Infectious Disease Advisor: What are the sex-specific barriers and facilitators of improved ART adherence?

Dr Karris: Several studies have demonstrated that women compared with men are less adherent to treatment and are more likely to experience nonstructured treatment interruptions.20-22 There are numerous sex-specific barriers and facilitators to adherence to ART that go beyond differences in side effects. This is in part due to women often caring more for others than for their own self-health. Factors such as caregiver burden are often cited as barriers to adherence.23

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Other sex-related inequalities affect ART adherence in women. For example, HIV-infected women report high rates of depression, stigma, and discrimination.24-26 There is fear of disclosure, which may be related to the threat of intimate partner violence.27,28 Worldwide, women also experience more vulnerability to economic and food insecurity.29 These socioeconomic disparities between men and women coupled with biologic differences make the care of women with HIV incredibly complex.

Infectious Disease Advisor: What are some of the facilitators of improved ART adherence?

Dr Karris: Increased adherence in women can be fostered through good relationships with their children30 and pregnancy.31.32 In fact, women are more adherent to therapy when they are pregnant to reduce the risk of vertical transmission. Another important facilitator is social or peer support among women.33 Community programs are an important means to improve adherence to ART and to address topics related to HIV prevention and cure within the female populations at risk for HIV.

Thankfully, ART today is simpler (due to fixed-dose combinations) and less toxic. However stigma, intimate partner violence, and other gender inequalities are big issues that are incredibly difficult to have an impact on.  Continued study into how these factors affect people living with HIV within the context of the cultures in which they are occurring (whether it is in the United States, Africa, or Asia) will allow us to make strides forward in women’s health, and not just for women living with HIV.

Infectious Disease Advisor: What is the impact of ART on the fertility of HIV-positive women?

Dr Karris: HIV, like many chronic inflammatory illnesses (eg, rheumatoid arthritis, inflammatory bowel disease), does appear to negatively affect fertility.34 A recent study suggests that the longer you have been infected with HIV, the less likely you are to become pregnant.35 Fertility does improve when women are treated with ART, but it does remain lower compared to HIV-negative, age-matched cohorts.35

Infectious Disease Advisor:  How does ART interact with contraception?

Dr Karris: Some ART decrease hormonal contraception levels when coadministered, resulting in lower contraceptive efficacy, while others increase hormonal contraception levels. Guidelines exist to help clinicians determine if the contraception their patients are using is appropriate.36,37 This is one reason we always recommend dual protection (ie, hormonal contraception and a barrier method like condoms) in women living with HIV who wish to avoid pregnancy.38