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Yale School of Nursing
Nathan Smith Clinic
Yale New Haven Health Systems
New Haven, Connecticut
Julie A. Womack, PhD, CNM, FNP-BC, has no relevant conflicts of interest to report.
A broad lens is required when we consider the health and well-being of women aging with HIV. Gynecologic concerns are important, but women with HIV experience multiple health-related concerns that are distinct from those of men, including a shorter life expectancy. Numerous factors likely contribute to this difference.
HIV infection may contribute to shorter life expectancy by damaging the immune system and driving chronic inflammation. Significant differences in immune activation between men and women with HIV have been described and attributed to sex chromosomal factors and sex hormones. Meier and colleagues demonstrated that women have higher CD8+ T-cell activation at any given viral load compared with men. The expression of interferon-stimulated genes has also been found to be higher in women compared with men, even when controlling for viral load. These differences in immune setpoint likely have clinical consequences and may partially account for the lower life expectancy of women with HIV compared with men.
Factors other than HIV are also likely to contribute to sex-based differences in life expectancy. Salter and colleagues found that HIV infection was associated with increased multimorbidity and was positively associated with increased multiple comorbid conditions at younger ages compared with uninfected individuals. In addition, women were more likely to have multiple comorbid conditions compared with men.
Polypharmacy, the concurrent use of ≥ 5 medications, may also contribute to reduced health in women aging with HIV. People with HIV experience polypharmacy at least 10 years sooner than uninfected controls, and the risk of negative outcomes (mortality, hospitalization, impaired functional status) increases with the number of medications. Adverse drug reactions increase as the number of medications increases, accounting for some of the negative outcomes associated with polypharmacy. In the general population, regardless of age, adverse drug reactions are more likely to occur in women than in men. Among people with HIV, there is an enhanced susceptibility to harm from polypharmacy. ART, particularly regimens with pharmacologic boosters such as ritonavir, may increase harms from polypharmacy because of potential interactions with many medications. Although research on this issue is lacking, it seems reasonable to assume that women with HIV are more susceptible to the harms of polypharmacy than men.
Substance use—particularly alcohol use—is another important consideration. In a study including data from 18,145 people with HIV and 42,228 uninfected individuals in the Veterans Aging Cohort Study, there was a greater risk of mortality for people with HIV at lower levels of alcohol use compared with uninfected individuals. Although alcohol use and abuse is more prevalent in men than in women in the general population, women have a greater risk of negative outcomes associated with alcohol use (eg, liver disease, dementia). These outcomes occur in women at lower levels of alcohol consumption compared with men, and the damage appears within shorter periods of excessive drinking. We have minimal data on the impact of alcohol use on the health of women with HIV, but again, the impact is likely similar to uninfected women.
Doubtless other, non-HIV–specific factors contribute to the shorter life expectancy of women compared with men with HIV. Another important area to explore is the role of intimate partner violence.
As in the general population, women’s health is not just gynecologic health—it must include and address issues that present differently in women compared with men. Gynecologic care is important; it is just not the whole story.
In your experience, what are the distinct healthcare needs of aging women with HIV? Please answer the polling question and join the discussion in the comments section.
Register here for an interactive Question and Answer Webinar on Wednesday, September 2, at 11:30 AM Eastern time, in which my expert colleagues answer your questions on caring for aging patients with HIV.