Signs and Symptoms of HIV in Women

How HIV Differs From Men by the Stage of Infection

In the United States, women account for roughly one in five new HIV infections each year. Although the majority of these are due to sexual contact, 19% are caused by shared needles in women who are illicit drug users.

Young female patient in distress at the doctor's office.

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In 2018, of the 1.2 million Americans living with HIV, an estimated 37,832 were women. Of these, 1 in 9 are thought to be unaware of their HIV status, according to data from the Centers for Disease Control and Prevention (CDC).

Although the signs and symptoms of HIV are largely the same whether you are female or male, there are several specific to women that can occur during early-stage or later-stage infection.

Acute HIV Infection

Acute HIV infection, also known as acute seroconversion, is the first of three stages of the disease immediately following exposure to the virus. During acute seroconversion, the immune system will produce defensive antibodies to help fight the virus and bring the infection under control.

From start to finish, acute seroconversion generally lasts for seven to 14 days, during which some people may experience symptoms (referred to as acute retroviral syndrome, or ARS). Symptoms are typically described as being flu-like with mild fever and body ache. Swollen lymph nodes and rash may also accompany.

As many as 43% of people will not experience any signs of acute HIV infection, according to a 2016 study in Emerging Infectious Diseases.

Disparities in Infection Rates

When acute symptoms do develop, they are generally the same in women as they are in men. Where they do vary is the rate of seroconversion.

Heterosexual women are twice as likely to get infected per sexual act compared to heterosexual men (due in part to the increased size and porosity of vaginal tissues compared to those of the penis).

These and other factors not only confers to higher rates of new infections among women compared to men—18% versus 8%, respectively—but also translates to faster disease progression.

According to a 2014 review in the Journal of Infectious Diseases, women with HIV have no less than a 1.6-fold greater risk of progressing to AIDS (the most advanced stage of the disease) than men.

HIV and STD Co-Infection

Other symptoms may develop during acute seroconversion if there an accompanying sexually transmitted disease (STD). This is not uncommon, with some studies suggesting that 1 in 7 people with HIV are co-infected with another STD at the time of their diagnosis. Other studies suggest the HIV/STD co-infection rate may be even higher.

Among women with HIV, the most common accompanying STDs are chlamydia, gonorrhea, trichomoniasis ("trich"), and syphilis. Having these infections—or even non-sexually transmitted ones like bacterial vaginosis (BV)—can increase a woman's risk of getting HIV by two- to three-fold.

Infections like these not only undermine the barrier function of the vaginal mucosa but also increase the concentration of immune cells at the site of the infection. Among them are CD4 T-cells, the very cells that HIV preferentially targets and infects.

In the case of co-infection, HIV may be identified by the signs and symptoms of the STD rather than those of HIV itself.

Symptom  Chlamydia Gonorrhea Trich Syphilis BV 
Burning with urination (dysuria) X X X   X
Vaginal discharge X X   X
Vaginal itchiness
(pruritus)
    X   X
Bleeding between periods
(metrorrhagia)
X X      
Pain with sex (dyspareunia) X X      
Strong, fish-like odor     X   X
Painless vaginal sore (chancre)       X  

It is for this reason that the CDC recommends HIV testing for anyone who seeks the diagnosis and treatment of an STD.

Chronic HIV Infection

By the end of the acute stage of infection, the immune system will have brought HIV under control and the virus will establish a set point during which viral activity (as measured by the viral load) will remain more or less stable for months and years.

This chronic stage of infection, referred to as clinical latency, is one in which the infection may progress silently with few notable symptoms. Even so, the virus will continue to infect and deplete CD4 T-cells that the body relies upon to trigger an immune response.

Over time, the loss of CD4 T-cells will lead to immunosuppression and an increased risk of opportunistic infections (OIs). They are considered "opportunistic" because an intact immune system would otherwise be able to control them.

As the number of CD4 T-cells progressively drops (as measured by the CD4 count), the risk, severity, and range of OIs will increase.

A CD4 count between 500 to 1,200 cells per cubic millimeter (cells/mm3) is considered normal. Any value between 250 and 500 cells/mm3 is a sign of immunosuppression.

Signs and Complications in Women

The symptoms of chronic HIV infection are often related to the development of OIs rather than the virus itself. With that said, secondary conditions affecting a woman's fertility and menstrual cycle can develop as a result of prolonged immune suppression and chronic inflammation.

The type of OIs commonly seen at CD4 counts between 250 and 500 are more or less the same whether you are female or male. These include herpes simplexherpes zoster (shingles), bacterial pneumonia, bacterial and fungal skin infectionstuberculosis, and HIV-associated meningitis.

The differences, in any, mainly involve a woman's reproductive tract. The symptoms may include:

