The study outcome raises some important issues regarding drug availability in the vagina and rectum after oral dosing and ancillary studies to explain these differences are urgently needed. To date the study groups receiving oral tenofovir and tenofovir gel have been discontinued as these treatments have been shown to be no more effective than placebo. Results from the study group receiving oral emtricitabine/tenofovir are expected in 2013.

      The Partners PrEP study, evaluated transmission-prevention in HIV-serodiscordant couples.15 In this study of 4,747 couples in Uganda and Kenya, the HIV-negative partners were randomised to receive tenofovir alone, emtricitabine/tenofovir, or placebo as daily oral PrEP. Results showed that PrEP substantially decreased the risk of transmission to both men and women compared with placebo, whether tenofovir was used alone (62% decrease; p=0.003) or with emtricitabine (73% decrease; p<0.0001).

      Another study, TDF2, was conducted in heterosexually active young adults in Botswana.16 A total of 1,219 individuals, aged 18 to 39 years, were randomised to receive daily oral emtricitabine/tenofovir or a matched placebo. All individuals received monthly HIV testing, and those who tested positive went on to receive counselling and treatment. Individuals who tested HIV negative were given their next month’s supply of emtricitabine/tenofovir and continued in the study. Significantly fewer HIV infections were observed in the active PrEP arm; 9 vs 24 in the placebo arm, which resulted in a 62.6% (p=0.0133) efficacy rate for emtricitabine/tenofovir.

      Women for Positive Action comment
      There are a number of limitations for the use of oral PrEP including lack of complete and consistent efficacy in all settings and short/long-term toxicity and cost may present challenges. Furthermore PrEP offers protection against HIV but not against other sexually transmitted diseases.

      PrEP has the potential to contribute to effective and safe HIV prevention if

      1. it is targeted to a population at high risk of HIV
      2. it is delivered as part of a comprehensive set of prevention services, including risk-reduction and PrEP medication adherence counselling, ready access to condoms, and diagnosis and treatment of sexually transmitted infections; and
      3. it is accompanied by monitoring of HIV status, side effects, adherence, and risk behaviours at regular intervals.

       

      Use of hormonal contraceptives and risk of HIV transmission

      Heffron et al. recently reported the results of a study assessing the association between hormonal contraceptive use and risk of contracting HIV-1 in women and HIV-1 transmission from HIV-1 positive women to their male partners.17 The 3,790 serodiscordant couples (i.e. one partner with HIV-1 infection and one partner without) were recruited either as part of the Partners in Prevention cohort or for the Couples Observational Study - two large prospective cohort studies in HIV-1 carried out across seven African countries.

      In two-thirds of couples the woman was HIV-positive, and in the other third, the man was HIV-positive. The partners with HIV had no history of AIDS-defining disorders, had CD4 counts of <250 cells/mm3 and were not using antiretroviral therapy. Rates of HIV-1 acquisition by women and HIV-1 transmission from women to men were compared among injectable and oral hormonal contraceptive users and non-users. The primary outcome measure was development of antibodies to HIV-1 (seroconversion).

      Results showed that during the course of the study, hormonal, injectable or oral contraception was used at least once by 21%, 16% and 7% of women without HIV respectively. Among the 1,314 couples in which the HIV-negative partner was female, rates of HIV-1 transmission were 6.61 per 100 person-years in women who used hormonal contraception and 3.78 per 100 person-years in those who did not (p=0.03). Among 2,476 couples in which the HIV-negative partner was male, rates of HIV-1 transmission from women to men were 2.61 per 100 person-years in couples in which women used hormonal contraception and 1.51 per 100 person-years in couples in which women did not use hormonal contraception (p=0.02).

      After adjusting for confounding factors (such as age and viral loads), women using any hormonal method had twice the risk of acquiring HIV as other women. This statistical analysis also reported that men whose HIV-positive partners used any form of hormonal contraceptive had twice the risk of contracting HIV as other men. Findings were particularly driven by injectable hormone contraception.

      Women for Positive Action comment
      The results of this analysis are crucial for women living with and at risk of HIV. Women should be counselled about potentially increased risk of contracting HIV-1 and transmission of HIV with hormonal contraception, especially injectable methods. However, this group is also highly susceptible to high rates of unintended pregnancies, thus family planning and contraception is also essential. Therefore, rather than abandoning hormone contraception, dual protection with condoms to decrease HIV-1 risk is essential to stress during reproductive counselling. Furthermore, condoms provide additional protection against HIV-1 and other sexually transmitted infections. This is particularly relevant in the African setting since injectable hormonal contraception is often the most practical mode of family planning. Finally, it is important to recall that all patients in this study were co-infected with herpes simplex virus type 2 and the implications of this co-infection on transmission should be considered.

       

      Sexual transmission of HIV: Questions for consideration

      If a person living with HIV assumes that having an undetectable viral load means they are unlikely to transmit the virus and so have unprotected sex, who is responsible if transmission occurs?

      Engaging in a sexual relationship is a matter of shared responsibility. The decision to not use condoms based on the results of research studies and advice given by healthcare professionals must be discussed with both partners during reproductive counselling and a mutual decision taken. To help a couple make an informed choice healthcare professionals must also provide up to date information from recent published research studies in a way that can be clearly understood by patients, in addition the importance of adherence to therapy for preventing transmission should be highlighted. If all those conditions are fulfilled, it is difficult to blame either partner if transmission occurs. However, in the case of multiple partnerships it should be considered that transmission may occur with another sexual partner than the “official” positive partner.

