Carlos del Rio, MD Hubert Professor and Chair Hubert Department of Global Health Rollins School of Public Health of Emory University Atlanta, Georgia Understanding.

Carlos del Rio, MDHubert Professor and ChairHubert Department of Global HealthRollins School of Public Health of Emory UniversityAtlanta, Georgia

Understanding and Addressing Cultural and Socioeconomic Barriers to Effective HIV Management

This program is supported by an educational grant from

clinicaloptions.com/hivUnderstanding and Addressing Cultural and Socioeconomic Barriers

Faculty Disclosures

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


1. CDC. HIV Surveillance Supplemental Report 2012;17(No. 4). Published December 2012.

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)

*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.

20%

2%

46%

29%

1% 1% <1%

12%

4%

65%16%

1% 1% <1%

American Indian/Alaska NativeAsianBlack/African AmericanHispanic/Latino*Native Hawaiian/otherPacific IslanderWhiteMultiple races



Diagnosis of HIV Infection Among MSM Aged 13-24 Yrs

*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.

By Race, 2007-201046 States and 5 US Dependent Areas

American Indian/Alaska Native Asian

Black/African American

Hispanic/Latino*

Native Hawaiian/otherPacific Islander

White

Multiple races

Dia

gn

ose

s (n

)

Yr of Diagnosis2007 2008 2009 2010

5000

4500

3500

3000

2500

2000

1500

1000

500

0


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.



Trends in Age-Adjusted* Annual Rates of Death due to HIV Disease

*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.

By Race, United States, 1990-2008

Dea

ths

per

100

,000

P

op

ula

tio

n

60

50

40

30

20

10

090 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

Black/African AmericanHispanic/Latino†

American Indian/Alaska NativeWhiteAsian/Pacific Islander


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

5. Murphy K, et al. CROI 2012. Abstract 1045.

N = 1471 women on continuous HAART

0

20

0 5 13

4

8

12

16

12111098764321Yr

White

Other

Black

0

20

0 5 13

4

8

12

16

12111098764321Yr

White

Other

Black

AIDS Death Non-AIDS Death


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

6. Ojikutu B. Adv Stud Med. 2010;10:37-41.

Timely diagnosis

Linkage to care

Retention in care


CDC: Differences in Continuum of Care in HIV-Infected Patients by Race

7. Hall HI, et al. AIDS 2012. Abstract FRLBX05.

100

80

60

40

20

0Black Hispanic or

LatinoWhite

81

62

80

67

3733

26

85

71

38 3530

3429

21

Pro

po

rtio

n o

f H

IV-I

nfe

cted

In

div

idu

als

in U

S (

%)

Diagnosed

Linked to care

Retained in care

Prescribed ART

Viral suppression


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.


Potential Barriers to Testing in Minorities

Patient-Related Factors Provider-Related Factors

Financial constraints Discomfort with healthcare Limited access HIV-related stigmatization and

discrimination Lack of knowledge about HIV/AIDS Fear of AIDS diagnosis Drug or alcohol use Mental illness

Complacency about risk Feelings of incompetence or

discomfort about high-risk behavior Missed opportunities to offer testing


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


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.


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.


Delay of ART in Substance Abusers

18. Westergaard RP, et al. J Int AIDS Soc. 2012;15:10.

CD4+ Cell Count200 cells/mm3

CD4+ Cell Count 350 cells/mm3

Pro

vid

ers

Lik

ely

to D

efer

AR

T (

%) No injection drug use

Abstinent x 3 mos

Occasional injecting

Daily injecting

CD4+ Cell Count 500 cells/mm3

100

80

60

40

20

0

90

70

50

30

10

*

*

P = .03*

*

*

*

*P < .001


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.


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


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.


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)

23. Tripathi A, et al. AIDS Res Hum Retroviruses. 2011;27:751-758.

1.000.990.980.970.960.950.940.930.920.910.900.890.880.870.860.85

360 3 6 9 12 15 18 21 24 27 30 33Mos to Death

Pro

bab

ilit

y o

f S

urv

ival

Retention in Care

Optimal

Suboptimal

Sporadic

Dropout


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.


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)

25. Gardner LI, et al. AIDS. 2005;19:423-431. 26. Craw JA, et al. J Acquir Immune Defic Syndr. 2008;47:597-606.

Manual available at:http://www.cdc.gov/hiv/topics/cba/pdf/artas_implementation_manual.pdf

http://www.cdc.gov/hiv/topics/cba/pdf/artas_implementation_manual.pdf


HIV in the New Millennium: A Social/ Medical Nexus

Mental Illness

Poverty Drugs

Infectious Diseases

HIV


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.


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 go28. Stone V, et al. HIV/AIDS in US Communities of Color. Springer. 2009.


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.


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.


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.


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.


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

Go Online to Earn CME Credit for This Activity on Overcoming Cultural and

Socioeconomic BarriersClinical 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

http://www.clinicaloptions.com/CulturalBarriers

Carlos del Rio, MD Hubert Professor and Chair Hubert Department of Global Health Rollins School of Public Health of Emory University Atlanta, Georgia Understanding.

Documents

j gen intern

black patients

j int aids

georgia understanding

j acquir immune defic

minorities minority

black vs white patients

withholdingdelay of