2. DAVID J. MALEBRANCHE, MD, MPH
Associate Professor
Division of General Medicine
Emory University
Atlanta, GA

3. Program Introduction
“While anyone can become infected with HIV, some Americans are at greater risk than others By focusing our efforts in communities where HIV is concentrated, we can have the biggest impact in lowering all communities’ collective risk of acquiring HIV.”
This program reviews the epidemiology of HIV/AIDS in black and Hispanic Americans and provides a forum for discussing strategies to improve testing, treatment, and adherence to care in communities of color.
Reference:
The White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United States. July Accessed August 17, 2011.
The White House Office of National AIDS Policy. National HIV/AIDS strategy for the United States. July Accessed August 17, 2011.

4. EPIDEMIOLOGY OF HIV/AIDS IN BLACKS AND HISPANICS

5. AIDS Diagnoses by Race/Ethnicity in the United States and Dependent Areas,a 1985-2009
Year of Diagnosis
Diagnoses, %
Black/African American
White
Hispanic/Latinob
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Asian
Multiple Races
United States and Dependent Areas
Black and Hispanic Americans have been disproportionately affected by HIV/AIDS since the epidemic’s beginning, and that disparity has deepened over time. In 1994, the percentage of AIDS diagnoses among black Americans (who represented ~12% of the US population) exceeded that of whites (who represented ~74% of the US population) for the first time, and has continued to increase since that time.
[Note: Hispanic/Latino is defined by CDC as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.]
Reference:
Centers for Disease Control and Prevention. HIV Surveillance by Race/Ethnicity (through 2009). Accessed August 17, 2011.
a The 5 US dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the US Virgin Islands. b Hispanic/Latino is defined by the CDC as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Centers for Disease Control and Prevention (CDC). HIV surveillance by race/ethnicity (through 2009). Accessed August 17, 2011.

6. Diagnoses of HIV and Population by Race/Ethnicity, 2009: 40 Statesa
In 2009, blacks and Hispanics combined accounted for 26% of the population and 70% of HIV diagnoses in the 40 states with confidential name-based HIV infection reporting since at least January 2006
Blacks accounted for 52% of the HIV diagnoses and 13% of the population of the 40 states; Hispanics accounted for 18% of HIV diagnoses and 13% of the population of the 40 states
Reference:
Centers for Disease Control and Prevention. HIV Surveillance by Race/Ethnicity (through 2009). Accessed August 17, 2011.
a Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. CDC. HIV surveillance by race/ethnicity (through 2009). Accessed August 17, 2011.

7. HIV Diagnoses by Subpopulation
HIV diagnoses in men (2009)
Black men: 47%; Hispanic/Latino men: 19%1
More new HIV infections occurred among young black men, aged 13 to 29 years, who have sex with men (MSM) than in any other age and racial group of MSM2
HIV diagnoses in women (2009)
Black women: 66%; Hispanic/Latino women: 14%1
In 2009, black men accounted for nearly half of all HIV diagnoses among men in the 40 states with confidential name-based HIV infection reporting since at least January 2006; black and Hispanic men together accounted for 66% of HIV diagnoses among men1
Black women alone accounted for 66% of all HIV diagnoses among women; black and Hispanic women together accounted for 80% of HIV diagnoses among women1
Black adolescents accounted for 75% of HIV diagnoses among those aged 13 to 19 years in 2009 (40 states); black and Hispanic adolescents together accounted for 88% of HIV diagnoses among adolescents3
References:
Centers for Disease Control and Prevention. HIV Surveillance by Race/Ethnicity (through 2009). Accessed August 17, 2011.
Centers for Disease Control and Prevention. HIV among African Americans. Accessed August 17, 2011.
Centers for Disease Control and Prevention. HIV Surveillance in Adolescents and Young Adults (through 2008). Accessed August 17, 2011.
HIV diagnoses in adolescents (aged 13 to 19 years: 2008)
Black adolescents: 73%, Hispanic/Latino adolescents: 13%3
1 CDC. HIV surveillance by race/ethnicity (through 2009). Accessed August 17, 2011.
2 CDC. HIV among African Americans. September Accessed August 17, 2011.
3 CDC. HIV Surveillance in Adolescents and Young Adults (through 2008). Accessed August 17, 2011.

