This article was originally published in the Winter 2008 issue of the San Francisco General Hospital Foundation News.
ast December, as she does every year, Deb Cohan eagerly anticipated the winter holidays-and not for the most obvious reasons. That’s when Cohan, the medical director of the Bay Area Perinatal AIDS Center (BAPAC), got to reconnect with her former patients and their thriving children at the annual San Francisco AIDS Foundation holiday party. Were it not for BAPAC, these families’ holidays might not have been so cheery.
Through a full complement of prenatal medical, social and educational services, BAPAC helps women and families infected and affected by HIV. As part of the Positive Health Program at San Francisco General Hospital and Trauma Center (SFGH), the BAPAC team effectively and compassionately guides clients from preconception counseling through delivery of healthy HIV-negative babies.
Established in 1989, BAPAC has helped to virtually eliminate perinatal HIV in San Francisco. Early on, BAPAC clients and their infants played a key role in research by volunteering in trials that showed that AZT markedly reduced the transmission of HIV from HIV-positive pregnant women to their babies (a.k.a. vertical transmission). Since then, researchers have developed Highly Active Antiretroviral Therapy (HAART) medications that prevent the vertical transmission of HIV. Cohan explains that if these women were not treated with effective antiretroviral therapies, the chances of their transmitting HIV to their babies would be about 25 percent. With medication, doctors are able to control the virus, bringing the risk of transmission down to less than one percent.
While the medical treatment is relatively straightforward, myriad psychosocial influences can complicate the issue of HIV prevention for BAPAC clients.
"Much of the emphasis in HIV care and prevention has been on men. But women, particularly pregnant women, have their own distinct needs," explains Cohan. "A pregnant woman who has HIV might have other children. She’s used to caring for others before herself. She might be head of the household and distracted by numerous life commitments.
"Those of us who work at BAPAC are trained to address these needs. We take a holistic approach to each woman’s health, addressing not only the medical care, but the real-life issues and challenges she faces," says Cohan. "We emphasize that the best way for women to take care of their kids is to take care of themselves."
Contrary to popular belief, most BAPAC clients don’t have the traditional risk factors, such as IV drug use or work in the sex industry, associated with the virus. Many are under the age of 30. Within BAPAC are two general client populations: women who already know they have HIV and become pregnant; and women who are newly diagnosed with HIV.
For the first group, those who already know they have HIV, BAPAC begins by providing preconception counseling.
"We help them decide if and when they want to get pregnant," says Cohan. "If not now, then we talk about how to use safe and effective contraception. We also provide gynecological care for HIV-infected women in our Positive Health Program."
Half of BAPAC clients have just discovered they have HIV. Often their greatest challenge is living with the stigma of being a young mother with the virus. For many, they are the only person they know with HIV. While it’s common for most people to "freeze and take their time getting their mind around the diagnosis," says Rebecca Schwartz, BAPAC’s Licensed Clinical Social Worker, "pregnant women diagnosed with HIV are on a different time line. They have to move quickly and get on medications."
BAPAC’s bilingual staff serves as the critical link between medical and community resources, bringing the various components of care together for HIV-infected pregnant women.
"Our clients need help accessing services," adds Schwartz. "Some need support to stabilize their lives. They want to be good mothers, of course, and we’re able to help them. We offer counseling and assistance with benefits and services that helps them in their home lives."
Much of Schwartz’s efforts are spent educating mothers-to-be who are often unfamiliar with medical terminology and methods.
"A lot of our women, especially immigrants, have had minimal exposure to the medical system. Many have had home births, and never had a Pap smear," she says. "I do a lot of interpreting, explaining what the medical suppliers are trying to provide. We talk about T cells and how to keep viral loads down. We teach them ways to minimize the risk to their babies."
Both Schwartz and BAPAC Nurse Practitioner Cynthia Feakins work in the San Francisco General Family HIV Clinic as well as at BAPAC. Their experience at the clinic helps them provide family-centered care, involving not just the woman and her baby, but her partner and other significant people in her life.
For more than a quarter century, San Francisco General Hospital has been a leader in the treatment of HIV and AIDS. In 1983, SFGH physicians established the world’s first AIDS clinic on SFGH’s Ward 86 to treat what was first seen as an epidemic among gay men. They also opened the first outpatient clinic there, now known as the Positive Health Program (PHP), to treat the greater HIV-positive community. As time wore on, researchers saw increasing numbers of women and children diagnosed with HIV. In 1989 BAPAC was established, under the PHP umbrella, to address the complex medical and social issues faced by women with HIV.
Not all of BAPAC’s work is carried out at San Francisco General. Staff have visited clients in their homes or hotels to ensure they are receiving the best possible care. Feakins also runs a health education group at the county jail to help high-risk women remain HIV-negative.
Certainly, those who work at BAPAC have learned a great deal about perinatal HIV. Part of their charge is educating others in the field. OB/GYN fellows are trained at San Francisco General in reproductive infectious disease; they then go on to provide care elsewhere in the United States and abroad.
"We know that interdisciplinary care is effective," says Cohan. "By training health care providers in this model, we can have a ripple effect in preventing the spread of HIV."
To that end, Cohan serves as the associate director of the National Perinatal HIV Consultation and Referral Service, based at SFGH. Staffed by specially trained obstetricians, pharmacists, HIV experts and family practice physicians, the hotline offers round-the-clock expert consultation for clinicians caring for HIV-positive women and their infants.
Cohan and her staff have even helped to change a California law. Last year, they worked with State Senator Carole Migden to overturn a ban on sperm from HIV-positive men for the purposes of assistive reproduction. Enacted in 1989, the ban was intended to help prevent the spread of HIV from a positive partner to a negative one. But for more than a decade medical technology has existed to "wash" the HIV from sperm; the cleansed sperm can then be used to impregnate a consenting woman. Sperm washing enables both the mother and child to remain HIV-free.
"Our team is helping to establish standards of care for how to offer these services," says Cohan, adding that, "The law was put on the books for good reason, but technology advanced beyond it."
While progress in HIV prevention and care has been remarkable, Cohan and others in the field know there is still much to be done. BAPAC is part of an international network of perinatal research studies.
"There are very few conditions where we can say we’ve made this much progress. That said, there is a stark contrast between resource-rich settings and resource-limited ones. Worldwide, there is an unacceptable amount of HIV transmission. In much of Africa, women can’t access services."
Cohan plans to travel to Africa this year to pursue research in international perinatal HIV.
"We’ve started collecting preliminary data for a trial of different HAART medications in pregnant women in rural Uganda," she says. "Our ultimate goal is to provide cocktail regimens to women worldwide, not just in resource-rich settings."
Meanwhile, Cohan reflects on the impact BAPAC has had on the lives of San Franciscans.
"A lot of women come to us suspicious of healthcare providers. We’ve been successful in helping them learn to trust the system," she says. "Imagine how many hundreds of people have come through the program since the 1980s. If a quarter of them had passed HIV on to their babies..."
Cohan doesn’t need to finish the thought. She’s got patients to treat with babies yet to be born. As always, she looks forward to seeing them at the next San Francisco AIDS Foundation party, enjoying their holiday seasons.