CATIE News

20 January 2011 

The impact of gender, race and geography on HIV infection

An international research team in North America and elsewhere has been studying HIV-positive people from the time of infection and for up to eight years after. As part of their efforts, they collected health-related data on more than 2,000 HIV-positive people, about 5% of whom were women. The researchers found that HIV-positive women were more likely to experience infections and other consequences of weakened immunity. Furthermore, women of colour were less likely than white males to receive antiretroviral therapy (ART). The possible reasons for these and other findings are explored later in this bulletin.

Study details

Between 1997 and 2007, researchers enrolled 2,277 HIV-positive people at study sites mostly in the United States but also in Canada, Australia and Brazil. Women made up 5.4% of the population enrolled and the majority of women (55%) were women of colour. Most of the males were white (77%). The women were generally slightly younger than the men—most people were in their early 30s.

Results

At the start of the study, the women had lower viral loads than the men—an average of 25,000 copies/ml vs. 71,000 copies/ml. Also, the women had slightly higher CD4+ cell counts than men—600 cells vs. 546 cells. In theory, these should have given women some health-related advantage, but as we will see, over the long-term, this did not happen.

Symptoms of recent HIV infection can be similar to those of a flu-like illness. Commonly reported symptoms of early HIV infection in the study were as follows:

  • fever—78%
  • fatigue—72%
  • muscle aches—57%
  • headache—50%
  • sore throat—46%

Women were less likely to report two or more of these symptoms than men. If the same is true of HIV-positive women in the community, it is possible that some women may not be aware that they may have acquired HIV infection and may therefore not get tested for HIV.

Treatment

Some of the study sites also undertook clinical trials for the very early treatment of HIV infection. The researchers found that women were less likely than men to receive ART for the first two years after diagnosis. Furthermore, both men and women of colour were less likely to receive ART than white people.

Among participants who received treatment, roughly similar proportions of women (72%) and men (81%) were able to suppress the levels of HIV in their blood.

Survival

Because survival is linked to having high CD4+ cell counts, researchers assessed changes in these cells over time. They found that roughly similar proportions of women (17%) and men (25%) had a CD4+ count of less than 200 cells—a critical threshold for the appearance of serious infections. However, more women of colour (40%) had their CD4+ count drop below 200 cells than men of colour (20%), white men (15%) and white women (5%).

Infections

The women participants were more likely to develop recurring bacterial pneumonia and fungal infections of the throat and mouth.

Women of colour experienced more HIV-related illnesses than other groups in the study.

Even after adjusting their findings for substance use and other factors, researchers could not find biomedical reasons for the differences between men and women over the long-term.

From biology to the everyday world

Results from several other studies in the U.S. have also reported worse health outcomes in HIV-positive women and/or people of colour. Taken together, these other studies suggest that differences in survival of HIV-positive women are rooted in socio-economic aspects of their lives.

Region, race and geography

In the present study, in general, ART seemed equally effective in people regardless of gender or race. However, HIV-positive people of colour who lived in the Southern U.S. (the “South”) were between 2 to 4.6 times more likely to develop HIV-related illnesses than HIV-positive white people living in the South.

The study team pointed out that, in general, people in the South, particularly black people, have a greater risk of death from any cause compared to the average American. They also underscore that the reasons for this disparity are related to socio-economic factors, which likely include the following:

  • poverty
  • access to healthcare
  • domestic violence
  • health behaviours
  • insufficient food
  • environmental factors

The present study did not collect data on socio-economic factors and is unable to provide any insight on how they might have influenced the health and survival of HIV-positive people.

However, an editorial accompanying the research in the Journal of Infectious Diseases provided insight and perspective on the study’s findings. In the editorial, public health researchers noted that the findings from the study suggest that if efforts to prevent new HIV infections and improve access to HIV care and treatment are to be sustained, then health issues related to gender and race/ethnicity need to be “understood and addressed.”

The editorialists also note that socio-economic factors seem to play an important role in affecting health and survival of people living with HIV. They added that although these factors are “theoretically modifiable,” socio-economic factors represent “complex health challenges” to public health. Therefore, collaboration between affected communities, governments and scientists are needed to help understand and relieve these challenges.

The findings from the present study are relevant to other high-income countries, such as Canada, Australia and countries in Western Europe as many of these socio-economic factors that affect health and behaviour are commonly found.

—Sean R. Hosein

REFERENCES:

1. Meditz A, MaWhinney S, Allshouse A, et al. Sex, race, and geographic region influence clinical outcomes following primary HIV-1 infection. Journal of Infectious Diseases. 2011 Feb 15;203(4):442-451.

2. Armstrong WS, del Rio C. Gender, race and geography: do they matter in primary human immunodeficiency virus infection? Journal of Infectious Diseases. 2011 Feb 15;203(4):437-438.