8. HIV Diagnosis Rates for Adults and Adolescents by Race and Gender, 2009 (40 US States)
Diagnosis rates in MSM (2006)2
Black: 1710 per 100,000
Hispanic: 716 per 100,000
White: 344 per 100,000
Black men have a higher HIV diagnosis rate than any other group: more than 8 times as high as the rate for white men and ~2.5 times as high as the rate for Hispanic men1
HIV infection rates are reported to be higher among black MSM than any other group of MSM (1710 vs 344 for white MSM and 716 for Hispanic/Latino MSM).2 It is important to recognize that many barriers to disclosing sexual behaviors exist in the health care setting. Diagnosis rates in MSM therefore reflect only individuals who report this behavior, which may not accurately represent the entire population of MSM
Hispanic men have the second highest HIV diagnosis rate (per 100,000 population) of any group: more than 3 times as high as the rate for white men.1
Black women have the highest HIV diagnosis rate among women and the third highest rate overall: ~3 times as high as the rate for white men, nearly 20 times as high as the rate for white women, and ~4 times as high as the rate for Hispanic women1
The HIV diagnosis rate in Hispanic women is nearly 5 times as high as the rate in white women and approaches the rate seen in white men1
The 40 states are: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. CDC. HIV surveillance by race/ethnicity (through 2009). Accessed August 17, 2011.
References:
Centers for Disease Control and Prevention. HIV Surveillance by Race/Ethnicity (through 2009). Accessed August 17, 2011.
The White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United States. July Accessed August 17, 2011.
1 CDC. HIV surveillance by race/ethnicity (through 2009). Accessed August 17, 2011.
2 The White House Office of National AIDS Policy. National HIV/AIDS strategy for the United States. July Accessed August 17, 2011.

9. HIV Transmission in Blacks and Hispanics in the United States, 2009a
Black Menb and Women
Hispanic Men and Women
MSM sexual contact
MSM sexual contact
Men: 68%
Men: 71%
Heterosexual contact
Heterosexual contact
Men: 20%
Women: 87%
Men: 14%
Women: 83%
In 2009, the most common route of HIV transmission among both black and Hispanic men was male-to-male sexual contact, followed by heterosexual contact and injection drug use
Heterosexual contact accounted for the vast majority of HIV diagnoses among black and Hispanic women, followed by injection drug use
The 40 states are: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. CDC. HIV surveillance by race/ethnicity (through 2009). Accessed August 17, 2011.
The 5 US-dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the US Virgin Islands.
Reference:
Centers for Disease Control and Prevention. HIV Surveillance by Race/Ethnicity (through 2009). Accessed August 17, 2011.
IDU
IDU
Men: 9%
Women: 13%
Men: 12%
Women:17%
a Forty US states and 5 US-dependent areas.
b Among black men, 3% were IDUs who had MSM sexual contact.
IDU, injection drug user. CDC. HIV surveillance by race/ethnicity (through 2009). Accessed August 17, 2011.

10. Age-adjusteda Average Annual Rate of Death due to HIV, United States, 2003-2007b
Deaths per 100,000 Population
In the most recent 5 years for which data were available, rates of death for both men and women resulting from HIV were highest among blacks and Hispanics. The rate among black women was higher than the rate among men in every racial/ethnic group with the exception of black men.
Reference:
Centers for Disease Control and Prevention. HIV Mortality (through 2007). Accessed August 17, 2011.
a Standard: age distribution of year 2000 US population.
b Hispanic/Latino can be any race.
CDC. HIV mortality (through 2007). Accessed August 17, 2011.

11. HIV TESTING AND TREATMENT: RECOMMENDATIONS AND REALITY

12. HIV Testing and Treatment: Reality
“While many gains have been made in the HIV/AIDS epidemic, from testing modalities to the diagnosis, care, and management of HIV infection and its complications, these gains have not been realized uniformly [T]hese disparities not only continue to drive the epidemic, but also the profound economic and human costs associated with it.”
Disparities in HIV testing and treatment are drivers of the HIV/AIDS epidemic in black and Hispanic populations, because undiagnosed and untreated HIV infection has critical implications at both the population level (ongoing transmission) and the personal level (survival).
Reference:
Cargill V, Fenton KA. The epidemiology, prevention, and control of HIV/AIDS among African Americans. In: Stone V, Ojikutu B, Rawlings MK, Smith KY, eds. HIV/AIDS in US Communities of Color. New York, NY: Springer; 2009:1-22.
Cargill V, Fenton KA. The epidemiology, prevention, and control of HIV/AIDS among African Americans. In: Stone V, Ojikutu B, Rawlings MK, Smith KY, eds. HIV/AIDS in US Communities of Color. New York, NY: Springer; 2009:1-22.