      If a person living with HIV assumes that having an undetectable viral load means they are unlikely to transmit the virus, then how often should their viral load be monitored to ensure that their partner is not at risk?

      All patients are statistically at risk of experiencing viral blips, which renders the significance of a transient positive viral load difficult to interpret, in terms of risk of transmission. We could reasonably assume from the Swiss Statement that a partner with HIV and an undetectable viral load for more than 2 or 3 years has a level of viral reservoir excretion sufficiently low and even virtually nonexistent. If adherence is optimal and viral load controlled for some years, it is not necessary to shorten the recommended delay for viral load check i.e. 3 to 6 months.

      Considering the results of the Partners trial, showing an increased risk of HIV transmission from both women to men and men to women, should hormonal contraception (and especially injecting contraception) be avoided and replaced by mechanical contraception?

      It is commonly recognised that injectable contraceptives (e.g. subcutaneous) delivering progestogen, increase the risk of hypermenorrhea, and therefore the risk of contracting HIV or transmitting HIV through infected blood. Oral contraception may be a suitable alternative option in cases of hypermenorrhea, but in all cases, dual contraception (use of both condoms and hormonal contraception) should be advised. During reproductive counselling it should be stressed that hormonal contraception should not be abandoned as it is one of the most effective methods for the avoidance of unwanted pregnancies, and it is the only method that can be chosen by women alone.

       

      References

      1. Cohen M et al. Antiretroviral treatment to prevent the sexual transmission of HIV-1: results from the HPTN 052 multinational randomized controlled ART. 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention; July 17-20, 2011; Rome, Italy. Abstract MOAX0102, 2011.
      2. Rohan LC et al. In vitro and ex vivo testing of Tenofovir shows it is effective as an HIV-1 microbicide. PLoS One 2010;5(2):e9310.
      3. Abdool Karim Q et al; CAPRISA 004 Trial Group. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 2010;329(5996):1168-74.
      4. VOICE (MTN-003). Available from: http://www.mtnstopshiv.org/news/studies/mtn003. Last accessed November 2011.
      5. García-Lerma JG et al. Prevention of rectal SHIV transmission in macaques by daily or intermittent prophylaxis with emtricitabine and tenofovir. PLoS Med 2008;5(2):e28.
      6. Tsai C-C et al. Prevention of SIV infection in macaques by (R)-9-(2-phosphonylmethoxypropyl) adenine. Science1995;270(5239):1197-99.
      7. Shih C-C et al. Postexposure prophylaxis with zidovudine suppresses human immunodeficiency virus type 1 infection in SCID-hu mice in a time-dependent manner. J Infect Dis 1991;163(3):625-27.
      8. Van Rompay KK et al. Simian immunodeficiency virus (SIV) infection of infant rhesus macaques as a model to test antiretroviral drug prophylaxis and therapy: oral 3'-azido-3'-deoxythymidine prevents SIV infection. Antimicrob Agents Chemother 1992;36(11):2381-86.
      9. Cardo DM et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med 1997;337(21):1485-90.
      10. Panlilio AL et al. Updated US public health service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. Morb Mortal Wkly Rep 2005;54:1-17.
      11. Smith DK et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the US department of health and human services. MMWR Recomm Rep 2005;54:1-20.
      12. Peterson L et al. Tenofovir disoproxil fumarate for prevention of HIV infection in women: a Phase 2, double-blind, randomized, placebo-controlled trial. PLoS Clin. Trials 2007;2(5):e27.
      13. NIAID: The FEM-PrEP HIV prevention study and its implications for NIAID research (2011) www.niaid.nih.gov/news/newsreleases/2011/Pages/FEMPrEP.aspx. Last accessed November 2011.
      14. FHI. FHI to initiate orderly closure of FEM-PrEP www.fhi.org/en/Research/Projects/FEM-PrEP.htm. Last accessed November 2011.
      15. Baeten J & Celum C. Antiretroviral pre-exposure prophylaxis for HIV-1 prevention among heterosexual African men and women: the Partners PrEP Study. Program and abstracts of the 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention; July 17-20, 2011; Rome, Italy. Abstract MOAX0106.
      16. Thigpen MC et al. Daily oral antiretroviral use for the prevention of HIV infection in heterosexually active young adults in Botswana: results from the TDF2 study. 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention; July 17-20, 2011; Rome, Italy. Abstract WELBC01.
      17. Heffron R et al; for the Partners in Prevention HSV/HIV Transmission Study Team. Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study. Lancet Infect Dis 2011 [Epub ahead of print].
    • World AIDS Day Press Release December 1, 2011

      Women for Positive Action discuss the impact of recent research on the sexual transmission of HIV in women
      To mark World AIDS Day (December 1, 2011), Women for Positive Action has released a commentary which discusses recent and ongoing research on prevention strategies for the sexual transmission of HIV. With expert opinion from Teresa Branco, Margaret Johnson, Karine Lacombe, Anne-Mette Lebech, Mona Loutfy, Angelina Namiba, Maria Jesús Pérez Elías and Sharon Walmsley, the article is focused on the potential clinical relevance of these studies. Women for Positive Action is led by a coalition of healthcare professionals, women living with HIV and community representatives from across Europe, Canada and Latin America. The group is committed to exploring the issues that face women with HIV and those involved in their care. The full article can be accessed at http://www.womenforpositiveaction.org/prevention-strategies-for-the-sexual-transmission-of-HIV/

      “Women are one of the fastest growing population groups at risk for HIV infection but research among this group is limited. Recent research has focussed on reducing sexual transmission of HIV; these studies are of particular interest for those involved in the care of women at risk of HIV e.g. women with an HIV-positive partner. It is important that we highlight this research and encourage additional studies to address the many challenges facing women at risk of HIV” said Dr Mona Loutfy, Associate Professor at the University of Toronto, and Infectious Diseases Specialist and Clinician Scientist at Women’s College Hospital, Toronto, Canada.

