339

HIV Infection in Women:

Implications for Drug Abuse

Treatment and Research

Peter A. Selwyn, M.D., M.P.H., and

Marc N. Gourevitch, M.D., M.P.H.

INTRODUCTION

This chapter highlights several features of the HIV (human immunodeficiency virus) epidemic in women, particularly women with a

history of drug use, emphasizing current trends and research concerning

transmission, epidemiology, clinical manifestations, access to care, and

pregnancy-related issues.

THE WORLDWIDE HIV EPIDEMIC

AMONG WOMEN

The World Health Organization has proposed that the following

three patterns of HIV transmission characterize the epidemic in different

populations: pattern 1, primarily male-to-male sex or injection drug

use; pattern 2, primarily heterosexual transmission; and pattern 3, other

avenues of risk or nonreporting (Chin and Mann 1988).

Worldwide, three-quarters of AIDS (acquired immunodeficiency

syndrome) cases occur in heterosexuals. Where heterosexual transmission predominates, as in sub-Saharan Africa, the ratio of new male to

new female infections is about 1 to 1 (Chin and Mann 1988). In the

United States, injection drug use is the most important risk factor for

HIV infection among women (Centers for Disease Control and Prevention 1995a).

These patterns of transmission are far from static. In certain areas

of the world, such as Southeast Asia, recent explosive increases in AIDS

cases have been linked to injection drug use, heterosexual transmission,

and the particular vulnerability of women in the commercial sex industry. Although the United States is viewed primarily as a pattern 1

country, heterosexual transmission of HIV has become of increasing
340

concern in many areas in the country, including the Northeast and

Southeast (Centers for Disease Control and Prevention 1995a).

AIDS AS CAUSE OF DEATH

AIDS is currently the leading cause of death among young adults in

the United States (Centers for Disease Control and Prevention 1996a).

In 1994, for persons 25 to 44 years old, AIDS was the leading cause of

death among men, the third leading cause of death among women, and

the leading cause of death among African-American women (Centers for

Disease Control and Prevention 1996a). In some cities in the northeastern United States, where HIV is concentrated among African-Americans

and Hispanics, AIDS has been the leading cause of death among men

and women ages 25 to 44 since the early 1990s (Selik et al. 1993).

AIDS INCIDENCE AND PREVALENCE

Distribution of incident AIDS cases among males and females in

the United States has a clear bicoastal pattern—the Northeast, Southeast, and Southwest and Puerto Rico (Centers for Disease Control and

Prevention 1996b). Among women, AIDS incidence is more heavily

concentrated in the Northeast and Southeast, Puerto Rico, and to a

smaller degree parts of the Southwest and West. It remains uncommon

in parts of the nonindustrial Midwest (Centers for Disease Control and

Prevention 1996c; Ellerbrock et al. 1991).

AIDS cases associated with injection drug use follow a similar

distribution, accounting for a preponderance of local cases in many

northeastern States and Puerto Rico (Centers for Disease Control and

Prevention 1996c). Thus, among drug users, women, and certain racial/

ethnic groups, the AIDS epidemic is generally concentrated in the same

geographic areas.

Health practitioners who care for women with HIV are familiar

with the sharp peak in the age distribution of those affected (median

age 35 years, with women ages 15 to 44 constituting 84 percent of all

female cases) (Centers for Disease Control and Prevention 1995a).

The secondary implications of this distribution are all too familiar—

the impact of a young-adult fatal disease on patients with HIV, their

families, and children.
341

Between 1981 and the end of 1992, more than 250,000 cases of

AIDS were reported to CDC (Centers for Disease Control and Prevention 1995b). From 1993 to 1995, this figure doubled: More than

500,000 cases were reported in the United States by the end of 1995

(Centers for Disease Control and Prevention 1995c). Women accounted

for 14 percent of this number (Centers for Disease Control and Prevention 1995b), compared with 24 percent during the 12-month period of

July 1995 through June 1996 (Centers for Disease Control and Prevention 1996c), further evidence of the sharp rise in the epidemic’s toll on

women. Seventy-five percent of cases among women, compared with

48 percent of cases among men, were among blacks and Hispanics

(Centers for Disease Control and Prevention 1995c).

