Some of the information contained in this Guide may cite the use of a particular drug in a dosage, for an indication, or in a manner other than recommended. Therefore, the manufacturer’s package inserts should be consulted for complete prescribing information.

This Guide contains information relating to general principles of medical care which should not be construed as specific instructions for individual patients. Recommendations for HIV care change frequently, so the care provider is cautioned that this 2001 edition is dated Febru-ary 2001. To find updated information, consult the listings in Chapter XV on Resources.

For the most current HIV/AIDS treatment guidelines, contact the
AIDS Treatment Information Service (ATIS):
United States & Canada: 1-800-HIV-0440
Fax number: 1-301-519-6616 TTY: 1-888-480-3739
International: 1-301-519-0459
Mailing Address: HIV/AIDS Treatment Information Service P.O. Box 6303
Rockville, MD 20849-6303 Web site: http://hivatis.org E-mail: atis@hivatis.org

Send Us Your Comments
E-mail: womencare@hrsa.gov
Fax to the attention of “Womencare”: 301-443-0791 (USA)
Postal address: Womencare
Parklawn Building, Room 11A-33 
5600 Fishers Lane Rockville, Maryland 20857 USA

Note that this and subsequent editions of
A Guide to the Clinical Care of Women with HIV will be available online.
Go to the HIV/AIDS Bureau Web site and click on the publication Women’s Guide: http://www.hab.hrsa.gov/

Dedication

     A Guide to the Clinical Care of Women with HIV is dedicated to Donna M. Davis, who died in June 1999.
She worked to improve the lives of women both in the U.S. and globally.

ACKNOWLEDGMENTS

A number of people made this Guide possible. Joan Holloway’s vision provided the framework for the Guide's inception and development. Magda Barini-García, MD, the Project Officer, skillfully shepherded and oversaw the project. Helen Schietinger, the Project Manager, coordinated the entire process masterfully and brought it to fruition. Others whose work was essential include staff from HRSA’s HIV/AIDS Bureau, Tom Flavin and Brad Read of the Office of Communications, and Carole McGeehan of the DHHS Program Support Center’s Media Arts Branch, and Molly L. Mullen, medical editor.

CONTRIBUTING AUTHORS

SILVIA M. ABULARACH, MD, MPH
ASSISTANT PROFESSOR
DIVISION OF GYNECOLOGIC ONCOLOGY
JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE BALTIMORE, MD

CARLA S. ALEXANDER, MD
ASSISTANT PROFESSOR OF MEDICINE
UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE BALTIMORE, MD

JEAN R. ANDERSON, MD
ASSOCIATE PROFESSOR
GYNECOLOGY AND OBSTETRICS
JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE BALTIMORE, MD

BARBARA ARANDA-NARANJO, PHD, RN, FAAN
CHIEF, DEMONSTRATION PROJECT DEVELOPMENT AND EVALUATION BRANCH HIV/AIDS BUREAU, HEALTH RESOURCES AND SERVICES ADMINISTRATION ROCKVILLE, MD

PATRICIA BARDITCH-CROVO, MD
ASSISTANT PROFESSOR
DIVISION OF INFECTIOUS DISEASES
JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE BALTIMORE, MD

VICTORIA A. CARGILL, MD, MSCE
OFFICE OF AIDS RESEARCH
NATIONAL INSTITUTES OF HEALTH BETHESDA, MD

CONNIE CELUM, MD, MPH
ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF WASHINGTON
SEATTLE, WA

LAURA CHEEVER, MD
CHIEF, HIV EDUCATION BRANCH
HIV/AIDS BUREAU, HEALTH RESOURCES AND SERVICES ADMINISTRATION ROCKVILLE, MD

RACHEL DAVIS, RN
CLINIC COORDINATOR
SOUTH TEXAS FAMILY AIDS NETWORK
UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER SAN ANTONIO, TX

JUDITH FEINBERG, MD
PROFESSOR OF MEDICINE
UNIVERSITY OF CINCINNATI COLLEGE OF MEDICINE CINCINNATI, OH

HENRY L. FRANCIS, M.D.
DIRECTOR, CENTER ON AIDS AND OTHER MEDICAL CONSEQUENCES OF DRUG ABUSE
(CAMCODA)
NATIONAL INSTITUTE ON DRUG ABUSE BETHESDA, MD

DONNA FUTTERMAN, MD
ASSOCIATE PROFESSOR OF PEDIATRICS ALBERT EINSTEIN COLLEGE OF MEDICINE
BRONX, NY

RUTH M. GREENBLATT, MD
PROFESSOR OF MEDICINE, EPIDEMIOLOGY AND BIOSTATISTICS UNIVERSITY OF CALIFORNIA AT SAN FRANCISCO
SAN FRANCISCO, CA

NANCY A. HESSOL, MSPH
DEPARTMENT OF MEDICINE
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO SAN FRANCISCO, CA

JOYCE SEIKO KOBAYASHI, MD
ASSOCIATE PROFESSOR
UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER
DENVER, CO

RANI LEWIS, MD
ASSOCIATE PROFESSOR
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY VANDERBILT UNIVERSITY MEDICAL CENTER NASHVILLE, TN

JANINE MAENZA, MD
ACTING ASSISTANT PROFESSOR DEPARTMENT OF MEDICINE
DIVISION OF ALLERGY AND INFECTIOUS DISEASES UNIVERSITY OF WASHINGTON
SEATTLE, WA