      Women for Positive Action is committed to raising awareness of the need to bridge the existing research gaps with the ultimate goal of improving the lives of women living with HIV.

      ---- ENDS ----

      Note to Editors
      Globally an estimated 33 million people are living with HIV. Women make up about 50% of HIV cases and a higher proportion of new diagnoses compared with men. This means that the share of HIV infection among women is increasing in several countries. Young women, in sub-Saharan Africa, aged 15-24 are three to four times more likely to become infected than young men (UNAIDS, 2009). The most common mode of infection is by heterosexual transmission and most women with HIV are of childbearing potential. Furthermore, women with HIV are more likely to present at a later stage of HIV infection than men.

      Although women represent 50% of people living with HIV globally and are one of the fastest growing population groups at risk for HIV infection, relatively little research has looked at women-specific issues, and women only account for about 20% of participants in clinical trials of HIV to date. As part of its mission Women for Positive Action aims to raise awareness around recent and ongoing studies that focus on women. Visit the multilingual website http://www.womenforpositiveaction.org for further information about Women for Positive Action and ongoing projects. Women for Positive Action is supported by a grant from Abbott.

      References
      UNAIDS 2009, http://www.unaids.org/en/default.asp

      For further information please contact the Women for Positive Action secretariat:

      Email: WFPA@litmus-mme.com
      Tel: +44 (0)20 7632 1969
      Address: Women for Positive Action, Program Secretariat, Litmus MME, 151 Shaftesbury Avenue, London WC2H 8AL, United Kingdom

    • East Meets West: Management of Women Living with HIV

      Women for Positive Action at the 13th European AIDS Conference, Belgrade, October 12-15, 2011

      Women for Positive Action was invited to participate in a mini-lecture at the European AIDS Conference in Belgrade as part of the session ‘When people living with HIV grow up to become adults or want children’. Speaking on behalf of the faculty, Dr Teresa Branco (Portugal) and Dr Mariana Mărdărescu (Romania) presented an overview of the challenges facing women living with HIV who wish to start a family, specifically focussing on differences across Europe.

      The epidemiology across the European region was discussed, highlighting that while the number of new diagnoses in western and central Europe is stabilising, it is still rising in eastern Europe. Dr Branco confirmed that in Portugal approximately 26% of the 40,235 people living with HIV are women and 1,156 of these were diagnosed during pregnancy. The principal modes of transmission in Portugal are heterosexual intercourse and intravenous drug use. Dr Mărdărescu highlighted that in Romania those children who contracted HIV during the late 1980s are now in early adulthood, many of whom are in stable relationships, often with an HIV-negative partner and now wish to start a family. In Romania, the main mode of HIV transmission is also through heterosexual intercourse and in 2010 there were a total of 10,405 people living with HIV/AIDS.

      For those living with HIV who wish to start a family the key assisted fertility techniques available include intrauterine insemination (IUI), in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) following sperm washing. Availability of these assisted fertility services varies largely across Europe irrespective of east, west, north and south, and access to these services mainly depends on whether they are privately or publically funded. The information on the access to these services is limited and is included in few regional or national guidelines. Furthermore, adoption is either not available for couples where one partner is HIV-positive or can be very challenging. The importance of reproductive discussions for the care of women with HIV as well as involving both partners in discussions and providing information and education was identified as a priority in the care of those with HIV who are wishing to start a family.

      Dr Mărdărescu also presented a UK-based case study ‘From pregnancy to baby and beyond’ as an example of a strategy that could be implemented in other countries to help support those who want to start a family, who are pregnant or who have already given birth. Based on a programme previously run in sub-Saharan Africa, the programme is based on training “Mentor Mothers” to offer peer support to women living with HIV to provide education, information and emotional support in all aspects of conception, antenatal and postnatal care. Please visit the Positively UK website for further information on ‘From pregnancy to baby and beyond’.

      Other aspects of the care for women living with HIV, such as the management of complications during pregnancy and mother-to-child-transmission were also explored in this session.

      Please click here to download the Women for Positive Action mini-lecture presentation.

    • Women for Positive Action at the XVIII International AIDS Conference, Vienna

      Women for Positive Action was delighted to participate in activities at the XVIII International AIDS Conference, Vienna, 18–23 July, 2010

      Building the leadership capacity of positive women through networks
      ICW women's network symposium
      Women for Positive Action collaborated with women's networks from across the globe as part of a symposium held by the International Community of Women Living with HIV/AIDS (ICW). The symposium aimed to highlight the importance of women's networks working together to enhance the lives of women living with HIV.

