HIV infection in women: Do sex and gender matter?



At least half of all HIV infections occur in women. Most women are of childbearing potential; therefore, issues encompassing reproduction and mother-to-child transmission are critical in the management of this population. The efficacy of antiretroviral therapy (ART) is similar in men and women, although rates of adverse events or toxicity may be higher in women, which, in turn, may be related to higher antiretroviral drug levels documented in pharmacokinetic studies. A substantial proportion of women may not derive the benefit of highly active ART because nonsuppressive regimens are commonly used, especially in resource-limited settings, to decrease mother-to-child transmission. The likely emergence of resistant virus can have long-term sequelae for the mother, child, and other exposed individuals. Additional studies are needed of sex/gender-related issues including antiretroviral toxicities, pharmacokinetic profiles of approved and novel agents, ART strategies during pregnancy to minimize HIV resistance, and determination of optimal antiretroviral regimens for women.

References and Recommended Reading

  1. 1.
    UNAIDS/WHO: AIDS epidemic update: November 19, 2007. Available at Accessed February 13, 2008.
  2. 2.
    Centers for Disease Control and Prevention (CDC): HIV transmission among black women—North Carolina, 2004. MMWR Morb Mortal Wkly Rep 2005, 54:89–94.Google Scholar
  3. 3.
    Joint United Nations Program on HIV/AIDS (UNAIDS): Report on the global AIDS epidemic. Available at Accessed September 22, 2007.
  4. 4.
    De Cock KM, Mbori-Ngacha D, Marum E: Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century. Lancet 2002, 360:67–72.PubMedCrossRefGoogle Scholar
  5. 5.
    Centers for Disease Control and Prevention: HIV/AIDS statistics and surveillance. Available at Accessed October 6, 2007.
  6. 6.
    Gray GE, McIntyre JA: Effect of HIV on women. AIDS Read 2006, 16:365–368, 373–377.PubMedGoogle Scholar
  7. 7.
    Ramjee G, Williams B, Gouws E, et al.: The impact of incident and prevalent herpes simplex virus-2 infection on the incidence of HIV-1 infection among commercial sex workers in South Africa. J Acquir Immune Defic Syndr 2005, 39:333–339.PubMedCrossRefGoogle Scholar
  8. 8.
    Quinn TC, Wawer MJ, Sewankambo N, et al.: Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000, 342:921–929.PubMedCrossRefGoogle Scholar
  9. 9.
    Watson-Jones D, Weiss HA, Rusizoka M, et al.: HSV trial team; Steering and Data Monitoring Committees: Effect of herpes simplex suppression on incidence of HIV among women in Tanzania. N Engl J Med, 2008, 358:1560–1571.PubMedCrossRefGoogle Scholar
  10. 10.
    Zorrilla CD: Antiretroviral combination therapy in HIV-1 infected women and men: are their responses different? Int J Fertil Womens Med 2000, 45:195–199.PubMedGoogle Scholar
  11. 11.
    Dunkle KL, Jewkes RK, Brown HC, et al.: Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 2004, 363:1415–1421.PubMedCrossRefGoogle Scholar
  12. 12.
    Clark RA, Squires KE: Gender-specific considerations in the antiretroviral management of HIV-infected women. Expert Rev Anti Infect Ther, 2005, 3:213–227.PubMedCrossRefGoogle Scholar
  13. 13.
    Gardner LI, Holmberg SD, Moore J, et al.: Use of highly active antiretroviral therapy in HIV-infected women: impact of HIV specialist care. J Acquir Immune Defic Syndr 2002, 29:69–75.PubMedGoogle Scholar
  14. 14.
    Gandhi M, Bacchetti P, Miotti P, et al.: Does patient sex affect human immunodeficiency virus levels? Clin Infect Dis 2002, 35:313–322.PubMedCrossRefGoogle Scholar
  15. 15.
    Sterling TR, Vlahov D, Astemborski J, et al.: Initial plasma HIV-1 RNA levels and progression to AIDS in women and men. N Engl J Med 2001, 344:720–725.PubMedCrossRefGoogle Scholar
  16. 16.