AIDS RISK CATEGORIES

Men who have sex with men still account for the majority (51 percent) of cumulative AIDS cases, although the proportion of such cases

has declined steadily over the past decade (Centers for Disease Control

and Prevention 1996c, 1995b). Injection drug use accounts for approximately 35 percent of AIDS cases to date (Centers for Disease Control

and Prevention 1996c). Among women, nearly one-half (46 percent) of

AIDS cases are directly attributable to injection drug use and 38 percent

to heterosexual contact (Centers for Disease Control and Prevention

1995c). Whereas approximately one-half of the cases resulting from

heterosexual contact involve sex with a male injecting drug user, twothirds of the AIDS cases among women are linked directly or indirectly

to injection drug use.

REVISED AIDS CASE DEFINITION

In 1993 CDC revised its AIDS case definition. Three clinical

conditions (invasive cervical cancer, pulmonary tuberculosis, and recurrent bacterial pneumonia) now qualify as AIDS diagnoses when present

in people with HIV infection (Centers for Disease Control 1992). The

new definition was the result of empirical, scientific, and epidemiologic

evidence as well as advocacy and support from those affected by HIV

and AIDS, who argued that women, certain racial/ethnic groups (particularly African-Americans and Hispanics), and injecting drug users were
342

underreported and undercounted by earlier AIDS definitions and case

reporting.

CLINICAL MANIFESTATIONS

One of the most striking findings regarding women and the AIDS

epidemic is that the clinical features of HIV among women are similar

to those among men—after controlling for access to care, other

sociodemographic variables, and gynecologic manifestations. CDC

reviewed AIDS-defining conditions from approximately 7,000 female

and 22,000 male injecting drug users with AIDS from 1988 through 1991

(Fleming et al. 1993). On multivariate analysis, after controlling for

race, age, and geographic region, there were only four differences in

AIDS-defining conditions by gender (out of a total of 22 specific infectious disease conditions and cancers included in the AIDS case definition at that time). Women were somewhat more likely to be diagnosed

with esophageal candidiasis (19.8 percent of women v. 13.7 percent of

men), cytomegalovirus disease (2.2 percent v. 1.5 percent), and herpes

simplex virus disease (4.4 percent v. 2.6 percent), and they were less

likely to be diagnosed with Kaposi’s sarcoma (1.6 percent v. 2.7 percent).

Women with HIV infection may be at greater risk for candidal infections

than men, perhaps because vaginal candidiasis may serve as a reservoir

for such infections. Other studies, however, found no significant differences between the sexes in clinical manifestations of HIV disease, apart

from the well-known association between male gender and Kaposi’s

sarcoma (Vlahov et al. 1994; Morlat et al. 1992; Beral et al. 1990).

STUDIES OF AIDS, WOMEN, AND DRUG ABUSE

Studies of Gynecologic Conditions and HIV

Investigators in Rhode Island studying women with HIV infection

developed a model depicting the progression of mucosal candidiasis

(Imam et al. 1990). Women presenting initially with vaginal candidiasis

had CD4 counts close to the normal range. Women with oral, and not

vaginal, candidiasis typically presented with substantially lower CD4

counts, whereas those with esophageal candidiasis had the lowest counts

(below 100/mm3).
343

A CDC-associated study of patients with HIV infection from several

geographically diverse American cities investigated gynecologic manifestations among the approximately 500 women in their sample. CD4

counts in women with candidal vaginitis (approximately 15 percent of

women) were lower than in those without candidiasis. Chronic or

recurrent candidal vaginitis was less common (approximately 5 percent

of women), bearing no clear relationship to immune status (Farizo et al.