      Speaking alongside representatives from Latin America, USA, Asia-Pacific and Africa, Angelina Namiba spoke about her personal experiences as part of European networks, including Women for Positive Action and WECARe+. 'Each Women's Network requires a clear vision and goals to enable them to evolve and work towards a common goal' highlighted Angelina 'For example, Women for Positive Action, which is led by a faculty of women living with HIV, healthcare professionals, and community representatives from Europe, Canada and Latin America aims to support both healthcare professionals and women living with HIV through the provision of resources.'

      All groups who participated in the symposium are committed to ensuring that women living with HIV are meaningfully involved in the formation, implementation, monitoring and evaluation of programs that impact their lives. This symposium offered an opportunity to raise awareness of the importance of ongoing support and work in this arena.

      Women's Networking Zone reception
      Women for Positive Action sponsored the Women's Networking Zone (WNZ) reception which was attended by over 150 people. During the reception Angelina Namiba and Ulrike Sonnenberg-Schwan thanked the organisers, on behalf of Women for Positive Action, for providing such an informative area for attendees.

      The WNZ was a community built forum within the International AIDS Conference open to the public - providing a place where community members, advocates, researchers, service providers, and decision-makers could meet, share, and learn together.

      Please visit the resource centre to download educational slide resources, available in English and Spanish. To access information about ongoing projects please visit the initiative page.

    • Criminalization of women living with HIV

      News article
      In some countries, criminal laws have been put in place to prosecute those who transmit or expose others to HIV infection. While these laws have been developed primarily for protection, there are concerns that they may in fact be counterproductive and undermine public health and human rights, particularly for women.
      A publication by the International Planned Parenthood Foundation, 'Verdict on a Virus', concludes that laws criminalizing HIV transmission may do more harm than good, especially for women and result in disproportionate number of women being prosecuted for HIV transmission or exposure.
      It is often the woman in a relationship who is first to find out about her HIV-status, and such laws would place the responsibility on her for disclosing her status to her partner. Such disclosure may put her at risk of violence and/or abandonment. Depending on the nature of her relationship, women may find it difficult to negotiate safer sex, making her more vulnerable to prosecution due to unintentional transmission. There are also fears that such broad criminal laws could result in women being prosecuted for transmitting HIV to a child during pregnancy or breastfeeding.
      Organizations such as UNAIDS are urging governments to limit criminalization to cases of intentional transmission, i.e. where a person knows his or her HIV positive status, acts with the intention to transmit HIV, and does in fact transmit it.
      Following an international consultation UNAIDS published a policy brief on the criminalization of HIV transmission in July 2008. They raised the concern that going beyond the 'intentional transmission' cases described above, may result in criminal sanctions being applied to people who are not deserve blame, which will further stigmatize people living with HIV and is likely to drive them further away from HIV prevention, treatment, care and support services.

      References:
      International Planned Parenthood Federation. Verdict on a Virus: Public Health, Human Rights and Criminal Law (November 2008) (http://www.ippf.org/en/Resources/Guides-toolkits/Verdict+on+a+virus.htm)
      UNAIDS/UNDP Policy brief - Criminalization of HIV Transmission (August 2008) (http://www.unaids.org/en/PolicyAndPractice/HumanRights/humanrights_criminalization.asp).

    • Routine male circumcision to reduce the spread of HIV?

      News article
      The United States Centers for Disease Control and Prevention (CDC) are considering recommendations for promoting routine circumcision for all baby boys born in the United States to reduce the spread of HIV. 
      Clinical trials undertaken in some African countries, such as Uganda, Kenya and South Africa, have shown that adult heterosexual males who are circumcised have up to 60% reduced risk of contracting HIV from a HIV positive woman.
      While every intervention that can potentially reduce HIV transmission should be investigated, in the case of male circumcision it has not been shown to offer women any protection from acquiring HIV. A study undertaken in Uganda investigated whether circumcision of HIV-infected men would reduce transmission of the virus to female sexual partners. Men were randomly assigned by to receive either immediate circumcision or circumcision delayed for 24 months (the control group). The HIV-negative female partners of the men were assessed at 6, 12, and 24 months to determine if they had contracted HIV. The trial was stopped early as it became apparent that circumcision of HIV-infected men was notable to reduce HIV transmission to their female partners.
      If the proposals in the US go ahead, circumcision may be recommended for infant boys in addition to adult males whose sexual practices put them at high risk of HIV infection.  While circumcision appears to offer some level of protection to men in certain settings, it only reduces the risk of HIV infection, it does not prevent it. Most importantly it must be remembered that male circumcision has not been shown to provide protection to women and measures, such as using condoms, are essential to avoid HIV transmission to women and infection with other sexually transmitted diseases.

