Women with HIV suffer a greater burden of of non-AIDS comorbidities than HIV-seronegative women in every age group, according to findings published in Clinical Infectious Diseases.
In one of the largest studies of the epidemiology of non-AIDS comorbidities (NACM) in female participants, the author, Ighovwerha Ofotokun, M.D., M.Sc., professor of medicine in the division of infectious diseases at Emory University School of Medicine, and his colleagues analyzed data from the Women’s Interagency HIV Study (WIHS), a nationally representative cohort of women living with HIV (WLWH) and at-risk HIV-seronegative women. Ofotokun’s team assessed 2,309 virologically suppressed WLWH and 923 HIV-seronegative participants in the WIHS with the median age of 50 years. Sixty-five percent of participants were Black and 70% had ever used cigarettes. Researchers also examined burden of NACM according to HIV serostatus and age. The median observation period was 15.3 years.
Overall, researchers found that total NACM were significantly higher among WLWH compared with HIV-seronegative women. Specific comorbidities, including psychiatric illness, dyslipidemia, non-AIDS-defining cancer, and kidney, liver, and bone disease, were all higher among WLWH.
The authors write: “Factors significantly associated with NACM burden were HIV seropositivity, older age, white race, obesity, income $24,000 or lower, cigarette use, crack/cocaine use, and alcohol abstinence. For virologically suppressed WLWH, traditional comorbidity risk factors were more commonly associated with NACM burden than were HIV-related clinical indices.”
Even more troubling for those with HIV, researchers found that NACM occur up to a decade earlier in WLWH compared with HIV-seronegative counterparts.
A Snapshot, but Questions Remain
In an accompanying commentary, Moises A. Huaman, M.D., M.Sc., and Carl J. Fichtenbaum, M.D., of the division of infectious diseases at the University of Cincinnati, recommended further research into why there are more non-AIDS comorbidities in WLWH. Speaking with TheBody, Fichtenbaum said that the study brings up as many questions as it answers—and that researchers now must be the “Sherlock Holmes of discovery” to understand the reasons for the comorbidity disparities for each disease.
“[The study] gives us some broad strokes, but often we [researchers] come up with very interesting findings and don’t go further. Here, the differences are worth investigating, and those differences may not be simple to explain.”
Fichtenbaum said it’s important to explore each comorbidity separately, both for women living with HIV and seronegative women. “Why one person gets kidney disease may be different than why one gets liver disease. For cancers, are there different risk factors, other than HIV itself?”
Women Face Unique Health Care Challenges
Ofotokun has said his findings emphasize the importance of screening and intervention for women living with HIV, including for cardiovascular disease and bone fracture risk, and he concludes that WLWH “should be prioritized in clinical guidelines for screening and intervention to mitigate comorbidity burden in this high-risk population.”
But statistics show that it’s not so simple for women, with or without HIV, to access those preventive services.
From the beginning of the epidemic, women have been affected by HIV, and in 2018, women accounted for nearly 20% of new HIV diagnoses in the U.S. and 24% of all people living with HIV in the U.S. Fortunately, the rate of new HIV diagnoses among women has declined 24% since 2010. Women of color, especially Black women, continue to represent the majority of new infections among women.
Lisa Diane White, deputy director of health education and policy at SisterLove, said that maintaining optimum health is difficult for women, regardless of their HIV status, for a variety of reasons.
“What we see is that the social determinants of health affect women to a greater degree, and when a woman has HIV, chances are [suppressing the virus] isn’t always at the top of her list.”
White cites the gender pay gap—which often forces women who are the sole income producers in their household to take more than one job, often without health insurance benefits—as one of the main reasons women find it more difficult to keep HIV, or any other disease, under control.
“And if you look at women who are responsible for the whole family, their kids, and even taking care of their men, they take care of themselves last,” she said. As for comorbidities for women living with or without HIV, “the first problem is, we don’t know we have them.
“The health care system is fractured. All of the interactions require conversations with doctors and specialists, and insurance. If you have diabetes, the doctor treating that might not be in conversation with the HIV doctor.”
That is, if a woman has easy access to doctors at all. White notes that depression and anxiety impact the ability to even seek out help for other medical issues, as well as the ability to adhere to medication. “And if she’s affected by violence, or doesn’t have a support system or stable housing, all of those things will affect her ability to get care.”
Getting health insurance, especially in a state that hasn’t expanded Medicaid as part of the Affordable Care Act (ACA, also known as Obamacare), can also put up obstacles to care. According to the Kaiser Family Foundation, low-income women, women of color, and non-citizen women are more likely to be uninsured than other women, and a greater percentage of single moms are uninsured (13%) than women in two-parent households (9%).
To eliminate some of these health care barriers, White recommends that every state expand Medicaid under the ACA, raising the minimum wage everywhere, and developing mechanisms for letting doctors share medical information and records for “whole-person care.”
All of those recommendations are especially important now, during the ongoing COVID-19 crisis, White says, because COVID infections, even when people can recover, can put even more burdens on health. “The COVID statistics are not just numbers. I know four people who have died [of COVID], and some of my staff have been sick. And we know that COVID is affecting Black and Brown people disproportionately, for a variety of reasons. So, now we’re seeing a pandemic on top of an epidemic on top of another epidemic.”