Elsevier

The Lancet

Volume 397, Issue 10279, 20–26 March 2021, Pages 1107-1115
The Lancet

Series
HIV and women in the USA: what we know and where to go from here

https://doi.org/10.1016/S0140-6736(21)00396-2Get rights and content

Summary

New diagnoses of HIV infection have decreased among women in the USA overall, but marked racial and geographical disparities persist. The federal government has announced an initiative that aims to decrease the number of new infections in the nation by 90% within the next 10 years. With this in mind, we highlight important recent developments concerning HIV epidemiology, comorbidities, treatment, and prevention among women in the USA. We conclude that, to end the US HIV epidemic, substantially greater inclusion of US women in clinical research will be required, as will better prevention and treatment efforts, with universal access to health care and other supportive services that enable women to exercise agency in their own HIV prevention and care. Ending the epidemic will also require eliminating the race, class, and gender inequities, as well as the discrimination and structural violence, that have promoted and maintained the distribution of HIV in the USA, and that will, if unchecked, continue to fuel the epidemic in the future.

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

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

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