Claire Borkert, M.D.: I am much more likely to think about a woman's care in the context of her significant others -- the people in her life she is caring for. The single most significant fact that separates women living with HIV from men living with HIV is that more than 60% of the women are caring for at least one child under the age of 16. They may also be caring for a partner, grandchildren and/or extended family members. One of my patients explained it best. She said, "I know from an intellectual standpoint that I am important, but when I had kids, I knew from an emotional standpoint that they would always come first -- no matter what." So you can't separate the care of the woman from the care, safety and security of her family.
Victoria Cargill, M.D.: This depends upon whether or not the woman is a new patient with no prior HIV care or has been in care before. I will handle these as two separate scenarios:
- If the woman is new to HIV care or newly diagnosed, we will try to learn the context of her diagnosis -- in other words, was she diagnosed while in treatment, during prenatal care or in an STD clinic?
- If she is substance using, I'll probe the issues around the role of a partner in her use, such as the provision of drugs, commercial sex work, sexual safety or domestic violence.
We will also ask: Does she have any children? Are they infected? If yes, are they on treatment? What's her role in treatment? Are her children living with her, or has she lost custody?
I'll take a sexual history, including gynecological history: past STDs, current practices, number of current partners. Did she use any barrier or safe-sex method? Does she have any history of syphilis in her lifetime? When was her last menstrual period? Does she have pregnancy concerns? Does she have a history of HPV [human papilloma virus, the virus that causes genital warts], treated or untreated? Abnormal Pap? Has she ever had a colposcopy [examination of vaginal and cervical tissue lining]?
We'll also find out if the patient has support systems in place. Does she have a network of support? A network of risk-partners, shooting/smoking/snorting buddies? These kinds of things may influence risky behavior or adherence [how regularly the woman takes her medication].
- If the woman has been in HIV care before, but is new to my office, we'll generally ask most of the same questions, with a few differences. For instance, we'll try to learn her reasons for changing her care -- it may provide us with insight into her particular issues. We'll ask her what medications has she been on, and how have they affected her -- including a discussion of any impact they may have had upon menstrual function.
- We'll survey the biggest challenges for her to be in care. Is it difficult for her to remain in care? If she's on medications, is it difficult for her to take them? We'll listen for support issues, child care issues, lack-of-support issues and stigma concerns.
Mardge Cohen, M.D.: Women with HIV are different from men with HIV physically, psychosocially and emotionally, as well as in their role as caregivers for their families and communities. An initial visit establishes the unique aspects of these categories for each woman, so the evaluation needs to include gynecologic and obstetric history including contraception use and reproductive concerns, medical history including hepatitis C, hypertension, diabetes, social history including work issues, sexual activities, drug, alcohol and smoking behaviors, HIV disclosure concerns, history of physical, sexual and emotional abuse, and a full physical exam including gynecologic exam.
The doctor and patient have to reach an understanding of how to treat the stage of HIV infection that is present, and review the indications, risks and benefits of treatment. There is much more to HIV infection care than antiretrovirals, and these should also be attended to by the doctor. Age-appropriate and clinically appropriate preventive screening assessments should be in place so the full spectrum of care can be provided. Attention to medical problems related to domestic violence, drug use, depression and hepatitis C seem particularly important in our experience.
In terms of domestic violence, 67% of women with HIV in the "Women's Interagency HIV Study," American Journal of Public Health (2000; 90:560-565), had a history of domestic violence, with 25% reporting recent abuse and 31% reporting a history of childhood sexual abuse. Our study lent credibility to the idea of a continuum of risk with early childhood abuse leading to later domestic violence, which may increase the risk of behaviors leading to HIV infection. Also, an Institute of Medicine [a national private organization] report called "Bridging the Quality Chasm" (March 2001) states that HIV, substance abuse and domestic violence are so closely associated with each other that they should be treated as almost one problem in terms of organization of healthcare delivery systems. This was included as an example of new paradigms of care needed to address healthcare needs of patients.
Ruth Greenblatt, M.D.: I do a comprehensive medical and social history on all new patients -- all my patients presently are women. Since many HIV patients in San Francisco are middle-class men, while the women tend to be poor and socially complex, I do tend to carefully assess ability to adhere to medication regimens and needed support. Our clinical program for women, which receives Ryan White Care funding, offers special resources for women clients, including a full-time social worker and treatment advocate. These services are not available to male clients who attend the same facility.
I also have a conversation with female patients regarding reproductive choices. Plans for pregnancy can influence treatment decision-making, such as when to begin and which antiretroviral medications to select. In addition, current pregnancy can affect CD4 cell count and other clinical parameters. Since the female patients at University of California-San Francisco are more likely than the average man to be homeless or to use recreational drugs, I obtain information on housing and drug use.