DoxyPEP: Using antibiotics to prevent STIs

Signs And Symptoms Of HIV In Women

Early on, human immunodeficiency virus (HIV) causes flu-like symptoms, which are similar across sexes. HIV symptoms in women may differ after the initial infection and include changes in menstrual cycles and increased vaginal infections.

HIV is an infection that attacks cells in your immune system, known as CD4 cells. If untreated, HIV may progress to acquired immunodeficiency syndrome (AIDS), which increases the risk of severe infections.

Women may experience unique symptoms of HIV. Read on to learn about how HIV affects women, special considerations for women with HIV, and when to consult a healthcare provider.

Generally, people with HIV do not have symptoms right away. It may take 10 years or longer for people with HIV to notice symptoms or complications. HIV symptoms progress in stages: acute and chronic HIV. Chronic HIV may progress into AIDS if untreated. Acute HIV symptoms develop within two to four weeks after HIV exposure. During this stage, HIV quickly multiplies and spreads throughout the body. Within two to four weeks after exposure, about two-thirds of people with HIV have flu-like symptoms such as fever, chills, and fatigue. Those symptoms are your body's natural response to infection. Other acute HIV symptoms include: Mouth ulcers Muscle aches Night sweats Rash Sore throat Swollen lymph nodes Chronic HIV is also known as asymptomatic HIV infection. It's possible for people not to have any symptoms or feel sick. Severe HIV complications, such as a weak immune system, take years to develop. With chronic HIV, HIV continues to multiply but at lower levels. Chronic HIV can last about 10 years before progressing to AIDS if untreated. People with HIV develop AIDS if their CD4 counts fall below a certain level. AIDS increases the risk of opportunistic infections, those that happen more often or severely in people with weak immune systems than others. In addition to opportunistic infections, AIDS symptoms include: Anal, genital, or mouth sores Blotches on the skin Depression Diarrhea Memory loss or other neurological problems Pneumonia Rapid unintentional weight loss Reoccuring fevers Swollen lymph nodes On average, people with AIDS survive for three years without treatment. However, people with AIDS who receive antiretroviral therapy (HAART) can live for more than 10 years after onset. Several HIV-related health changes during chronic HIV infection are specific to women. It's possible not to experience any complications for quite some time. Still, they can eventually develop. Bone Loss People with HIV, especially women with HIV, experience faster bone loss than others without HIV. Generally, women tend to lose bone faster than men because of the hormonal changes after menopause. Having HIV can affect women's bone loss more so than usual. Early Menopause Menopause happens when you do not have a menstrual period for at least 12 months. In the United States, the average age for menopause is 52. People with HIV tend to enter menopause earlier than that. You may notice various changes, including the onset of hot flashes, during the time leading up to menopause. A hot flash causes sudden heat in the upper part or all of your body. The sensation can last anywhere from 30 seconds to 10 minutes and can happen at varying frequencies. Typically, people with HIV have more severe hot flashes than those without the virus. Menstrual Cycle Changes You may notice changes to your menstrual cycle if you have HIV. For example, people with HIV might miss their periods. They might also have lighter or heavier bleeding than before having HIV. People with HIV are more likely to have severe premenstrual syndrome (PMS) symptoms than others, such as: Backache Bloating or a gassy feeling Changes in appetite Constipation Cramps Diarrhea Headache Irritability Sleeping too little or too much Swollen or tender breasts In the United States, about 2% of transgender people make up new HIV diagnoses. Social and medical factors may affect symptoms in transgender women with HIV. Transgender women may face several obstacles in receiving proper healthcare compared to people with different gender identities. For example, transgender women may experience discrimination in healthcare settings, such as being called by the incorrect name or pronouns. Some evidence suggests that transgender women with HIV may have concerns over interactions between HIV medicines and gender-affirming treatments. Research has found that transgender women may develop more severe bone loss and have a higher risk of heart disease than others with HIV. As a result, transgender women with HIV are less likely to take HIV medicine than others. Recognizing those obstacles and taking steps to reduce them may help improve outcomes among transgender women with HIV. For example, experts advise healthcare providers to consider gender-affirming healthcare history (e.G., past hormone use or surgery) and adjust HIV medicines accordingly. HIV attacks and weakens the immune system. As a result, women with HIV have a higher risk than others of developing health conditions, such as: Cervical cancer: This cancer begins in the cervix, or the lowermost part of the uterus. Certain strains of human papillomavirus (HPV) are among the most common causes of cervical cancer. Women with HIV are more likely to have HPV than others. People with low CD4 counts are more likely to have abnormal cells in their cervix that may develop into cancer. Flu: People with low CD4 counts or those not taking HIV medicine are