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?
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 health care needs of patients.
What are some of the biggest issues facing women with HIV?
The biggest issue that women with HIV face is how many issues they face. The medical and psychosocial aftereffects of HIV and other associated infections and complications can be quite devastating. Managing their medication regimens, managing their jobs and families, worrying about transmission to others, recovering from difficulties during disclosure and managing other medical and gynecologic problems are all major issues for women with HIV.
Recently, we also found that a history of using drugs, being African American, and having a history of abuse was associated with not taking appropriate antiretroviral regimens, even when medically indicated. Special attention to treatment referrals for abuse and drug use as well as efforts to provide equitable access to medications is essential to overcome these obstacles.
Women with HIV who are pregnant or considering getting pregnant face an enormous array of issues in addition to coping with their own illness: deciding on the correct perinatal transmission-reduction regimen, considering C-section, dealing with issues of family disclosure, worrying over HIV transmission to their infant and over their ability to see their child grow up are all enormous issues. I continue to be moved by how strong and nurturing the women I care for are, especially considering how many obstacles they have faced and how many there are still to face. I am truly grateful for having had this opportunity for the past 17 years.
Updated August 18, 2004
Mardge Cohen, M.D.
Mardge Cohen, M.D., a senior physician at Stroger (Cook County) Hospital in Chicago, has been the Director of Women's HIV Research since 2000. She has also been the principal investigator for the Women's Interagency HIV Study Chicago Consortium since 1994, and is currently principal investigator of the Chicago site of the Centers for Disease Control multi-site study, "Mother Infant Rapid Intervention at Delivery." She has been co-investigator for the Stroger Hospital Community Program Clinical Research on AIDS and the Subunit of the Women Infant Transmission Study since 1990 and 1991, respectively.
Additionally, she is the founder and former director of the Women and Children HIV program at Stroger Hospital. She began the program in 1988; with the help of Robert Wood Johnson funding in 1989 and Ryan White Title IV support in 1993, the program has grown to serve more than 1,200 women, partners and children with HIV infection. Dr. Cohen is the author of dozens of publications, including "Medically Eligible Women Who Do Not Use HAART: The Importance of Abuse, Drug Use, and Race," American Journal of Public Health, 2004; "Causes of Death Among Women With HIV Infection in the Era of Combination Antiretroviral Therapy," American Journal of Medicine, 2002; "Women and HIV: Creating an Ambience of Caring," Journal of American Medical Women's Association, 2001; "Women Coping With HIV/AIDS," Social Science and Medicine, 2001; and "Domestic Violence and Childhood Sexual Abuse in Women With HIV Infection and Women at Risk for HIV," American Journal of Public Health, 2000.
Currently, Dr. Cohen is involved in an initiative to provide rapid HIV testing in all Illinois delivery rooms. Since 2004 she had traveled to Rwanda to offer HIV treatment and primary care to women infected with HIV during the 1994 genocide.
Dr. Cohen is the proud recipient of the Ron Sable Activist Award from the Crossroads Fund Chicago and was named the Advocate of the Year by the AIDS Legal Council of Chicago and the Service Provider of the Year by the AIDS Foundation of Chicago.