    Junghans C, Ledergerber B, Chan P, et al.: Sex differences in HIV-1 viral load and progression to AIDS. Swiss HIV Cohort Study. Lancet 1999, 353:589; author reply 590–591.PubMedCrossRefGoogle Scholar
  17. 17.
    Moroni M: Sex differences in HIV-1 viral load and progression to AIDS. ICONA Study Group. Italian cohort of HIV-1 positive individuals. Lancet 1999, 353:589–590; author reply 590–591.PubMedCrossRefGoogle Scholar
  18. 18.
    Evans JS, Nims T, Cooley J, et al.: Serum levels of virus burden in early-stage human immunodeficiency virus type 1 disease in women. J Infect Dis 1997, 175:795–800.PubMedCrossRefGoogle Scholar
  19. 19.
    Sterling TR, Lyles CM, Vlahov D, et al.: Sex differences in longitudinal human immunodeficiency virus type 1 RNA levels among seroconverters. J Infect Dis 1999, 180:666–672.PubMedCrossRefGoogle Scholar
  20. 20.
    Moore RD, Cheever L, Keruly JC, Chaisson RE: Lack of sex difference in CD4 to HIV-1 RNA viral load ratio. Lancet 1999, 353:463–464.PubMedCrossRefGoogle Scholar
  21. 21.
    Anastos K, Gange SJ, Lau B, et al.: Association of race and gender with HIV-1 RNA levels and immunologic progression. J Acquir Immune Defic Syndr 2000, 24:218–226.PubMedGoogle Scholar
  22. 22.
    Prins M, Robertson JR, Brettle RP, et al.: Do gender differences in CD4 cell counts matter? AIDS 1999, 13:2361–2364.PubMedCrossRefGoogle Scholar
  23. 23.
    Hader SL, Smith DK, Moore JS, Holmberg SD: HIV infection in women in the United States: status at the millennium. JAMA 2001, 285:1186–1192.PubMedCrossRefGoogle Scholar
  24. 24.
    Moore AL, Kirk O, Johnson AM, et al.: EuroSIDA group: Virologic, immunologic, and clinical response to highly active antiretroviral therapy: the gender issue revisited. J Acquir Immune Defic Syndr 2003, 32:452–461.PubMedCrossRefGoogle Scholar
  25. 25.
    Benson CA, Collier AC, Bosch R, et al.: Pre-treatment factors that predict responses to potent antiretroviral therapy: findings from the AACTG A5001. Presented at 10th Conference on Retroviruses and Opportunistic Infections. Boston, MA: February 10–14, 2003.Google Scholar
  26. 26.
    Palella FJ, Gathe J, Brutus A, et al.: Gender comparisons in long term responses among patients receiving nelfinavir and dual nucleoside reverse transcriptase inhibitors as first ever highly active antiretroviral activity. Presented at XIV International AIDS Conference. Barcelona, Spain: July 7–12, 2002. Abstract WePeB5967.Google Scholar
  27. 27.
    Keiser P, Yazdani B, Koen G et al.: The effect of gender and weight on treatment outcome in nelfinavir-treated patients: a case control study. Presented at 10th Conference on Retroviruses and Opportunistic Infections. Boston, MA: February 10–14, 2003.Google Scholar
  28. 28.
    Gandhi, M, Aweeka F, Greenblatt RM, Blaschke TF: Sex differences in pharmacokinetics and pharmacodynamics. Annu Rev Pharmacol Toxicol 2004, 44:499–523.PubMedCrossRefGoogle Scholar
  29. 29.
    Fletcher CV, Jiang H, Brundage RC, et al.: Sex differences in virologic response and saquinavir pharmacology in ACTG 359. Antiviral Ther 2003, 8(Suppl 1): abstr 128.Google Scholar
  30. 30.
    Wathen L, Freimuth W, Cox S, et al.: Combination therapy with delavirdine plus zidovudine versus zidovudine alone: demographics, HIV viral load and CD4 changes in female patients. Presented at the 1997 National Conference on Women and HIV. Pasadena, CA: May 4–7, 1997.Google Scholar
  31. 31.
    Moore RD, Keruly JC, Chaisson RE: Incidence of pancreatitis in HIV-infected patients receiving nucleoside reverse transcriptase inhibitor drugs. AIDS 2001, 15:617–620.PubMedCrossRefGoogle Scholar
  32. 32.
    Bersoff-Matcha SJ, Miller WC, Aberg JA, et al.: Sex differences in nevirapine rash. Clin Infect Dis 2001, 32:124–129.PubMedCrossRefGoogle Scholar
  33. 33.
    Currier JS, Yetzer E, Potthoff A, et al.: Gender differences in adverse events on ritonavir: an analysis from the Abbot 247 study. Presented at the 1997 National Conference on Women and HIV. Pasadena, CA: May 4–7, 1997. Abstract 304.7.Google Scholar
