We searched PubMed and Embase on Aug 31, 2019, for English language manuscripts published between Jan 1, 2010, and Aug 30, 2019, focusing on the HIV epidemic among cisgender and transgender women in the USA. Search strategies were based on a combination of controlled vocabulary, including medical subject headings (MeSH) and related keywords. We searched for the keywords “women”, “transgender women”, and related commonly used terms, in combination with “HIV” in MeSH, “human immunodeficiency
SeriesHIV and women in the USA: what we know and where to go from here
Introduction
Powerful social, economic, political, and structural forces promote and maintain the demographic and geographical distribution of HIV among women in the USA.1 Laws, government policies, and influence groups restrict the electorate,2, 3 resulting in reduced access to HIV prevention and care (eg, by limiting sex education, restricting the reproductive rights of women, and thwarting attempts to expand health insurance coverage).1 Mass incarceration, poverty, racism, homophobia, gender norms, and inequity reinforce each other's effects and work together to promote sexual network patterns that spread HIV.4 Stigma and violence against women further exacerbate these effects. These forces are among those that increase the susceptability of cisgender women (cis women) and transgender women (trans women) to HIV infection, worsen their health outcomes, and increase their mortality. In early 2019, the US Department of Health and Human Services announced its goal of reducing incident HIV infections by 90% within 10 years.5 With this goal in mind, we outline some important features of the current HIV epidemic among women in the USA and make recommendations for addressing them.
Section snippets
The significance of race and place
At the end of 2016, adult and adolescent women comprised almost a quarter (23·7% or 235 004 individuals) of all people diagnosed and living with HIV in the USA.6 The US Centers for Disease Control and Prevention (CDC) estimates that an additional 11% of women with HIV were unaware of their infection.7 Although 50% of 7401 new cases among women reported in 2017 occurred in women between the ages of 25 and 44 years, new diagnoses occurred among women of all ages, with 14% of these women aged
Diversity among women
Distinct subgroups of women with HIV are present in the USA, and each group has unique experiences and challenges.
HIV and other health issues
People with HIV experience many comorbidities that reflect concomitant biological, psychological, and social structural factors in their lives. In the following sections, we highlight a few comorbidities with particular significance for women, especially older women.
Cure
Persistence of the HIV reservoir that harbours latent HIV in CD4 memory T cells in the peripheral blood and tissues has frustrated efforts to cure HIV infection. Research suggests that sex differences exist in HIV latency and the size of the HIV reservoir.66 Oestrogen inhibits HIV transcription, and oestrogen receptor 1 has a key role in maintaining HIV latency. Ex-vivo administration of oestrogen inhibits T-cell receptor activation of transcription, whereas oestrogen-receptor antagonists
Prevention: treatment-as-prevention and PrEP
Many studies have shown that sexual contact with people whose plasma HIV loads are undetectable does not result in HIV transmission.68, 69, 70, 71 This recognition underpins the undetectable equals untransmittable initiative of the Prevention Access Campaign.72 This message has the potential to drastically decrease HIV-related stigma and improve the quality of life for women and men with HIV,73 and should be widely and rapidly disseminated.74
PrEP is the other major biomedical HIV prevention
Recommendations
The pillars of the Ending the HIV Epidemic initiative include early diagnosis, rapid and effective administration of ART to maintain durable viral suppression, and use of PrEP to prevent HIV infection among people at high risk.5 Much of the approach involves ensuring effective implementation and scale-up of the strategies already available in the nation's considerable armamentarium for HIV prevention and care. We outline a number of issues that are particularly relevant to features of the HIV
Conclusion
Ending the HIV epidemic among women in the USA and improving the lives of women with HIV will require universal access to health care. This process will also require unfettered access to behavioural health care, housing, food security, child-care programmes, and other supportive services that allow women to exercise agency in their own HIV prevention and care. Yet these services alone will not end AIDS. Ending the HIV epidemic in the nation will also require eliminating the race, class, and
Search strategy and selection criteria
References (99)
- et al.
The effect of menopause on the innate antiviral activity of cervicovaginal lavage
Am J Obstet Gynecol
(2015) - et al.
Are new antiretroviral treatments increasing the risks of clinical obesity?
J Virus Erad
(2019) - et al.
Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis
J Acquir Immune Defic Syndr
(2011) - et al.
HIV infection and heart failure outcomes in women
J Am Coll Cardiol
(2017) - et al.
Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study
Lancet HIV
(2018) - et al.
Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study
Lancet
(2019) - et al.
Providers should discuss U=U with all patients living with HIV
Lancet HIV
(2019) - et al.
Trends in the use of oral emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis against HIV infection, United States, 2012–2017
Ann Epidemiol
(2018) - et al.