more likely to have complications from the flu than others. One of the most common flu complications is pneumonia. Heart disease: This is a group of conditions that affect your heart. Heart disease occurs when fatty substances build up in your arteries that carry blood to your heart. Certain HIV medicines may increase heart disease risk. Eating a healthy diet, regularly exercising, and not smoking help prevent heart disease. Hepatitis: This is an infection of the liver. Experts advise people with HIV to receive vaccines that prevent hepatitis A and B and regular tests for hepatitis B and C. Kidney disease: HIV may infect your kidney cells. As a result, HIV—as well as some HIV medicines—may damage the filters, or nephrons, in your kidneys that produce urine and remove waste. Pneumocystis pneumonia (PCP): Normally, your body keeps a balance of "bad" and "good" germs in your body. One of those "bad" germs is Pneumocystis jirovecii, a fungus. That fungus may grow out of control in people with weak immune systems, like those with HIV. Sexually transmitted infections (STIs): These infections spread through sexual contact. Some people with HIV are at risk for certain STIs, like herpes and pelvic inflammatory disease (PID). STIs may cause more severe symptoms and be harder to treat in people with HIV than others. Vaginal yeast infections: These infections happen when a fungus, Candida albicans, overgrows in the vagina. Candida overgrowth may occur if you have an illness that weakens your immune system, such as HIV. Vaginal yeast infections that happen at least four times a year are most common among people with chronic HIV. Pregnant or breastfeeding people and those taking HIV medication may be at risk for potential complications.  Transmission to Children HIV can pass from mother to child during pregnancy, birth, and breastfeeding. Still, people with HIV can have healthy pregnancies. The risk of passing HIV to an infant is less than 1% if you take precautions. A healthcare provider will likely advise the following precautions: Getting tested for HIV if you are pregnant or trying to become pregnant: A healthcare provider may advise testing again during your third trimester if you are HIV-negative but at risk of contracting the virus. Taking pre-exposure prophylaxis (PrEP): This medicine can help prevent HIV if you test negative for the virus but are at risk of contracting it. Using HIV medicine: This helps keep HIV at undetectable levels in your body. You may be able to deliver vaginally if your HIV levels are low. HIV medicine also prevents the virus from spreading through breast milk.  Pregnant people with HIV—and their children once they are born—need to take HIV medicine to reduce the risk of transmission. HIV Medicine Complications People with HIV can take antiretroviral therapy (ART) to bring and keep HIV at undetectable levels. ART allows people to live with few complications and minimal risk of passing HIV to others. Generally, women taking ART may have different—sometimes more severe—side effects from HIV medicines. Certain HIV medicines may cause nausea, rashes, and vomiting at higher rates in women than others. Some HIV medicines can interact with hormonal birth control and increase the risk of unintended pregnancy. You can use any form of birth control if you have HIV. Still, you might need a secondary form of protection if you typically use hormonal methods like implants, pills, or shots. Talk with a healthcare provider about the best birth control option if you take ART. Consult a healthcare provider or go to a clinic to receive a blood test if you suspect that you have had exposure to HIV and have flu-like symptoms. Any number of illnesses may cause those early symptoms and do not necessarily mean you have HIV. Still, the only way to know for sure is a blood test. Some people with HIV never develop early symptoms. A blood test is essential if you think you have had exposure to HIV and do not have flu-like systems.   Early diagnosis is vital for HIV. The sooner you receive a blood test and diagnosis, the sooner you can start treatment to bring and keep HIV at undetectable levels. Staying in close contact with healthcare providers is essential. HIV puts you at an increased risk of complications from infections. Talk to a healthcare provider about what to do if there is a change in your health, such as if you get the flu. Practicing safer sex, sometimes called "safe sex," can help prevent spreading STIs. The only way to completely prevent the spreading of STIs is to abstain from all forms of sex. However, ways to have safer sex include: Using a barrier, such as condoms, internal condoms, dental dams, and/or latex or nitrile gloves when you have any form of sex, including when using sex toys Getting regular STI testing Washing your hands before and after touching your or your partner's genitals Washing sex toys with soap and water before and after use—you can also use condoms on sex toys Using alcohol or other substances responsibly—drinking or getting high can lower your decision-making ability and could lead to forgetting to use barriers, using condoms incorrectly, or not practicing good hygiene Women with HIV may notice early menopause, menstrual cycle changes, and more frequent vaginal infections than average. HIV may impact bone loss and cervical cancer risk.  Consult a healthcare provider if you think you have had exposure to HIV. A blood test is the only way to know if you have HIV. The sooner you know you have HIV, the sooner you can begin treatment to bring and keep HIV at undetectable levels.

