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Understanding and Addressing Cultural and Socioeconomic Barriers to Effective HIV Management

Understanding and Addressing Cultural and Socioeconomic Barriers to Effective HIV Management. Carlos del Rio, MD Hubert Professor and Chair Hubert Department of Global Health Rollins School of Public Health of Emory University Atlanta, Georgia.

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Understanding and Addressing Cultural and Socioeconomic Barriers to Effective HIV Management

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  1. Understanding and Addressing Cultural and Socioeconomic Barriers to Effective HIV Management Carlos del Rio, MDHubert Professor and ChairHubert Department of Global HealthRollins School of Public Health of Emory UniversityAtlanta, Georgia This program is supported by an educational grant from

  2. Faculty Disclosures Carlos del Rio, MD, has disclosed that he has received consulting fees from Gilead Sciences and Pfizer.

  3. Diagnosis of HIV Infection and Population by Race, 2010 (46 States) Diagnosis of HIV Infection (N = 47,129) Population, 46 States (N = 292,196,890) American Indian/Alaska Native Asian Black/African American Hispanic/Latino* Native Hawaiian/otherPacific Islander White Multiple races <1% <1% 1% 1% 1% 1% 2% 4% 12% 20% 46% 16% 65% 29% *Hispanic/Latinos can be of any race. Note: Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays but not for incomplete reporting. 1. CDC. HIV Surveillance Supplemental Report 2012;17(No. 4). Published December 2012.

  4. Diagnosis of HIV Infection Among MSM Aged 13-24 Yrs 5000 4500 3500 3000 2500 2000 1500 1000 500 0 By Race, 2007-201046 States and 5 US Dependent Areas Black/African American Diagnoses (n) Hispanic/Latino* White Native Hawaiian/otherPacific Islander Asian Multiple races American Indian/Alaska Native 2007 2008 2009 2010 Yr of Diagnosis *Hispanic/Latinos can be of any race. Note: Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing risk-factor information, but not for incomplete reporting. Data exclude men who reported sexual contact with other men and injection drug use. 2. CDC. HIV Surveillance Supplemental Report 2012;17(No. 4). Published December 2012.

  5. Very High Incidence of New HIV Infections in Young Black MSM • HPTN 061: 1553 high-risk black MSM in 6 US cities • 11% aware of HIV infection at baseline • 12% received a new HIV diagnosis upon baseline testing • 75% HIV negative at study entry • Incidence of new HIV infections over 1 yr of follow-up • Entire cohort: 2.8% • Men aged 18-30 yrs: 5.9% • Men with STI at baseline: 6.0% 3. Koblin B, et al. IAS 2012. Abstract MOAC0106.

  6. Trends in Age-Adjusted* Annual Rates of Death due to HIV Disease By Race, United States, 1990-2008 60 50 40 30 20 10 0 Black/African American Hispanic/Latino† American Indian/Alaska Native White Asian/Pacific Islander Deaths per 100,000 Population 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 *Standard: age distribution of 2000 US population. †Hispanic/Latinos can be of any race. The racial/ethnic categories other than Hispanic/Latino are all non-Hispanic/non-Latino. Note: For comparison with data for 1999 and later yrs, data for 1990-1998 were modified to account for ICD-10 rules instead of ICD-9 rules. 4. CDC. HIV Surveillance Supplemental Report 2012;17(No. 4). Published December 2012.

  7. WIHS: Black HIV+ Women Twice as Likely to Die of AIDS Than White HIV+ Women • Black race predicted reduced adherence to HAART but remained associated with AIDS death after adjusting for adherence N = 1471 women on continuous HAART Cumulative Incidence (%) AIDS Death Non-AIDS Death 20 20 Black 16 16 Black Other 12 12 White 8 8 White Other 4 4 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Yr Yr 5. Murphy K, et al. CROI 2012. Abstract 1045.

  8. What Accounts for These Disparities in HIV Incidence and Outcome? #1: Late testing/failure to test #2: Delays in initiating treatment #3: Poor long-term continuity of treatment Timely diagnosis Linkage to care Retention in care 6. Ojikutu B. Adv Stud Med. 2010;10:37-41.

  9. CDC: Differences in Continuum of Care in HIV-Infected Patients by Race Diagnosed Linked to care 100 Retained in care 85 81 80 Prescribed ART 80 71 Viral suppression 67 62 60 Proportion of HIV-Infected Individuals in US (%) 38 37 40 35 34 33 29 30 26 21 20 0 Hispanic or Latino Black White 7. Hall HI, et al. AIDS 2012. Abstract FRLBX05.

  10. Addressing Specific Aspects of Care: Late Diagnosis and Missed Testing • Minorities less likely than whites to receive HIV testing • 45% first tested within 1 yr of AIDS diagnosis • Characteristics of these late testers • Younger • Exposed through heterosexual contact • Less educated • Black or Hispanic 8. CDC. MMWR Morb Mortal Wkly Rep. 2003;52:581-586.

