Primary Care Of The HIV Infected Woman

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Primary Care Of The HIV Infected Woman

• Laura Armas-Kolostroubis MD
• Texas/ Oklahoma AETC
• Parkland Health and Hospital System

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Objectives

• Describe main elements of primary care in women
• List three age specific screenings for well
  womans health

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Primary Care

• The Institute of Medicine definition
• The provision of integrated, accessible care
  services by clinicians who are accountable for
  addressing a large majority of the personal
  health care needs, developing a sustained
  partnership with patients, and practicing in the
  context of family and community

Institute of Medicine, 1996, pI
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Primary Care

• Longitudinal care
• Continuity with a single provider
• Comprehensive approach to patients multiple
  medical needs
• Primary care providers is the coordinator of
  patients care
• One of the ambulatory care services patient may
  receive

Kovner, et al Health Care Delivery in the United
States 8th edition, 2005
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Primary Care of Women

• Diagnosis and management of medical disease
• Reproductive needs assessment
• Gynecological and obstetrical conditions
• Psychological and behavioral medicine
• Age specific preventive measures and health
  maintenance counseling

Carlson, et.al. Primary Care of Women 2nd
edition 2002
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Primary Care of Women

• Problems that occur exclusively in women
• Problems encountered in primary case practice
  that manifest differently, or respond differently
  to treatment, in women compared with men
• Problems that occur more commonly in women

Carlson, et.al. Primary Care of Women 2nd
edition 2002
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Primary Care of Women

• Patient centered
• Evidence based
• Culturally competent
• Social and temporal feasibility

Straus, et al Evidence Based Medicine How to
practice and teach EBM 3rd edition 2005
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Primary Care of HIV Infected Women

• Diagnosis and management of medical disease
• Reproductive needs assessment
• Gynecological and obstetrical conditions
• Psychological and behavioral medicine
• Age specific preventive measures and health
  maintencance counseling

HIV INFECTION
Carlson, et.al. Primary Care of Women 2nd
edition 2002
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Primary Care of HIV infected Women

• Diagnosis and management of HIV infection and
  other medical diseases
• HIV related
• Acute
• Chronic
• Co-infections
• Pregnancy

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HIV Related Conditions in Women

• In 1999, the five most common infections in women
  with AIDS were
• PCP
• Esophageal Candidiasis
• MAC
• Wasting Syndrome
• Recurrent pneumonia

MMWR 4814, 1999
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HIV Related Conditions in Women

• In 2005, the five most common infections in women
  with AIDS at Parkland

Armas L, et al WHICC, 2006 Poster Presentation
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Acute Problems in HIV Infected Women
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Chronic Problems in HIV Infected Women
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Chronic Problems in HIV Infected Men
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Primary Care

• Thyroid Disease
• TSH annually
• Look for symptoms (subclinical presentations)
• Easily treatable with replacement

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Primary Care

• HTN
• Diuretics vs ACE-I
• Reproductive ability/ desire
• Age specific
• Other co-morbidities
• Secondary causes
• NSAIDs
• Substances alcohol, smoking and drugs
• Contraceptives

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Co-Infections

• HCV
• Less frequent than in men
• Different disease manifestations and progression
  in men than women
• HBV
• TB
• HSV
• HPV

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HPV

• Most common co-infection in women
• Abnormal cervical cytology
• Vaginal dysplasia
• Anal dysplasia and cancer

Klein J, et al WHICC, 2006 Poster Presentation
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(No Transcript)
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Primary Care of Women

• Diagnosis and management of medical disease
• Reproductive needs assessment
• Gynecological and obstetrical conditions
• Psychological and behavioral medicine
• Age specific preventive measures and health
  maintenance counseling

Carlson, et.al. Primary Care of Women 2nd
edition 2002
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Gynecological Issues

• Sexually Transmitted Diseases
• Contraception
• Menstrual Abnormalities
• Sexual dysfunction
• Menopause hormonal management
• Uro-gynecological problems

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Attitudes of HCW toward HIV infected women

• Baylor College of Medicine in Houston
• 61 on ART
• 25 first diagnosed in hospital
• 68 some prenatal care
• 29 waited until 2nd. Trimester to seek prenatal
  care
• Experienced providers and HCW
• Negative losses in personal relationships
• Reluctant to disclose
• Even with excellent emotional health, developed
  depression and trouble coping

Rochon II WHIVS, Dallas 2005
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Primary Care of Women

• Diagnosis and management of medical disease
• Reproductive needs assessment
• Gynecological and obstetrical conditions
• Psychological and behavioral medicine
• Age specific preventive measures and health
  maintenance counseling

Carlson, et.al. Primary Care of Women 2nd
edition 2002
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HIV Infected and Affected

• Insomnia is common in caregivers of AIDS
  patients, particularly after the demise of the
  loved one
• Women frequently become the bereaved partner
• Mikan S,et al utilized a behavioral intervention
  to improve quality of sleep demonstrating
  significant improvement after 3 and 5 weeks with
  subsequent quality of life and health seeking
  behaviors

Mikan S, et al WHICC, 2006 Abstract
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Primary Care

• Psychiatric conditions
• Depression
• Drug to drug interactions
• Co-morbid pre-HIV conditions
• Schizophrenia
• Mental retardation
• Organic brain syndromes (cocaine)
• Substance Abuse

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Primary Care of Women

• Diagnosis and management of medical disease
• Reproductive needs assessment
• Gynecological and obstetrical conditions
• Psychological and behavioral medicine
• Age specific preventive measures and health
  maintenance counseling

Carlson, et.al. Primary Care of Women 2nd
edition 2002
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Health Maintenance and Counseling

• To maintain the health of women who are HIV
  infected greater time and resources should be
  invested to optimize outcomes
• As this female population ages screening
  recommendations should be implemented acccordingly

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Preventive Measures

• Immunizations
• Td
• PVX
• Influenza
• Hepatitis screening and immunizations as
  recommended
• Avoid live attenuated virus vaccines
• HSV ? HPV ?

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Health Screening Breast

• Self Breast Examination every month after age 20
• Clinical Breast Exam yearly after the age 20
• Screening mammograms
• Baseline at age 35
• Every year ages 40-70
• Earlier if Family History
• Diagnostic mammogram if lesion detected

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Health Screening Pap

• Cervical Cytology at initial visit, then q6
  months x 1 year
• If normal q year
• If abnormal colposcopy
• Any abnormal lesion should be evaluated (biopsy)

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Health Screening Bone

• Osteoporosis
• AIDS is a risk factor for decreased BMD
• ARV may play a role ? PIs
• Other factors hyperthyroid, dilantin, smoking,
  weight and nutritional status
• Screening and access to screening
• Covered for postmenopausal women q 3-5 years
• Spotty general practice

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Nutritional Counseling

• Dietary Habits
• Calcium intake
• Iron supplementation
• Moderation in salt, alcohol, fats
• Find out about diet fads

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Occupational Health

• Manual vs white collar labor
• Single household
• The two full time jobs of women
• Maybe 3 or 4
• Shift work
• Schedule for meals
• Confidentiality
• American with Disability Act and HIPAA regulations

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Thanks to

• Women and girls who inspire us to keep on going
• Attendees, specially those who submitted their
  work to share with us
• Volunteers and Moderators
• Speakers and their institutions
• Texas Oklahoma AETC, Parkland Health and Hospital
  System, UT Southwestern
• Sponsors

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IV WHICC

• March 7, 2007
• Location TBD