The Growing Danger of AIDS

S arah Lyons couldn't imagine what her problem was. She would awaken in the middle of the night drenched with sweat. Her glands were constantly swollen and tender. She couldn't shake a low-grade fever. Debilitating fatigue had become an overwhelming fact of her life. She knew she must have a serious medical problem, but she couldn't figure out what it was—and neither could her doctors.

It was 1986, and AIDS had become a widely publicized disease known to strike homosexual men and injection drug users. The word most often used to describe AIDS was “deadly,” because there was no cure or effective treatment, and patients often died within months of diagnosis.

But AIDS wasn't something that women like Sarah Lyons (not her real name) worried about. A white, middle-class, 33-year-old telephone company worker from the suburbs of Baltimore, Sarah never thought of AIDS as she trekked from one doctor to another seeking a diagnosis for her puzzling combination of symptoms. Months of consultations, biopsies, and spinal taps failed to provide an answer, as doctors tested her for a variety of diseases and conditions, but never even speculated that she might have AIDS.

Finally, even though she had never injected drugs, even though she was in a sexual relationship that she thought was mutually monogamous, Sarah was tested for HIV, the human immunodeficiency virus that causes AIDS. Her test was positive—she was indeed infected with HIV. Her diagnosis was ARC, or AIDS-related-complex, the name then used for the set of symptoms that is caused by HIV but is not yet fully developed or “full-blown” AIDS.

Years later, as Sarah would go on to fight the ravages of full-blown AIDS, women with symptoms like hers would still find themselves groping for a diagnosis. Because as AIDS—acquired immunodeficiency syndrome —moved into its second decade, the health care system in the United States was only beginning to see it as a disease that should concern women.

Some Sobering Statistics

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The sad fact is that AIDS in women can no longer be ignored or minimized because so many women are being stricken. Currently, the number of AIDS cases is rising more rapidly among women than any other population group. According to the federal Centers for Disease Control and Prevention (CDC), which tracks cases of infectious diseases in this country, 40,702 cases of AIDS in women had been reported by October 1993, accounting for more than 12 percent of the total number of cases in adults. AIDS was the fourth leading cause of death in women aged 15 to 44, and the second leading cause of death for black and Hispanic women in this age group.

A brief glimpse at statistics over the years shows how dramatically the AIDS epidemic among women has grown in this country. In 1981, when AIDS was called “GRIDS” for gay-related immunodeficiency syndrome, six cases of AIDS were reported in American women. A year later that number was up to 52; within another year it had quadrupled. In 1986, nearly 2,000 women in the United States had been diagnosed with AIDS. By 1989, the number exceeded 10,000. And by 1993, that number had quadrupled again.

THE SOARING AIDS RATE IN WOMEN

Year by year cumulative totals; source: Centers for Disease Control and Prevention, September 1993

And, as with all AIDS statistics, these numbers represent only the tip of the iceberg. When AIDS was first defined, total cases numbered in the dozens and HIV, the virus, had not yet been identified. The syndrome was characterized by deficiencies in patients' immune systems that provided the opportunity for a variety of infections to set in. These infections (discussed below) were called opportunistic infections, and the AIDS diagnosis was based on their presence.

From HIV to AIDS

After the HIV virus was identified in 1984, a more definitive diagnosis became possible. But infection with HIV does not mean you have AIDS, which, in fact, is the final stage of HIV infection. Many less severe and less life-threatening infections often develop before full-blown AIDS sets in. Through the years, the CDC has expanded its definition of AIDS to include more diseases—including some gynecological conditions—but the number of actual AIDS cases remains only a small proportion of those infected with HIV.

The term “ARC,” (Aids-related Complex) which was used to describe Sarah Lyons' condition, has largely been replaced by “HIV disease.” Another commonly used phrase is simply “HIV/AIDS.” Although the epidemic is too young for patterns to be completely predictable, it has become increasingly evident that most, if not all, cases of HIV infection will eventually progress to full-blown AIDS. However, it may take ten years or longer after infection with HIV for any symptoms to appear, and years longer for an AIDS diagnosis to be made.

Clearly, the more than 40,000 cases of AIDS in women in the United States represent only a fraction of the HIV/AIDS problem for women in this country. The CDC estimates that 1 million Americans are infected with HIV, and as many as 12 percent—or 120,000—are female. Moreover, the fastest growing method of transmission is heterosexual contact—the way women are most likely to get the disease.