1992).

Thus, the exact relationship between vulvovaginal candidiasis and

level of immune function remains to be fully defined. Similarly, the

actual incidence, severity, and relationship of pelvic inflammatory disease

(PID) to immune function in women with HIV infection has not yet

been clearly established. Further study is needed to define the impact

of HIV infection and associated immunosuppression on these and other

gynecologic diseases.

A 1987 to 1991 study of Louisiana women with HIV compared those

who injected drugs with those who did not (Clark et al. 1993). Thirtyeight percent of women in the drug-using group had a history of syphilis

compared with 14 percent in the noninjection group. PID occurred in

about 5 percent of women in each group.

In a 1992 comprehensive review of the literature on cervical disease

and HIV, Mandelblatt and coworkers (1992) examined the association

between HIV and cervical neoplasia and found odds ratios (ORs) ranging

from 3 to 10 (summary OR=4.9) for increased risk of cervical dysplasia

in women with HIV infection. Since then, additional studies have

shown a strong relationship between cervical dysplasia and HIV infection

(Adachi et al. 1993). Cervical dysplasia worsens with the degree of

immune suppression (Klein et al. 1994). It appears to be mediated

through human papilloma virus (HPV) and especially through the more

oncogenic HPV subtypes. More research is needed to determine the

most effective strategy for cervical cytologic screening and long-term

followup and on the impact of newer antiretroviral therapies and other

HIV care interventions on cervical disease and other gynecologic conditions in women with HIV. Several prospective cohort studies of women

with HIV now under way should help answer many of these questions.
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SEROPREVALENCE AND

SEROINCIDENCE STUDIES

Chiasson and colleagues (1990) conducted a study of HIV seroprevalence in a sexually transmitted disease clinic in New York. The

study included a multivariate analysis of risk factors for HIV infection

by sex in relation to different predictor variables. Among women, crack

use, prostitution, and sex-for-drug relationships were important risk

factors. Independent risk factors that predicted HIV infection in women

and men included syphilis, crack use, and contact with prostitutes using

crack. More recently, a strong association has been shown between

having early syphilis and undergoing HIV seroconversion among female

drug users in the Bronx (Gourevitch et al. 1996). Such findings highlight the urgent need for research and intervention trials aimed at

enabling women to avoid some of these well-defined pathways of acquiring HIV.

Survival Studies

Early in the HIV epidemic, women who developed AIDS did very

poorly. Data from a 1981 to 1985 San Francisco study showed that

the median survival time after AIDS diagnosis for women was a scant

1.1 months compared with approximately 10 months in men. Survival

for both groups increased over time, but in 1990 the survival timeframe

remained lower for women (11.1 months v. 14.6 months) (Lemp et al.

1992).

Differences in survival by gender often diminish or disappear, however, when stage at presentation and access to and utilization of care are

taken into account. In the same San Francisco study, treatment with

antiretroviral therapy—either AZT (zidovudine) or ddI (didanosine)—

had a major effect on survival rates (Lemp et al. 1992). Women who

received therapy survived longer than those who did not, and the

percentages of women and men receiving therapy who survived for 1 year

were indistinguishable. In more recent analyses, in which access to care

and socioeconomic status were assessed, no difference in rates of disease

progression or of survival between men and women with HIV infection

was found (Chaisson et al. 1995). When differential rates of disease

progression are observed in women and men, such differences should

not be ascribed to biologic factors.
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Access to and Utilization of Care Studies

Additional data support the notion that women with HIV infection

may have poorer access to or less use of medical care than men. Data

published by Schoenbaum and Webber (1993) demonstrated that HIV

is often underrecognized among women during an emergency room visit.

In their seroprevalence study, the investigators determined whether any

evidence existed for screening for HIV infection or drug abuse in patients who received care in the emergency room. Of persons who had

undiagnosed HIV infection, males with infectious disease were screened

for HIV more often by the emergency room staff. Women at high risk

for HIV were underevaluated and underscreened for HIV infection

compared with men who presented with similar conditions.