13. HIV Testing Recommendations
Repeat screening
Annually for those at high risk, eg, those who have had unprotected sex since previous test
ALL patients aged 13 to 64 years in ALL health care settings
Routine HIV testing
In 2006, the CDC recommended universal HIV testing during routine medical care for all patients aged 13 to 64 years in all health care settings, repeated at least annually for those at high risk
For pregnant women, an initial test should be performed as early as possible during pregnancy; repeat testing during the third trimester (<36 weeks gestation) has been found to be cost-effective even in areas of low HIV prevalence
Anyone who has had unprotected sex is at risk. Individuals likely to be at high risk include heterosexuals who have had more than one partner since their most recent HIV test, or those whose partners have had more than one partner since the patient’s most recent HIV test
Reference:
Centers for Disease Control and Prevention. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings Accessed August 17, 2011.
CDC. MMWR. 2006;55(RR14): Accessed August 17, 2011.

14. Risk-based HIV Testing Strategies: Missed Opportunities
Number and Percentage of Health Care Visits by Late Testersa Who Had Visited a Health Care Facility Before the Date of HIV Diagnosis, South Carolina,
Reported diagnosis
Number
Percentage
Visits with diagnosis likely to prompt an HIV test
1711
21.4
Sexually transmitted disease and related diagnoses
165
2.1
Symptoms suggestive of acute retroviral syndromeb
1191
14.9
Diseases possibly related to HIVc
478
6.0
Diseases probably related to HIVd 94
1.2
Intravenous drug use and related behaviors 85
1.1
Visits with diagnosis not likely to prompt an HIV test
6277
78.6
Total visits
7988
100.0
Late testers had an average of 4 health care visits in the years before HIV diagnosis.
From 2001 to 2005 (before publication of the 2006 recommendations for universal testing), a total of 4315 HIV diagnoses were reported in South Carolina; 41% of these individuals were diagnosed with AIDS within one year of the initial HIV diagnosis (so-called late testers). Among late testers, 73% of them made a total of 7988 visits to a South Carolina health care facility during , before their first reported positive HIV test. For 79% of these visits, the diagnoses were not likely to prompt HIV testing using a risk-based strategy. These findings highlight the limitations of risk-based HIV testing and suggest that routine HIV testing might lead to earlier diagnoses, providing important benefits at both the individual and community levels.1
Nationally, 32% of blacks and 38% of Hispanics are diagnosed with AIDS within one year of receiving an HIV diagnosis.2
References:
Centers for Disease Control and Prevention. Missed opportunities for earlier diagnosis of HIV infection—South Carolina, MMWR Morb Mortal Wkly Rep. 2006;55(47):
a N = Reported in South Carolina during
b Including fever, lymphadenopathy, and rash.
c Including peripheral neuropathy, pneumonia, and thrombocytopenia.
d Including cerebral toxoplasmosis, pulmonary tuberculosis, and thrush.
CDC. MMWR. 2006;55(47): Accessed August 17, 2011.

15. Blacks and Hispanics Have Higher Rates of Undiagnosed HIV Infection
Estimated Number and Rate (per 100,000 Population) of Persons Age ≥13 Years Living with Undiagnosed HIV Infections, by Race/Ethnicity and Sex, 2006─United States
By transmission category, the highest rates of undiagnosed infection were seen among men with HRHC, followed by MSM.
Number
Rate
95% CI
White
Male Female
72,000
62,800
9200
42.2
75.6
10.5
Black/African American
Male
Female
113,000
77,500
35,700
380.3
556.5
225.7
Hispanic
41,900
34,700
7200
126.4
201.6
45.2
Asian/Pacific Islander
4500
3700
800
38.6
66.0
13.2
American Indian/Alaska Native
1200
848
336
60.4
87.4
33.0
Total
232,700
94.2
Using a combination of HIV and AIDS surveillance data, CDC researchers concluded that of the more than 1 million people living with HIV in the United States at the end of 2006, an estimated 21% were undiagnosed (ie, unaware of their infection). Differences were evident across racial/ethnic and behavior groups:
Each nonwhite group had a significantly greater percentage (higher rate) of undiagnosed HIV infection compared with whites; blacks had the highest rates of undiagnosed infection, and black men had the highest rate overall
By transmission category, the highest percentage of undiagnosed HIV (26.7%) was among men with a transmission category of high-risk heterosexual contact (HRHC), defined as reporting heterosexual contact with a person known to have, or to be at high risk for, HIV infection (eg, an injection drug user). The second highest percentage of undiagnosed HIV was among MSM (23.5% overall; white MSM: 19.8%; Hispanic MSM: 26.3%; black MSM: 27.2%)
Reference:
Campsmith ML, et al. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of J Acquir Immune Defic Syndr. 2010;53:
CI, confidence interval; HRHC, high-risk heterosexual contact. Campsmith ML, et al. J Acquir Immune Defic Syndr. 2010;53:

16. Undiagnosed Persons Contribute Disproportionately to New Infections
More than 1 million persons are living with HIV in the United States (2006)
About 75% aware (diagnosed)
About 25% unaware (undiagnosed)
About 32,000 new HIV infections each year are sexual transmissions
Aware: 14,720
Unaware: 17,280
If all diagnosed + 57% reduction in UAV
Sexual transmissions ↓ to 7430
31% reduction in new infections:
14, = 22,150
Research suggests that those who are infected with HIV but not diagnosed disproportionately contribute to new infections. Reasons might include higher levels of circulating HIV in the early stages of the disease and/or greater behavioral risks among those who are infected but undiagnosed. Therefore, increasing the number of HIV-infected persons who are diagnosed and linked to effective care and prevention programs has the potential to significantly reduce new HIV infections over time.
In 2006, CDC researchers estimated that each year, more than half of new sexually transmitted HIV infections in the United States can be attributed to the approximately 25% of individuals living with HIV who are unaware of their infection. Parameters included: 33% of the aware group are at low risk of transmitting HIV owing to low/undetectable viral loads; a 57% relative reduction in the prevalence of unprotected anal and vaginal intercourse (UAV) with at-risk partners among aware versus unaware persons (based on findings from a 2005 meta-analysis). Results suggested that if the unaware were all diagnosed, new HIV infections attributed to sexual transmission could theoretically be reduced by 31%.
Reference:
Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:
UAV, unprotected anal and vaginal intercourse. Marks G, et al. AIDS. 2006;20:

17. HIV Treatment Recommendations
Initiate combination ART in the following patients
CD4 cell count <350 cells/mm3 or AIDS-defining illness
CD4 cell count 350 cells/mm3 to 500 cells/mm3
HIVAN or HBV coinfection
Pregnant (regardless of CD4 cell count)
Combination ART optional in patients with
DHHS treatment guidelines, revised in 2011, recommend initiating combination ART in several groups: all patients with a CD4 cell count less than 350 cells/mm3 or an AIDS-defining illness; patients with a CD4 cell count cells/mm3; all patients with HIV-associated nephropathy (HIVAN) or hepatitis B coinfection; and all pregnant women with HIV, regardless of CD4 cell count. The guidelines panel was split as to initiating ART in patients with CD4 cell counts higher than 500 cells/mm3: half of the panel supported initiating therapy in these patients, and half considered it to be optional.
Reference:
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January 10, 2011; Accessed August 17, 2011.
CD4 cell count >500 cells/mm3
AIDS, acquired immunodeficiency syndrome; ART, antiretroviral therapy; HBV, hepatitis B virus; HIVAN, HIV-associated nephropathy. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. DHHS. January 10, 2011; Accessed August 17, 2011.

18. ART Use and Clinical Outcomes in Black and Hispanic Populations
Is nonwhite race independently associated with increased mortality and poor outcomes?
Do disparate outcomes reflect racial differences in comorbidities and access to care?
Race-specific data are limited and mixed
Although treatment recommendations do not differ by race, the rates of mortality, use of ART, and clinical outcomes do. Minorities have historically been underrepresented in HIV clinical studies; data exploring racial differences in mortality and clinical outcomes have been limited and the results mixed. Some studies have reported that race is independently associated with increased mortality and poor outcomes while on ART, whereas other studies have reported that disparate clinical outcomes reflect differences in comorbidities and access to care. Next, we will first review differences in comorbidities and access to care and then consider the data.

19. Racial Differences in Key Comorbidities
Blacks
Disproportionately affected by HCV, heart disease, diabetes, obesity, and cancer1,2
NHANES ( ): HCV infection prevalence 2.6% versus 1.3% for whites2
Hispanics
Disproportionately affected by diabetes, renal disease, obesity, cervical cancer3
Blacks and Hispanics are disproportionately affected by a number of health conditions that may be further exacerbated by HIV infection and complicate HIV treatment.1,2 The prevalence of HCV infection is significantly higher among blacks compared with whites, with peak prevalence in black men aged 40 to 49 years.3 The prevalence of HCV coinfection among individuals with HIV is estimated to be 30%-40% overall, and 70%-95% in HIV-infected IDUs and hemophiliacs.4 HIV/HCV-coinfected patients have several poor prognosis factors: lower rates of spontaneous HCV clearance; increased HCV viral loads; decreased rates of successful virologic response to HCV treatments; faster progression to cirrhosis; and increased risk of developing liver decompensation, end-stage liver disease, and hepatocellular carcinoma (HCC). However, HCV coinfection does not appear to increase HIV- and AIDS-related complications or decrease rates of successful HIV antiretroviral treatment.4
References:
CDC. Highlights in minority health and health disparities. February
US Department of Health and Human Services. The Office of Minority Health. Hispanic/Latino Profile. Accessed August 17, 2011.
McQuillan GM, Kruszon-Moran D, Denniston MM, Hirsch R. Viral hepatitis. NCHS data brief, no 27. Hyattsville, MD: National Center for Health Statistics. 2010: 1-7.
US Department of Health and Human Services: Health Resources and Services Administration. Guide for HIV/AIDS Clinical Care Accessed August 17, 2011.
HCV, hepatitis C virus; NHANES, National Health and Nutrition Examination Survey.
1 CDC. Highlights in minority health and health disparities. February Accessed August 17, 2011.
2 McQuillan GM, et al. Viral hepatitis. NCHS data brief, no 27. Hyattsville, MD: National Center for Health Statistics; March 2010.
3 DHHS. Hispanic/Latino profile. Accessed August 17, 2011.

