There are roughly 1.2 million individuals in the United States living with HIV, and in 2022 people assigned female at birth accounted for 19% of new HIV infections.1 In 2023, Georgia had the second highest rate of new HIV diagnoses in the South, with metro Atlanta, in particular, having the highest HIV diagnosis rate in the state.2 Within our state, black cisgender women are the second most common demographic with an HIV diagnosis, and the number of people over 50 years old living with HIV in Georgia continues to grow.3
We know that antiretroviral therapy (ART) has made a considerable impact on the management of HIV, helping keep viral loads clinically low and as such, improving patient longevity.4 We also know that these same medications, along with HIV itself, can interact with and/or lead to other health conditions. For our patients living with HIV who are undergoing menopause, there are important considerations to make based on the limited evidence that we have available:5, 6
• The onset of menopause is likely to be earlier than the general population by 3 years with approximately 1 in 4 women living with HIV (WLHV) undergoing menopause before 45 years of age.7,8,9
• There is also an increased risk of developing premature ovarian insufficiency (POI): 1-3% WLWH are at increased risk of developing POI compared to 1% to <1% in the general population.
• Menopausal symptoms, such as vasomotor symptoms, sleep disturbance, mood changes, and sexual dysfunction, may also be more severe in this population. Importantly, in the general population, Black and Latinx women – populations that are also disproportionately affected by HIV – are more likely to experience longer or more burdensome symptoms, which may further impact quality of life.10 In addition, the risk of osteoporosis may be amplified by both HIV infection and certain antiretroviral therapies.
• Beyond symptom burden, menopause may have important immunologic implications in WLWH. The menopausal transition has been associated with increased immune activation, including elevations of innate immune activation markers such as soluble CD14 and CD163, reflecting macrophage activation that may contribute to HIV-related comorbidities. This process is further modified by estrogen depletion during menopause, and loss of its anti-inflammatory effects.11,12,13
• Hormone replacement therapy (HRT) is underutilized among WLWH. Low uptake appears strongly associated with limited discussion of menopause in routine HIV care with only about 45% of WLWH reporting having had conversations with their providers. Concerns about potential drug–drug interactions between HRT and ART (particularly boosted protease inhibitors [i.e., including cobicistat or ritonavir], or some NNRTIs) may also contribute, although data on clinically significant interactions remain limited.14
• Available evidence suggests that HRT is safe and beneficial for WLHV and there may be a need for higher doses to achieve symptom relief. In specialty clinic settings, approximately 73% of women receiving therapy report symptomatic improvement, with no serious adverse effects observed. Some data also suggest potential cardiovascular benefits, including reductions in carotid plaque and there are also bone health benefits to HRT. There is no evidence that menopause adversely affects HIV disease markers, including CD4 counts, viral load, or response to antiretroviral therapy.15,16,17,18
• There is a paucity of data on non-HRT based menopause management for WLWH. Non-HRT options include medications such as selective serotonin reuptake inhibitors (SSRIs: e.g., paroxetine), serotonin-norepinephrine reuptake inhibitors (SNRIs: e.g., venlafaxine), gabapentin and the newer neurokinin 3 (NK3) receptor antagonists (e.g., fezolinetant).19 These generally have few to no known interactions with ART and empirically in our experience have been well tolerated by WLWH.
Overall, menopause care remains under addressed but an important component of comprehensive HIV management. It is important that WLWH are appropriately screened and screened early for perimenopause and, if possible, have access to menopause specialists for initiation of medication management.
NB: We acknowledge that we have used gendered language for communication purposes. We do not intend to ostracize people’s diverse identities.
References
1 HIV.gov. “U.S. Statistics.” Last modified February 12, 2026. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics. Accessed: February 16, 2026.
2 Rob Spahr, “HIV/AIDS Epidemic in the Southeastern U.S.,” Rollins Magazine, Fall 2025, https://sph.emory.edu/magazine/2025/fall/hivaids-epidemic-southeastern-us.
3 Georgia Department of Public Health. “Georgia HIV Surveillance Data.” Last modified June 10, 2025. https://dph.georgia.gov/epidemiology/hiv-epidemiology-unit/georgia-hiv-surveillance-data. Accessed February 16, 2026.
4 Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV. Department of Health and Human Services. Available at https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/whats-new. Accessed February 16, 2026.
5 Scofield D, Moseholm E, Aebi-Popp K, Hachfeld A; Women Against Viruses in Europe (WAVE), European AIDS Clinical Society. Electronic address: wavesecretariat@eacssociety.org. Management of menopause in women living with HIV – A comparative guideline review. Maturitas. 2024 May;183:107937. doi: 10.1016/j.maturitas.2024.107937. Epub 2024 Feb 9. PMID: 38367364.
6 Tariq S, Delpech V, Anderson J. The impact of the menopause transition on the health and wellbeing of women living with HIV: A narrative review. Maturitas. 2016 Jun;88:76-83. doi: 10.1016/j.maturitas.2016.03.015. Epub 2016 Mar 18. PMID: 27105703.