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Common Myths About HIV And AIDS

Over the past 3 decades, mistaken ideas about HIV and AIDS have sometimes brought on the behaviors that cause people to get the virus. Although we still have questions about HIV, researchers have learned a lot -- enough to know that people who are HIV-positive aren't dangerous or doomed

HIV isn't spread through touch, tears, sweat, saliva, or pee. You can't catch it by:

You can get it from infected blood, semen, vaginal fluid, or breast milk.

Because the virus is passed through blood, people have worried that they could get it from biting or bloodsucking insects. Several studies show that doesn't happen, even in areas with lots of mosquitoes and cases of HIV.

When bugs bite, they don't inject the blood of the person or animal they bit before you. Also, HIV lives for only a short time inside them.

The risk from oral sex is almost negligible compared with other types of sex. In theory, it seems possible if your partner has HIV, but in reality, that is not the case.

Most men get HIV through sexual contact with other men. But you can get the virus from heterosexual contact with an infected person, too: About 1 in 6 men and 3 in 4 women do. Women who have sex with women have the lowest risk of transmission.

You can have HIV without any symptoms for years. The only way for you or your partner to know if you're positive is to get tested. The long period of asymptomatic infection is why the CDC recommends that everyone between 18 and 64 be tested at least once as part of routine blood work. Anyone at an increased risk of getting HIV from sexual contact or from injecting drug use should get tested more often.

Antiretroviral drugs (ART) improve the lives of many people who have HIV and help them live longer. But many of these drugs are expensive and some may have serious side effects. And,  with the exception of a newer drug that can be given by injection, you have to take them every day. There's no cure for HIV, which is why treatment must be lifelong. And drug-resistant strains of HIV can make treatment harder.

Prevention is cheaper and easier than managing a lifelong condition and the problems it brings.

In the early years, when the disease was epidemic and no treatment was available, the death rate from AIDS was extremely high. But today's drugs allow people who have HIV or even AIDS to live much longer, normal, and productive lives. If you start drug treatment right away and take it correctly, it's possible you won't ever develop AIDS. And you may live as long as you would have without the virus.

HIV could make you more likely to get diseases like cancer, heart disease, and kidney disease. So take your HIV medicine as prescribed and protect yourself with a healthy lifestyle. And tell your doctor about any other health problems you have. HIV drugs can interfere with other medications and make some conditions harder to control.

Years ago, people with HIV did need to take a lot of pills. Now, most people starting on HIV treatment take one or two pills daily as part of antiretroviral therapy. You may be able to take medicines that combine two or three drugs in a single pill.

HIV treatments can lower the amount of virus in your blood to a level that doesn't show up in blood tests. This is called an undetectable viral load. Studies show that if your viral load is undetectable, you cannot transmit the virus sexually. But if you miss doses of your HIV meds or stop using them, you can pass the virus to others. So be sure to take them exactly as prescribed.

You should practice safe sex so you won't give the virus to someone else. Even if you and your partner both have HIV and undetectable virus, wearing condoms can protect you both from other, possibly drug-resistant, strains, as well as other sexually transmitted diseases.

You may be able to safely have children. Doctors can help you take steps to lower -- or remove -- the chance that you'll pass the virus to your partner during conception. If you're pregnant, your doctor will give you HIV drugs to protect you and your baby. The baby may also be given medication after birth.

HIV isn't a government conspiracy to kill minorities. Rates of infection are higher in African American and Latino people, but that may be due in part to less access to health care and other social and economic factors.

Can Women Living With HIV Safely Breastfeed?

The HIV reservoir in breast milk was reassuringly limited in a preliminary study on two individuals with long-term, sustained viral suppression.

No HIV RNA copies were detected in breast milk fluid from two women living with HIV (WLWH), one an exceptional elite controller (EEC) with 9 years of spontaneous viral control and the other on antiretroviral treatment (ART) with undetectable viral loads for years, reported Natalia Laufer, MD, PhD, an infectious disease researcher at the University of Buenos Aires in Argentina, and colleagues.