Differences in access to care for women and men have been demonstrated in other settings as well. Moore and colleagues (1991) used

medicaid records from the State of Maryland to determine whether

people diagnosed with AIDS during the period following the initial

release of AZT (mid-1987 through 1989) had indeed received the

medication during that period. Only one-third of the women studied

were offered or received AZT compared with more than one-half of the

men. People of color and injecting drug users were less likely to receive

AZT than men who had sex with men. In keeping with these data,

Stein and coworkers (1991) studied persons with HIV infection in

several cities to determine the likelihood of AZT being offered in

different clinical settings. This study found that injecting drug users,

women, and African-Americans were less likely to be offered AZT.

Differences in access to and effective use of health care resources must

be considered in interpretation of data suggesting gender differences in

the observed course of progression of HIV infection.

Another study looked at characteristics predicting which HIVinfected women with newborns would seek care for HIV (Butz et al.

1993). Women whose babies were HIV-infected were more likely to

seek care than women whose babies were not infected. Of those women

seeking care, however, injecting drug users and those who had been

incarcerated were less likely to receive care. Combinations of demographic and behavioral variables may distinguish those not trying to

access care and those trying to do so without success.

In a correlational analysis, Piette and coworkers (1993) analyzed

persons who needed a specific service—mental health, housing, home
346

care, transportation, or entitlements (e.g., medicaid, Aid to Families

with Dependent Children)—to learn whether they were in need of

other services. One-half identified as needing drug treatment services

also needed, but were not receiving, mental health services; one-half

needed housing; one-third needed transportation and entitlements; and

one-fifth needed home care. Women who are HIV-infected and use

drugs thus face multiple risks and are subject to a broad array of influences and adverse conditions that affect health outcomes. Innovative

approaches are needed to improve such outcomes.

Drug Use and Methadone Studies

At Montefiore Medical Center, several studies of women and men

who were drug users in a methadone treatment program were conducted

(Gourevitch et al. 1996; Schoenbaum et al. 1989; Selwyn et al. 1989a,

1989b, 1989c). A prospective cohort study also was conducted to assess

disease manifestations and use of care over time (Selwyn et al. 1989d,

1992, 1993). These studies linked AIDS research projects and comprehensive onsite medical care to patient-scheduled visits at a methadone

maintenance treatment program. High levels of compliance were

achieved both with the clinical care provided and with the associated

research effort (Selwyn et al. 1993).

HIV Progression to AIDS

The cohort study at the center followed 318 HIV-infected drug

users, about one-half of them women, and found no difference by gender

(or by race or ethnicity) in the rate of progression from HIV infection

to AIDS over a median of 3 years of followup (Selwyn et al. 1992).

Thus, in a seroprevalent population with ready and equal access to

drug treatment and medical services, sex and race had no influence on

clinical outcome. Greater age was associated with increased risk for

progression, as has been found in other studies, because of either the

increased time since infection or biologic phenomena associated with

aging.

More than 80 percent of male and female patients (stratified by

CD4 cell counts) participating in methadone treatment in the authors’

program voluntarily used the onsite primary care services (Selwyn et al.

1993). In the group considered most eligible for HIV-related therapies
347

(fewer than 200 CD4 cells/mm3), approximately 80 percent were receiving ongoing antiretroviral therapy with AZT or prophylaxis for

Pneumocystis carinii pneumonia. Persons in this more immunosuppressed

group used primary care services at an average rate of once per month,

without differences in use between men and women. The incidence

of AIDS among HIV-infected study participants with a CD4 count

below 500/mm3 who received AZT was 62 percent lower than those

not receiving AZT (Selwyn et al. 1992). Thus, in a structured setting

in which medical care is linked to drug abuse treatment, gratifying

outcomes can be achieved in terms of ongoing care. Men and women

showed no significant differences in use of services or in the course of

their disease. Active drug use was not associated with a decline in

immune status or more rapid progression of HIV disease.

