Helping Women Understand Their True HIV Risk

Heather Boerner

October 26, 2017

MILAN — To know a woman's real risk for HIV, you have to know more than her sexual behavior and history of sexually transmitted infections. You also have to know about her partner and the background HIV prevalence where she lives, an expert said here at the 16th European AIDS Conference.

This information can identify the invisible vulnerable: women who are at risk of acquiring HIV not because of their own behavior, but because of the circumstances of their lives, said Nneka Nwokolo, MD, from Chelsea and Westminster Hospital in London.

"Women need to accurately perceive their risks," she told the packed audience, and "healthcare workers are in a unique position to help them do that."

In much of the world, PrEP guidelines are aimed at obvious risks: behavior by the patients themselves that can make them vulnerable to HIV. Often this includes men who have sex with men, sex workers, people with many sexual partners, and people who do not use condoms. This might be why some PrEP guidelines, such as those in Switzerland, don't include women at all.

In European guidelines, "there's very little guidance on when to recommend PrEP for women," Dr Nwokolo said.

In the United States, heterosexual women at high risk for HIV are addressed in the PrEP implementation guidelines. They recommend that physicians determine risk by asking a woman if she has a partner living with HIV, has multiple sex partners, has a history of inconsistent or nonexistent condom use, has engaged in sex work, or has had a recent bacterial sexually transmitted infection.

But the guidelines do not mention risks to a woman's partners.

Partner Imperil

"There's this idea, and I think it's very prevalent even among healthcare providers, that certain kinds of women can't catch HIV," Dr Nwokolo told Medscape Medical News. "Why are we ignoring the fact that there are all these women who don't fit into the traditional risk categories — they are not from a black African background, not intravenous drug users, not having sex with a lot of people — and they have HIV?"

To illustrate the hidden risks women face, Dr Nwokolo presented several composite case studies during the Women Against Viruses in Europe (WAVE) workshop.

In one, she described Precious, a 35-year-old married woman with two children who lives in London but is originally from Nigeria. She only has sex with her husband and they do not use condoms. She tested negative for HIV 7 years ago when she had her last child. Her sexually transmitted infection status is unknown.

She also described Maria, a 25-year-old, white, heterosexual woman who lives in London. She has had six casual partners in the previous 6 months and rarely uses condoms. She's had chlamydia in the past and has genital herpes.

"So who would be a good candidate for PrEP?" Dr Nwokolo asked the audience. Attendees picked up a small electronic device and voted. No one thought only Precious ought to receive PrEP, about one-quarter of the audience thought Maria should receive PrEP, and about one-third thought both could be candidates.

Because of the context in which they are having sex, Precious might be at greater risk for HIV than Maria, Dr Nwokolo explained.

"It's important to recognize that many partners — male partners — of black African women, who make up the majority of women who have HIV in the United Kingdom, have other partners," she said. "So the major risk for HIV acquisition for black African women, certainly in the United Kingdom, is their male partners."

These women are doubly compromised by circumstance, she added. Not only might their partners be having sex outside the relationship, the women themselves might feel they can't demand condom use or decline sex.

These women "may not think about their risk of HIV because they don't perceive that they have any control over that risk. So they put it to the back of their minds and just hope for the best," she pointed out.

Where Sex Occurs

Maria, who has all the individual risk markers for HIV, might not be at risk, at least not in London.

HIV acquisition is "actually quite low" among heterosexuals in the United Kingdom, Dr Nwokolo reported.

However, if Maria lived in the Ukraine, where HIV rates are 20% among heterosexuals who inject drugs, she might be a good candidate for PrEP. And if she lived in a region with a great deal of undiagnosed and untreated HIV, her behavior could put her at high risk.

In the United States, guidelines take such risks into account, and state that "clinicians should consider the epidemiologic context of the sexual practices reported by the patient," Dr Nwokolo explained.

This is important because some areas, particularly the Southern states, have very high rates of HIV and of late diagnosis, meaning that people can be dating and having sex without realizing they are infected with the virus.

Talking About Risk

The presentation was thought-provoking and really shows us the limitations of our own perception of patient risk, said Karoline Aebi-Popp, MD, from the University of Bern in Switzerland. "Doctors need to take a thorough sex history, including not only the number of sexual partners, but also their sex practices and where they are from."

But the suggestion that women from African backgrounds are more likely to acquire HIV from a single sex partner who has other partners went a bit too far for Annette Haberl, MD, from Frankfurt University in Germany, who said she sees a lot of couples of African origin.

It could be that on an individual basis, Precious might be in a situation where she needs PrEP, "but I don't know if it's so different from couples from other origins," Dr Haberl told Medscape Medical News.

The goal, said Dr Nwokolo, is not to convince a woman like Precious that she needs PrEP. It is to start the conversation in a nonstigmatizing way and to introduce the idea that PrEP is for women, too.

If a woman sees her partner going out with his other girlfriend, it might prompt her to think about PrEP, she explained.

"It's up to us as healthcare providers to encourage women to know their risks and support them in accessing PrEP," she added.

Dr Nwokolo reports receiving funding from ViiV Healthcare, Gilead Sciences, and Janssen. Dr Aebi-Popp has disclosed no relevant financial relationships.

16th European AIDS Conference. Presented October 25, 2017.

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