Karen Tashima, M.D., is one of two women to win The Body's Leadership Award in the physician category. She's part of a growing group of women who have become leaders in the world of HIV. Dr. Tashima entered HIV care at precisely the right time. It was 1995, the year that everything in the world of HIV care had begun to change. Finally there was a regimen that worked. Dr. Tashima acknowledges feeling grateful that The Miriam Hospital -- where she works in Providence, Rhode Island, was involved in some of the most important HIV research trials of the time. She had the opportunity to be involved in the initial trials of indinavir (Crixivan) and then was an investigator in the landmark studies on efavirenz (Sustiva, Stocrin) in combination with AZT (zidovudine, Retrovir) and 3TC (lamivudine, Epivir). The combination of efavirenz + AZT + 3TC has become one of the most successful HIV treatment regimens. Dr. Tashima is now director of HIV clinical trials at The Miriam Hospital.
She says the combination of providing patient care and doing research is what keeps her interested and prevents burn out. Treating patients and conducting research, she notes, inform each other. She loves being able to bring the latest research to her patients and is pleased that so many of them had the opportunity to get on those early, successful studies.
How long have you been practicing?
Can you describe how your ability to treat people with HIV has changed over the years?
I started working in HIV in 1995 and very soon after that we had access to the protease inhibitors. In 1996, when people came into the office, they were so sick that often they had to be put into the hospital immediately. But there were a lot of interesting things happening then. Our office was participating in the indinavir trials and, as a result, we witnessed the patients on that trial slowly improve -- which was the first time we were really seeing a treatment work.
Soon after that we started using the viral load test, even though at the time its use was controversial. And then, following that, we were in the efavirenz studies. We had 60-70 patients on that study and we had great experiences with that drug too. As you can see, our patients benefited from these new developments.
What's your client demographic?
Dr. Charles Carpenter started the HIV clinic at The Miriam Hospital in the 1980s for women. He really wanted a safe space for women to get their HIV care. At the time, the clinic in Fall River, Mass., also provided care for a caseload that included 50% mostly white women who had acquired HIV through drugs and sex.
Now, 40% of our patients are women. Cause of HIV transmission is around 40% intravenous drugs and 60% sexual transmission. Around 25% of our patients are Hispanic from either the Dominican Republic or Puerto Rico. So it's a real benefit to speak Spanish. In our Fall River clinic [Family Healthcare Center at SSTAR], we also have a few Portuguese patients from the Azores or Cape Verde. Recently we have seen African refugees from Liberia who have lived most of their lives in a refugee camp.
What are the particular needs for women with HIV?
Some of women's needs relate to their children. Gynecological care has been a focus. One of the studies done at our hospital, the HIV Epidemiology Research Study (HERS), found that women had abnormal pap smears, although it was rare for them to progress to cervical cancer. Depression among women was also found to be significant and mortality was higher among the women who were very depressed. Depression really affects HIV disease.
How are you seeing these women from various cultures deal with telling their relatives and others that they are HIV positive?
Everyone is concerned about disclosure, but perhaps Hispanic women and men are even more concerned. It prevents them from feeling comfortable with what's going on. Very few want to disclose, even to their family. This makes them feel isolated and more depressed. The Liberians also don't want others to know. Communication with the Liberians is also an issue, because of cultural and language difficulties. Their experiences in the refugee camps color everything.
Are you seeing more patients testing positive because of methamphetamine use?
It's a big concern. For a couple of years now, we have been talking to patients about safe sex. But it's such a behavioral thing. You can talk a lot about it, but you may not have an impact. In our area, we have more cocaine and heroin use. In our clinic, one of our programs assesses patients for drug use and then we hook them up for drug counseling. We have two social workers on staff.
What's the best thing about your job?
Treating patients is very rewarding. I spend 50% of my time doing research and because of this, I can share with them new findings and have them join one of the trials. I am in charge of research here at The Miriam Hospital and I am the co-principal investigator of the AIDS Clinical Trial Group unit [this group is the largest HIV clinical trials organization in the world]. I'm also doing neuro-cognitive research on HIV/hepatitis C coinfection.
What's the most exciting research you've done so far?
The most exciting study I've been involved with is the pivotal Dupont 006 study. It was a phase 3 study that showed that efavirenz + AZT + 3TC was superior to indinavir and AZT + 3TC. I think it is one of the most important studies in HIV so far. That regimen has become the gold standard to compare new regimens against. In fact, we still have patients on the regimen who were in the study five to six years ago.
What's the worst thing about your job?
What have been your greatest successes in your work?
Being part of clinical studies and having input in how the studies are conducted. Being part of studies that have such a dramatic impact on patient care. I've also been interested in other things like cardiovascular and renal disease in people with HIV. I think one of the most important questions today is: How does HIV infection impact the rate of heart and kidney disease? I think because of our success with HIV treatment, we are now looking more at the whole person. And this is mostly because we provide primary care for all our HIV patients. As providers, we know our patients better than anyone else. I've seen patients over a 10-year period. We provide all their care. So we need to be vigilant about heart disease, and about smoking. We want our patients to be as healthy as possible. Particularly now that so many of them are doing well with regards to their HIV.
