Claire Borkert, M.D.: Historically in Western medicine, few women have been involved in clinical trials that involve a disease found in both men and women. Gratefully, there are now more studies looking longitudinally at women-specific issues (the WIHS -- Women's Interagency HIV Study -- for example), but much more needs to be done. Estrogens may reduce drug clearance, via the cytochrome P450 system -- drugs called protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) are also metabolized through this system. This could become more and more important as women live longer with HIV and enter menopause and may have to consider hormone replacement therapy. Drug pharmacokinetics may also change during the menstrual cycle -- there is so much we don't know related to the female endocrine system that may be very different from men's. We need more women-specific studies and comparative studies to address some of these issues.
Victoria Cargill, M.D.: We continue to need a heavy emphasis on prevention, especially targeted to women, that is responsive to not only the context of their lives, but the contexts within which their risk behavior occurs.
We need treatment education and advocacy for women, to help them understand some of the unique decisions and challenges ahead of them regarding HIV infection.
We need increased awareness among HIV-infected women about the risk of cervical and other cancers, and the need for increased vigilance by them and their health care providers.
We need more substance-abuse treatment slots, and improved delivery of substance-abuse treatment where women get "one-stop shopping" care. One-stop shopping means that a woman will be best served if she can get her substance-abuse treatment at the same place she receives her medical care. Better still if the place provides child care and also has social services on site. Then all of her needs are housed under one roof. This makes it easier to make sure she is routed correctly from one site to the next, and makes it more likely that she will be engaged because all that she needs is there. Plus she won't have to run from one end of town to the other -- buses, car fare, children being dragged all over town, she herself may not feel well, etc.
Also, if a woman goes into treatment, in some communities there are limited resources available to her if she has children. By and large, women will not go into treatment if that means that they will either lose their children or have to give up their children to an outside care provider. To understand the powerful disincentive this can be for women you need only go back to the situation in South Carolina, where women were drug tested without their knowledge in prenatal clinics and then arrested -- sometimes in labor and delivery -- and taken away.
For almost every racial and ethnic group of women -- perhaps with the exception of Native Americans and Asian Pacific Islanders -- more than half of HIV cases can be linked to substance abuse. Women need help with their substance abuse like anyone else does, but the issues for them are different. There is a gap between the treatment slots available and the need in the community.
A broader societal view dictates that we consider the economic futures of the women who are becoming infected. Until we offer greater incentives and opportunities for economic growth, the complex forces of racism, poverty and social alienation will continue to affect women and serve as fuel for the HIV epidemic, robbing these women of their very lives.
Ruth Greenblatt, M.D.: It is of critical importance that women living with HIV have access to comprehensive care services that provide HIV expert care, state-of-the-art gynecologic and obstetric services and social work-case management to assist with complex lives. Failure to get appropriate medical treatment -- or to adhere to it -- continued drug use and sexual-risk behaviors threaten to perpetuate this epidemic.