The Spread of Aids

Although AIDS was viewed for years in the United States as a disease most likely to strike homosexual men and drug users who shared needles, the picture that was emerging worldwide had quite a different look. In Africa, where the incidence of disease also grew rapidly in the early to mid-1980s, women were and still are just as likely as men to be its victims and most cases have been spread through heterosexual contact. Many epidemiologists, scientists who track the spread of disease, have warned that the pattern in Africa is likely to be duplicated in the United States in the years to come.

The international statistics are sobering. A United Nations study conducted in 1993 estimated that 3,000 women around the world become infected every day. By the year 2000, some AIDS experts say, more than 40 million people worldwide will be infected with HIV and at least half will be women.

In the United States, AIDS in women is clustered in certain racial groups and geographic areas. About one-quarter of the cases are in white women, with black and Hispanic women accounting for the remaining three-quarters, even though they represent only 19 percent of the population. Cases tend to be concentrated in urban areas in the East Coast, with some studies showing focal points with alarmingly high levels of infection. For example, a survey of women attending public family planning clinics in New York found rates of HIV infection of nearly 1 percent in clinics in the Bronx, and close to that in Queens and Brooklyn.

However, as the stories of Sarah Lyons and hundreds of other women illustrate, dismissing HIV/AIDS as a problem that only affects a certain portion of the population could be a deadly mistake for any woman. The AIDS virus does not discriminate.

What AIDS Looks Like

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AIDS was first observed in 1981 by physicians in New York City and San Francisco. A growing number of homosexual men were turning up in medical offices and hospital emergency rooms, with a diverse group of symptoms that could not be explained. The sickest among them often had Pneumocystis carinii pneumonia (PCP), a type of pneumonia that is caused by a common organism that most people readily fight off; or Kaposi's sarcoma, a skin cancer that shows up as purplish blotches on the skin, generally strikes elderly men, and is usually quite treatable.

Laboratory testing found that these patients had severely impaired immune systems. Certain white blood cells important in fighting infection, called T-lymphocyte cells or, more specifically, CD4 cells, are usually found in concentrations of about 1,000 per cubic millimeter in a healthy person. In people with AIDS, these counts were often found to be below 200.

Doctors were also seeing a growing number of patients who—like Sarah Lyons—had unexplainable symptoms that were often resistant to treatment. A list was soon developed of warning symptoms of HIV infection. These include:

• Chronic fever
• Extreme fatigue
• Diarrhea
• Unintentional weight loss
• Persistent sweating at night
• Swollen lymph glands
• Fungal infections, including thrush, a yeast infection of the mouth

Doctors also began to see that as HIV infection progressed and the immune system became less and less able to fight off infections, many more serious diseases were likely to take hold:

• Kaposi's Sarcoma
• Pneumocystis carinii pneumonia (PCP)
• Bacterial infections of the blood and lungs
• Other cancers, such as lymphoma
• Severe oral or genital herpes
• Cryptococcal meningitis, a fungus which infects the brain
• Cytomegalovirus (CMV) infection, which often causes blindness
• Tuberculosis
• Mycobacterium avium-intracellulare (MAI), a tuberculosis-like organism that causes generalized infection
• Neurological disorders, including progressive mental derangement
• Diarrhea caused by Cryptosporidium and other parasites

In 1993, the CDC expanded its definition of AIDS to include anyone with a CD4 cell count below 200 who was infected with HIV, and added several previously unlisted medical conditions to the roster of typical warning signs, including cervical cancer. Many female AIDS activists felt that this listing of cervical cancer was a long overdue recognition that AIDS in women often had a different look than AIDS in men.

What AIDS Looks Like in Women

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PCP pneumonia is the single most common AIDS-defining infection in both men and women, and all of the conditions listed above (except Kaposi's sarcoma, which is rarely seen in women) affect women as well as men. But women with HIV/AIDS bear the burden of a range of additional complications. HIV infection can cause unique gynecological problems; it can make existing gynecological problems worse; and it can prevent normal healing.

Because it was years before HIV/AIDS was thought of as a disease that strikes women, specific problems that women experience were not associated with AIDS. For many women, this meant that they were never diagnosed with AIDS, even though they may have died of a condition associated with HIV infection. Now, women with abnormal Pap smears, pelvic inflammatory disease, persistent yeast infections, and genital ulcers have to consider the possibility that HIV is the source of their problems since all of these conditions have been associated with HIV.