Although it is important not to ignore possible effects of drug use

on viral replication, disease expression, and immune function, any such

biologic effects on HIV progression are probably eclipsed by the impact

of HIV-related therapies, when they are used. Active drug users may be

less likely to seek and receive therapy and ongoing care than drug users

in recovery or nonusers. Thus, not seeking therapy and ongoing care is

likely to be the principal manner in which drug use affects the progression of HIV-related disease.

Pregnancy Outcomes

Several studies have suggested that HIV infection, at least in its

earlier stages, does not have a deleterious effect on the course of pregnancy or on the frequency of adverse birth outcomes (Selwyn et al.

1989c; Minkoff et al. 1990). The effect of late-stage HIV infection on

pregnancy outcome is less defined. Moreover, pregnancy, which has

been hypothesized to be an immunosuppressive state, does not appear to

adversely affect the clinical course of HIV infection (Deschamps et al.

1993). For HIV-infected women who use drugs during pregnancy, the

effects of the drug use on pregnancy and birth outcomes may be more

deleterious than the effects of HIV itself.

ACTG 076

ACTG 076, the international clinical trial of the effect of AZT

on perinatal HIV transmission, included women with CD4 counts
348

greater than 200/mm3 who received AZT during the second and

third trimesters of pregnancy (Connor et al. 1994). The results

showed that 25.5 percent of the infants whose mothers received placebos

during pregnancy acquired HIV infection compared with 8.3 percent of

infants whose mothers received AZT—less than one-third the risk of

transmission in the AZT group. This was the first study to demonstrate

the efficacy of any intervention in preventing HIV transmission between

mother and infant. In the United States, drug-using women constitute

the majority of women with HIV infection. Intensive efforts are needed

to make interventions available to HIV-infected drug users before and

during pregnancy to maximize the effectiveness of treatment for this

high-risk population.

SOCIAL ISSUES

The issues of abuse, victimization, and other violence against drugdependent women are particularly important, not only as they relate to

drug dependence in general, but also because of their connection to HIV

infection. The prevalence of sexual and other types of abuse—both

prior and current—among drug users is believed to be high and must be

addressed in the context of drug treatment programs and medical treatment settings (Dansky et al. 1995).

A medical anthropologist recently wrote of the importance of understanding not only the epidemiology and biology of AIDS, but also the

social context in which the disease and the epidemic take place for

women, particularly for poor women of color. An HIV-positive woman

in New Orleans was quoted as saying, “You think AIDS is a problem?

No way, I got real problems” (Ward 1993). This statement highlights

the perception among some populations affected by AIDS that they are

also vulnerable to violence, homelessness, poverty, and drug abuse.

Ironically, AIDS is now the leading cause of death in many of these

populations. An agenda must be developed for more cross-disciplinary

research, not only in epidemiology and biology, but also in the behavioral

and social sciences, to address the social context of AIDS, with the

ultimate goal of improving the integration of women with HIV into the

system of medical care and other services.
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CONCLUSION

For women with HIV, one aspect of continuing clinical research

should be gynecologic manifestations of the disease, including research

on the most effective strategies for treating these complications in

women with HIV infection and the impact of new HIV therapies on

these conditions. In addition, health service research is important to

reach across disciplines and focus on the important questions of improving access to and utilizing needed medical and social services for HIVinfected women. Finally, without attention to the basic issues of gender

inequality, empowerment, and self-sufficiency for women, efforts to

prevent the further spread of HIV and treat its complications in women

will continue to be compromised.

REFERENCES

Adachi, A.; Fleming, I.; Burk, R.D.; Ho, G.Y.; and Klein, R.S. Women with

human immunodeficiency virus infection and abnormal Papanicolaou

smears: A prospective study of colposcopy and clinical outcome. Obstet

Gynecol 81:372-377, 1993.

