Comorbidities in Women Living With HIV

A Systematic Review

Sonia Raffe; Caroline Sabin; Yvonne Gilleece


HIV Medicine. 2022;23(4):331-361. 

In This Article


This review confirms the high burden of age-related morbidity experienced by WLWH. As compared with HIV-negative women, WLWH are at an increased risk of an acute cardiovascular event, reduced BMD and impaired cognitive performance. Female sex was also consistently identified as a risk factor for renal disease in PLWH.

However, this review also highlights the inadequacy of our understanding of the drivers behind this increased disease burden. During screening and assessment of eligibility, multiple large studies were excluded due to poor female representation among participants or a failure to present any sex-based analysis. Only 21 studies focused specifically on comorbidities in women (five cardiovascular, four bone and eight neurocognitive disease); notably no studies looked specifically at renal disease in WLWH.

There may be underlying, HIV-driven biological mechanisms contributing to this increased burden of comorbid disease. Fitch et al.[13] identified differing patterns of coronary calcification between women living with and without HIV, which raised questions as to the efficacy of our current tools for screening for ischaemic heart disease in WLWH. Similarly, to ensure the safe use of medication that acts on the central nervous system in WLWH, we need a better understanding of the increased cognitive vulnerability highlighted by Rubin et al..[48] To ensure we are able to screen and manage comorbidities effectively in WLWH, it is essential that future research explores these mechanisms by focusing specifically on women.

A number of other limitations impair our ability to draw conclusions from this review. The studies lack geographical diversity, restricting our ability to generalize the results. The marked differences in population demographics, behaviours, healthcare systems and approach to HIV treatment between settings also impair our ability to draw any meaningful comparisons between different studies. Few studies focused on postmenopausal women which may not capture the true impact of ageing and comorbid disease in WLWH.

However, by far the greatest factor limiting our ability to draw conclusions from this review is the number of both acknowledged and unacknowledged confounding factors. Control groups were often poorly matched, particularly in terms of ethnicity. This is profoundly important when we consider how readily different populations are able to access healthcare. Abraham et al.[32] noted that the rate of HIV viral suppression was markedly lower in black than in non-black participants (47% vs. 73%). Ogunbayo et al.[31] also found that WLWH, of whom a higher proportion were black compared with the MLWH, were significantly less likely to undergo coronary revascularization following MI. These two studies, both from North America, highlight the need to explore sex and race-related inequality in the healthcare setting as a barrier to WLWH accessing care.

Very few studies attempted to report on wider socioeconomic factors that influence health and access to healthcare. Those that did found striking differences in measures such as educational attainment,[21,45] household income[21] and unemployment[18] between WLWH and either MLWH or HIV-negative controls.

In order to provide the best possible care and support for women as they age with HIV, it is essential that more research, focusing specifically on women, explores the complex and multiple drivers behind the increased burden of age-related comorbidities in this population. Potential biological mechanisms must be explored, but equally it is essential that we gain a greater understanding of the multiple factors that drive disparities in healthcare to improve the holistic management of WLWH.