20. Racial Differences in Key Factors That Influence Access and Adherence to Care
Comment
Income
Blacks and Hispanics are nearly 3 times as likely to live in poverty1
Health-insurance coverage
48% of blacks and 59% of Hispanics are either uninsured or covered by Medicaid, compared with 23% of whites2,3
Cultural/ language barriers
Cultural differences may delay/prevent care; language barriers limit access to information on HIV testing and care
Immigration and
migration
Foreign-born blacks and Hispanics may not access care owing to fear of deportation; migration patterns can preclude ongoing care
Blacks and Hispanics are also disproportionately affected by a number of factors that may influence access and adherence to care.
[Ask participants which factors are most relevant to them. Additional information is provided on the following 7 slides for each factor listed in the table; review only the slides covering the factors the participants identify as most relevant.]
References:
Kaiser Family Foundation. Poverty Rate by Race/Ethnicity, States ( ), U.S. (2009). Accessed August 22, 2011.
Kaiser Commission on Medicaid Facts: Medicaid’s Role for Black Americans. May Accessed August 22, 2011.
Kaiser Commission on Medicaid Facts: Medicaid’s Role for Hispanic Americans. May Accessed August 22, 2011.
1 Kaiser Family Foundation. Poverty Rate by Race/Ethnicity ( ), U.S. (2009). Accessed August 22, 2011.
2 Kaiser Commission on Medicaid Facts: Medicaid’s Role for Black Americans. May Accessed August 22, 2011.
3 Kaiser Commission on Medicaid Facts: Medicaid’s Role for Hispanic Americans. May Accessed August 22, 2011.

21. Racial Differences in Key Factors That Influence Access and Adherence to Care (cont’d)
Comment
Distrust of the health care system
History of research abuses and personal experiences of unequal treatment may lead to avoiding care and nondisclosure of status
Stigma
Fear of added stigma may prevent individuals who already face racial and/or gender biases from getting tested and seeking care
Substance abuse and depression
The 2 most common comorbid conditions with HIV; associated with increased mortality and high-risk behaviors1
Incarceration
Nonwhites incarcerated at significantly higher rates than whites2
References:
US Department of Health and Human Services: Health Resources and Services Administration. Guide for HIV/AIDS Clinical Care Accessed August 22, 2011.
US Department of Justice. Bureau of Justice Statistics. Prisoners in December Accessed August 22, 2011.
1 DHHS: Health Resources and Services Administration. Guide for HIV/AIDS Clinical Care Accessed August 22, 2011.
2 DHHS. Bureau of Justice Statistics. Prisoners in December Accessed August 22, 2011.

22. Income
In the setting of poverty, HIV testing and treatment may be sacrificed to competing demands for basic needs
$11,000/year (individual)
$22,000/year (family of 4)
12.9 million blacks
16.7 million Hispanics
In 2009, 35% of blacks and 34% of Hispanics in the United States lived below the federal poverty line
In the setting of poverty, HIV testing and treatment may be sacrificed to competing demands for food, housing, clothing, and basic needs. Blacks and Hispanics are nearly 3 times as likely to live in poverty as whites: in 2009, approximately 12.9 million black Americans (35%) and 16.7 million Hispanic Americans (34%) lived below the federal poverty line (~$11,000/year for an individual or $22,000/year for a family of 4). Poverty is linked to a number of other factors that may influence access to care, such as homelessness, decreased literacy, and lack of health insurance coverage.
Reference:
Kaiser Family Foundation. Poverty Rate by Race/Ethnicity ( ), U.S. (2009). Accessed August 22, 2011.
Kaiser Family Foundation. Poverty rate by race/ethnicity, states ( ), U.S. (2009). Accessed August 17, 2011.

