Women Progress to AIDS at Lower Viral Loads

Treatment recommendations based on measures of HIV burden must be changed for women, new findings suggest. The new data show that women with HIV infection have lower viral load measurements than men. This would appear to be good news, but the data also show that women develop AIDS as quickly as men. These findings remain statistically significant even when adjusted for CD4 cell count, race, and recent drug use.

"Proportional-hazards models show that women with the same viral load as men had a 1.6-fold higher risk of AIDS (95 percent confidence interval (CI), 1.1-2.32); or, equivalently, that women with half the viral load of men had a similar time to AIDS as men," wrote Johns Hopkins researcher Homayoon Farzadegan and colleagues ("Sex Differences in HIV-1 Viral Load and Progression to AIDS," Lancet, 1998;352:1510-4). Farzadegan et al. analyzed 812 blood specimens obtained from 650 injection-drug users in an ongoing, observational study of community clinic-based patients. They measured HIV loads by branched-chain DNA (bDNA) tests, reverse-transcriptase polymerase chain reaction (PCR) assays, and quantitative microculture.

When women were compared to men, their median virus load was 3,365 vs. 8,907 copies/mL by bDNA (P=0.001); 45,416 vs. 93,130 copies/mL by polymerase chain reaction (PCR) (P=0.02); and five vs. eight infectious units per million peripheral blood cells by quantitative microculture (P=0.015). Farzadegan et al. noted that current U.S. Public Health Service (PHS) guidelines recommend beginning antiretroviral therapy for patients with viral loads of 10,000 copies/mL when CD4 counts are 500 cells/(micro)L. These guidelines, however, were developed from data collected in studies of men.

"A downward revision of the viral-load threshold for women by as much as half (5,000 copies/mL) might be prudent," they warned. "The possibility that women, according to current guidelines, will be under-treated on a population level must be carefully considered." The authors warned that their findings should not be interpreted to mean that women have a shorter time to AIDS after HIV infection. They instead stressed the interpretation that the relationship between viral load and AIDS is different for men and women. Exactly why the observed phenomenon occurs is unexplained.

This study was supported primarily by a grant from the National Institute on Drug Abuse, with additional funding provided by the U.S. Centers for Disease Control and Prevention (CDC). The corresponding author for this study is Homayoon Farzadegan, Johns Hopkins School of Hygiene and Public Health, 615 N. Wolfe Street, Room E6004, Baltimore, Maryland 21205 USA. E-mail: hfarzade@jhsph.edu.

Women's Health Weekly: December 14, 1998 issue (excerpted with permission)

Mortality Differences Between Men and Women Following First Heart Attack

Mortality after a heart attack is higher in women than in men. To better understand why this is so, Marrugat et al. conducted a prospective study of patients with acute myocardial infarction from 1992 to 1994, gathering data in four teaching hospitals in Spain. All patients were aged 80 years or younger and included 331 women and 1129 men. Outcomes were measured by survival at 28 days and mortality or readmission at 6 months.

The study showed that women were older when they had heart attacks, and presented more often with diabetes, hypertension or previous angina. They developed more severe heart attacks than men, (acute pulmonary edema or cardiogenic shock occurred in 24.8% of women and 10.5% of men,) and women were less likely than the men to receive thrombolytic therapy. However, rates of angioplasty and bypass surgery at 28 days and revascularization procedures at 6 months were similar in both sexes. Unfortunately, the 6-month mortality rate for women was 25.8% for the women and 10.8% for the men, and the readmission rates were 23.3% for women and 12.2% for men.

After the data had been adjusted for age, etc., women had greater risk of death at both 28 days and 6 months. This study showed that the women had more lethal first heart attacks than the men, regardless of age, other illnesses, or previous angina.

Marrugat et al, JAMA (10-28-98) Vol. 230 pp. 1405-1409

ACOG: Public Underestimates Women's Heart Attack Risks

A new U.S. survey suggests that both sexes view heart attack as a greater health risk for men than for women. And both sexes are more aware of the symptoms of heart attack in a man than in a woman. This lack of information about women and heart disease is jeopardizing women's lives, warned The American College of Obstetricians and Gynecologists (ACOG) at a press briefing on December 8, 1998.

"The public perception that heart disease is a man's disease is both wrong and dangerous," said Vicki L. Seltzer, MD, immediate past president of ACOG and professor and chair of the department of obstetrics and gynecology at the Long Island Jewish Medical Center. "Cardiovascular disease is not only the No. 1 killer of women, but women are also likely to fare worse than men once they experience a heart attack," she asserted.

In every year since 1984, cardiovascular disease has claimed the lives of more females than males. Yet nearly half (47.4 percent) of the 1,031 respondents to a survey conducted by Yankelovich Partners believe that men are at greater risk than women for a heart attack. Sixty-five percent of men believe they are personally at greater risk for a heart attack than are women. In contrast, only 38 percent of women believe they are personally more at risk. This underestimation of women's risk is not present when it comes to other diseases: most survey respondents perceive no difference in their risk levels for other conditions such as cancer or diabetes.

"If women don't believe they get heart attacks, then women won't worry about them or take steps to prevent them," noted Seltzer. "What women don't know can hurt them. And what men don't know about cardiovascular disease and women can be devastating to the women they love."

The ability to recognize signs of a heart attack is critical, since every minute lost can diminish the chances for survival. Yet nearly four out of 10 women (38 percent) are not sure they would recognize the signs of a heart attack in a woman. Women are actually more confident about recognizing the signs of a heart attack in a man (with a 72 percent confidence rate) than in a woman (62 percent confidence rate). Only one-quarter (24 percent) of both men and women are aware that certain heart attack symptoms are more common in women, such as nausea or dizziness, than in men, who may tend to feel pain in the center of the chest.