      References:
      Wawer MJ, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009;374(9685):229-37.
      Centers for Disease Control and Prevention, 2008. Male circumcision and risk for HIV transmission and other health conditions: implications for the United States. http://www.cdc.gov/hiv/resources/factsheets/PDF/circumcision.pdf

    • United Nations creates new Women’s Agency

      News article
      The United Nations (UN, www.un.org) has created a ‘Women’s Agency’ to promote the rights and well-being of women worldwide and to work towards gender equality.
      This initiative will result from the merger of four existing departments – the UN Development Fund for Women (UNIFEM), the Division for the Advancement of Women, the Office of the Special Adviser on Gender Issues and the UN International Research and Training Institute for the Advancement of Women (UN-INSTRAW).
      UNAIDS - Joint United Nations Programme on HIV/AIDS (accesskey:1)UNAIDS – the joint United Nations programme on HIV/AIDS (www.unaids.org) – has welcomed this advance and aims to work closely with the new agency to promote women’s access to health and development.
      It is well known that women are disproportionately affected by the AIDS epidemic. More than 60% of people living with HIV in sub-Saharan Africa are women and three out of four young people living with HIV are female. Gender inequalities, sexual abuse, violence, conflict and poverty often increase women’s vulnerability to HIV.
      UNAIDS believes that protecting women from becoming infected with HIV and treating women living with HIV can help stem the epidemic. In addition, preventing women from becoming infected in the first place and increasing their access to treatment also directly contributes to reducing the number of children being born with HIV and becoming orphans.
      Working alongside the new agency, UNAIDS hopes to strengthen the capacity of women’s organizations to deliver critical maternal and child health services to women and girls at a grassroots level.

    • Improving the well-being of children affected by HIV - a knowledge gap

      More than 13 million children under the age of 15 have lost a parent due to HIV and AIDS. There are also many children who have HIV-positive parents or carers. These children are not only affected by the impact of HIV and AIDS on the people around them, but are also potentially vulnerable to HIV transmission themselves. These factors can have an impact on their emotional well-being compared with other children of the same age.
      A number of strategies are generally adopted in clinical practice with the aim of improving the emotional well-being of children affected by HIV and AIDS – but how effective are they and what evidence exists to support their use?
      To investigate this, a review was undertaken to look at published studies in order to assess the effectiveness of the various interventions. Surprisingly, the investigators found that no properly designed and controlled studies of interventions for improving the psychosocial well-being of children affected by HIV and AIDS had in fact been undertaken.
      They concluded from this that current practice is based on anecdotal knowledge and on the results of studies that do not provide a strong evidence base for the effectiveness of these interventions. In the absence of rigorous intervention studies, the body of knowledge consists of ‘lessons learned’, child psychological theory, or is extrapolated from related research in the adult population.
      This investigation highlighted the urgent need for high quality intervention studies in children. The investigators recommended that the quality and quantity of such studies could be improved by establishing a greater partnership between programme implementers and researchers.
      However, it was recognized that such knowledge should not replace the urgent need for rigorous monitoring and evaluation of existing programmes and intervention studies to ensure that clinical practice and policy are truly evidence based. This will avoid the situation where children are subjected to interventions which show no benefit or interventions that could unintentionally lead to harm.

      Reference
      King E, De Silva M, Stein A, Patel V. Interventions for improving the psychosocial well-being of children affected by HIV and AIDS. Cochrane Database Syst Rev 2009; Apr 15;(2):CD006733.

    • Antiretroviral medications in pregnancy - weighing the risks and benefits

      The use of antiretroviral therapy during pregnancy and in the newborn baby has resulted in a decrease in mother-to-child transmission (MTCT) of HIV to less than 1% in areas that have adequate resources to provide these medications.
      Despite these benefits, questions remain regarding their safety for the mother, the fetus, and the child.  Some studies have found associations between antiretrovirals and premature birth or other adverse pregnancy outcomes, but data are conflicting making it difficult to draw firm conclusions.
      The Antiretroviral Pregnancy Registry (APR; www.apregistry.com) has been established to collect information on any major birth defects effect associated with a prenatal exposure to antiretroviral medication and the outcomes of pregnancy.
      The APR’s most recent report, up to July 2008, provides the most comprehensive source of information on the safety of antiretrovirals in human pregnancies. The results are encouraging – they found 2.7 birth defects per 100 live births which does not differ from the rates usually found in the general population (US data).
      There is also the question of whether highly active antiretroviral therapy (HAART) is necessary for all pregnant women. The effects of some antiretroviral medications on the body are altered significantly during pregnancy and placental transfer from the mother to the fetus is variable. Undoubtedly, the choice of which antiretroviral to use in a pregnant women must take into consideration the need for rapid control of viral suppression and both maternal and fetal safety. On balance, however, studies suggest that the well-documented benefits of HAART for preventing MTCT generally outweigh the potential risks to the fetus, infant, and mother.

      However, it is clear that possible adverse effects of antiretroviral medications are of concern, and questions remain as to the best treatment strategy in this setting. More data on the effects of antiretrovirals during pregnancy are needed and this can only be provided by large randomized trials of antiretroviral treatment strategies used during pregnancy and the neonatal period.

      Reference
      Stek AM. Antiretroviral medications during pregnancy for therapy or prophylaxis. Curr HIV/AIDS Rep 2009;6(2):68-76.

    • Bone density in women living with HIV and hepatitis B or C

      Literature report
      Italian investigators have discovered that HIV-positive women who are also infected with hepatitis B or C have lower bone density than HIV-positive women who do not have hepatitis co-infections. Importantly, this difference is not apparent in men.