Thrush (also called yeast infection) is often the first clue that a woman has HIV infection. Thrush, the commonly used name for a fungus infection caused by the Candida organism, is also called candidiasis. It can occur in the mouth or throat, or in the vagina. As T-cell counts decline, thrush becomes more and more likely to develop.

AIDS IN WOMEN: THE CURRENT ETHNIC PROFILE

Source: Centers for Disease Control and Prevention, September 1993

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Women with HIV are also particularly susceptible to infection with human papillomavirus. This virus is thought to cause genital warts and has also been associated with cervical cancer and other forms of cervical disease. Women with HIV/AIDS have been found to have ten times the number of abnormal Pap smears (the test for abnormal cervical cells) as non-HIV-infected women.

Because of the high incidence of cervical abnormalities in HIV-infected women, many gynecologists now recommend that these patients have a Pap smear every six months. However, some studies have found that the Pap smear can fail to detect abnormalities.

Colposcopy, a more invasive way of examining the cells of the vagina and cervix, is being used more and more for diagnostic purposes in women with HIV/AIDS. It is an expensive procedure and not routinely recommended. However, it is a diagnostic alternative that you can discuss with your doctor

HOW AIDS HAS SPREAD TO WOMEN

Source: Centers for Disease Control and Prevention, September 1993

When AIDS cases in women first started getting attention, some studies found that women were not living as long as men after they were diagnosed. It soon became clear that this was not because the disease was striking women harder than men, or because women were less responsive to treatment. Rather, the reason for shorter survival times was thought to be socio-economic. Women with AIDS were more likely to be poor, with less access than men to social and medical services and thus, less likely to get prompt medical attention. They were also less likely to get a definitive diagnosis of HIV disease because of the perception of HIV as a male problem. It is now clear, however, that women who get a prompt diagnosis and are aggressively treated for HIV/AIDS and its opportunistic infections can expect to live just as long as men.

How AIDS is Spread

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HIV/AIDS is spread through bodily fluids, most frequently blood, male seminal fluid, or female vaginal secretions. For transmission to occur, the infected fluid must enter the uninfected person's body through some kind of cut or opening in the skin or mucous membranes in the body.

The virus can be transmitted at any stage of infection. You need not be symptomatic, or even know you are infected, in order to pass the AIDS virus to someone else. People are most infectious within the first six months to one year following their own infection, and then six to ten years later as their immune system becomes more suppressed.

However, exposure does not necessarily mean infection. Epidemiologists are still trying to determine why some people become infected when they are exposed and others do not, and what other factors may be involved. Studies on the wives of hemophiliac men with AIDS have found some that did not become infected with HIV despite repeated sexual contacts over years. On the other hand, some cases of transmission are documented from just one sexual contact.

The CDC divides the source of existing HIV infection among women into four categories, with the following percentage of cases in each (as of September 1993):

Heterosexual contact is the fastest-growing category for both men and women. In 1992 it replaced injection drug use as the most likely mode of transmission to women. And it is quite likely that the numbers for this category are underestimated, because if a woman injects drugs, that is listed as her transmission category, even if she also has a sexual partner who is HIV-infected and may have infected her.

In explaining the transmission of the AIDS virus in women, it is helpful to look at a slightly different classification of categories:

Sexual transmission

HIV/AIDS is primarily a sexually transmitted disease. Like any other sexually transmitted disease, it can be spread through homosexual or heterosexual contact. Because AIDS was first observed in this country in the gay community, it was often perceived as a gay disease, but that is a serious misunderstanding.

Women are more at risk than men to be infected through heterosexual contact because there are still many, many more men than women who are infected. In other words, a woman has a greater chance of selecting an infected sexual partner than a man does.

The easiest way for HIV to be transmitted sexually is through anal intercourse. This is because the delicate tissue in the anus can easily tear during sex. Other reasons for the efficiency of anal transmission include the neutral pH of the anal region, which is an environment that HIV seems to like, and the existence of receptor cells in the anus to which HIV attaches itself.

