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Interviews with Top Doctors Treating HIV-Positive Women -- Ruth Greenblatt, M.D.

Ruth Greenblatt, M.D.

Ruth Greenblatt, M.D.

Ruth Greenblatt, M.D. is the professor of clinical medicine and epidemiology at the University of California-San Francisco. She is also the principal investigator for the Bay Area Research Consortium on Women and AIDS, and sees patients at the University of California-San Francisco's Women's HIV Program.

Dr. Greenblatt received her medical degree from Case Western Reserve University in Cleveland in 1981. She then went on to do her residency at the University Hospitals of Cleveland, followed by an infectious disease fellowship at the University of Washington and a research methodology fellowship at the University of California.

She has authored dozens of publications and submissions, including "Epidemiology of AIDS in Women and Heterosexually Transmitted HIV, Management of HIV Disease in Women," AIDS Clinical Review, 1992; "The Natural History of HIV Infection in Women: The Bay Area Research Consortium on Women and AIDS," Oral Manifestations of HIV Infection, Quintessence Publishing, 1995; and "Effectiveness of Highly Active Antiretroviral Therapy Among HIV-1 Infected Women," submitted to the American Journal of Epidemiology and presented at the 1999 National Conference on Women and HIV/AIDS.

Dr. Greenblatt was nominated for the Chancellor's Award for Advancement of Women in 1997 and 1998. She was named the University of California Champion of Diversity in 1999. In 2005, she won the Association of American Medical Colleges' Women in Medicine Leadership Development Award.

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 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.

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

I am not so sure if the side effects are different, or if they are of different significance to women. Body habitus (build) changes are of great concern. For women, fat accumulation in the abdomen and breast enlargement can be mistaken for pregnancy. Hair loss is a common complaint, but not exclusively in association with antiretroviral therapies. Probably anecdotally, several of my female patients have had severe sleep disturbances and dysphoria [feeling unhappy or unwell] with efavirenz [Sustiva, Stocrin], though other providers in our program have used the medication without a problem.

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

Each woman is unique. All are coping with a chronic disease that requires long-term treatment and medical follow-up. All are facing potential stigmatization. Many women in the U.S. with HIV are poor and must cope with limited resources, inadequate housing, past problems with drugs and, for some, a truly chaotic life. Many women living with HIV are mothers or have interest in becoming mothers. Recent advances in preventive therapies for pregnant women do not completely eliminate the anxiety attendant with HIV infection and risk of transmission. Many women also report menstrual irregularities and cervical, vulvar and anal epithelial dysplasias [abnormal developments of the cell lining, often a precursor of cancer] are common, and are an ongoing concern for many patients.

HIV care is lumped into general medical practice, which has many implications for the services we provide. Female patients tend to be especially in need of counseling and close follow-up for medication adherence, depression, domestic violence, substance dependency and social issues. Current reimbursement for clinical services covers only a brief clinic visit, which is inadequate for the needed standard of care. Our program is completely dependent on Ryan White Care funds to provide the needed service -- if this funding is cut, we will be in deep trouble.

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

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.

 

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