      It is known that people who are co-infected with HIV and also hepatitis B or C have higher rates of serious health complications, one of which can be low bone density. A decrease in bone density (also known as bone mass) is normal in both men and women as they age. In women, this decline is increased during menopause; in fact, a woman can lose up to 20% of her total bone mass in the 3–6 years after her menopause. Low bone density can result in the development of osteoporosis and lead to an increased risk of fracture.
      The Italian study assessed the risk factors for reduced bone density at the hip and spine, over and above what would normally be expected, in a group of men and women with HIV, some of whom were also infected with hepatitis B or C. They found that both HIV/hepatitis co-infection and being female were associated with low bone density measurements.
      Women co-infected with hepatitis C had significantly lower bone density in their spine than women infected with HIV only – this difference was not seen in men. In addition twice as many women as men were found to have low bone density measurements in this body region.
      The same pattern was seen when hip bone density was investigated, even after taking into account factors such as use of antiretroviral therapy, smoking, and levels of physical activity that might influence the results.
      The investigators concluded that viral hepatitis was associated with a higher risk of low bone density among HIV-infected women but not amongst HIV-infected men, but the reason for this difference is currently unclear.

      Reference
      Lo Re V et al. Viral hepatitis is associated with reduced bone mineral density in HIV-infected women but not men. AIDS 23: 2191-98, 2009.

    • WFPA Press Release March 4, 2010

      Women for Positive Action: an International Partnership Dedicated to Enhancing the Lives of Women Living with HIV

      To mark International Women’s Day (March 8, 2010) Women for Positive Action are launching a series of tools to raise awareness of the challenges facing women living with HIV/AIDS today. Women for Positive Action (WFPA) is led by a broad coalition of healthcare professionals, women living with HIV and community representatives from Europe, Canada and Latin America. This global initiative aims to support health care professionals and women living with HIV through the provision of resources, which are available for download, in English and Spanish, at www.womenforpositiveaction.org.

      To view the multimedia news release, please click on:
      http://multivu.prnewswire.com/mnr/prne/wfpa/40788

      "Women living with HIV face many challenges as a consequence of their disease and its treatment including depression, guilt, isolation, discrimination and body image concerns" said Sharon Walmsley, Director of HIV Clinical Research, University of Toronto, Canada, “The new WFPA resources will encourage education and stimulate communication between women with HIV and those who care for them”. The educational resources include information on current best practices and research, in addition to informative case studies.

      WFPA brings together a unique combination of those involved in the care of women living with HIV with the first-hand perspectives of those living with HIV themselves. Ophelia Haanyama Ørum, Senior Advisor, Global Partnerships on HIV and AIDS, Noah’s Ark Foundation, Stockholm, Sweden added “The women living with HIV represented in the WFPA initiative welcome the opportunity to incorporate our experiences and expertise into health and social care solutions for women everywhere who are affected by HIV.” The group aims to empower, educate and support the needs of women living with HIV, their healthcare professionals and community advocates involved in their care.

      The theme for International Women’s Day this year is ‘Equal rights, equal opportunities: Progress for all’, and provides the ideal opportunity to consider the unique impact of HIV on women. Understanding the effect of the disease is a key step in improving the lives of women and working towards bridging gender inequalities in HIV.

      Globally an estimated 33 million people are living with HIV. Women make up about 50% of HIV cases and a higher proportion of new diagnoses compared with men. This means that the share of HIV infection among women is increasing in several countries. Young women, in sub-Saharan Africa, aged 15–24 are three to four times more likely to become infected than young men (UNAIDS, 2009). The most common mode of infection is by heterosexual transmission and most women with HIV are of childbearing potential. Furthermore, women with HIV are more likely to present at a later stage of HIV infection than men. Visit www.womenforpositiveaction.org for further information about WFPA and ongoing projects. WFPA is supported by a grant from Abbott.

      Reference:
      UNAIDS 2009, http://www.unaids.org/en/default.asp

      For further information please contact:
      Women for Positive Action
      Program Secretariat
      Litmus MME
      151 Shaftesbury Avenue
      London WC2H 8AL
      United Kingdom
      Tel: +44 (0)20 7632 1815
      WFPA@litmus-mme.com

    • Major trial of microbicide gel launched

      Literature report
      The VOICE Study (Vagina and Oral Interventions to Control the Epidemic) is a large clinical trial that has recently commenced to investigate whether antiretroviral (ARV) drugs normally used to treat HIV infection can also be used to prevent it. The study will investigate whether applying a vaginal microbicide gel containing an ARV every day or taking an oral ARV tablet once a day can reduce a woman's risk of acquiring HIV.
      The main aim of VOICE is to evaluate the safety and effectiveness of the two regimens, however it will also aim to find out which of the two options – the tablet or the gel – the women in the study prefer to use.
      Up to 5,000 women will be enrolled in VOICE at clinical trial sites in Uganda, South Africa, Zambia and Zimbabwe.  VOICE is being conducted under the leadership of the US National Institutes of Health (NIH)-funded Microbicide Trials Network (MTN), which is based at the University of Pittsburgh and Magee-Women’s Research Institute.
      Although correct and consistent use of male condoms has been shown to prevent HIV infection, women often cannot control if or when condoms are used by their male partners. Women are also twice as likely as their male partners to acquire HIV during unprotected sex, due in part to biological factors that make them more susceptible to infection.
      VOICE Study co-chair Jeanne Marrazzo, Associate Professor of Medicine in the Division of Allergy and Infectious Diseases at the University of Washington in Seattle, USA, commented that “Women need safe and effective methods for preventing HIV that they can control themselves, and need methods that they are willing and able to use.”
      Researchers at the Uganda and Zimbabwe sites are also conducting a companion study called VOICE B, or the Bone Mineral Density Sub-study. VOICE B will involve about 300 women who have been randomized to the oral tablet groups to determine the potential effects, if any, that the oral ARVs may have on bone health in HIV-negative women.

