EDITORIAL * EDITORIAL

Women and HIV infection and AIDS in Canada: Should we worry? Catherine A. Hankins, MD, MSc, FRCPC W orld AIDS Day, Dec. 1, is a reminder to us all that despite herculean efforts and substantial gains in our knowledge of acquired immunodeficiency syndrome (AIDS) we still face tremendous challenges. During the past year there has been considerable discussion in Canada about the so-called myth of AIDS among heterosexuals. Is AIDS simply a disease that occurs in people at high risk such as homosexual men and injection drug users? Should women in Canada and the clinicians who treat them be concerned about the risk of human immunodeficiency virus (HIV) infection, or has it all been blown out of proportion? Worldwide, AIDS is transmitted primarily through heterosexual, not homosexual, intercourse. In North America and some countries of Western Europe HIV infection entered the male homosexual population and remained there for some time. To this day in Canada AIDS case surveillance continues to reflect a predominance among homosexual men: 78.6% of the adult AIDS cases to date have homosexual or bisexual activity listed as the sole risk

factor.' However, AIDS case data reflect the past. We must look to HIV seroprevalence data for a clearer picture of the extent and nature of this epidemic, because the incubation period for AIDS is now estimated to be 10.6 to 13.0 (median 11.0) years.2 We have to look beyond AIDS statistics to know whether we should be concerned about heterosexual transmission and the risk to Canadian women. By early 1990 more than 3 million women worldwide, most of whom were of childbearing age, had HIV infection.3 In industrialized countries some

women are infected through the sharing of drug injection equipment. In developing countries unsafe blood transfusions and inadequately sterilized equipment play a role because the likelihood of hospital admission and treatment with parenteral medication and blood transfusion is greater among women than among men.4 Globally, though, heterosexual transmission remains the main route of HIV transmission among women. Of the 229 AIDS cases reported to the Federal Centre for AIDS, Ottawa, as of Sept. 4, 1990, 55% resulted from heterosexual activity, 23% from the receipt of infected blood or blood products and 6% from injection drug use; the risk factors were undetermined in 12%, and information was unavailable in 4%. Women still represent only 5% of all AIDS cases in Canada, so it is not surprising that most of us have underestimated the extent to which Canadian women are at risk for HIV infection. Seroprevalence data from large populationbased studies in several provinces are painting a truer picture. The highest rates among childbearing women have been documented in Quebec: I woman in 1638 who gave birth to a live infant in 1989 was infected with HIV.5 The rate in Ontario for the 9 months ending July 1990 is 1 in 3195 (Dr. Randolph Coates: personal communication, 1990). In this issue (see pages 1187 to 1192) Schechter and associates present data from an anonymous seroprevalence study of HIV infection among pregnant women in British Columbia and, the Yukon Territory from March to September 1989. They found that 1 pregnant woman in 3704 had HIV infection. It is difficult to understand the significance of

Dr. Hankins is a public health epidemiologist at the Centre for AIDS Studies, Department of Community Health, Montreal General Hospital, and is an assistant professor ofepidemiology at McGill University, Montreal.

Reprint requests to: Dr. Catherine A. Hankins, Centre for AIDS Studies, Department of Community Health, Montreal General Hospital, 300A -980 Guy St., Montreal, PQ H3H 2K3 CAN MED ASSOC J 1990; 143 ( 11)

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these rates. One approach is to look at estimates of the number of women with HIV infection determined on the basis of these studies. In 1989 in Quebec, for example, it was estimated that 56 women who gave birth to a live infant had HIV infection and that 988 women of childbearing age had HIV infection.5 Women who lived in areas of Montreal island with revenues below the provincial median accounted for 71% of the cases; this indicated a clear association between socioeconomic status and HIV infection among women. Compounding the relatively recent realization by epidemiologists that HIV was infecting Canadian women have been the difficulties clinicians face in recognizing HIV infection in their female patients. Women may not present for assessment if they misinterpret their symptoms, are too involved with caretaking responsibilities, have not established a good relationship with a physician or cannot overcome feelings of fear or denial. Even if they present, diagnosis may be delayed if physicians do not suspect HIV infection because of the nonspecific signs and symptoms: fatigue, fever, diarrhea, weight loss and vaginal infection. The natural history of HIV infection in women has not been well studied; however, unique features such as recurrent or persistent vulvovaginal candidiasis have been reported.6 Abnormal Papanicolaou smears and cervical dysplasia due to papilloma virus, persistent or recurrent genital herpes infection, menstrual abnormalities and pelvic infection due to sexually transmitted diseases complete the clinical picture. None of these is uncommon in sexually active women of childbearing age. Women presenting with full-blown AIDS in Canada are twice as likely as men to have opportunistic infections; 35.4% of all women with AIDS have presented with one or more such infections.1 Kaposi's sarcoma is found in only 2.1% of women. Pneumocystis carinii pneumonia remains the predominant presenting condition in men (49.1%) and women (49.8%). It may not be easy to diagnose in women if the possibility of HIV infection has not been considered. Clinicians in Canada who continue to believe that HIV transmission among heterosexuals does not exist or is merely an African or Caribbean anomaly will be missing the boat. Although some women with HIV infection in Canada will be easily recognizable because they inject illicit drugs, come from countries where heterosexual transmission predominates or have had many sexual partners, most will not. In Montreal a study in family practice and community clinics specializing in sexually transmitted diseases documented that, since 1979, 11.0% of the 694 women knew that they had had sexual intercourse with an injection drug user, and 11.7% 1172