HIV is also transmitted through vaginal intercourse, and again the risk is greater for women than it is for men. Studies have found that women are more than twice as likely to become infected by men, than men by women. There are several reasons for this. First, there is more virus contained in semen than in vaginal fluid; and second, semen has access to a large surface area, the vagina and cervix; and third, when a man ejaculates into a woman, the seminal fluid remains inside her for hours, giving the virus plenty of time to infect.

The presence of other sexually transmitted diseases also increases the risk of HIV infection. If you have any kind of abrasions or lesions on your vagina, there is an increased chance of infection if you are exposed to the virus. Genital ulcers increase your risk both of being infected and of infecting your partner if you are HIV-positive.

Although theoretically HIV could be transmitted through oral sex, no cases have been confirmed, and most epidemiologists think that it is unlikely.

Another form of sexual transmission is artificial insemination. If a woman is artificially inseminated with HIV-infected sperm, she can become infected. However, most sperm banks now screen for HIV.

Contaminated Blood

A second way that HIV can be spread from one person to another is through contact with blood or blood products that are contaminated with HIV. Most commonly, this occurs when users of illicit drugs share needles. After drugs are injected, the user withdraws the needle, extracting a few drops of his blood into the syringe, and this blood goes directly into the body of the next person to use it. This is an all too efficient method of transmitting bloodborne viruses. It also occurs in health care facilities in some countries where needles and syringes are reused without proper sterilization.

In the initial stages of the AIDS epidemic, hundreds of people were infected when they received contaminated blood in transfusions. Similarly infected were hemophiliacs, who rely on products manufactured from the blood of many donors. Since the discovery of HIV, screening of all blood products has become a routine part of blood collection procedures and there is now only an infinitesimal chance that HIV will be transmitted in this way. However, because AIDS was associated with blood transfusions, many Americans are confused and think that they can become infected with HIV by donating blood. In this country, blood is taken from donors with sterile needles that have never before been used, and there is no way a blood donor can be infected with HIV while donating blood.

Maternal/fetal Transmission

The third primary means of HIV transmission is maternal/fetal transmission. About 30 percent of pregnant HIV-infected women pass the virus to their babies, either during pregnancy or at the time of birth. The exact mechanism of transmission is not understood. Why as many as 70 percent of babies escape infection is also not clear. HIV is also found in breast milk, and some babies have been infected through nursing. AIDS and pregnancy is discussed in greater detail later in this chapter.

Other Means of Transmission

There is a documented case of a dentist with AIDS transmitting the disease to his patients, although how it occurred has eluded medical detectives. Obviously, it is theoretically possible for it to happen if the dentist has an open cut or sore on his hand that bleeds in the patient's mouth. However, this is extremely unlikely since dentists almost always wear gloves when they work with patients.

This is true for all dental, medical, and surgical procedures. Studies have been done of at least two surgeons who had AIDS, and it was found that none of their patients had been infected. In fact, the health care worker is at greater risk of being infected than the patient.

There is also a theoretical possibility that HIV could be transmitted through procedures such as haircuts or manicures, if an infected practitioner is bleeding and a client has an open cut or infected blood from a previous client is passed along on an unsterilized instrument. However, these too are very unlikely ways for the virus to be spread, and no cases have been documented.

How AIDS is not Transmitted

Unlike the common cold and flu viruses, HIV is not airborne and cannot be spread through coughing, sneezing, touching, or any other kind of casual contact. You cannot get it from toilet seats, doorknobs, or mosquito bites. People live in the same household for years with HIV-infected people without becoming infected. HIV-infected children go to school without any threat of spreading the virus to other children. Caretakers routinely change the diapers of HIV-infected babies without becoming infected.

It has become apparent through the years that HIV is a very difficult virus to transmit, unless the conditions are exactly right, as in sexual contact. Unfortunately, because of the deadly nature of AIDS, many rumors and much misinformation have grown around the subject. A properly informed person who takes appropriate precautions has little to fear.

How to Protect Yourself from AIDS

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HIV is a virus that is spread through certain actions that can be controlled. However, two activities most often involved in the spread of HIV are drug addiction and sexual activity, both of which can be compulsive and difficult to control. Despite this, progress is being made.

Knowing how AIDS is spread is the first line of defense. An example can be seen in the gay community, where HIV infection rates have gone down as the impact of AIDS has been felt and procedures for safer sex have been widely publicized.

The only sure means of prevention is abstention. This applies to both drugs and sex. If you don't inject drugs, if you don't have sexual intercourse, then you will run no risk of being infected by HIV through these modes of transmission.