7 Calvet GA, Grinsztejn BG, Quintana Mde S, Derrico M, Jalil EM, Cytryn A, de Andrade AC, Moreira RI, Alves MR, Veloso Dos Santos VG, Friedman RK. Predictors of early menopause in HIV-infected women: a prospective cohort study. Am J Obstet Gynecol. 2015 Jun;212(6):765.e1-765.e13. doi: 10.1016/j.ajog.2014.12.040. Epub 2014 Dec 31. PMID: 25557206.
8 Chakalisa UA, Cole-Haley S, Morroni C, Nwokolo N. HIV and menopause: current evidence, gaps, and future directions for integrated care. Curr Opin Infect Dis. 2026 Feb 1;39(1):16-21. doi: 10.1097/QCO.0000000000001168. Epub 2025 Nov 27. PMID: 41311203.
9 Van Ommen CE, King EM, Murray MCM. Age at menopause in women living with HIV: a systematic review. Menopause. 2021 Dec 1;28(12):1428-1436. doi: 10.1097/GME.0000000000001871. PMID: 34854838.
10 Hachfeld A, Atkinson A, Stute P, Calmy A, Tarr PE, Darling K, Babouee Flury B, Polli C, Sultan-Beyer L, Abela IA, Aebi-Popp K; Swiss HIV Cohort Study (SHCS). Women with HIV transitioning through menopause: Insights from the Swiss HIV Cohort Study (SHCS). HIV Med. 2022 Apr;23(4):417-425. doi: 10.1111/hiv.13255. Epub 2022 Feb 22. PMID: 35194949; PMCID: PMC9306735.
11 Kanapathipillai R, Hickey M, Giles M. Human immunodeficiency virus and menopause. Menopause. 2013 Sep;20(9):983-90. doi: 10.1097/GME.0b013e318282aa57. PMID: 23531684.
12 Peters BA, Xue X, Sheira LA, Qi Q, Sharma A, Santoro N, Alcaide ML, Ofotokun I, Adimora AA, McKay HS, Tien PC, Michel KG, Gustafson D, Turan B, Landay AL, Kaplan RC, Weiser SD. Menopause Is Associated With Immune Activation in Women With HIV. J Infect Dis. 2022 Jan 18;225(2):295-305. doi: 10.1093/infdis/jiab341. PMID: 34174074; PMCID: PMC8763955.
13 Peters BA, Hanna DB, Xue X, Weber K, Appleton AA, Kassaye SG, Topper E, Tracy RP, Guillemette C, Caron P, Tien PC, Qi Q, Burk RD, Sharma A, Anastos K, Kaplan RC. Menopause and Estrogen Associations With Gut Barrier, Microbial Translocation, and Immune Activation Biomarkers in Women With and Without HIV. J Acquir Immune Defic Syndr. 2024 Jul 1;96(3):214-222. doi: 10.1097/QAI.0000000000003419. PMID: 38905473; PMCID: PMC11196004.
14 Same as 4.
15 Bull L, Tittle V, Rashid T, Nwokolo N. HIV and the menopause: A review. Post Reprod Health. 2018 Mar;24(1):19-25. doi: 10.1177/2053369117748794. Epub 2017 Dec 17. PMID: 29251186.
16 Chirwa M, Taghinejadi N, Macaulay G, Mandalia S, Bellone C, Panay N, Brum R, Nwokolo N. Reflections on a specialist HIV menopause service: Experiences of managing menopause in women living with HIV: Experiences of managing menopause in women living with HIV. HIV Med. 2022 Apr;23(4):426-433. doi: 10.1111/hiv.13256. PMID: 35249262.
17 King EM, Prior JC, Pick N, van Schalkwyk J, Kestler M, Tkachuk S, Loutfy M, Murray MCM. Menopausal hormone therapy for women living with HIV. Lancet HIV. 2021 Sep;8(9):e591-e598. doi: 10.1016/S2352-3018(21)00148-X. Epub 2021 Aug 9. PMID: 34384545.
18 Peters BA, Hanna DB, Sharma A, Anastos K, Hoover DR, Shi Q, Moran CA, Jackson EA, Alcaide ML, Ofotokun I, Adimora AA, Haberlen SA, Cohen M, Tien PC, Michel KG, Levine SR, Hodis HN, Kaplan RC, Yin MT. Menopausal Hormone Therapy and Subclinical Cardiovascular Disease in Women With and Without Human Immunodeficiency Virus. Clin Infect Dis. 2023 Feb 8;76(3):e661-e670. doi: 10.1093/cid/ciac620. PMID: 35903868; PMCID: PMC10169435.
19 ACOG Practice Bulletin No. 141: management of menopausal symptoms. Obstet Gynecol. 2014 Jan;123(1):202-216. doi: 10.1097/01.AOG.0000441353.20693.78. Erratum in: Obstet Gynecol. 2016 Jan;127(1):166. doi: 10.1097/AOG.0000000000001230. Erratum in: Obstet Gynecol. 2018 Mar;131(3):604. doi: 10.1097/AOG.0000000000002513. PMID: 24463691.3.