Patient recommendations for PrEP information dissemination at family planning clinics in Atlanta, Georgia
Contraception
(2019) - et al.
Policies and politics that promote HIV infection in the Southern United States
AIDS
(2014)
Democratic contraction? Political consequences of felon disenfranchisement in the United States
Am Soc Rev
Felon disenfranchisement in the United States: a health equity perspective
Am J Pub Health
Social context, sexual networks, and racial disparities in rates of sexually transmitted infections
J Infect Dis
Ending the HIV epidemic: a plan for the United States
JAMA
HIV Surveillance Report, 2017
HIV among women
Unequal declines in absolute and relative disparities in hiv diagnoses among Black women, United States, 2008 to 2016
Am J Pub Health
Disparities in incidence of human immunodeficiency virus infection among Black and White women—United States, 2010–2016
Morb Mortal Wkly Rep
US and world population clock
NCHHSTP AtlasPlus
Communities in crisis: is there a generalized HIV epidemic in impoverished urban areas of the United States?
Examination of HIV infection through heterosexual contact with partners who are known to be HIV infected in the United States, 2010–2015
AIDS
Contribution of anal sex to HIV prevalence among heterosexuals: a modeling analysis
AIDS Behav
HIV infection linked to injection use of oxymorphone in Indiana, 2014–2015
N Engl J Med
HIV diagnoses and viral suppression among US women in rural and nonrural Areas, 2010–2017
J Rural Health
Durable viral suppression and transmission risk potential among persons with diagnosed HIV infection: United States, 2012–2013
Clin Infect Dis
Time spent with HIV viral load above 1500 copies/ml among patients in HIV care, 2000–2014
AIDS
Transgender demographics: a household probability sample of US adults, 2014
Am J Pub Health
Characteristics of transgender women living with HIV receiving medical care in the United States
LGBT Health
Antiretroviral treatment interruptions among Black and Latina transgender women living with HIV: characterizing co-occurring, multilevel factors using the gender affirmation framework
AIDS Behav
Estimating the prevalence of HIV and sexual behaviors among the US transgender population: a systematic review and meta-analysis, 2006–2017
Am J Pub Health
Characterizing the HIV care continuum and identifying barriers and facilitators to HIV diagnosis and viral suppression among Black transgender women in the United States
J Acquir Immune Defic Syndr
Characterizing the HIV care continuum among transgender women and cisgender women and men in clinical care: a retrospective time-series analysis
Clin Infect Dis
“We don't treat your kind”: assessing HIV health needs holistically among transgender people in Jackson, Mississippi
PLoS One
Transgender women living with HIV frequently take antiretroviral therapy and/or feminizing hormone therapy differently than prescribed due to drug–drug interaction concerns
LGBT Health
Transgender women, hormonal therapy and HIV treatment: a comprehensive review of the literature and recommendations for best practices
J Int AIDS Soc
Decreased tenofovir diphosphate concentrations in a transgender female cohort: implications for human immunodeficiency virus preexposure prophylaxis
Clin Infect Dis
The intersection between women's reproductive desires and HIV care providers' reproductive health practices: a mixed methods analysis
Matern Child Health J
Parenting desires among individuals living with human immunodeficiency virus in the United States
Open Forum Infect Dis
HIV and pregnant women, infants, and children
Antiretroviral therapy and adverse pregnancy outcome: the elephant in the room?
J Infect Dis
Neural-tube defects and antiretroviral treatment regimens in Botswana
N Engl J Med
Optimizing responses to drug safety signals in pregnancy: the example of dolutegravir and neural tube defects
J Int AIDS Soc
Adverse pregnancy outcomes among women who conceive on antiretroviral therapy
Clin Infect Dis
Postpartum HIV care continuum outcomes in the Southeastern USA
AIDS
“In the United States, we say, ‘No breastfeeding,’ but that is no longer realistic”: provider perspectives towards infant feeding among women living with HIV in the United States
J Int AIDS Soc
HIV among people aged 50 and older
Comparison of mucosal markers of human immunodeficiency virus susceptibility in healthy premenopausal versus postmenopausal women
AIDS Res Hum Retrovir
Rising obesity prevalence and weight gain among adults starting antiretroviral therapy in the United States and Canada
AIDS Res Hum Retrovir
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2021, The LancetCitation Excerpt :Because sexual and gender minority individuals, including men who have sex with men and transgender women who have sex with men, now account for most new HIV infections in the USA, advancing and protecting LGBTQ rights, access to services, and engagement in the response are essential, as is the training of health-care workers to provide culturally congruent and competent care. Protecting and advancing women's access to sexual and reproductive health services, including contraceptive services, is also essential.12 US women need to be included in HIV prevention and treatment trials.
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