      Further information about the study can be found at: http://www3.niaid.nih.gov/news/QA/VOICEqa.htm

    • Call to prioritize cervical cancer screening for HIV-positive women

      Literature report
      Almost one in four HIV-positive women in the USA does not opt to undergo an annual Papanicolaou (Pap) test for cervical cancer even though they are at an increased risk for the disease, according to a study reported in the Journal of Acquired Immune Deficiency Syndromes. Due to the increased risk of cervical abnormalities, HIV treatment guidelines recommend annual Pap tests for HIV-infected women.
      Dr Alexandra Oster and colleagues from the Centers for Disease Control and Prevention assessed screening prevalence and associated factors among HIV-infected women using data collected during 2000–2004 in an interview study of HIV-infected persons in 18 US states. Of the 2,417 women interviewed, 556 (23.0%) did not report receiving a Pap test during the past year. Not choosing to have a Pap test was associated with increasing age and most recent CD4 count of <200 cells/mL. Odds of a missed Pap test increased for women whose most recent pelvic examination was not performed at their usual place of HIV care.
      The investigators concluded that HIV care providers should ensure that HIV-infected women receive annual Pap tests, recognizing that missed Pap tests are more likely among older women and those with low CD4 cell counts. They also suggested that there should be greater integration of HIV and gynecologic care, and clinicians should be made aware about the recommendations for screening in HIV-positive women
      They commented that, "The risk of cervical cancer has not decreased since the introduction of highly active antiretroviral therapy, highlighting the continued importance of cervical cancer screening in this population. Cervical cancer screening should be a high priority for HIV-positive women”.


      Reference:
      Oster AM, Sullivan PS, Blair JM. Prevalence of cervical cancer screening of HIV-infected women in the United States. J Acquir Immune Defic Syndr 2009;51(4):430–6.

    • Cognitive decline in HIV-positive women

      Literature report
      Researchers in Chicago, USA, have highlighted the fact that the level of cognitive impairment – a decline in mental functioning and the ability to carry out tasks that require thinking, planning, and memory – among HIV-positive women is higher than that in non-infected individuals.
      The investigators also noted that to date women have been under-represented in neuropsychological studies of HIV infection. However a small number of studies have reported significantly higher levels of cognitive impairment among HIV-positive women compared with HIV-negative subjects, regardless of their symptom status and whether they have an AIDS diagnosis. This impairment was most evident on psychomotor tasks – those that require a degree of physical movement. Notably, the risk of such impairment was found to increase among HIV-positive women who were not taking antiretroviral therapy. Age and depressive symptoms were also risk factors for poorer mental functioning.
      The researchers concluded that the potential female-specific aspects of HIV-associated cognitive disorders required further investigation and that new studies were needed to asses the impact of other relevant factors, such as female hormones, post-traumatic stress disorder and other mental health conditions.

      Reference:
      Maki PM, Martin-Thormeyer E. HIV, cognition and women. Neuropsychol Rev 2009;19(2):204–14.

    • Elimination of mother-to-child transmission - a realistic goal?

      News article
      Considerable advances have been made in the reduction of mother-to-child transmission (MTCT) in developing countries.
      In many industrialized countries, treatment with antiretroviral drugs (ARVs), often with Caesarean section delivery and always combined with breastfeeding avoidance, have significantly reduced MTCT from 25% to 1–5%.
      However, breastfeeding by HIV-positive women in poorer communities within developing countries is often unavoidable – in fact avoidance of breastfeeding places infants at greater risk of illness or of dying if formula milk is prepared without using clean water. Commonly, these communities have inadequate health care resources to help HIV-positive pregnant women and mothers, and this has contributed to the lack of success in reducing MTCT.
      So the question remains – how can we reduce breastfeeding transmission of HIV while improving survival of infants born to HIV-infected mothers in developing countries? Data are now available that strongly suggest that breastfeeding transmission has been substantially decreased in regions that have adopted a preventative treatment strategy targeted at both infants and mothers.
      The advances identified in the recent study have been achieved primarily by the use of ARVs in breastfeeding infants, with the aim of preventing them acquiring the virus, coupled with the treatment of HIV-infected lactating mothers – allowing them to continue to breastfeed while minimizing the risk of MTCT.
      However to achieve the ultimate goal of elimination of MTCT, these measures need to be part of a comprehensive approach to the problem and include the prevention of unwanted pregnancies in all women living in areas with high levels of HIV infection, primary prevention of HIV infection in women of child-bearing age, and an improvement in the health service facilities for these women.
      Current World Health Organization recommendations suggest individualized counselling to determine the best feeding method for each woman.

      References:
      Coovadia H. Current issues in prevention of mother-to-child transmission of HIV-1. Curr Opin HIV AIDS 2009;4(4):319–24.
      Horvath T, Madi BC, Iuppa IM, Kennedy GE, Rutherford G, Read JS. Interventions for preventing late postnatal mother-to-child transmission of HIV. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006734.
      Jackson DJ, Goga AE, Doherty T, Chopra M. An update on HIV and infant feeding issues in developed and developing countries.  J Obstet Gynecol Neonatal Nurs 2009;38(2):21929.

