Many manifestations of HIV disease are similar in men and women. Both men and women with HIV may have non-specific symptoms even early in disease, including low-grade fevers, night sweats, fatigue, and weight loss. Anti-HIV therapies, as well as treatments for other infections associated with HIV, appear to be similarly effective in men and women. Other conditions, however, occur in different frequencies in men and women. HIV-infected men, for instance, are eight times more likely than HIV-infected women to develop a skin cancer known as Kaposi's sarcoma. In some studies, women had higher rates of herpes simplex infections than men.

Data from several studies conducted by CPCRA found that HIV-infected women were also more likely than HIV-infected men to develop bacterial pneumonia. This finding may be explained by factors such as a delay in seeking care among HIV-infected women as compared to men, and/or less access to anti-HIV therapies or preventive therapies for Pneumocystis carinii pneumonia, or PCP.

Woman-Specific Symptoms of HIV Infection
Women also experience HIV-associated gynecologic problems, many of which occur in uninfected women but with less frequency or severity.

Vaginal yeast infections, common and easily treated in most women, often are particularly persistent and difficult to treat in HIV-infected women. Data from WIHS suggest that these infections are considerably more frequent in HIV-infected women. Health care providers commonly use a drug called fluconazole to treat yeast infections. A CPCRA study demonstrated that weekly doses of fluconazole can also safely prevent oropharyngeal and vaginal, but not esophageal yeast infections, without resulting in resistance to the drug.

Other vaginal infections may occur more frequently and with greater severity in HIV-infected women, including bacterial vaginosis and common STIs such as gonorrhea, chlamydia, and trichomoniasis.

Severe herpes simplex virus ulcerations, which are sometimes unresponsive to therapy with the standard drug acyclovir, can severely compromise a woman's quality of life.

Idiopathic genital ulcers, with no evidence of an infectious organism or cancerous cells in the lesion, are a unique manifestation of HIV infection. These ulcers, for which there is no proven treatment, are sometimes confused with those caused by herpes simplex virus.

Human papillomavirus (HPV) infections, which cause genital warts and can lead to cervical cancer, occur more frequently in HIV-infected women. A precancerous condition associated with HPV, called cervical dysplasia, is also more common and more severe in HIV-infected women and more apt to recur after treatment.

Pelvic inflammatory disease (PID) appears to be more common and more aggressive in HIV-infected women than in uninfected women. PID may become a chronic and relapsing condition as a woman's immune system deteriorates.

Menstrual irregularities frequently are reported by HIV-infected women and are being actively studied by NIAID-supported scientists. Although menstrual irregularities were equally common in HIV-infected women and at-risk HIV-negative women in a WIHS survey, women with CD4+ T-cell counts below 50 per cubic millimeter (mm3) of blood were more likely to report no periods than were uninfected women, or HIV-infected women with higher CD4+ T-cell counts.

GYNECOLOGIC SCREENING
CDC currently recommends that HIV-positive women have a complete gynecologic evaluation, including a Pap smear, as part of their initial HIV evaluations, or upon entry to prenatal care, and another Pap smear 6 months later. If both smears are negative, annual screening is recommended thereafter in asymptomatic women. The agency also recommends more frequent screenings-every 6 months-for women with symptomatic HIV infection, prior abnormal Pap smears, or signs of HPV infection.

EARLY DIAGNOSIS
Some women in the United States have poor access to health care. In addition, women may not think they are at risk for HIV infection. They may not heed symptoms that could serve as warning signals of HIV infection, such as recurrent yeast infections. PID and the other symptoms discussed above should signal health care providers to offer women HIV testing with counseling.

Early diagnosis of HIV infection allows women to take full advantage of antiretroviral treatments and preventive medicines for opportunistic infections when their health care providers think it is appropriate. Both appropriate therapy and preventive drugs can forestall the development of AIDS-related symptoms and prolong life in HIV-infected women as well as men. Early diagnosis also allows women to make informed reproductive choices. Health care providers should be alert to early signs of HIV infection in women. In addition, all women should consider HIV testing if they have engaged in behaviors that put them at risk of infection.

SURVIVAL AMONG HIV-INFECTED WOMEN
Women whose HIV infections are detected early and receive appropriate treatment survive as long as HIV-infected men. Although several studies have shown HIV-infected women to have shorter survival times than men, this may be because women are less likely than men to be diagnosed early.

In an analysis of several studies involving more than 4,500 people with HIV infection, women were 33 percent more likely than men to die within the study period. The investigators could not definitively identify the reasons for excess mortality among women in this study, but they speculated that poorer access to or use of health care resources among HIV-infected women as compared to men, domestic violence, homelessness, and lack of social supports may have been important factors.