Australia is winning battles against HIV transmission in gay and bisexual men, and after witnessing the virus’ devastating impact on this community in the 1980s and ‘90s, this is a cause for celebration. A recent trial involving almost 10,000 homosexual men in NSW showed that use of pre-exposure prophylaxis, or PrEP, caused HIV transmission to be 90% lower than otherwise expected.
The Australian Federation of AIDs Organisations has also just released Agenda 2025; a fully costed national plan to achieve virtual HIV elimination in four years, which could prevent an estimated 6,000 infections and save about $1.4 billion in treatment and care costs. But as transmission among gay men subsides, we can’t forget there are other groups living with HIV in the shadows – including women.
HIV diagnoses among gay and bisexual men have declined by more than 20 per cent in the five years to 2019, but rates of heterosexual transmission in Australia remain steady, and now represent approximately 21% of annual transmission.
You might be surprised to learn that women make up around 11% of people living with HIV in Australia. Misplaced assumptions about who is at risk of HIV can mean some women experience a delayed diagnosis, causing them to miss the benefits of early intervention therapies and sustain greater damage to their immune systems.
Stigma and an understandable desire for privacy about a HIV diagnosis can also reduce women’s confidence in accessing services. We know the use of preventative measures by women are extremely low; men currently account for 98.5% of PrEP uptake.
Women living with HIV face a number of unique reproductive and sexual health challenges, and GPs, family planning clinicians, obstetricians and gynaecologists play a vital role in providing ongoing care.
Women living with HIV are up to six times more likely to develop cervical cancer, because their bodies are less likely to naturally clear the human papilloma virus. So, for HIV positive women we recommend cervical screening every 3 rather than 5 years.
Unique contraceptive considerations also come into play. While women living with HIV have multiple options, the hormonal IUD can be a suitable choice as it provides highly effective long-acting reversible contraception and is also unaffected by antiretroviral therapies. By contrast, antiretroviral therapies can cause the pill, the vaginal ring and the contraceptive implant to be less effective, and the depo injection can worsen bone density loss sometimes caused by the treatment.
For older women living with HIV, menopause can occur earlier and with more severe symptoms, including debilitating hot flushes and night sweats. Unfortunately, we hear from women that they are not always offered the same effective treatments for these symptoms as other women, despite the benefits of hormonal therapy for hot flushes and for their bone health.
There is a perception in the wider community that HIV simply isn’t a concern for women, or for heterosexual people. While any person can potentially contract HIV, our understanding of the groups at risk in Australia has changed over time. Injecting drug use remains a rare form of HIV transmission, and HIV rates are extremely low among female sex workers. HIV infection in women mostly occurs through heterosexual contact, usually with a partner from a country known to have a high prevalence of HIV.
Transmission is also rising among Aboriginal and Torres Strait Islander people, who are diagnosed between 1.3 to 1.9 times the rate of other Australians. While HIV infection rates during pregnancy are quite low we urgently need guidelines for providing PrEP to pregnant women, as well as women who are breastfeeding.
The good news is that we are moving in the right direction. In 2018, HIV diagnoses in Australia hit a seven-year low. However, to achieve full elimination, we need to focus on broader and newer groups at risk of transmission, and we can’t leave women out of the conversation.