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Ending a Viral Legacy
by Eve Jacobs

Arlene Bardeguez, MD, MPH, professor in the Department of Obstetrics, Gynecology and Women's Health and director of HIV services at UMDNJ-New Jersey Medical School.

We can't shake our sense of guilt when we meet Arlene Bardeguez outside the newborn nursery at UMDNJ-University Hospital on a Monday morning in September. We know that she had to juggle her schedule to carve out a quarter hour to spend posing for the camera - and we're aware that picture-taking does not quite match the seriousness of the other demands of her day. She arrives late - apologizing but offering no excuses - then organizes herself quickly and gives us her full attention for that small space of time. That's her way. She has an awe-inspiring line-up of activities on her calendar for today, and every day, but at each stop, she gives her all.

It's her smile that captivates us. Warmth and sincerity come shining through- this is a strong professional woman who's all about taking care of others. Great good luck was with the women and babies of Newark, and all of New Jersey, when she chose her line of work, or it chose her.

A graduate of the University of Puerto Rico Medical School, Bardeguez came to New York in 1981 to do a residency in obstetrics and gynecology at Catholic Medical Center in Queens. She clearly remembers her first encounter with HIV/AIDS. She was asked to attend a lecture in 1982 on the "gay men's disease," and questioned the relevancy to her work, which entailed "doing deliveries and writing discharge notes." But about six months later, she recalls seeing a woman with oral thrush and wasting syndrome, who was pregnant and eventually died. "She was one of the first reported cases of a pregnant woman who had HIV infection," Bardeguez says.

"We actually ended up having two patients with no known risk factors for the disease. The other came in with a cough and was treated several times for a presumed upper respiratory infection, and ended up dying of full blown PCP pneumonia. We then tracked her history and found that her first husband was an IV drug abuser," the physician says. "So I soon became very sensitized that this is affecting women who are not necessarily IV drug abusers. But I never really planned to follow that career because it was sort of a dead end. I mean, there was no hope at that point."

Hope came later, but certainly too late for many. In the meantime, Bardeguez completed her residency in '85 and a fellowship in maternal and fetal medicine at Nassau County Medical Center in '87. She chose to concentrate on high risk obstetrics, taking care of pregnant women with diabetes, high blood pressure and other chronic conditions, as well as those with drug and alcohol addictions. When she began working in Newark that year, the number of HIV-positive women was climbing steadily and many of their infants were coming into this world already infected with the virus and doomed to die very young. Some of those women were receiving no prenatal medical care, and were showing up at the hospital ready to deliver their babies. In many cases, the women did not even know they were HIV-infected until their babies tested positive for the virus.

When the AIDS epidemic took hold in this country, a diagnosis of the disease was generally a death sentence. But by the mid- to late-'80s, AZT and prophylaxis for PCP and TB were incorporated into the care of this population, and proved to be life-savers, literally snatching terminally ill patients from death's grip.

Bardeguez added to her high-risk obstetrics practice women infected with HIV, who were also often riddled with other major medical problems. She teamed up with pediatric AIDS specialist James Oleske, and others, to focus on this fairly invisible, but hard-hit, group. Many of the women were poor and most were minorities, and they were taking care of their families, but not themselves. It became a chilling point of conversation in the medical community that the women would not seek medical treatment until they were so ill that they could no longer function in their family roles. At that point, it was often too late to save them, and sometimes too late to save their babies. The term "boarder babies" was coined for those infants left behind in the hospital by HIV-infected mothers who could not take care of them.

It was those women, and their babies, who Bardeguez championed, and still does. She and Oleske launched a controversial, but ultimately very successful, nationwide clinical trial testing if AZT, administered to pregnant HIV-positive women during their pregnancies and during the birth process, and to the infants for six weeks after birth, could stem transmission of the virus from mother to child. "And lo and behold," says Oleske, "we saw instead of the 30 percent of infants being infected and sick and dying of AIDS, it went down to 8 percent."

Bardeguez points out that before this trial, physicians always advised women to stay away from all drugs during pregnancy, and so this was a radical idea. At that time, she says, AZT had to be taken five times a day, which required the women to be deeply committed to this protocol. Also, newborns were being given a powerful drug, and there was no data to indicate they could tolerate it, or that it would do them any good.

The care of HIV-infected women was also modified to decrease the prevalence of other contributing factors for perinatal HIV-1 transmission by providing treatment and prophylaxis of sexually transmitted diseases such as herpes, referral to substance abuse programs, prevention of preterm labor by behavior modification and considering operative delivery when all else failed. Finally, in the late 90s, cohort studies showed the relationship between reducing HIV viral load and reducing the transmission rate, so an aggressive approach to decrease viral load in pregnant women with the use of HAART (Highly Active Anti-retroviral Therapy) was recommended by the U.S. Public Health Task Force. Implementation of all these strategies resulted in lowering the perinatal transmission rate in the U.S. to 1 to 2 percent, although it still hovers between 25 and 40 percent in the rest of the world.

Bardeguez and her research team continue to participate in clinical trials - now concentrating on the evaluation of safety and pharmacokinetics of different combinations of antiretroviral drugs for maternal safety and to further decrease the transmission rate. More than two decades after HIV was first reported, women of all ages, races and ethnicities continue to get infected in this country and worldwide. "We have acquired new knowledge in the management of these pregnancies and their long-term outcome because of the unselfish willingness of many women to participate in studies and clinical trials. But until we get a cure, there is still work to do," says Bardeguez.

Thus, the doctor and her team remain tireless in working on behalf of these women and their families. It takes an extraordinary amount of a doctor's time to ensure that each HIV-infected woman who enters UMDNJ-University Hospital in Newark has a safe and healthy pregnancy, and delivers a healthy baby. But Bardeguez has also assumed a leadership role in bettering the lot of all HIV-infected pregnant women and their children worldwide. She never questions whether she made the right choice in her specialty, because she knows how much her efforts count in ensuring that the legacy bestowed from one generation to the next will not include this dreaded virus.

Bardeguez, whose work has been recognized with a New Jersey Pride Award in 1999 and an Edward J. Ill Award, given by the Academy of Medicine of New Jersey, in 2001, is the only maternal and fetal medicine specialist in New Jersey with HIV expertise to make the list of America's "top docs."