PAUL PHAM, PHARMD
RESEARCH ASSOCIATE
DIVISION OF INFECTIOUS DISEASES
JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE BALTIMORE, MD

CHIA C. WANG, MD, MS
ACTING INSTRUCTOR
DEPARTMENT OF MEDICINE
DIVISION OF INFECTIOUS DISEASES UNIVERSITY OF WASHINGTON SEATTLE, WA

FOREWORD
Joseph F. O’Neill, MD, MPH

Dear Colleagues:

The Ryan White CARE Act program of the Health Resources and Services Administration is pleased to make this Guide available to clinicians caring for women living with HIV/AIDS. We believe it is the first comprehensive clinical manual on this topic, and the need for such a guide has never been greater. The World Health Organization estimates that the number of people living with HIV/AIDS is rapidly approaching 50 million, and that women constitute 45–50% of the total. Already, in several regions of the world, more than half of the people living with HIV/AIDS are women. But these statistics tell only part of the story. In addition to facing unique clinical issues, women living with HIV/AIDS are often challenged by social isolation, poverty, discrimination, and lack of access to quality health care.

     Please note that this Guide for the care of women has been written almost entirely by women. This is testimony to the enormous contribution that women have made in the battle against HIV/AIDS on every front and in every community across the globe. However, no medical guide can stand alone in assuring that women will receive the best treatment available. In addition to furthering our clinical knowledge, we must commit ourselves to addressing the myriad social and economic issues that hamper effective prevention and access to care for seropositive women.

     Please regard this as “our” Guide. It belongs to the global community of clinicians who struggle daily with HIV/AIDS, caring for people with competence, compassion, and equality. More than 20,000 copies of the preliminary edition of the Guide have been distributed at the XIII International Conference on AIDS in Durban, South Africa, and at other major meetings. As a result, comments and suggestions were received from Russia to Botswana and from China to Portugal. However, a manual like this is never finished. We need your continuing feedback to constantly reshape the Guide into a clinical tool that will be of maximum utility to all of us. We also need partners to help translate this Guide into the many languages of “our” community, so please send your suggestions. At the end of this Foreword, you will find information on where to send your comments by post, fax, or e-mail. You will also find the Web site address for the online version of the 2001 Guide.

     We all owe a debt of gratitude to John G. Bartlett, MD. His guide, Medical Management of HIV Infection, was the inspiration and template for this volume. He graciously allowed us to adapt many of the charts and algorithms for this book.

     Finally, I want offer my personal thanks to the editor, Jean R. Anderson, MD, for her tireless dedication and perseverance in creating this Guide. Her efforts have made a profound change possible. This Guide, I believe, will mark a turning point in significantly improving the care of women living with HIV/AIDS.

Cordially,

JOSEPH F. O’NEILL, MD, MPH
DIRECTOR, HIV/AIDS BUREAU
HEALTH RESOURCES AND SERVICES ADMINISTRATION U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Send Us Your Comments
E-mail: womencare@hrsa.gov
Fax to the attention of “Womencare”: 301-443-0791 (USA)
Postal address: Womencare
Parklawn Building, Room 11A-33 
5600 Fishers Lane Rockville, Maryland 20857 USA

Note that this and subsequent editions of
A Guide to the Clinical Care of Women with HIV will be available online.
Go to the HIV/AIDS Bureau Web site and click on the publication Women’s Guide: http://www.hab.hrsa.gov/

INTRODUCTION
Jean R. Anderson, MD

Despite the dramatic advances made in understanding the natural history of HIV disease and the development of effective antiretroviral therapies, the AIDS epidemic continues to grow. And that growth has displayed some disturbing trends. HIV/AIDS morbidity and mortality increasingly impact the poor, the disenfranchised, and the young. Women are traditionally over-represented in these groups.

     The growing number of women living with HIV/AIDS is a dominant feature of the evolving epidemic. In addition, because they are often diagnosed later and generally have poorer access to care and medications, women tend to have higher viral loads and lower CD4 counts. Women living with HIV/AIDS also must contend with vulnerability related to reproductive issues and domestic violence. Finally, women living with HIV/AIDS are usually relied upon to meet the care needs of children and other family members, many of whom are also HIV-positive.

     For these, and other reasons, a manual addressing the primary care needs unique to women with HIV infection is long overdue. This manual represents an attempt to fill this gap. Our target audiences are clinicians who provide primary care to women. This Guide might also be of interest to individuals seeking a more in-depth understanding of how to care for women with HIV/AIDS.

     The book you have in your hands is a preliminary edition, a work in progress, and we welcome your comments and suggestions. Please send any feedback to the postal, fax, or e-mail addresses found throughout the book and on the inside covers. We are particularly eager for this Guide to be translated into other languages. Please let us know if you can help or suggest partners.

     This preliminary edition is focused primarily on the problems facing HIV-infected women in the developed nations, primarily the United States. Our goal is that in future editions of this Guide we can take a more global perspective and address the care of women with HIV/AIDS in both developed and developing nations.

     I want to offer my personal thanks to Helen Schietinger and Magda Barini-García for their championing this Guide throughout its development, displaying enormous tact, tenacity, and attention to detail. Without them, this manual would never have been published.

     Finally, we want to acknowledge the women with HIV/AIDS who have been the inspiration for this manual. Their strength is celebrated and their struggle is not forgotten. We offer this Guide as a tribute to them, and to the providers who have taken on this struggle and made it their own.

JEAN R. ANDERSON, MD
EDITOR