ARCW HIV Clinic Provides Care for Women in Need

With women the fastest-growing population of people with HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency syndrome), the need for a concentrated focus on women with HIV has become apparent.

The AIDS Resource Center of Wisconsin (ARCW) Medical Center is the largest provider of HIV health care in Wisconsin, with medical, dental and mental health clinics available to people with HIV disease. ARCW hosts a Women's HIV Clinic, with the Medical College of Wisconsin providing medical staff and Children's Hospital of Wisconsin contributing nursing case management.

Iram Nadeem, MD, Medical College of Wisconsin Assistant Professor of Medicine, serves as the Medical Director of the ARCW and sees the clinic as filling a crucial need. "Because of women being more vulnerable to HIV and AIDS, we saw a need for more attention to women's issues," she explained.

HIV is the initial and more easily treatable stage of the disease. "Once the patients are AIDS-defined, they are often times sicker and tolerate medications poorly," notes Dr. Nadeem. Also, AIDS tends to bring on a host of infections like tuberculosis and increase susceptibility to cervical cancer.

"All women are welcome here regardless of economic status and their ability to pay," says Dr. Nadeem. "We seek to provide services that combine sensitivity with expertise."

Different Responses to Medication
The formation of the Women's Clinic was driven by the necessity of addressing women's special needs regarding HIV and AIDS. The estimated proportion of AIDS cases diagnosed has more than tripled among women over the past two decades, climbing sharply from 8% in 1985 to 27% in 2004.

Especially alarming is the dramatic rise of AIDS cases among women of color, most notably African-American women. By 2004, 80% of all women with AIDS were women of color. Sixty-four percent of women with AIDS were African-American, according to the Centers for Disease Control. Women are especially vulnerable to contracting an HIV infection from heterosexual intercourse because vaginal mucous is significantly exposed to seminal fluid.

Moreover, women face the prospect of additional severe complications. "Women with HIV are five times more likely to be diagnosed with cervical cancer and have significantly higher rates of recurrent vaginal yeast infections and pelvic inflammatory disease than women who don't have HIV disease," Dr. Nadeem said. "All of these medical problems are compounded by the difficulty women with HIV have in accessing medical care due to child care responsibilities, lack of transportation and serious financial problems."

Further, women and men have notable differences in how they respond to HIV and AIDS medications. "The majority of studies of these drugs have been on men. So we find that one of the main anti-retroviral medications causes nausea a lot more commonly in women than men," Dr. Nadeem observes. In other cases, the side effects are more severe for women. "There is a definite gender difference in the response to medications," she notes.

ARCW, the Medical College and Children's Hospital collaborate in federally-assisted programs used for the primary care of women and children.

One Key Aim: Making Women Comfortable
On one half-day a month, the entire ARCW facility is exclusively focused on treating women (and urgent cases for men.) This means a lot symbolically to female HIV and AIDS patients, according to Dr. Nadeem. "This is a place where they can go and feel comfortable. There are three female providers with whom they can talk about issues or problems."

The range of services available to women includes health care, counseling, a support groups, and legal aid.

"Whether they're having a cold -- which can be problematic because of their weakened immune systems -- or problems with their HIV meds or a pregnancy, they know that there are people here who will understand, "she says.

The clinic, which accepts patients age 18 and older, currently serves about 124 women. While HIV and AIDS cross class and financial lines, most patients have low incomes, with a substantial number of African-American and Latina women.

An Oasis of Calm
The Women's Clinic can be an oasis of calm in otherwise turbulent lives for patients who must battle poverty as well as disease, says Dr. Nadeem. "Often, there is constant turmoil in their lives. We see fragmentation in family after family."

"Traditionally, women have put themselves last, especially women living at a poverty level," she explains. "They place the welfare of their children ahead of their own. They may or may not have the support of partners.

"If they find themselves HIV-infected, it's hard to access specialized HIV care," Dr. Nadeem says. "Additionally, there is a huge degree of depression among these women, and sometimes drugs and alcohol add to it."

Some patients get tested late, and their partners often don't them tell they are themselves infected, and the women get sick, notes Dr. Nadeem. "Or the women get pregnant and finally get tested, and discover that they have HIV."

Poverty and Powerlessness as Factors
A fundamental problem that many of the clinic's patients "feel a deeply-rooted sense of powerlessness that affects sexual relationships," Dr. Nadeem says. "They feel powerless, and don't know how to negotiate condom use."

New anti-HIV creams and gels, now under development, will eventually give women more control over HIV and AIDS protection. But these products are still being tested and are not widely available, so condoms remain the primary means of preventing HIV transmission. To stop the transmission of AIDS, Dr. Nadeem cautions that everyone should be familiar with those whom they're sexually intimate. "If you don't, get tested for AIDS," she urges. If men insist that they will not use condoms, HIV and AIDS will continue to spread among women. Early symptoms of HIV can be as simple as a cold or sinus infection that hangs on for three or four weeks, sudden weight loss, an unexplained rash, or a coating on the tongue.

Moreover, sometimes in the early part of HIV, there are symptoms, but the body's immune system suppresses them and keeps them under control. But the disease may be advancing without outward symptoms due to the severe weakening of the immune system.

Access to Healthcare Also an Issue
Once women become infected, gaining access to health care can be difficult. Fully 42% of the clinic's patients have no health insurance, with the remainder relying on Medicaid and other government programs. Very few have commercial insurance coverage, says Dr. Nadeem.

For many women without health insurance, locating a source of payment for health services requires a painstaking search. "Some women may qualify under Social Security disability, but they must be deemed disabled, which means that they must have advanced AIDS," says Dr. Nadeem. In the past, these benefits were extended to HIV-infected patients, but are now restricted to cover only those with more advanced illness.

Other government-supported health programs are highly fragmented in their coverage, providing a measure of coverage for some and not for others. The result, in Dr. Nadeem's observation: "Finding coverage is very, very difficult. And with all their medical issues, people are just getting by."

More Poverty, Fewer Hospitals
By 2004, Milwaukee's median income was 25% less it was in 1979. While more health needs become apparent among Wisconsin residents - especially those with few financial resources - the number of inner-city hospitals is shrinking: nine have closed over the last three decades, many of them fairly recently.

Despite the fundamental problems with the health system, Dr. Nadeem remains deeply dedicated to doing what she can to provide both direct assistance and hope to HIV and AIDS. "At the clinic, the women find themselves in a very different environment, where their health needs are taken seriously and they are treated with dignity," she concludes.

To contact the Women's AIDS Clinic, call 414/273-1991.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.