23. Health-insurance Coverage
Black Americans: 20091
Hispanic Americans: 20092
Health insurance coverage is critical to gaining access to HIV/AIDS care because of the expense involved in ongoing medical management. In 2009, nearly half of all black Americans were uninsured or covered by Medicaid, and nearly 60% of Hispanic Americans were uninsured or covered by Medicaid (whites: 13% uninsured; 11% covered by Medicaid).1,2
References:
Kaiser Commission on Medicaid Facts: Medicaid’s Role for Black Americans. May Accessed August 22, 2011.
 Kaiser Commission on Medicaid Facts: Medicaid’s Role for Hispanic Americans. May Accessed August 22, 2011.
Total = 37 million
Total = 49 million
1 Kaiser Commission on Medicaid Facts: Medicaid’s Role for Black Americans. May Accessed August 22, 2011.
2 Kaiser Commission on Medicaid Facts: Medicaid’s Role for Hispanic Americans. May Accessed August 22, 2011.

24. Cultural/Language Barriers
Cultural barriers1
Cultural beliefs, gender roles, and sexual norms may delay or prevent persons from getting tested and entering treatment
Cultural differences may impede interactions with health care system and providers
Language barriers
Limit access to health information and patient-provider communication
Cultural beliefs, gender roles, and sexual norms may delay or prevent blacks and Hispanics from getting tested and/or entering care. Once in care, cultural differences may impede interactions with the health care system and provider1
Individuals for whom English is a second language may have limited access to information on HIV prevention, testing, and treatment. Miscommunication can also occur. The provider may not understand the patient’s concerns and therefore not address them. The patient may not understand how to take prescribed medication or why medication adherence and engagement in care are important1
Although patient-provider racial concordance may ameliorate some of these issues, HIV patient and physician demographics dictate that many HIV encounters will continue to be cross-cultural3
References:
Martorell C. HIV/AIDS and the Latino populations in the US: Epidemiology, prevention, and barriers to care and treatment. In: Stone V, Ojikutu B, Rawlings MK, Smith KY, eds. HIV/AIDS in US Communities of Color. New York, NY: Springer; 2009:1-22.
AMA. Total physicians by race/ethnicity— Accessed August 22, 2011.
1 Martorell C. HIV/AIDS and the Latino populations in the US: Epidemiology, prevention, and barriers to care and treatment. In: Stone V, Ojikutu B, Rawlings MK, Smith KY, eds. HIV/AIDS in US Communities of Color. New York, NY: Springer; 2009:1-22.

25. Cultural/Language Barriers
Physicians by Race/Ethnicity, 20082
Cultural beliefs, gender roles, and sexual norms may delay or prevent blacks and Hispanics from getting tested and/or entering care. Once in care, cultural differences may impede interactions with the health care system and provider1
Individuals for whom English is a second language may have limited access to information on HIV prevention, testing, and treatment. Miscommunication can also occur. The provider may not understand the patient’s concerns and therefore not address them. The patient may not understand how to take prescribed medication or why medication adherence and engagement in care are important1
Although patient-provider racial concordance may ameliorate some of these issues, HIV patient and physician demographics dictate that many HIV encounters will continue to be cross-cultural3
References:
Martorell C. HIV/AIDS and the Latino populations in the US: Epidemiology, prevention, and barriers to care and treatment. In: Stone V, Ojikutu B, Rawlings MK, Smith KY, eds. HIV/AIDS in US Communities of Color. New York, NY: Springer; 2009:1-22.
AMA. Total physicians by race/ethnicity— Accessed August 22, 2011.
1 American Medical Association. Total physicians by race/ethnicity— Accessed August 22, 2011.

26. Immigration and Migration
Diagnoses of HIV Infection Among Adult and Adolescent Hispanics/Latinosa, by Sex and Country of Birth,
2009─40 States and 5 US Dependent Areas
Males
Females
N = 6615
N = 1625
Among Hispanics diagnosed with HIV in 2009, only slightly more than one-third reported being born in the United States.1 Individuals who are foreign-born may not access HIV screening and treatment services because they fear deportation, regardless of citizenship status.2 In addition, migration patterns of transient Hispanic populations can preclude ongoing engagement in HIV care, resulting in inadequate HIV control and increased risk of transmission.2
References: 
CDC. HIV Surveillance by Race/Ethnicity (through 2009). Accessed August 22, 2011.
Martorell C. HIV/AIDS and the Latino populations in the US: Epidemiology, prevention, and barriers to care and treatment. In: Stone V, Ojikutu B, Rawlings MK, Smith KY, eds. HIV/AIDS in US Communities of Color. New York, NY: Springer; 2009:1-22.
a Hispanics/Latinos can be of any race. CDC. HIV Surveillance by Race/Ethnicity (through 2009). Accessed August 17, 2011.