  11. Potential Barriers to Testing in Minorities

  12. Tools to Increase HIV Testing • Opt-out testing • Incorporate testing into routine care • Use reminder mechanism to prompt testing • Increase outreach, education • Work with community business organizations that have the trust of the minority community • eg, churches, barber shops, nail salons • Assure patients of confidentiality

  13. Addressing Specific Aspects of Care: Delays in Initiating HIV Care • Characteristics associated with delay to HIV care or treatment • Black,[10,11] Hispanic[12] • No insurance[11] • Less education[11] • Delays in HIV care > 3 mos[12] • 56% more likely in black vs white patients • 53% more likely in Hispanic vs white patients • Among patients with access to care, no disparity in outcomes by race, despite lower adherence in minorities[13] 10. Bhatta MP, et al. Am J Med Sci. 2010;339:133-140. 11. Anthony MN et al. AIDS Care. 2007;19:195-202. 12. Turner BJ, et al. Arch Intern Med. 2000;160:2614-2622. 13. Silverberg MJ, et al. J Gen Intern Med. 2009;24:1065-1072.

  14. Clinicians’ Attitudes May Result in Withholding or Delay of ART in Minorities • Minority race often associated with perceived nonadherence; may led to withholding/delay of ART[14-16] • In earlier study (1996-1998), 89% of HCPs said adherence an important factor in decision to prescribe PIs[17] • Explained delayed use of PIs in minorities, women, poor • In MACH14, lower adherence among black patients not explained by differences in demographics, depression, or substance abuse[17] • Possible contributing factors: mistrust of HCPs, health illiteracy, healthcare system inequities 14. Bogart LM, et al. Med Decis Making. 2001;21:28-36. 15. Thrasher AD, et al. J Acquir Immune Defic Syndr. 2008;49:84-93.16. Simoni JM, et al. J Acquir Immune Defic Syndr. 2012;60:466-472. 17. Wong MD, et al. J Gen Intern Med. 2004;19:366-374.

  15. Delay of ART in Substance Abusers No injection drug use Abstinent x 3 mos 100 * Occasional injecting 90 Daily injecting * 80 70 P = .03 * 60 Providers Likely to Defer ART (%) 50 * 40 * 30 * 20 10 CD4+ Cell Count200 cells/mm3 CD4+ Cell Count 350 cells/mm3 CD4+ Cell Count 500 cells/mm3 0 *P < .001 18. Westergaard RP, et al. J Int AIDS Soc. 2012;15:10.

  16. Discrimination, Distrust, and Adherence • Responses in a midwestern survey[19] • 71% reported discrimination in HIV treatment based on race • 66% reported discrimination based on socioeconomics/class • HIV Cost and Services Utilization Study[20] • 40% of respondents reported discriminatory healthcare • 24% of respondents reported some mistrust of HCPs • More discrimination → greater distrust, weaker beliefs regarding treatment benefit → poorer adherence 19. Bird ST, et al. AIDS Patient Care STDS. 2004;18:19-26. 20. Thrasher AD, et al. J Acquir Immune Defic Syndr. 2008;49:84-93.

  17. Challenging Stereotypes Regarding Readiness for and Adherence to ART • Assessing ART readiness is critically important • Provide adherence support • Understand the patient’s social situation and challenges • Other possible strategies • Support groups • Peer educators • Treatment buddies • Case managers

  18. Addressing Specific Aspects of Care: Poor Long-term Continuity of Treatment • Single-center study from Vanderbilt Clinic[21] • Lower percentage of time on ART for black vs nonblack patients (47% vs 76%; P < .001) • Higher mortality in black patients; difference gone after adjusting for time on ART • Single-center study from UAB-Birmingham[22] • Black race associated with higher risk of missed clinic visit within first yr of HIV care (OR: 2.74; 95% CI: 1.77-4.23) • Missed visit within first yr of care associated with higher mortality risk (HR: 2.90; 95% CI: 1.28-6.56) 21. Lemly DC, et al. J Infect Dis. 2009;199:991-998. 22. Mugavero MJ, et al. Clin Infect Dis. 2009;48:248-256.

  19. Nonretention in HIV Care Associated With Poor Survival • Retrospective statewide study in South Carolina • Retention defined as ≥ 1 visit in each of four 6-mo periods over 2 yrs • Retention categorized as • Optimal (visits in 4 intervals) • Suboptimal (visits in 3 intervals) • Sporadic (visits in 1 or 2 intervals) • Dropout (no visits) 1.00 0.99 0.98 0.97 0.96 0.95 0.94 0.93 Probability of Survival 0.92 0.91 Retention in Care 0.90 Optimal Suboptimal Sporadic Dropout 0.89 0.88 0.87 0.86 0.85 0 3 6 9 12 15 18 21 24 27 30 33 36 Mos to Death 23. Tripathi A, et al. AIDS Res Hum Retroviruses. 2011;27:751-758.