What is the biggest challenge you face as a clinician? Would other clinicians give a similar answer?
There are still patients who have failed multiple regimens and who are healthy enough now although they have lots of resistant virus. We also have patients who cannot tolerate medications. I have a young woman who has several children, but she cannot swallow meds. We all have some patients reluctant to take pills. These patients are an ongoing challenge. Another challenge is getting our patients to have sex responsibly.
What do you think is the biggest problem people with HIV face today?
I think times have changed and some patients do not realize how devastating HIV infection can be. They seem not to realize the potential for serious health consequences from HIV. So it's a balancing act really -- making sure they understand how serious HIV can be and how much of an active role they have to take regarding their health. But, of course, we want to avoid scaring people. So it's really a complex message we need to convey. HIV is a really serious disease and getting patients engaged in health care is important.
Do you think that the prevention efforts are sufficient? Anything you would change?
Routine HIV testing. Finding ways to combat discrimination.
What single change would you like to see in HIV care? Why? What would it accomplish?
It's still the stigma issue. Getting people to get routine HIV testing could change this because people may have more compassion for the next person who has HIV. Stigma is everywhere. It extends into the health profession. People with HIV still feel stigma from all parts of society, even the medical field. Many communities don't want to believe that HIV affects them. I don't think that's changed over the years.
What do you provide in terms of education or counsel for a patient who is just diagnosed?
In our clinic, patients work with our social worker or case manager first. This allows patients to get additional counseling. I think it's critical that every clinic has this sort of support. The community-based organizations near us also do educational things. We don't have a lot of group sessions, although we do have a group for people with hepatitis C infection.
What treatment regimen would you choose if you had to begin treatment today?
Combivir (AZT/3TC) + efavirenz, because I was involved in this study and I saw the great success. Also, we know a lot about this combination since we've been using it so long now.
What's the key to a great healthcare provider/patient relationship?
Trust and good communication.
Do you have many patients who are proactive?
Many patients who are proactive are more likely to have come to terms with disease. Our patients have gotten more savvy. Being proactive could mean simply that they follow up with appointments. I am most concerned about the people who don't show up. In our health center at Fall River, our case manager will call patients if they miss appointments. It's so important that they continue their care.
How do you maintain a positive outlook and avoid burning out?
I think that my job is varied enough that I don't burn out. I work in two excellently run clinics. We have great nurses and social workers. There is always help you can get for the patient, including psychological support, whatever it is. There are a lot of resources in the clinic. Having a job where I combine research and clinical care informs each other. In addition, because I'm involved in research, I feel that the field is always improving for patients.
If you weren't a clinician, what would you be?
From the time I was in high school, I wanted to be a physician. I guess though, if I weren't a physician, I enjoy languages a lot, so I might've done something with that. But I am thrilled to be a physician, it suits my personality.
Where did you grow up?
I was born in Baltimore, Md., and then lived in Chicago, Ill., until third grade. Then we moved to the suburbs of Honolulu, Hawaii, and that was great. We went to the beach and had a pool and life was good. All my cousins were surfers. My dad was born in Hawaii, so all of his family is there. Later we moved to Houston, Texas.
What kind of work do your parents do?
My father is an oncologist.
When did you decide on medical school? What was your major in college?
I decided I wanted to go to medical school when I was in high school. My major in college was biochemistry.
What made you decide to go into HIV care?
Realizing HIV needed more docs! I was doing my fellowship at Mass General [Massachusetts General Hospital in Boston] and I heard a lot about the early HIV studies. I also saw the HIV care provided there at the time, and because I was coming out of working at the lab for a few years, I thought it was important to jump in and see what it was like. I came down to the group in Providence, Rhode Island. They were a young group of physicians doing lots of exciting things. It turned out to be a good move.
Who were the most influential people in your life, both professionally and personally?
My mom, who encouraged me to have a full-time career while raising a family.
What do you do in your spare time?
I spend time with my kids, ski and travel.
Do you have a partner? What is your partner's job? Kids?
I have three kids, ages 13, 10 and 7. My partner is a physician.
How do you balance having three children and being such a busy physician?
My husband is in private practice and he comes home at a predictable time. He is the one who allows me to do it all. He may be the one doing all the pick ups and as the kids get older, it's more challenging. We do the best we can. The house remains dusty.
Where do you live? What kind of community is it?
A town in Massachusetts neighboring Providence, Rhode Island.
What's currently on your bedside table for reading?
I just finished Aloft by Chang-Rae Lee. I sneak in time on the weekends or at night. I like to read fiction and poetry.
What kind of music do you like to listen to?