HIV Still a Huge Issue for Women, Says Dr. Susan Blumenthal

Although the overall number of HIV infections in the U.S. is down, women still account for 20 percent of all new HIV infections while African-American women account for approximately two-thirds of this population. This racial disparity is shocking considering that African-American women only represent 13 percent of the population yet constitute 64 percent of all new HIV infections. Equally alarming is the fact that 84 percent of new female HIV infections are attributed to heterosexual sex. Biologically, women are more vulnerable than men to become infected with HIV during unprotected sex.

In response to this, amfAR, The Foundation for AIDS Research, releases their "Women and HIV/AIDS in the US: Fast-Tracking the End of an Epidemic" Issue Brief, which highlights the challenges women in the U.S. continue to face in accounting for new HIV infections.

Key to reducing HIV infections among women is advocating for healthcare public policy changes, says amfAR Senior Policy and Medical Advisor, Dr. Susan Blumenthal. Last year, 25 state governments opted out of expanding Medicaid through the Affordable Care Act (ACA). This has led to millions of women -- particularly African-American women -- being uninsured, impeding efforts to deliver effective HIV care, prevent the spread of HIV and ultimately save lives at a critical moment in the fight against HIV/AIDS.

Among those public policy changes that women need to see in order to make a lasting change are ensuring women are adequately represented in clinical trial research; developing prevention technologies specifically for women; doing interventions for women facing HIV as a result of violence; increasing access to women's reproductive healthcare; and advocating for Medicaid expansions.

"Women are not small men; there are distinct differences," said Blumenthal, speaking about the need for women to participate in clinical trials. "The new national prescription to look at sex differences in diseases will help not only women, but men as well."

Blumenthal said that a significant health oversight in the '80s was failing to include women in the Centers for Disease Control and Prevention's definition of HIV/AIDS, or in clinical trials of AIDS medications. This resulted in a rapid increase of HIV in women in the U.S. and around the world.

"While we've made progress and declining rates have been seen in the past decade, all too many women are HIV-positive," said Blumenthal. And these high rates are not just in developing countries. "In Washington, DC, 93 percent of women with HIV are African-American. DC has a higher prevalence of women with HIV than some places in Africa, like Liberia, Congo, Ethiopia or Mali. In the U.S., African-American men who have sex with men (MSM) have much higher rates, but still, one of five new HIV infections are in women, and one of four people living with HIV are women. We need to target prevention and treatment to women."

Blumenthal says that we have a lot of catching up to do to get women included in research studies by the National Institute of Health; for data to be analyzed for sex differences; and for the Food and Drug Administration to include this analysis for approved devices (or to indicate on the label if women were not included.)

Worldwide, 50 percent of the HIV epidemic is in women. In sub-Saharan Africa, 60 percent of new HIV infections are among women aged 16-24. It is these women for whom we need to develop prevention technologies. Blumenthal says that the NIH and private sector organizations are supporting this research, but notes that these technologies are only as good as those who use them.

"We need vaginal rings with long-acting microbicides; injections; or products that combine contraceptives and PrEP to reduce the stigma of using something in your sexual relationship," said Blumenthal. "We really need these discreet, long-acting products to improve adherence."

In developing countries -- and even in the U.S. -- women often don't have the ability to make partners engage in safer sex practices. In the U.S., about one in 30 women have experienced intimate partner violence. Among women with HIV, it's about 55 percent.

"This is an area that we need to focus on," said Blumenthal. "Women experience high rates of physical abuse and sexual violence and trauma, and women with HIV are disproportionately affected. Violence increases their risk, but there is also the risk of violence upon disclosure of HIV to their partner. The focus of our government work is to develop and disseminate interventions."

Blumenthal praised the ACA for providing preventative, no-cost screenings for survivors of partner violence. We must find more interventions that work, and scale them up in communities.
Another key to stopping new infections is to get HIV-positive women into treatment. About 88 percent of women living with HIV have been diagnosed, but only 45 percent of those are in care, and only 32 have achieve viral suppression. Ryan White, Medicaid and Medicare need to create systems of community outreach.

"You're not really effectively treated until you're suppressed," says Blumenthal. "We have a lot of work to do to engage and retain them in care. That's one of our biggest challenges, because if you take the meds as prescribed you can live a long life. Then, treatment becomes prevention, because the risk of passing HIV on to others is reduced 96 percent."

We need to reach women at their health care providers, supermarkets and schools, and to have innovative community outreach. The U.S. has invested in PEPFAR programs to do this abroad; Blumenthal said we should learn from these lessons and share the success stories in our own country.

Finally, women cannot be truly healthy until they can control their own reproductive health. We must bundle services for women into one-stop shops of integrated health care so that it's easier to make healthy choices. And we must put these centers of care into the communities where women live. We not only prevent needless suffering, but save a lot of money if we can prevent new HIV infections.

Although Blumenthal is encouraged by the researchers, both men and women, who are involved in clinics like Columbia and the University of Pittsburgh, she said that HIV isn't just a men's or women's issue, but everyone's issue. We need to work together to protect our partners, and train physicians to be more attentive to women and recognize sex differences.

"We don't want to have AIDS amnesia when it comes to women," said Blumenthal. "In America, while the rates among MSM are very high, we can't forget that one in four people infected with HIV is a woman, and that it's the leading cause worldwide of death for women of childbearing age. This is a significant population, and allowing stigma or discrimination prevent us from reaching women with the care they need only perpetuates the problem."