Short of that, there are steps you can take to reduce risk. Drug users should never share needles. Some cities have started needle exchange programs so that addicts will, at least, have uncontaminated needles. At the very minimum, a used needle should be sterilized with a bleach mixture to kill the AIDS virus.

With sexual behavior, keep in mind that you are being exposed not only to your partner, but to every person your partner has ever had sex with. The only way you can be sure that you are not being exposed to HIV is if you are certain that your partner is HIV-negative (which can be established by testing, as explained in the next section), and equally certain that your partner is currently not having sex with anyone else.

If you are not confident of both of these facts, the best way to protect yourself is to use a condom during every act of sexual intercourse. A latex condom in place throughout all genital and anal contact has been shown to be an effective barrier against the spread of HIV. However, no barrier method is foolproof and the tiniest pinprick in a condom could allow the passage of HIV. (Note that while the condom is also a birth control device, other methods of birth control do not prevent the spread of disease. Just because you are taking birth control pills, for example, does not mean that you need not use condoms to protect yourself from HIV.)

Some spermicides, particularly nonoxynyl-9, have been found to kill HIV in laboratory settings, although this effect has not been proven in actual practice. Using a spermicide may provide a second layer of prevention, but it could also have the reverse effect. Some women are sensitive to certain spermicides in which case the spermicide can cause vaginal irritation, thereby easing transmission of the virus.

For women, insisting on the use of condoms for all acts of sexual intercourse may mean employing new means of negotiation with sexual partners and taking control of relationships in a new way. Men may be resistant to using condoms; women may be reluctant to threaten a relationship by introducing the subject. These are issues that every woman must work out for herself, along with her partner.

In late 1993 a new device was marketed in the U.S.—the female condom. It is a latex sheath that is comparable to the male condom, except that it fits into the vagina rather than being slipped over the penis. It has a two flexible rings: one on the closed end that goes up into the vagina to rest against the cervix; the other at the open end that hangs outside the vagina. The female condom is a rather bulky device and marketing tests found many aesthetic objections to it, but it does offer protection that a woman can control. As such, it is an important first step in providing women with a protective tool that is under their own initiative.

Remember, too, that drugs play a role in the transmission of HIV apart from needle-sharing. Drugs and alcohol impair judgment and can affect your ability to make responsible decisions in sexual situations.

Getting tested for HIV

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Shortly after HIV was discovered in 1984, a laboratory procedure became available to test for the presence of the virus. Today, AIDS testing is widely accessible through state and local health departments, clinics (particularly infectious disease clinics and clinics that specialize in the treatment of sexually transmitted diseases), and some private doctors and laboratories. The test requires only the drawing of a small amount of blood. It is quite reliable and may be free or inexpensive at a public clinic. In some areas it is possible to be tested anonymously under a number or fictitious name. In most settings you can expect to learn the results within a week.

The most widely used test looks not for the virus itself, but for antibodies that the immune system produces when it is infected with the virus. Actually two tests are usually performed. If the first test, called the ELISA (enzyme-linked immunosorbent assay), is positive for the presence of HIV antibodies, a confirmatory test called the Western blot is done.

Most people who are infected with HIV produce antibodies within a couple of months of infection. If you think you have been exposed to the virus and a test performed shortly after this exposure turns out to be negative, you should probably wait another couple of months and be tested again. By six months after exposure, most people will have the antibodies necessary to produce an accurate test result.

Because of the confusion and misinformation that often surround the subject of HIV/AIDS, testing for HIV should always be accompanied by counseling, both before the test is given and when the results are known. It is important to understand what a positive (infected) test result means for you and for your sexual partner(s), and what steps you can take to deal with the problem. Likewise, don't interpret negative (uninfected) test results as permission to continue irresponsible and risky behavior.

For years, AIDS testing was dismissed by many as having little value because there was not much that could be done if you knew you were HIV-positive. Also, many people feared that if it were known they were infected with the AIDS virus, they could lose their health insurance, their jobs, and even their friends and family. It is not hard to see why, for many, it seemed better not to know.

However, that situation is changing as more treatment options become available for HIV/AIDS patients. Preventive therapies are now available for HIV infection itself, as well as for some of the opportunistic infections. There is much you can do to help yourself if you know you are infected with HIV.