Very low levels of cellular HIV DNA were detected in these women (0.08 and 0.74 HIV DNA copies per million cells, respectively). Additionally, the EEC showed no HIV provirus while the ART patient showed just 4 defective HIV copies in 11 million cells, Laufer and colleagues wrote in the Annals of Internal Medicine.

"The most significant finding is the extremely low levels of cellular HIV DNA in both women and the absence of intact HIV in the breast milk of the elite controller," Laufer told MedPage Today.

She told MedPage Today that this study is "the first detailed description of the HIV reservoir in breast milk cells, contributing new insights into how HIV behaves during lactation," and joins the body of research trying to understand the "optimal virological scenario" for WLWH who wish to chest/breastfeed.

For many years, high-income nations have discouraged WLWH from breastfeeding in order to prevent any HIV transmission risk at all. But these guidelines are evolving, in part motivated by WLWH who wish to breastfeed and the recent mantra that "Undetectable = Untransmittable." Earlier this year, the American Academy of Pediatrics okayed breastfeeding for some WLWH on ART.

For WLWH not on ART, HIV transmission through breast milk can be as high as 16 to 20%, most commonly in areas where formula and safe water can be limited, according to an accompanying editorial by Lynne Mofenson, MD, of the Elizabeth Glaser Pediatric AIDS Foundation in Washington, D.C., and William Short, MD, MPH, of the University of Pennsylvania Perelman School of Medicine in Philadelphia.

The editorialists cautioned that while research has proven that sexual transmission does not occur in people living with HIV who have reached and sustained an undetectable viral load, the risk for breast milk transmission for this same group is low -- but not nonexistent.

Laufer acknowledged that the principle of "Undetectable = Untransmittable" isn't fully applicable to breastfeeding, but suggested that the present findings are promising and "support the idea that with close monitoring and adherence to ART, the risk of HIV transmission through chest/breastfeeding is extremely low, which could influence future guidelines," adding that "this is crucial in contexts where formula feeding may not be practical or safe."

Ultimately, authors concluded that "this preliminary study shows that evaluating the HIV landscape in breast milk is feasible and lays the groundwork for future studies evaluating paired blood or breast milk samples from a larger number of WLWH with long-term viral suppression who are receiving new-generation ART."

Mofenson and Short said the study's findings support shared-decision making between people with undetectable HIV viral loads on ART and their healthcare team.

In fact, the study was inspired by one patient who wanted to breastfeed despite having HIV, Laufer said. That woman, referred to as the "Esperanza patient," was the EEC who had 9 years of spontaneous viral control. She did not breastfeed but for 7 weeks voluntarily extracted her breast milk for the research.

The second participant, the WLWH receiving ART, was on abacavir-lamivudine-dolutegravir and had an undetectable viral load for more than 5 years. This woman breastfed for 12 months without transmitting HIV to her child.

Finally, an HIV-negative woman served as control for the study.

From breast milk, HIV viral loads were assessed via centrifugation with a limit of quantification less than 40 HIV RNA copies/mL. HIV DNA was measured with a polymerase chain reaction (PCR) test as well as a full-length individual proviral sequencing (FLIPS) assay.

The study was limited by its small sample size -- just two WLWH -- and had limited follow-up. Additionally, it wasn't designed to evaluate HIV transmission risk, the investigators acknowledged.

In terms of future research, Laufer said the team will focus on studying larger cohorts of WLWH and examining how different ART regimens and varying durations of viral load suppression affect HIV reservoirs in breast milk to inform breastfeeding guidelines.

Rachael Robertson is a writer on the MedPage Today enterprise and investigative team, also covering OB/GYN news. Her print, data, and audio stories have appeared in Everyday Health, Gizmodo, the Bronx Times, and multiple podcasts. Follow

Disclosures

Laufer and colleagues had no conflicts of interest. Short reported being a consultant for ViiV Healthcare, and Mofenson reported being a consultant for the WHO.

Primary Source

Annals of Internal Medicine

Source Reference: Osegueda A, et al "HIV reservoir landscape in breast milk from long-term virally suppressed individuals" Ann Intern Med 2024; DOI: 10.7326/ANNALS-24-00085.

Secondary Source

Annals of Internal Medicine

Source Reference: Mofenson LM, Short WR "Breastfeeding, antiretroviral therapy, HIV transmission, and the HIV reservoir" Ann Intern Med 2024; DOI: 10.7326/ANNALS-24-02186.

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