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were aware that at least one of their sexual partners was bisexual.7 The fear of rejection or of destabilization of a relationship may keep people from disclosing their sexual activities or past or current injection drug use. For example, if a bisexual man is found to have HIV infection he may be reticent to share this information with his female partner because his sexual orientation will be revealed; likewise, if a woman is infected she may resort to secrecy because of a fear of abandonment by her male partner. Most of these situations are resolved through supportive communication: the physician can allow the patient to inform his or her partner, the physician can meet with both members of the couple to discuss the problem, or the partner can visit the physician alone. Most patients recognize that they have a responsibility to inform or allow their partners to be informed of the risk of HIV infection. Rarely is it necessary for a physician to breach patient confidentiality to inform a sexual partner at risk. Unwillingness to disclose appears to be prevalent in casual relationships; it has been reported that many men would lie about risk behaviour or their HIV antibody status if asked by a female partner.8 It seems unlikely that many of these women would even be aware of their exposure. The sexual history is now routinely taken during a clinical assessment; however, physicians should be aware that a history of no risk, even for a monogamous woman, does not rule out the potential for HIV transmission to a woman from her primary sexual partner. Should we routinely test our female patients at the time of their annual contraceptive visit regardless of the sexual history? No. HIV antibody testing in Canada still requires informed consent, the provision of counselling before and after testing, and confidentiality. Crucial to a woman's decision to take the test will be an exploration of the consequences of a positive test result. Who would need to be informed? Whom could she rely on for assistance? Would there be a possibility of early intervention with experimental therapies? What medical and psychologic follow-up would the physician provide or arrange? Would her employment, housing or financial security be jeopardized if other people found out? Would her knowledge of her HIV antibody status facilitate planning for the future or help with major life decisions? What would the effect be on her decision to have children? Most women will apparently have a positive attitude toward HIV antibody testing, possibly because they may be poorly informed of the consequences or they expect to have a negative test result. Anxiety may surface during the usual 3 to 5 weeks of waiting for the results and appear as insomnia, depression and withdrawal.

If the result is positive the initial response may be denial, shock, numbness and rage. Clinicians must allow their patients to vent these feelings; also, they should explore again with the patient the names of people to whom the patient can turn for support. In addition to discussing follow-up medical procedures, behaviours needed to maintain mental and physical health, and the type of support services available from local community groups physicians should assess the need for psychosocial follow-up and professional support. Men and women alike are extremely vulnerable immediately after being informed of a positive test result because they begin to realize then that their life will never again be the same. Since many will be too distraught to concentrate on instructions about safer sex the instructions should be repeated in more detail at a subsequent visit. If women are at risk for HIV infection what are the implications for physicians? They must start by being aware of the risk and by advising their sexually active female patients to practise safer sex if they decide to have sexual intercourse under circumstances of unknown risk. If physicians help women to develop better negotiating and communication skills with respect to sexual matters not only can they help to prevent disease but they may actually improve sexual health. Physicians must recognize that many women have partners who are unwilling to practise safer sex and that it may be impossible for some women to insist that sexual activity be conditional on the use of a condom. Also, there is increasing evidence that women believe condoms decrease sexual pleasure and are not appropriate when a couple is "in love".9 Major changes in the attitudes of both men and women are essential if they are to collaborate for protection through safer sex. For women in long-term partnerships it is inconceivable to introduce condom use without undermining the trust that is basic to most of these relationships. Cooperation is required to negotiate protection for both partners. If neither partner has HIV infection the safest option is mutual monogamy. Lack of sexual satisfaction in the primary relationship may prompt outside liaisons. If the

primary relationship is to remain condom free safer sex must be practised in any outside liaison. Clinicians can play an important role in preventing HIV transmission to women in primary relationships by emphasizing this message to their male and female patients. Worrying about women and HIV infection and AIDS in Canada does not help. Clinicians should gain an understanding of the nature and extent of the problem, raise their index of suspicion, develop good counselling skills and prepare to talk frankly with all adolescent and adult patients, men or women, about the risk of HIV infection. These are more appropriate responses to an epidemic that must be taken seriously and thoughtfully.

References 1. Surveillance Update: AIDS in Canada, Federal Centre for AIDS, Ottawa, Sept. 4, 1990

2. Lemp GF, Payne SF, Rutherford GW et al: Projections of AIDS morbidity and mortality in San Francisco. JAMA 1990; 263: 1497-1501 3. Chin J: Current and future dimensions of the HIV/AIDS pandemic in women and children. Lancet 1990; 336: 221-224 4. Fleming AF: AIDS in Africa 3:116-140

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an update. AIDS Forsch 1988;

5. Hankins CA, Laberge C, Lapointe N et al: HIV infection among Quebec women giving birth to live infants. Can Med Assoc J 1990; 143: 885-893 6. Anderson J, Horn J, Atkinson J et al: Gynecologic infection in women with HIV infection [abstr 2052]. Presented at the VIth International Conference on AIDS, San Francisco, June 20-24, 1990

7. Hankins C, Corobow G, Gendron S et al: Une etude seroepidemiologique portant sur la clientele feminine de quatre cliniques de MTS a Montreal. Ann Assoc Can Fr Av Sci 1989; 57: 328

8. Cochran SD, Mays VM: Sex, lies and HIV [C]. N Engi J Med 1990; 322: 774-775

9. Heterosexual behaviors and factors that influence condom use among patients attending a sexually transmitted disease clinic - San Francisco. MMWR 1990; 39: 685-689

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Women and HIV infection and AIDS in Canada: should we worry?

EDITORIAL * EDITORIAL Women and HIV infection and AIDS in Canada: Should we worry? Catherine A. Hankins, MD, MSc, FRCPC W orld AIDS Day, Dec. 1, is a...
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