  34. 34.
    Study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM): Fat distribution in women with HIV infection. J Acquir Immune Defic Syndr 2006, 42:562–571.CrossRefGoogle Scholar
  35. 35.
    Tien PC, Cole SR, Williams CM, et al.: Incidence of lipoatrophy and lipohypertrophy in the women’s interagency HIV study. J Acquir Immune Defic Syndr 2003, 34:461–466.PubMedCrossRefGoogle Scholar
  36. 36.
    Gervasoni C, Ridolfo AL, Trifirò G, et al.: Redistribution of body fat in HIV-infected women undergoing combined antiretroviral therapy. AIDS 1999, 13:465–471.PubMedCrossRefGoogle Scholar
  37. 37.
    Justman JE, Benning L, Danoff A, et al.: Protease inhibitor use and the incidence of diabetes mellitus in a large cohort of HIV-infected women. J Acquir Immune Defic Syndr 2003, 32:298–302.PubMedCrossRefGoogle Scholar
  38. 38.
    Howard AA, Floris-Moore M, Arnsten JH, et al.: Disorders of glucose metabolism among HIV-infected women. Clin Infect Dis 2005, 40:1492–1499.PubMedCrossRefGoogle Scholar
  39. 39.
    Dolan SE, Huang JS, Killilea KM, et al.: Reduced bone density in HIV-infected women. AIDS 2004, 18:475–483.PubMedCrossRefGoogle Scholar
  40. 40.
    Arnsten JH, Freeman R, Santorol N et al.: HIV infection and protease inhibitor use are not associated with reduced bone mineral density in older HIV-infected women. Presented at 10th Conference on Retroviruses and Opportunistic Infections. Boston, MA: February 10–14, 2003.Google Scholar
  41. 41.
    Anastos K, Hessol N: The association of bone mineral density with HIV infection and antiretroviral treatment in women. Presented at 11th Conference on Retroviruses and Opportunistic Infections. San Francisco, CA: February 8–11, 2004.Google Scholar
  42. 42.
    Clark RA, Theall K: Population-based study evaluating association between selected antiretroviral therapies and potential oral contraceptive failure. J Acquir Immune Defic Syndr 2004, 37:1219–1220.PubMedCrossRefGoogle Scholar
  43. 43.
    Currier J: HIV Infection in women: an update. HIV/AIDS Annual Update 2003. Available at (learning modules). Accessed October 10, 2007.
  44. 44.
    Mildvan D, Yarrish R, Marshak A, et al.: Pharmacokinetic interaction between nevirapine and ethinyl estradiol/norethindrone when administered concurrently to HIV-infected women. J Acquir Immune Defic Syndr 2002, 29:471–477.PubMedGoogle Scholar
  45. 45.
    Watts D, Minkoff H: Managing pregnant patients. In AIDS Therapy. Edited by Dolin R, Masur H, Saag MS. Philadelphia: Elsevier; 2003:381–399.Google Scholar
  46. 46.
    Loko MA, Toure S, Dakoury-Dogbo N, et al.: Decreasing incidence of pregnancy by decreasing CD4 cell count in HIV-infected women in Cote d’Ivoire: a 7-year cohort study. AIDS 2005, 19:443–445.PubMedCrossRefGoogle Scholar
  47. 47.
    Bucceri A, Luchini L, Rancilio L, et al.: Pregnancy outcome among HIV positive and negative intravenous drug users. Eur J Obstet Gynecol Reprod Biol 1997, 72:169–174.PubMedCrossRefGoogle Scholar
  48. 48.
    Mofenson LM; Centers for Disease Control and Prevention, US Public Health Service Task Force: US Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. MMWR Recomm Rep 2002, 51(RR-18):1–38; quiz CE1–4.PubMedGoogle Scholar
  49. 49.
    Watts DH: Management of human immunodeficiency virus infection in pregnancy. N Engl J Med 2002, 346:1879–1891.PubMedCrossRefGoogle Scholar
  50. 50.
    Connor EM, Sperling RS, Gelber R, et al.: Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994, 331:1173–1180.PubMedCrossRefGoogle Scholar
  51. 51.
    De Santis M, Carducci B, De Santis L, et al.: Periconceptional exposure to efavirenz and neural tube defects. Arch Intern Med 2002, 162:355.PubMedCrossRefGoogle Scholar
  52. 52.
    Fundarò C, Genovese O, Rendeli C, et al.: Myelomeningocele in a child with intrauterine exposure to efavirenz. AIDS 2002, 16:299–300.PubMedCrossRefGoogle Scholar
