Women living with HIV: identifying and managing their menopause, age-related, and psychosocial health needs in a metropolitan sexual health service in Sydney, Australia

Introduction

Globally, 53% of people living with HIV are women, and women account for nearly half of all new HIV infections.¹ In Australia, 12% of all people living with HIV are women.² In 2021, an estimated 3630 women were living with HIV in Australia, including 300 undiagnosed women and 64 newly diagnosed women.² A high proportion (49%) of those newly diagnosed were diagnosed late, and most (68%) were born overseas.² Despite these figures, women are not considered a priority population in the current Australian Eighth National HIV Strategy.³ Due to cultural, linguistic, and socioeconomic factors, many women living with HIV face barriers to accessing healthcare.^4–6 Furthermore, women living with HIV in Australia experience a complex intersection of aging and HIV-related comorbidities in addition to menopause, mental health conditions, and psychosocial challenges that are under-recognised and often unaddressed in clinical settings.^4–6

Women living with HIV experience greater age-related comorbidities at a younger age and higher mortality when compared with men living with HIV.⁷ In contrast to HIV-negative women, women living with HIV have a higher burden of cardiovascular disease, renal disease, and cognitive impairment, as well as reduced bone mineral density.⁷ Menopause, an independent risk factor for cardiometabolic disease, osteoporosis, and cognitive impairment, affects women living with HIV at an earlier age.⁸ Menstrual abnormalities, such as heavy menstrual bleeding and abnormal cycle length, are more common among women living with HIV and carry potential clinical implications such as anaemia and subfertility.⁹ In addition, women living with HIV experience earlier and more severe menopausal symptoms, which impact quality of life, mood, and cognitive function, with potential effects on adherence to antiretroviral (ARV) therapy.¹⁰ Women living with HIV experience disproportionately higher rates of mental health conditions when compared with the general population, HIV-negative women, and men with HIV.¹¹ Women approaching menopause are at highest risk of developing depression, anxiety, and menopause-associated psychological symptoms.¹² Women living with HIV age 45 years and older with mental health issues are less likely to engage in HIV care, resulting in non-adherence to ARV therapy and missing clinic appointments.¹² Intimate partner violence (IPV), which is associated with poorer HIV clinical outcomes,¹³ disproportionately affects women living with HIV and globally affects at least one in three women living with HIV.¹³

Despite an international call for women-centred HIV care, integrating reproductive and mental health care,¹⁴ Australian HIV guidelines provide minimal guidance on managing women living with HIV, specifically none on menopause or IPV screening. European and British guidelines on managing women living with HIV also lack comprehensive guidance. As a quality improvement project, we sought to identify gaps in clinical management of menopause, age-related comorbidities, and psychosocial health in women living with HIV attending our service. The Sydney Local Health District (SLHD) Department of Sexual Health Medicine (DSHM), also known as RPA Sexual Health, is a publicly funded service in metropolitan Sydney providing routine HIV care to approximately 350 people living with HIV annually.

Methods

A clinical audit of all cisgender female patients with HIV who attended SLHD DSHM for routine HIV care at least twice between 1 January 2021 and 1 January 2023 was undertaken. Patients who attended once in this period were excluded, as they were either passing travellers or patients who typically received routine HIV care from other local health services, such as the SLHD Department of Immunology HIV Clinic.

Data were manually collected from medical records and included patient demographics; HIV data, including immunovirological status and treatment; reproductive health indicators, including menstrual problems and menopause; comorbidities; chronic disease risk screening; and psychosocial health factors, including IPV screening.

Results were audited against standards of care outlined in HIV care guidelines from the Australasian Society for HIV Medicine (ASHM), the European AIDS Clinical Society, the British HIV Association; in addition to the NSW Health policy on IPV screening.^15–18

This study was approved by the SLHD Royal Prince Alfred Hospital Human Research Ethics Committee (2023/ETH01911/STE03089), who granted a waiver of consent.

Results

Twenty-seven patient files were examined (Table 1). Age ranged from 23 to 70 years, with a median age of 44 years. All women were virologically suppressed at most recent testing. Nearly half (13/27, 48.1%) of women were age 45 years and older. Menopause status was not recorded for one-third (4/13, 30.8%) of these women, and almost half (6/13, 46.2%) were postmenopausal at their last appointment (Table 2). Most women age 45 years and older did not have documented screening of menopausal symptoms (9/13, 69.2%), menopausal hormone therapy (MHT) use (7/13, 53.8%), or recent mammogram results (10/13, 76.9%). Only half of all women had their body mass index (14/27, 51.9%), smoking (13/27, 48.1%), and alcohol intake (12/27, 44.4%) assessed and documented in the prior 12 months. Nearly three-quarters had blood pressure (19/27, 70.4%), lipids (21/27, 77.8%), and glucose (21/27, 77.8%) checked, and almost all (26/27, 96.3%) had liver and kidney function assessed in the prior 12 months. Only 2/13 (15.4%) women age 45 years and older had a calculated absolute cardiovascular disease risk recorded in the prior 12 months. No women age 40 years and older had a documented Fracture Risk Assessment Tool (FRAX) score in the prior 12 months. No women had been screened for cognitive impairment. Most (19/27, 70.4%) women had no audited comorbidities, and many (16/27, 59.3%) had a regular general practitioner. One-fifth (5/27, 18.5%) of women had a documented history of depression or anxiety. Screening for IPV was rare; of those screened in the past 2 years (8/27, 29.6%), 3/8 (37.5%) women disclosed current IPV, and 4/8 (50.0%) women disclosed past IPV. One woman disclosed reproductive coercion.