Another reason to know your HIV status is to prevent spreading the infection to others. This is important if you are beginning a new sexual relationship, and of particular importance if you are thinking of becoming pregnant.

How is HIV/AIDS Treated?

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There is no cure for AIDS. There is no vaccine. These bleak facts are the bottom line for the disease that has become one of the biggest killers of young women in the world.

However, there are a number of treatments that are prolonging lives and improving the quality of life for infected patients. Billions of dollars are spent every year in a search of treatments and vaccines. Research trials are investigating how combinations of drugs work on the disease. Even without an actual cure, many physicians predict that one day HIV/AIDS may be a disease that can be managed with medications, much like diabetes or high blood pressure, and that patients will be able to live long and productive lives.

Most of the testing on AIDS-related drugs has been done on men, and some of these drugs may have different actions when taken by women. New studies are gradually gathering information that is specific to women. Meanwhile, doctors must rely on information gained from existing tests and their own experience and intuition in tailoring dosages and combinations for their female patients.

Treatment falls into two categories: medication that works against the AIDS virus itself, and medication that treats the opportunistic infections, including gynecological problems.

Antiviral Medication

Technically HIV is classified as a retrovirus. Such viruses contain an enzyme called reverse transcriptase, which is what they use to reproduce themselves. There are currently four drugs used to treat HIV infection, and all four work to prevent the action of reverse transcriptase. These drugs are:

• Zidovudine (AZT or Retrovir)
• Didanosine (ddI or Videx)
• Zalcitabine (ddC or Hivid)
• Stavudine (d4T or Zerit)

These compounds have been shown, both in the laboratory and in patients, to slow the progress of HIV infection and to prolong life. However, all are powerful drugs with potentially toxic side effects. AZT may cause anemia, and patients may require blood transfusions to supplement red blood cell levels. Didanosine has been associated with inflammation of the pancreas, and zalcitabine with harm to the nerves, causing, in particular, numbness in the feet. Among other side effects of these drugs are headaches, fever, and nausea.

Also, over time the virus may develop resistance to a particular drug, reducing its effectiveness after prolonged use. Switching from one drug to another is effective for some patients who develop tolerance.

Some studies have found that HIV-infected women using zidovudine have higher rates of liver disease than men taking the drug. Women taking this medication should have periodic checks of liver function.

Fighting off Opportunistic Infections

Since Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection in both male and female AIDS patients, special attention has been given to developing ways to prevent it. Three drugs have been found effective in preventing PCP: trimethoprim-sulfamethoxazole (Bactrim, Septra), which is taken orally; dapsone, also taken orally; and pentamidine (Pentam, NebuPent), which is taken through aerosol inhalation.

With the exception of dapsone, these drugs can be given intravenously to treat PCP after it develops.

Fluconazole (Diflucan), an oral anti-fungal medication, has been used to prevent thrush and cryptococcal infections in patients with very low CD4 counts. Rifabutin (Mycobutin), a new drug, is being used to prevent Myobacterium avium-intracellulare infections in these patients.

Treating Gynecological Problems

The gynecological problems of HIV-infected women should be treated promptly and aggressively. Because of the association between HIV and cervical disease, regular Pap smears are imperative, and colposcopy and biopsy are recommended following abnormal Paps. Abnormal growth of cervical cells can be treated with electrocautery or loop diathermy, procedures that burn away affected tissue; cryotherapy, which freezes it; laser vaporization; or cone biopsy, which removes the tissue surgically. Cervical cancer is usually treated with a hysterectomy to remove the entire uterus.

Pelvic inflammatory disease is sometimes resistant to treatment in HIV-infected women. Some gynecologists recommend admitting patients with PID to the hospital, so they can be treated with intravenous (IV) antibiotics. The usual course for a moderately severe case is a week's hospitalization with IV treatment, followed by two weeks on oral antibiotics.

Vaginal thrush, or candidiasis, is probably the most common gynecological problem experienced by women with HIV/AIDS. There are several simple preventive measures that may help ward off these yeast infections. For example, cotton underwear (rather than less absorbent nylon) can cut down on moisture, which promotes the growth of the Candida organism. Some doctors advise reducing intake of caffeine, sugar, and alcohol, which are thought to promote yeast infections, although these connections are not well established. Douching is discouraged, since it may wash out natural organisms in the vagina that prevent Candida infection. Antibiotics taken for other infections can increase the chances of developing thrush, but eating yogurt can help reduce the risk. Topical anti-thrush medications such as miconazole (Monistat) or clotrimazole (Mycelex-G or Gyne-Lotrimin) are effective, but often a two-week course is advised, instead of the standard seven-day treatment. If the infec tion is particularly stubborn, treatment with oral anti-fungals may be necessary.

