Every prostitute has HIV

HIV infection: aspects specific to women are underrepresented

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Dtsch Arztebl 2004; 101 (48): A-3242 / B-2745 / C-2603
Zylka-Menhorn, Vera; Merten, Martina
As part of an AIDS prevention project, a street worker distributes condoms to prostitutes in Krakow, Poland. Photos: IHRD
With the motto "Women, Girls, HIV and AIDS", the World AIDS Day wants to raise awareness of a gender-oriented view of HIV medicine.

Worldwide, more than half of all HIV-infected women and girls. In Germany, the proportion of women in the infectious disease is significantly lower, but here too every fourth new infection was found in a woman in 2003. Nevertheless, a “women-specific” view of HIV infection has long been disregarded, although the immunodeficiency has gender-related differences, the roots of which are not only in the pathophysiology but also in the psychosocial area. HIV-infected women have less contact with the health system, are represented to a smaller extent in studies and are less likely to receive adequate therapy.
The World AIDS Day, which has been proclaimed by the World Health Organization (WHO) on December 1st since 1988, aims to raise awareness of these deficits with the motto "Women, Girls, HIV and AIDS". As an example of gender-specific differences, Prof. Dr. med. Norbert Brockmeyer, President of the German AIDS Society (DAIG) and spokesman for the Competence Network HIV / AIDS, the virus concentration in the blood. In HIV-infected women, a lower viral load is initially observed than in men, although the time until AIDS develops is comparable in both sexes. “It has not been researched whether this difference should influence the choice and timing of therapy,” said Brockmeyer.
The side effects and interactions of current antiretroviral therapies are also unclear, although international clinical studies indicate that certain drugs cause different side effects in women than in men. "There is an urgent need for research," emphasized Brockmeyer. So far there is hardly any data on this topic in Germany. This should change with a study initiated by the Competence Network HIV / AIDS.
Expertise for Eastern Europe
There are also gender-specific symptoms that can indicate a recent infection with HIV, but are often not recognized as such. In women, these are recurrent vaginal infections, pathological cervical smears and therapy-resistant inflammation of the pelvis. According to current studies, low serum albumin levels and high concentrations of C-reactive protein also seem to mean a poor prognosis for HIV-infected women.
Most HIV-positive women in Germany are between 20 and 40 years old and therefore of childbearing age. An HIV infection of the child was rare in the approximately 250 pregnancies that are carried out each year in this country by women who are known to be HIV-infected, due to the prophylactic medication. Nevertheless, in 2004, 19 HIV infections were diagnosed in children of migrant women. The Robert Koch Institute in Berlin therefore appeals to gynecologists to offer all pregnant women an HIV test.
With regard to sex education, too, it is mainly women who pass on information about protective behavior, says Ulrich Heide, board member of the German AIDS Foundation. Protection by condoms is the method of choice to prevent infection. This requires women in certain cultures to change their role behavior, characterized by openness, refusal of unprotected sexual intercourse, recognition and assertion of their own wishes and needs.
“For biological reasons, too, women need special protection against HIV,” explains Joyce Dreezens-Fuhrke from the German AIDS Service Center. Studies have shown that women are twice as likely to get HIV infection from unprotected sex as men. Therefore, women-specific aspects should be given greater consideration in the development of vaccines.
In the meantime, the infection rates in Eastern Europe and Central Asia continue to rise rapidly, and people are dying because access and / or the administration of the antiretroviral therapy regimen are not guaranteed according to the current state of knowledge. In the case of an HIV infection, however, strict adherence to complex therapy plans is essential in order to achieve treatment success and avoid the development of resistance. Out of concern about the situation, the German AIDS Society and the Competence Network HIV / AIDS have started the initiative for a pool of experts. 17 scientists could be won among its members, who pass the basics of HIV therapy on to colleagues in Russia and Eastern Europe in a one-week seminar on an honorary basis. In advance, the outgoing doctors are prepared in a workshop for the culture and the situation in the destination country.
Break through taboos
In many developing countries, but also in Eastern European countries, HIV prevention plays a subordinate role among prostitutes. According to the WHO, the spread of the HI virus can be between 60 and 90 percent in places where women and men have little access to prevention and care programs. In the countries where preventive measures could be taken in the context of prostitution, for example in Thailand and Cambodia, the infection rates could be drastically reduced.
An (online) guide that the WHO has developed in cooperation with the Society for Technical Development (GTZ) and networks of prostitutes from all over the world over the past year and a half is intended to help reduce the health risks for men and women and their customers. The guide - also known as the “toolkit” - contains a mixture of practical instructions, data and analyzes as well as more than 130 documents, manuals and research studies on the subject of HIV prevention. It is aimed at organizations, self-help groups and individuals who are active in the field of sex work. Another document in the “Toolkit”, which is designed to help program managers design projects, contains information on health protection in prostitution (making sex work safe). GTZ senior advisor on HIV / AIDS, Thomas Kirsch-Woik, describes the toolkit as a “living tool kit” that can be constantly updated. So far it has been difficult to build up a worldwide network of prostitutes because many countries have closed themselves to the issue. "Taboo topics such as prostitution or migration are only slowly emerging," says Kirsch-Woik.
Dr. med. Vera Zylka-Menhorn
Martina Merten
The HIV / AIDS toolkit can be downloaded from www.who.int/hiv/toolkit/sw. From 2005 it is also available on CD-ROM and in printed form.