Discussion

Our study found that women living with HIV who attended our service for routine HIV care had low rates of screening for menopause, comorbidities, and other health determinants as recommended by international HIV guidelines.

The demographics of women included in this study were likely reasonably representative of women living with HIV in Australia. Most women in this study were born overseas, primarily in Asia or sub-Saharan Africa, and age 45 years and older (48.1%), consistent with Australian data. Kirby’s HIV Dataset in 2021 reported that half of women living with HIV in Australia were age 40 years and older, and one-fifth were age 50 years and older.¹⁹ This reflects the global trend of a growing population of aging women living with HIV.

The proportion of postmenopausal women living with HIV in this study (22.2%) was similar to that previously reported in Australia (21%).⁵ However, previously reported rates of menopausal symptoms (42%) and MHT use (17%) among postmenopausal women living with HIV in Australia were much higher than our study findings.⁵ This is probably due to our lack of routine menopause discussion with patients, which is not uncommon among HIV clinicians and other healthcare providers. In Europe 44% of HIV clinicians are not confident in ascertaining menopausal status in women living with HIV,²⁰ whereas in Canada 55% of postmenopausal women living with HIV have never discussed menopause with their healthcare providers.²¹ Lack of expertise and comprehensive guidelines on management of menopause in women living with HIV are commonly cited reasons.²⁰ In Australia women in general, regardless of HIV status, are not adequately assessed and treated for menopause in primary care.²² This care gap would benefit from the development of Australian guidelines on menopause management in HIV. European and British HIV care standards recommend annual routine assessment of menopause from age 40 years and 45 years, respectively.^16,17

The disclosure rate of IPV among women living with HIV screened at our service was high, in keeping with the high lifetime prevalence of IPV among women living with HIV in the USA (55%) and UK (52%).¹³ However, our overall IPV screening rate was low (26.9%) when compared with the average IPV routine screening rate at other publicly funded NSW health services (62.7%)²³ and Family Planning Australia (69%),²⁴ which is another major sexual and reproductive health service in NSW. Reasons could include clinician and structural factors such as lack of confidence, personal bias, time restrictions, language barriers, and cultural safety concerns.²⁵ These barriers may be magnified by patient factors such as shame and stigma,²⁵ which women living with HIV may already face in relation to their HIV status. NSW Health recommends 12-monthly IPV routine screening in mandated services, such as antenatal and mental health services, while noting screening may also be conducted in sexual health services.¹⁸ Given the high prevalence of IPV among women living with HIV and the multidisciplinary nature of women-centred HIV care, routine IPV screening should be an appropriate and feasible health intervention for HIV clinicians, including at sexual health services.

Other care gaps demonstrated in this study are low rates of annual screening for lifestyle risk factors, comorbidities, and mental health symptoms, as endorsed by Australian, European, and British HIV care guidelines.^15–17

As a result of our study findings, SLHD DSHM has implemented longer appointment times with women living with HIV, introduced clinician education on managing women living with HIV, increased staff education on IPV screening, and developed a clinician reference tool for routine monitoring of women living with HIV that includes sections dedicated to contraception, menopause, mental health, and IPV (Table 3). Our aim is to deliver holistic women-centred HIV care with a trauma- and violence-informed approach, without which the health needs of women living with HIV will remain unmet.

The majority of data from this audit were extracted from the review of medical records. We assume that if an issue was not documented it was not assessed during a patient’s consultation, which may be incorrect. While this study captured all women living with HIV who regularly attended our service, the small sample size also limits generalisability to other HIV services.

Conclusion

Women living with HIV in Australia are a culturally, linguistically, and socioeconomically diverse group with intersectional challenges and complex health needs. This study highlights care gaps for women living with HIV that should be addressed through provision of women-centred HIV care that encompasses reproductive and mental health. We adapted our clinician reference tool for the routine monitoring of women living with HIV from ASHM’s HIV Monitoring Tool to include extra sections on contraception, menstruation, menopause, IPV, and psychological wellbeing (Table 3). We encourage other HIV clinics to implement a similar tool and call on ASHM to expand guidance and training opportunities for clinicians who care for women living with HIV.