Beral, V.; Peterman, T.A.; Berkelman, R.L.; and Jaffe, H.W. Kaposi’s sarcoma

among people with AIDS: A sexually transmitted infection? Lancet

335:1439-1441, 1990.

Butz, A.M.; Hutton, N.; Joyner, M.; Vogelhut, J.; Greenberg-Friedman, D.;

Schreibeis, D.; and Anderson, J.R. HIV-infected women and infants. Social

and health factors impeding utilization of health care. J Nurse Midwifery

38:103-109, 1993.

Centers for Disease Control. 1993 revised classification system for HIV

infection and expanded surveillance case definition for AIDS among

adolescents and adults. MMWR Morb Mortal Wkly Rep 41(RR-17):1-19,

1992.

Centers for Disease Control and Prevention. First 500,000 AIDS cases—United

States, 1995. MMWR Morb Mortal Wkly Rep 44:849-853, 1995b.

Centers for Disease Control and Prevention. Update: AIDS among women—

United States, 1994. MMWR Morb Mortal Wkly Rep 44:81-84, 1995a.

Centers for Disease Control and Prevention. U.S. HIV and AIDS cases

reported through June 1995. HIV/AIDS Surveillance Rep 7(2):7, 1995c.

Centers for Disease Control and Prevention. AIDS map. MMWR Morb Mortal

Wkly Rep 45(15):316, 1996b.

Centers for Disease Control and Prevention. Update: Mortality attributable to

HIV infection among persons aged 25-44 years—United States, 1994.

MMWR Morb Mortal Wkly Rep 45:121-125, 1996a.
350

Centers for Disease Control and Prevention. U.S. HIV and AIDS cases

reported through June 1996. HIV/AIDS Surveillance Rep 8(1):17, 1996c.

Chaisson, R.E.; Keruly, J.C.; and Moore, R.D. Race, sex, drug use, and

progression of human immunodeficiency virus disease. N Engl J Med

333(12):751-756, 1995.

Chiasson, M.A.; Stoneburner, R.L.; Lifson, A.R.; Hildebrandt, D.S.; Ewing,

W.E.; Schultz, S.; and Jaffe, H.W. Risk factors for human immunodeficiency

virus type 1 (HIV-1) infection in patients at a sexually transmitted disease

clinic in New York City. Am J Epidemiol 131(2):208-220, 1990.

Chin, J., and Mann, J.M. The global patterns and prevalence of AIDS and HIV

infection. AIDS 2(1):S247-S252, 1988.

Clark, R.A.; Brandon, W.; Dumestre, J.; and Pindaro, C. Clinical manifestations of infection with the human immunodeficiency virus in women in

Louisiana. Clin Infect Dis 17:165-172, 1993.

Connor, E.M.; Sperling, R.S.; Gelber, R.; Kiselev, P.; Scott, G.; O’Sullivan,

M.J.; VanDyke, R.; Bey, M.; Sheaver, W.; Jacobson, R.L.; Jimenez, E.;

O’Neill, E.; Bazin, B.; Delfraissy, J.-F.; Culnane, M.; Coombs, R.; Elkins, M.;

Moye, J.; Stratton, P.; and Balsley, J. Reduction of maternal-infant

transmission of human immunodeficiency virus type 1 with zidovudine

treatment. N Engl J Med 331:1173-1180, 1994.

Dansky, B.S.; Saladin, M.E.; Brady, K.T.; Kilpatrick, D.G.; and Resnick, H.S.

Prevalence of victimization and post-traumatic stress disorder among

women with substance abuse disorder: Comparisons of telephone and inperson assessment samples. Int J Addict 30:1079-1099, 1995.