  • Recurrent yeast infections: The condition, called vaginal candidiasis, is the result of the overgrowth of a common type of fungus called Candida. The frequency and severity of yeast infection increase in tandem with declines in the CD4 count. Vaginal candidiasis is the counterpart to oral thrush experienced by both men and women.
  • Vaginal ulcers: Herpes simplex virus type 2 (HSV-2) is the virus most commonly associated with genital herpes. In people with HIV, the risk of herpes outbreaks increase at CD4 counts under 500. Vaginal herpes often the first manifestation of HIV in women (given that between 52% and 72% of people with HIV are thought to be coinfected with HSV-2).
  • Genital warts: Genital warts, also known as condylomas, are most commonly linked to human papillomavirus (HPV). Studies suggest that women with HIV are twice as likely to get HPV than women without, including high-risk strains linked to cervical cancer.
  • Abnormal periods: Women with HIV experience more menstrual problems, including amenorrhea (absence of menstruation) and oligomenorrhea (infrequent menstruation), than HIV-negative women. The risk increases with declines in the CD4 count. Although the cause of this is poorly understood, a low body mass index (common in women with advanced HIV) and untreated HIV infection are considered key risk factor.
  • Chronic pelvic pain: In the same way that STDs can facilitate HIV transmission, the persistent inflammation spurred with HIV can increase a woman's vulnerability to bacterial STDs like chlamydia and gonorrhea. This accounts for higher rates of pelvic inflammatory disease (PID) among women with HIV. Chronic pelvic pain, irregular periods, and pain with sex are common features of PID.
  • Impaired fertility: PID can lead to serious complications in some women, including infertility and ectopic pregnancy. Because HIV suppresses the immune response, women with HIV are less able to control PID even when treatment is prescribed. As such, women with HIV are more likely to experience complications of PID than women without, including a tubo-ovarian abscess (TOA).
  • Premature menopause: Premature menopause, defined as the onset of menopause before 40, can sometimes occur in women with HIV. Women who smoke, have a low CD4 count, and have low physical activity are more likely to be affected. By contrast, healthy women with HIV tend to experience menopause around the age of 50.
  • Bone problems: Back pain, stooped posture, a loss of height, and bones that break easily are common signs of osteoporosis. Osteoporosis can affect anyone but is most common in postmenopausal women. Among women with HIV, the risk of osteoporosis is four times greater than that of women without. In addition to HIV infection, hepatitis C co-infection and certain HIV drugs are linked to increased bone mineral loss.

In addition to symptoms, women with HIV will often experience changes that are only recognized during a pelvic exam. This may include an abnormal PAP smear or signs of cervical dysplasia (a precancerous condition affecting the cervix).

AIDS

The third stage of HIV infection is acquired immune deficiency syndrome (AIDS), characterized by symptomatic disease. This is the phase where the immune defenses have been all but wiped out, leaving you in an immunocompromised state.

Without the means to defend yourself from common and uncommon diseases, a person with AIDS runs a high risk of severe and potentially life-threatening illness. These not only include infections but certain types of cancers as well.

According to the CDC, a person is said to have progressed to AIDS when:

  • The CD4 count under 200 cells/mm3.
  • A person gets one of 28 AIDS-defining conditions irrespective of the CD4 count

AIDS-defining conditions include disease are rarely seen outside of immunocompromised people. They also involve common OIs that have disseminated (spread) from their typical site of infection to other parts of the body.

According to the CDC, the median time of progression from initial HIV infection to AIDS is 11 years.

Symptoms of AIDS in Women

The symptoms of AIDS vary little between women and men. There are some variations, including evidence that women with HIV experience greater cognitive decline and may be more likely to experience signs of HIV encephalopathy (a.k.a. AIDS dementia complex) than men.

The one AIDS-defining condition exclusive to women is invasive cervical cancer (ICC). This is the advanced stage of cervical cancer in which tumor cells have spread to tissues deeper within the cervix or to other parts of the body. Though ICC can affect both HIV-positive and HIV-negative women, the incidence among women with HIV is up to seven times greater.

As with other HIV-associated conditions, the risk of ICC increases with declines in the CD4 count. Women with CD4 counts under 200 are six times more likely to get ICC than those whose CD4 counts over 500.

Arguably more concerning is the fact that the incidence of ICC among women with HIV has remained largely unchanged since the 1990s. This is unlike other AIDS-defining conditions that are rarely seen today due to the advent of combination antiretroviral therapy.

Though the reasons for this remain unclear, some studies have suggested that women with HIV are more likely to be infected by less prevalent high-risk strains of HPV that current vaccines cannot protect against.

Non-HIV-Related Conditions

In addition to HIV-related conditions, there are a number of non-HIV-related illnesses commonly seen in people with long-term infection. These include cancers and aging-related diseases that often develop 10 to 15 years earlier in people with HIV than those without.

Under the burden of chronic inflammation, cells can undergo dramatic changes that literally age them, leading to a phenomenon knows as premature senescence. Particularly if left untreated, HIV can increase the risk of non-HIV-related cancers and cardiovascular diseases, including heart attacks and strokes.

In some cases, women are disproportionately affected. Studies suggest, for instance, that women with HIV have a higher risk of heart disease than men due to the activation of white blood cells called monocytes that promote cardiovascular inflammation.

Similarly, women with HIV who engage in anal sex are at increased risk of anal cancer (due to HPV co-infection). While anal cancer is relatively rare in the United State, women with HIV are 30 times more likely to be affected than women in the general population.

Non-AIDS-defining cancers are today the leading cause of death in people with HIV in the developed world, according to research published in the Journal of the International AIDS Society.

A Word From Verywell

Although certain symptoms may suggest you have HIV, the absence of symptoms should not be considered an all-clear flag. Today, an estimated 1 in 7 Americans living with HIV remain undiagnosed, either because they have no idea they have been infected or are ignoring their suspicions.

If diagnosed and treated early, people with HIV can not only live long, healthy lives but reduce the risk of HIV-related and serious non-HIV-related illnesses by up to 72%.

The U.S. Preventive Services Task Force currently recommends once-off HIV testing for all Americans 15 to 65 as part of a routine medical exam. If you have risk factors for HIV and have not been tested, there may be no better time to do so than now.

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