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Interviews with Top Doctors Treating HIV-Positive Women -- Claire Borkert, M.D.

Claire Borkert, M.D.

Claire Borkert, M.D.

Claire Borkert, M.D., was the co-medical director of the East Bay AIDS Center (EBAC) in Oakland, Calif., from 1992 until her death from cancer in June 2010. She was a guest lecturer for the University of California-San Francisco/University of California-Berkeley joint medical program, teaching an HIV and biochemistry curriculum class to third-year students. She is also the annual HIV lecturer for the UC-Berkeley School of Optometry.

Dr. Borkert was a social worker for 10 years. At the age of 32 she decided to go to the University of Tennessee-Memphis Medical School. She then completed an internal medicine residency at the County of Alameda Medical Center Primary Track Internal Medicine Program.

Dr. Borkert was involved in many studies with UCSF's pharmaceutical/expanded access and community consortium clinical trial group, including the enrollment of women in ACTG (AIDS Clinical Trials Group) perinatal trials.

Additionally, Dr. Borkert's research group developed and initiated a collaboration with other clinics in order to determine why women enroll (or fail to enroll) in clinical trials.

Dr. Borkert was known to her many friends, relatives and patients as exceptionally warm and generous. Her passing, on June 24, 2010, was a tremendous loss to the HIV community. Read an obituary for Dr. Borkert released by WORLD (Women Organized to Respond to Life-Threatening Diseases), of which she was a member of the Board of Directors.

When a woman with HIV visits your office for the first time, do you evaluate her care differently than you would evaluate a man's care?

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.

Do you see different side effects in women than in men?

The most noticeable side effects I have observed have been metabolic -- the so-called fat-redistribution syndromes, which in a woman translates to significantly enlarged breasts and abdomen. Women are complaining of back problems more frequently and are not uncommonly mistaken for being pregnant, which can be quite traumatic for some women. This may be more pronounced in women who were overweight to begin with, before starting HAART. Again, the overall effect this has on how women see themselves -- on their self-esteem -- can be devastating.

There are other potentially life-threatening concerns. Obese women over 40 are more likely to develop lactic acidosis, which has been linked to mitochondrial toxicity due to reverse transcriptase inhibitors.

Drug levels can also vary significantly in women. One study showed dramatic differences in the amount of time single-dose nevirapine [Viramune] stayed in the bodies of pregnant women. Generally, other studies have indicated that nevirapine may clear more slowly from women's bodies, making them more at risk potentially for rash and liver toxicities. Obviously, more pharmacokinetic studies of nevirapine in women [how women's bodies process the drug] need to occur.

What are some of the biggest issues facing women with HIV?

Empowerment of women worldwide, and helping to protect women from domestic violence -- perhaps empowering women to believe they have options when their safety is in question. Women need to feel more in control of their own bodies, so they can more effectively make their own decisions and choices. It is amazing to witness the strength and ingenuity of some of my female patients -- sometimes caring for others in very difficult and complicated situations, yet finding the courage and ability to do it, while at the same time feeling very disempowered in their relationship with the man in their life. We need to understand that empowering women doesn't mean disempowering men, and that truly we can all win when there is an equal playing field.

What other important issues should we pay attention to regarding women and HIV?

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.

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