Deschamps, M.M.; Pape, J.W.; Desvarieux, M.; Williams-Russo, P.; Madhavan,

S.; Ho, J.L.; and Johnson, W.D. A prospective study of HIV-seropositive

asymptomatic women of childbearing age in a developing country. J Acquir

Immune Defic Syndr 6:446-451, 1993.

Ellerbrock, T.V.; Bush, T.J.; Chamberland, M.E.; and Oxtoby, M.J. Epidemiology

of women with AIDS in the United States, 1981-1990. JAMA 265:2971-

2975, 1991.

Farizo, K.M.; Buehler, J.W.; Chamberland, M.E.; Whyte, B.M.; Froelicher, E.S.;

Hopkins, S.G.; Reed, C.M.; Mokotoff, E.D.; Cohn, D.L.; Troxler, S.;

Phelps, A.F.; and Berkelman, R.L. Spectrum of disease in persons with HIV

infection in the United States. JAMA 267:1798-1805, 1992.

Fleming, P.L.; Ciesielski, C.A.; Byers, R.H.; Castro, K.G.; and Berkelman, R.L.

Gender differences in reported AIDS-indicative diagnoses. J Infect Dis

168:61-67, 1993.

Gourevitch, M.N.; Hartel, D.; Schoenbaum, E.E.; Selwyn, P.A.; Davenny, K.;

Friedland, G.F.; and Klein, R.S. A prospective study of the association of

syphilis and HIV infection in injecting drug users. Am J Public Health

86:1112-1115, 1996.
351

Imam, N.; Carpenter, C.C.; Mayer, K.H.; Fisher, A.; Stein, M.; and Danforth,

S.B. Hierarchical pattern of mucosal candida infections in HIV-seropositive

women. Am J Med 89(2):142-146, 1990.

Klein, R.S.; Ho, G.Y.; Vermund, S.H.; Fleming, I.; and Burk, R.D. Risk factors

for squamous intraepithelial lesions on Pap smear in women at risk for

human immunodeficiency virus infection. J Infect Dis 170:1404-1409, 1994.

Lemp, G.F.; Hirozawa, A.M.; Cohen, J.B.; Derish, P.A.; McKinney, K.C.; and

Hernandez, S.R. Survival for women and men with AIDS. J Infect Dis

166(1):74-79, 1992.

Mandelblatt, J.S.; Fahs, M.; Garibaldi, K.; Senie, R.T.; and Peterson, G.B.

Association between HIV infection and cervical neoplasia: Implications for

clinical care of women at risk for both conditions. AIDS 6:173-178, 1992.

Minkoff, H.L.; Henderson, C.; Mendez, H.; Gail, M.H.; Holman, S.;

Willoughby, A.; Goedett, J.J.; Rubinstein, A.; Stratton, P.; Walsh, J.H.;

et al. Pregnancy outcomes among mothers infected with human

immunodeficiency virus and uninfected control subjects. Am J Obstet

Gynecol 163(5):1598-1604, 1990.

Moore, R.D.; Hidalgo, J.; Sugland, B.W.; and Chaisson, R.E. Zidovudine and

the natural history of the acquired immunodeficiency syndrome. N Engl J

Med 324:1412-1416, 1991.

Morlat, P.; Parneix, P.; Douard, D.; Lacoste, D.; Dupon, M.; Chene, G.;

Pellegrin, J.L.; Ragnaud, J.M.; Dabis, F.; and the Groupe d’Epidemiologie

Clinique du SIDA en Aquitaine. Women and HIV infection: A cohort

study of 493 HIV-infected women in Bordeaux, France, 1985-1991. AIDS

6:1187-1193, 1992.

Piette, J.D.; Fleishman, J.A.; Stein, M.D.; Mor, V.; and Mayer, K. Perceived

needs and unmet needs for formal services among people with HIV disease.

J Community Health 18:11-23, 1993.

Schoenbaum, E.E.; Hartel, D.; Selwyn, P.A.; Klein, R.S.; Davenny, K.;

Rogers, M.; Feiner, C.; and Friedland, G.H. Risk factors for human

immunodeficiency virus infection in intravenous drug users. N Engl

J Med 321:874-879, 1989.

