A Podcast Discussion With Kimberly Smith, M.D., M.P.H., and Valerie Stone, M.D., M.P.H.
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Bonnie Goldman: Hello and welcome to HIV Management Today -- a new, clinical management series from TheBodyPRO.com. This podcast is entitled: "Clinical Management of the HIV-Infected Woman" and it's the second podcast in the series. I'm Bonnie Goldman, editorial director of TheBodyPRO.com.
Joining us are two of the top HIV clinician/researchers in the United States. Dr. Valerie Stone is an associate professor of medicine at Harvard Medical School and an HIV/AIDS clinician at Massachusetts General Hospital, where she was Director of the Women's HIV/AIDS Program from 2002 to 2008. Dr. Kimberly Smith is associate professor of medicine in the Department of Infectious Diseases at Rush University Medical Center and an active investigator and chair of several studies in the AIDS Clinical Trials Group. In our short discussion they will summarize the top issues in managing the care of the HIV-infected woman.
Welcome Dr. Smith and Dr. Stone. Let's start at the very beginning. Dr. Smith, I wonder if you can describe how you evaluate an HIV-infected woman's care differently from the care of a man.
Presentation to Care
Kimberly Smith: How I approach women is not hugely different than how I approach men. First, I try to get a feel for their emotional state in dealing with this disease. Most of the time, I see patients within days, or a couple of weeks, of them having gotten the diagnosis. I try to assess how they cope with the situation. I try to understand what their history is with regard to where they may have acquired HIV, and to what degree they have an idea about that. So, my first step is always to get a feel for where they are.
Once I can assess if the patients are really ready to start thinking about their HIV care, then I try to educate them about HIV. I tell them, in lay terms, what happens as a result of the virus and what we will be trying to accomplish in the first visit, which is to get an idea about whether they have any symptoms at all. Have they lost any weight? Are they having chronic diarrhea?
One of the differences with HIV-infected women is that some of the symptoms that they may have can be things like vaginal discharge, itching or a yeast infection. I try to get at those types of questions.
Then I explain to them what we're going to do from a lab standpoint: explaining to them the basics of CD4 count, the basics of viral load and then the basics of treatment.
To sum up my approach toward women at their initial visit: I try to assess first their social situation, their coping skills, whether they are symptomatic and if they have any issues that are going on at present; then I try to educate them about what we're doing today and where we're going forward. But that's not hugely different than how I approach men, except that the symptoms that may be present in women can be different than in men.
Bonnie Goldman: What kind of symptoms would be more common?
Kimberly Smith: As I mentioned, I'm mostly looking for whether they have any gynecological issues. Are they having any kind of discharge? Do they have vaginal pain, or itching? Are they having pain with sexual intercourse? Are they currently sexually active?
I try to get those kinds of questions answered pretty early on. Those are the things that are dramatically different from men, as far as the history that you take straight off the bat.
Valerie Stone: I completely agree with Dr. Smith. I would just emphasize some of the things she's said. I've found over the years that many women come to their initial appointment with set things that they want answered, that they want to get educated about. If those things aren't taken care of, the women often can feel frustrated and disappointed. Sometimes this stems from prior negative experiences with the health care system. This is true particularly for minority women, women of color.
I try to be really clear at the beginning of the appointment about what they want to accomplish in that visit. As Dr. Smith said, I also try to make clear to them the things that I think are important for us to try to accomplish in that first visit. We try to get through as much of both of those sets of goals as possible. If necessary, the full evaluation may get stretched to a second appointment so that we make sure that everything that's necessary gets done -- that not only do I get an understanding of who they are and where their disease is, but that they, also, get to take care of symptoms or concrete needs and services that they may want to take care of in those first visits.
Kimberly Smith: One of the other things that I think can be different when we're looking at men versus women is that men tend to lose weight sooner. A lot of the men that I see, even before they have progressed to more advanced disease, are losing weight. Whereas women -- particularly African-American women -- tend to not have lost weight. They may have somewhat of a change in their appetite, but they are typically still, weight-wise, doing about the same as they were. So, I don't look for weight loss as being a symptom of HIV in women as much as men.
Bonnie Goldman: Is there an understanding of the mechanisms responsible for that?
Kimberly Smith: Probably the same reasons why it's easier for men to lose weight when they are trying to. [Laughs.]
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