AIDS and Pregnancy

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AIDS in babies first brought widespread attention to women with AIDS, and the women were largely regarded not as AIDS patients themselves, but as the means of transmission to their children. Although that emphasis is changing, the fact remains that many women who are infected with HIV are first diagnosed when they are pregnant, or shortly after they give birth.

Still, pregnant HIV-infected women have not been studied systematically. Many questions remain about the effect of pregnancy on the course of the disease in the mother, about the effect of HIV on the developing baby, and about the effect of anti-HIV medications on the baby.

Pregnant women who are diagnosed with HIV need to be told of the chances of transmitting the infection to their babies so that they can make an informed choice about continuing or terminating the pregnancy.

It is also not clear whether HIV infection has a negative impact on the pregnancy. Nearly three-quarters of the babies born to HIV-infected mothers will not be infected themselves. However, because babies carry their mothers' antibodies, even non-infected infants will test positive for HIV for a year or longer after birth.

Although a slight decline in immune function has been observed in healthy pregnant women, it is not clear that pregnancy worsens the health of women with HIV/AIDS. Studies have shown mixed results, but a clear pattern of worsening health with pregnancy is not apparent.

Most obstetricians who treat women with HIV/AIDS recommend that these women take the same medications as those who are not pregnant. Indeed, one recent study has shown that AZT can cut the risk of transmitting HIV to the baby by fully two-thirds. Other studies have shown that AZT does not cause fetal malformations, fetal distress, or premature birth. It seems likely that a course of AZT during pregnancy may soon become accepted practice in the presence of HIV.

Whether she takes AZT or not, any HIV-infected woman who is pregnant or planning to become pregnant needs to discuss the situation with her doctor. Some of the drugs used against opportunistic infections are known to harm developing babies. Less is known about the effects of didanosine and zalcitabine; but for the sake of the baby, a woman without symptoms who still has a healthy CD4 count can probably safely delay treatment with these drugs until after the completion of pregnancy.

Because it is thought that infants may become infected with HIV during delivery, some doctors suggest that HIV-infected women deliver by Cesarian section, rather than vaginally, to lessen the chance of infection. Others point out that HIV is more efficiently transmitted through blood than vaginal fluids, so that C-section may actually increase the risk of infection for the baby.

HIV-infected women who are pregnant carry a heavy emotional load. At this time of new beginnings, they are forced to face the fact that they have a fatal disease and may not live to see their babies grow up. On top of this, they are confronted by the possibility of an HIV-infected child, with all the burdens that implies. Women in this situation need support from their loved ones, from other women who have been in a similar situation, and from health care professionals.

Hope for the Future

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AIDS, since it was first identified, has posed a variety of not only medical, but also social and political problems. Until recently, the plight of HIV-infected women was totally overlooked. Now, however, the HIV/AIDS treatment community in this country has finally begun to address the problems of women with AIDS. Most large cities now have support groups for such women. More and more drug trials are enrolling women and special studies are being set up specifically for women. Gynecologists and family practitioners are increasingly likely to recognize symptoms of HIV infection in their female patients, and refer them to specialists if they do not feel capable of treating them.

Although AIDS is often viewed with despair, there is good reason for hope. As more and more people learn how to protect themselves from infection, the spread of AIDS can be slowed. And for those who are infected, research continues to show slow but steady progress. As accurate information about the spread of HIV makes its way to the public, every woman can learn that it is within her power to prevent herself from becoming infected with HIV.

In June 1993, the federal government announced the beginning of the Women's Interagency HIV Study, a four-year project that is studying what HIV/AIDS in women looks like, how it progresses, and how it is best treated. Future research will concentrate on how HIV affects the female reproductive systems and will examine more closely the mechanisms of heterosexual and maternal/fetal transmission of HIV.

In little more than a decade, we've learned a tremendous amount about HIV/AIDS. As research and education continue, they can only mean continuing progress in treatment and prevention—progress that can save and prolong lives and give valid reasons for at least some optimism about this devastating disease. 