Schoenbaum, E.E., and Webber, M.P. The underrecognition of HIV infection in

women in an inner-city emergency room. Am J Public Health 83:363-368,

1993.

Selik, R.M.; Chu, S.Y.; and Buehler, J.W. HIV infection as leading cause of

death among young adults in US cities and states. JAMA 269(23):2991-

2994, 1993.

Selwyn, P.A.; Alcabes, P.; Hartel, D.; Buono, D.; Schoenbaum, E.E.; Klein, R.S.;

Davenny, K.; and Friedland, G.H. Clinical manifestations and predictors of

disease progression in drug users with human immunodeficiency virus

infection. N Engl J Med 327:1697-1703, 1992.
352

Selwyn, P.A.; Budner, N.S.; Wasserman, W.C.; and Arno, P.S. Utilization of onsite primary care services by HIV-seropositive and seronegative drug users

in a methadone maintenance program. Public Health Rep 108(4):492-500,

1993.

Selwyn, P.A.; Carter, R.J.; Schoenbaum, E.E.; Robertson, J.V.; Klein, R.S.; and

Rogers, M.F. Knowledge of HIV antibody status and decisions to continue

or terminate pregnancy among intravenous drug users. JAMA 261:3567-

3571, 1989a.

Selwyn, P.A.; Hartel, D.; Lewis, V.A.; Schoenbaum, E.E.; Vermund, S.H.; Klein,

R.S.; Walker, A.T.; and Friedland, G.H. A prospective study of the risk of

tuberculosis among intravenous drug users with human immunodeficiency

virus infection. N Engl J Med 320:545-550, 1989d.

Selwyn, P.A.; Hartel, D.; Wasserman, W.; and Drucker, E. Impact of the AIDS

epidemic on morbidity and mortality among intravenous drug users in a

New York City methadone maintenance program. Am J Public Health

79:1358-1362, 1989b.

Selwyn, P.A.; Schoenbaum, E.E.; Davenny, K.; Robertson, V.J.; Feingold, A.R.;

Shulman, J.F.; Mayers, M.M.; Klein, R.S.; Friedland, G.F.; and Rogers, M.F.

Prospective study of human immunodeficiency virus infection and

pregnancy outcomes in intravenous drug users. JAMA 261:1289-1294,

1989c.

Stein, M.D.; Piette, J.; Mor, V.; Wachtel, T.J.; Fleishman, J.; Mayer, K.H.; and

Carpenter, C.C.J. Differences in access to zidovudine (AZT) among

symptomatic HIV-infected persons. J Gen Intern Med 6:35-40, 1991.

Vlahov, D.; Muñoz, A.; Solomon, L.; Astemborski, J.; Lindsay, A.; Anderson, J.;

Galai, N.; and Nelson, K.E. Comparison of clinical manifestations of HIV

infection between male and female injecting drug users. AIDS 8:819-823,

1994.

Ward, M.C. A different disease: HIV/AIDS and health care for women in

poverty. Cult Med Psychiatry 17:413-430, 1993.
353

AUTHORS

Peter A. Selwyn, M.D., M.P.H.

Associate Director

AIDS Program

Associate Professor of Medicine, Epidemiology, and Public Health

Yale University School of Medicine

135 College Street, Suite 323

New Haven, CT 06510

(203) 737-2685 (Tel)

(203) 737-4051 (Fax)

peter.selwyn@yale.edu (E-mail)

Marc N. Gourevitch, M.D., M.P.H.

Director of HIV Services

Montefiore Medical Group

Montefiore Medical Center

Assistant Professor of Epidemiology and Social Medicine

Albert Einstein College of Medicine

111 East 210th Street

Bronx, NY 10467

(718) 920-6481 (Tel)

(718) 231-8655 (Fax)