"The bottom line is that women are not as worried about heart attack and stroke as they should be," Seltzer stated. In fact, studies show that women do not go to the hospital following a heart attack as quickly as men do. The delay is all the more serious because women may actually suffer a more severe form of heart attack than men do. "Women worry about breast cancer, but we're dying from heart attack," added Seltzer. "In reality, one in 26 women will die of breast cancer while almost one in two will die of cardiovascular disease."

Among the other survey findings:

• Women fear breast cancer nearly twice as much as they fear the risk of a heart attack (35 percent versus 16 percent), with Alzheimer's disease being the third condition women fear most (11 percent). In fact, each year more than 11 times as many women die of cardiovascular disease as of breast cancer. More American women die each year from cardiovascular disease (over 500,000) than from the next 16 causes of death combined.
  
  
• Only 10 percent of women fear stroke more than any other medical condition. Stroke -- another major component of cardiovascular disease -- is the third-leading cause of death for U.S. women, killing 96,000 women in 1995.
  
  
• Fewer than half of women over age 50 have ever discussed their risk of heart attack with their doctor.
  
  
• Most women and men over age 34 say they are making positive lifestyle changes, such as adopting healthier eating habits (95 percent), beginning an exercise program (86 percent), or taking steps to reduce stress in their lives (78 percent).

Explaining why obstetrician-gynecologists are involved, Luella Klein, MD, ACOG vice president for women's health issues, noted, "Cardiovascular disease is a woman's issue, one that should concern women of all ages because the disease process can start in a woman's earlier decades. As the primary caregivers for most women in this country, ob-gyns can educate their patients about preventing this insidious disease."

"Although men have a higher prevalence of coronary heart disease than women throughout the life span, as women age they fare worse from heart attacks," said Deborah M. Smith, MD, MPH, interim chair of the department of ob-gyn at Howard University Hospital in Washington, D.C. "Post-menopausal women are more likely than men to die during their first attack and to suffer a second attack within a year of the first," she noted.

"Smokers increase their risk for cardiovascular disease. Also at greater risk are African-American women, who have higher rates of diabetes mellitus and of hypertension," Smith warned. The death rate from heart attack is more than 38 percent higher for African-American women than for Caucasian women, and the death rate from stroke is 76 percent higher. "Risks can still be lowered," added Smith, "since women at mid-life can make life-style changes and follow medical recommendations that result in a better quality of life for the second half of life."

"The good news from the survey is that more women and men over age 34 seem to be making lifestyle changes that can prolong their lives," observed Vivian M. Dickerson, MD, director of the division of general obstetrics and gynecology at the University of California-Irvine Medical Center. "Women may be less aware that certain protective steps previously approved for men have now been approved for women as well," she added.

In October 1998, the U.S. Food and Drug Administration (FDA) approved the use of aspirin to prevent stroke in women who have already suffered a transient ischemic attack (TIA or "mini-stroke") or a stroke. The step comes 18 years after the FDA confirmed this benefit for men. For both women and men, the FDA also approved the use of aspirin to treat a suspected heart attack once it occurs; to help prevent heart attack and stroke in certain high-risk individuals; and to prevent a second or recurrent stroke in those who have previously suffered a stroke.

In the past, most research about treatments for heart disease has focused on men. Women who have suffered cardiac events such as a heart attack or bypass surgery have suffered worse outcomes than men. "That scenario may change, as medicine pays attention to gender-specific factors in women's care," noted cardiologist Elsa-Grace V. Giardina, MD, professor of clinical medicine at Columbia-Presbyterian Hospital in New York. "However, only recently have there been studies enrolling enough women to see if there are differences between men and women in treatment and outcomes from heart disease. When it comes to heart attacks and stroke, we are just at the starting point in our understanding of how women and men differ."

"The use of oral contraceptives does not increase a woman's cardiovascular disease risk. In fact, newer pill formulations may improve lipoprotein profiles, such as by increasing HDL, or the so-called 'good' cholesterol," noted Rogerio Lobo, MD, chair of the department of ob-gyn at Columbia-Presbyterian Medical Center in New York. The only exception: women smokers over age 35 should not take oral contraceptives.

In post-menopausal women, numerous observational studies have suggested that women on estrogen therapy experience a 50 percent reduction in morbidity and mortality associated with coronary artery disease. These data have been corroborated by short-term clinical trials and studies of animals, "but more data are needed from clinical trials to fully characterize the benefits of hormonal use in post-menopausal women," Lobo said.

With new research being conducted daily, it can be difficult for women to assess the often conflicting study results, and they turn to their physician -- and the news media -- for help. "Rarely does one study define the truth," cautioned Herbert B. Peterson, MD, chief of the women's health and fertility branch at the U.S. Centers for Disease Control and Prevention in Atlanta, Georgia. "For the physician, interpreting an individual woman's risk for disease based on studies of populations is a challenge," he said. "For the journalist, discussing the limitations of studies when interpreting data is a must."

Dr. Seltzer announced ACOG's "HeartStrong Woman" campaign, a joint effort with the Bayer Corporation that will include dissemination of free consumer education brochures to women through their gynecologists as well as through a toll-free number: 1-888-567-0595. The brochure, HeartStrong Woman: Your Personal Action Plan for Heart Health, has been designed to help women of all ages assess their risk for cardiovascular disease and offers tips on how to lead a healthier life. The Yankelovich Partners survey of 1,031 adults age 35 or older was conducted during Fall 1998. The margin of error is +/-3.1 percentage points with a 95 percent confidence level. Results were weighted on gender and age dimensions to reflect the population of Americans age 35 or older nationwide.

Women's Health Weekly: December 14, 1998 issue (excerpted with permission)

CWH Journal Watch: February 1999