  • Posters

    • Women for Positive Action: A Unique Initiative

      This poster was presented at the 3rd HIV & Women Workshop which was held in Toronto in January 2013. It describes the aims of the Women for Positive Action initiative and summarises some of it's key activities. 

      • Download Women for Positive Action: A Unique Initiative poster
  • Presentations

    • Women for Positive Action at the Women’s Networking Zone, XIX International AIDS Conference, Washington DC

      Women for Positive Action partnered with the Women’s Networking Zone at the XIX International AIDS Conference. Faculty members led three interactive workshop sessions providing positive support and recommendations on how women can deal with a selection of challenges faced following a diagnosis of HIV. The faculty presented challenges from both the perspective of a women living with HIV and a healthcare professional, demonstrating the importance of a strong partnership in responding to women’s needs.

    • Management of HIV infection in Women

      This slide kit on treatment options and issues concerning women living with HIV in the UK was developed and presented by Women for Positive Action faculty member, Professor Margaret Johnson for the Trans-Sylvanian International Women's meeting that took place in Romania in January 2012.

      Please click here to download the presentation.

    • East Meets West: Management of Women Living with HIV

      Women for Positive Action was invited to participate in a mini-lecture at the European AIDS Conference 2011 in Belgrade, as part of the session ‘When people living with HIV grow up to become adults or want children’. Speaking on behalf of the faculty, Dr Teresa Branco (Portugal) and Dr Mariana Mardarescu (Romania) presented an overview of the challenges facing women living with HIV who wish to start a family, specifically focussing on differences across Europe.

      Please click here to download the presentation.

    • Prevention, fertility, contraception and pregnancy

      This slide kit on prevention, fertility, contraception and pregnancy in women living with HIV was developed and presented by Women for Positive Action faculty member, Dr Sharon Walmsley for the Trans-Sylvanian International Women's meeting held in Romania in January 2012.

      Please click here to download the presentation.

  • Publications

    • An emotional burden - what do women living with HIV go through?

      Those with HIV are enjoying longer lives due to advances in disease management. As a consequence, disease and treatment-related factors can impact emotional health at several stages of life. This article, published in Positive Nation, highlights the emotional health challenges faced by women living with HIV and includes personal contributions from Women for Positive Action members. Click here to access the article.

    • Faith and spirituality in the lives of women living with HIV

      Published in Positively Women magazine, this article discusses how faith and spirituality can help women to deal with the physical and emotional challenges faced from living with HIV. The article highlights that faith leaders can play a positive role in supporting those with HIV and discusses how integrating faith into disease management may form an important part of care for some women.
      Click here to access the article.

      This is a sample copy of Positively Women magazine. Over the past year Positively Women has addressed many issues affecting women living with HIV including: human rights; living with HIV in prison; pregnancy and access to healthcare. If you a woman living with HIV and are interested in subscribing to this magazine please call 020 7713 0444 or email info@positivelyuk.org.

    • Caring for women living with HIV: gaps in the evidence

      Women living with HIV often receive the same care as men, despite evidence suggesting potential gender differences in the physiological, psychological, behavioural and social response to treatment. One key reason for this is the lack of robust data specifically related to the treatment of women and an overall lack of women involved in HIV clinical research. This paper reviews the current knowledge of the clinical status of women living with HIV and highlights areas requiring further study; particularly focussing on clinical management, sexual health, emotional wellbeing and treatment access. Click on the link below to access the article.

      Mona R Loutfy, Lorraine Sherr, Ulrike Sonnenberg-Schwan, Sharon L Walmsley, Margaret Johnson and Antonella d’Arminio Monforte on behalf of Women for Positive Action. Caring for women living with HIV: gaps in the evidence.  Journal of the International AIDS Society. 2013;16:18509

    • A review of reproductive health research discussing women living with HIV

      Women living with HIV have the right to safe and healthy reproductive choices, which should be the same as those provided to non-HIV-positive women. Currently, access to the relevant reproductive health resources and services, such as advice on contraception and fertility services, for women is far from optimal. This paper reviews the normalisation of reproductive health by discussing preconception considerations, contraception, maternal health, and post-partum issues in the context of HIV. Click on the link below to access the article.

      Mona R Loutfy, Ulrike Sonnenberg-Schwan, Shari Margolese and Lorraine Sherr on behalf of Women for Positive Action. A review of reproductive health research, guidelines and related gaps for women living with HIV. AIDS Care. 2013;25(6):657-66.

    • HIV-positive women in clinical trials: A gap in the facts

      This article, published in HIV Treatment Update, highlights the importance of including women in clinical trials, reviewing differential responses to therapy and the difference in inclusion rates in clinical trials between men and women. Click here to access the article.

    • Raising awareness of the shortage of women in HIV clinical trials

      This opinion piece, published in AIDS journal, addresses the current under-representation of women living with HIV in clinical trials. The aim of this publication is to raise awareness of the need for women to be considered at all stages during the design, conduct, interpretation, reporting and application of clinical research in HIV, so that they can obtain fair and equal benefit from these studies. Click below to access the article.

      d'Arminio Monforte, Antonella; González, Lorena; Haberl, Annette; Sherr, Lorraine; Ssanyu-Sseruma, Winnie; Walmsley, Sharon L; on behalf of Women for Positive Action. Better mind the gap: addressing the shortage of HIV-positive women in clinical trials. AIDS. 2010;24(8):1091-1094.