  53. 53.
    Bryson Y, Stek A, Mirochnick M, et al.: for the PACTG 353 Team: Pharmacokinetics (PK), antiviral activity and safety of nelfinavir (NFV) with ZDV/3TC in pregnant HIV-infected women and their infants: PACTG 353 Cohort 2. Presented at 9th Conference on Retroviruses and Opportunistic Infections. Seattle, WA: February 24–28, 2002.Google Scholar
  54. 54.
    Acosta EP, Bardeguez A, Zorrilla CD, et al.: Prediatric AIDS Clinical Trials Group 386 Protocol Team: Pharmacokinetics of saquinavir plus low-dose ritonavir in human immunodeficiency virus-infected pregnant women. Antimicrob Agents Chemother 2004, 48:430–436.PubMedCrossRefGoogle Scholar
  55. 55.
    Stek A, Mirochnick M, Capparelli E et al.: Reduced lopinavir exposure during pregnancy: preliminary pharmacokinetic results from PACTG 1026. Presented at XV International AIDS Conference. Bangkok, Thailand: July 11–16, 2004.Google Scholar
  56. 56.
    Mirochnick M, Fenton T, Gagnier P, et al.: Pharmacokinetics of nevirapine in human immunodeficiency virus type 1-infected pregnant women and their neonates. Pediatric AIDS Clinical Trials Group Protocol 250 Team. J Infect Dis 1998, 178:368–374.PubMedGoogle Scholar
  57. 57.
    Taha TE, Kumwenda NI, Hoover DR, et al.: Nevirapine and zidovudine at birth to reduce perinatal transmission of HIV in an African setting: a randomized controlled trial. JAMA 2004, 292:202–209.PubMedCrossRefGoogle Scholar
  58. 58.
    Thistle P, Spitzer RF, Glazier RH, et al.: A randomized, double-blind, placebo-controlled trial of combined nevirapine and zidovudine compared with nevirapine alone in the prevention of perinatal transmission of HIV in Zimbabwe. Clin Infect Dis 2007, 44:111–119.PubMedCrossRefGoogle Scholar
  59. 59.
    Lallemant M, Jourdain G, Le Coeur S, et al.: Perinatal HIV Prevention Trial (Thailand) Investigators: Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. N Engl J Med 2004, 351:217–228.PubMedCrossRefGoogle Scholar
  60. 60.
    Nolan M, Fowler MG, Mofenson LM: Antiretroviral prophylaxis of perinatal HIV-1 transmission and the potential impact of antiretroviral resistance. J Acquir Immune Defic Syndr 2002, 30:216–229.PubMedGoogle Scholar
  61. 61.
    Eshleman SH, Becker-Pergola G, Deseyve M, et al.: Impact of human immunodeficiency virus type 1 (HIV-1) subtype on women receiving single-dose nevirapine prophylaxis to prevent HIV-1 vertical transmission (HIV network for prevention trials 012 study). J Infect Dis 2001, 184:914–917.PubMedCrossRefGoogle Scholar
  62. 62.
    Mandelbrot L, Landreau-Mascaro A, Rekacewicz C, et al.: Agence Nationale de Recherches sur le SIDA (ANRS) 075 Study Group: Lamivudine-zidovudine combination for prevention of maternal-infant transmission of HIV-1. JAMA 2001, 285:2083–2093.PubMedCrossRefGoogle Scholar
  63. 63.
    Flys TS, Donnell D, Mwatha A, et al.: Persistence of K103N-containing HIV-1 variants after single-dose nevirapine for prevention of HIV-1 mother-to-child transmission. J Infect Dis 2007, 195:711–715.PubMedCrossRefGoogle Scholar
  64. 64.
    McConnell M, Bakaki P, Eure C, et al.: Effectiveness of repeat single-dose nevirapine for prevention of mother-to-child transmission of HIV-1 in repeat pregnancies in Uganda. J Acquir Immune Defic Syndr 2007, 46:291–296.PubMedCrossRefGoogle Scholar
  65. 65.
    Jourdain G, Ngo-Giang-Huong N, Tungyai P, et al.: Perinatal HIV Prevention Trial Group: Exposure to intrapartum single-dose nevirapine and subsequent maternal six month response to NNRT1 regimens. Presented at 11th Conference on Retroviruses and Opportunistic Infections. San Francisco, CA: February 8–11, 2004.Google Scholar

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© Current Medicine Group LLC 2008

Authors and Affiliations

  1. 1.Jefferson Medical College of Thomas Jefferson UniversityPhiladelphiaUSA

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