  20. Evidence-Based Recommendations for Entry Into and Retention in HIV Care • Systematic monitoring of successful entry into HIV care recommended for all individuals diagnosed with HIV • Brief, strengths-based case management recommended for individuals with a new HIV diagnosis • ATRAS: evidence-based intervention • Consider intensive outreach for individuals not engaged in medical care within 6 mos of new HIV diagnosis • Consider using peer or paraprofessional patient navigators 24. Thompson MA, et al. Ann Intern Med. 2012;156:817-833.

  21. ARTAS: Best Practice for Linkage to Care • CDC-sponsored multicenter, controlled intervention study • Conducted in university[25] and community[26] settings • Intensive, short duration, time limited • Interventions client centered/strengths based • 79% (497/626) entered medical care within first 6 mos[26] • Median time spent per client: 5.8 hrs (mean: 7.2 hrs) Manual available at: http://www.cdc.gov/hiv/topics/cba/pdf/artas_implementation_manual.pdf 25. Gardner LI, et al. AIDS. 2005;19:423-431. 26. Craw JA, et al. J Acquir Immune Defic Syndr. 2008;47:597-606.

  22. HIV in the New Millennium: A Social/ Medical Nexus Mental Illness HIV Poverty Drugs Infectious Diseases

  23. What Might Patients Need to Stay in Care? • Common needs • Mental health services • Substance abuse treatment • Benefits advocacy • Childcare • Transportation • Companion services • Respite care 27. Stone V, et al. HIV/AIDS in US Communities of Color. Springer. 2009.

  24. Culturally Competent Care May Improve Communication, Trust • Know the culture personally • Provider interpreter services • Recruit, retain staff representative of patient community • Recognize role of traditional healers • Provide culturally appropriate pamphlets, activities in relevant languages • Include family, community in care • Ask patients what they need and address those needs • Make the clinic a desirable place to go 28. Stone V, et al. HIV/AIDS in US Communities of Color. Springer. 2009.

  25. Examples of Considerations That May Improve Communication/Trust • Some patients prefer to be called by formal name[29] • Direct eye contact important for some patients[29] • Explain why information is needed before asking; be aware of potential mistrust[29] • Be aware of importance of religion, spirituality[29] • Allow religious items at bedside • Be aware of importance of prayer, including group prayer • Some patients may be less comfortable with psychosocial talk[30] 29. Cichicki M. Living With HIV: A Patient’s Guide. McFarland & Co Inc Publishers. 2009. 30. Beach MC, et al. J Gen Intern Med. 2010;25:682-687.

  26. Specific Considerations for Latino Patients • “Latino” applies to a heterogeneous ethnic group representing different countries, cultures, lifestyles, norms[31] • Within Latino population, there is variability in[31] • HIV exposure risk factors • Education level • Access to medical, psychosocial care • Less acculturation among Latinos associated with[32] • Less testing for HIV, HCV • Greatly likelihood of testing HIV positive 31. Corales RB. AIDS Read. 2007;17:87. 32. Kelley CF, et al. AIDS Read. 2007;17:73-88.

  27. Disparities Can Be Overcome: The Ryan White HIV/AIDS Program • Integrated federally funded multidisciplinary program designed to deliver comprehensive HIV care for the economically disadvantaged • Program components • Primary care • Specialty care (substance abuse, mental health) • Supportive care (case management, nutrition, adherence, emergency assistance, transportation) 33. Moore RD, et al. Clin Infect Dis. 2012;55:1242-1251.

  28. Effective HIV Care Overcomes Disparities • Outcomes in 6366 patients treated in Baltimore, Maryland, between 1995 and 2010 • 87% of patients receiving ART • Median HIV-1 RNA: < 200 copies/mL • Median CD4+ cell count: 475 cells/mm3 • OIs: 2.4/100 patient-yrs; mortality 2.1/100 person-yrs • Expected longevity for HIV-infected patients: 73 yrs • No differences in outcomes by demographic group 34. Moore RD, et al. Clin Infect Dis. 2012;55:1242-1251.

  29. Conclusions • Nature of HIV epidemic continues to change • Cultural factors can significantly affect access, retention in HIV care • Culturally competent care can reduce barriers • Comprehensive HIV care improves outcomes, reduces disparities

  30. Go Online to Earn CME Credit for This Activity on Overcoming Cultural and Socioeconomic Barriers Clinical Focus:concise online CME-certified module with large slide thumbnails paired with supporting text discussion by Carlos del Rio, MD, and interactive polling questions clinicaloptions.com/CulturalBarriers

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