27. HIV Diagnoses by Race and Place of Birth: Massachusetts, 2006-2008
Total Diagnoses, %
Surveillance data from the Massachusetts Department of Public Health highlight regional differences in immigrant populations. Approximately two-thirds of Hispanics and more than half of blacks diagnosed with HIV in Massachusetts from 2006 to 2008 were foreign-born.
Reference:
Massachusetts Department of Public Health Office of HIV/AIDS. Detailed data tables: people born outside the US. Accessed August 22, 2011.
NH, non-Hispanic. Massachusetts Department of Public Health Office of HIV/AIDS. Accessed August 22, 2011.

28. Non US Born People Diagnosed with HIV Infection by Gender and Region of Birth: Massachusetts,
Region of Birth
Male N %
Female
State
Total N
Caribbean Basin 82 24 80 34
162 28
Central and South America
110 32 23 10
133
Central and South Asia 9 3 1
<1 2
N Africa & Middle East
N America & Europe 35 4 39 7
Pacific Rim
Southeast Asia 13 6 19
Sub-Saharan Africa 83
116 49
199
Unspecified 8 15
Total
343
100
238
581
Using a combination of HIV and AIDS surveillance data, CDC researchers concluded that of the more than 1 million people living with HIV in the United States at the end of 2006, an estimated 21% were undiagnosed (ie, unaware of their infection). Differences were evident across racial/ethnic and behavior groups:
Each nonwhite group had a significantly greater percentage (higher rate) of undiagnosed HIV infection compared with whites; blacks had the highest rates of undiagnosed infection, and black men had the highest rate overall
By transmission category, the highest percentage of undiagnosed HIV (26.7%) was among men with a transmission category of high-risk heterosexual contact (HRHC), defined as reporting heterosexual contact with a person known to have, or to be at high risk for, HIV infection (eg, an injection drug user). The second highest percentage of undiagnosed HIV was among MSM (23.5% overall; white MSM: 19.8%; Hispanic MSM: 26.3%; black MSM: 27.2%)
Reference:
Campsmith ML, et al. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of J Acquir Immune Defic Syndr. 2010;53:
Data Source: MDPH HIV/AIDS Surveillance Program . (percentages may not add up to 100% due to rounding); data aas of 1/1/10..

29. Distrust of the Health Care System
Historical treatment1
Personal experiences of unequal treatment2
HIV/AIDS conspiracy theories1
“If you are new to this virus and you are looking for some help, and you go to that window and [they give] you a snotty attitude, you are going to turn around and walk back out of that clinic.”
“Sometimes I have to go to just any emergency hospital and I am reluctant to share my status. Therefore, I put myself at risk because I can’t tell them I am taking HIV medications.”
“In the ER they don’t want to be bothered with you, and they will tell you anything to send you back to your own physician.”
Distrust of the health care system among minorities may be based on historical treatment of minorities, including research abuses such as the Tuskegee Study of Untreated Syphilis in the Negro Male, conducted by the US Public Health Service from 1932 to 1972; personal experiences of unequal treatment; and/or HIV/AIDS conspiracy theories. This distrust may result in delaying or forgoing care, or failing to disclose HIV status to health care providers other than the primary HIV care provider, omissions that may compromise care.
References:
CDC. US Public Health Service Syphilis Study at Tuskegee. Accessed August 22, 2011.
Aziz M, Smith KY. Challenges and success in linking HIV-infected women to care in the United States. Clin Infect Dis. 2011;52(Suppl2):S231-S237.
Sayles JN, Ryan GW, Silver JS, et al. Experiences of social stigma and implications for healthcare among a diverse population of HIV positive adults. J Urban Health. 2007;84:
1 Aziz M, Smith KY. Clin Infect Dis. 2011;52(suppl):S231-S237.
2 Sayles JN, et al. J Urban Health. 2007;84:

30. Stigma Heterosexual man Heterosexual woman Homosexual man
“My whole stigma thing was that it was a straight-up gay disease. You got it, man; you must have screwed some dude.”
Heterosexual woman
“It’s assumed that if a woman is HIV-positive, she either shot drugs or she was a slut, and there’s just no other way.”
The stigma commonly associated with HIV infection differentiates it from other life-threatening diseases and can profoundly affect the lives of those living with HIV/AIDS and those in communities with high HIV/AIDS prevalence. Fear of being identified as HIV-positive may prevent individuals from getting tested, accessing care and medications, and disclosing their HIV status to friends, family, and even health care providers. Individuals identified as HIV-positive may face marginalization at work, in their personal lives, in the gay community, and in health care settings. For minorities with HIV, stigma and blame may be intensified by coexisting marginalization related to race, gender, and sexual orientation. Issues related to stigmatization may also differ by gender and sexual orientation. For example, heterosexual men may be labeled gay; women may be labeled prostitutes or injection drug users; and MSM with HIV may face intensified homophobia (eg, HIV is a deserved punishment for being gay).
Reference:
Sayles JN, Ryan GW, Silver JS, et al. Experiences of social stigma and implications for healthcare among a diverse population of HIV positive adults. J Urban Health. 2007;84:
Homosexual man
“Being an ethnic minority in the gay community seems like a piece of cake compared to what HIV status is now.”
Sayles JN, et al. J Urban Health. 2007;84:

31. Substance Abuse and Depression
Substance abuse and depression are common comorbid conditions with HIV1,2
Increased mortality1
Impaired quality of life1
Decreased adherence to ART1
Increased risk behaviors1
Substance abuse and depression are the 2 most common comorbid conditions with HIV; both are associated with decreased mortality, impaired quality of life, decreased adherence to ART, and increased risk behaviors. The multiple stressors of living with HIV (eg, reduced social support, isolation) as well as the effects of HIV medications may contribute to depression.
References:
US Department of Health and Human Services: Health Resources and Services Administration. Guide for HIV/AIDS Clinical Care Accessed August 22, 2011.
Bing EG, Burnam A, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58:
1 DHHS. Guide for HIV/AIDS Clinical Care Accessed August 22, 2011.
2 Bing EG, et al. Arch Gen Psych. 2001;58:

32. Incarceration
Estimated Number of Sentenced Prisoners, Federal or State, 2009
60% of male inmates were Black or Hispanic
43% of female prisoners were Black or Hispanic
In 2009, more black men were incarcerated in the United States than any other racial group. Black and Hispanic men combined accounted for 60% of male inmates in the nation’s prisons; black and Hispanic women combined accounted for 43% of female inmates.1 These numbers are strikingly disproportionate when you consider that blacks accounted for only 12% and Hispanics 15% of the US population in High rates of incarceration may increase the likelihood of multiple, concurrent sexual relationships and create continuity-of-care challenges for those who are infected with HIV.3
References
United States Department of Justice. Bureau of Justice Statistics. Prisoners in December Accessed August 22, 2011.
US Census Bureau. Fact Sheet: United States. Accessed August 22, 2011.
El-Sadr WM, Mayer KH, Hodder SL. AIDS in America—forgotten but not gone. N Engl J Med. 2010;362:
US Department of Justice. Bureau of Justice Statistics. Prisoners in December Accessed August 22, 2011.

33. Incarceration and HIV: Co-epidemics
High-risk behaviors
Highly prevalent among inmates1
Sharing syringes
Multiple sex partners, unprotected sex
A reported 1.5% of inmates have HIV/AIDS2
HCV incidence is 10 times higher among inmates1
Substance abuse, mental-health disorders
Incarceration, infectious disease
Substance use and mental health disorders are highly prevalent in the prison population and are thought to play a key role in the overlap of infectious disease and incarceration. Both substance abuse and mental health disorders are associated with increased high-risk behaviors, which can lead to incarceration and put inmates at high risk for becoming infected with HIV, hepatitis C virus (HCV), and other infectious diseases. These behaviors may include unsafe substance use (eg, sharing syringes) and high-risk sexual behavior (eg, having multiple sex partners or unprotected sex).1 A reported 1.5% of inmates have HIV/AIDS,2 and the incidence of HCV is 10 times higher among inmates than among non-inmates and 33% higher among women than among men.1
For many inmates, prison health service provides their first access to consistent health care.1 However, inmates may choose not to disclose their HIV status, leading to treatment interruptions during incarceration. During 2008, only 24 states reported testing all inmates for HIV at some time during custody.2 For those receiving treatment while incarcerated, treatment interruption may occur upon release, when the challenges of finding housing and employment supersede the need to establish community-based care.1
References
US Department of Health and Human Services: Health Resources and Services Administration. Guide for HIV/AIDS Clinical Care
Maruschak LM. HIV in Prisons, Accessed August 22, 2011. 
US Department of Justice. Bureau of Justice Statistics. Prisoners in December Accessed August 22, 2011.
Nearly 730,000 inmates were released from the nation’s prisons in 20093
1 DHHS. Guide for HIV/AIDS Clinical Care Accessed August 22, 2011.
2 Maruschak LM. HIV in Prisons, Accessed August 22, 2011. 
3 US Department of Justice. Bureau of Justice Statistics. Prisoners in December Accessed August 22, 2011.

34. ART Use and Outcomes in Blacks and Hispanics: Selected Studies
Fourie J, Flamm J, Rodriquez-French A, et al. ARTEMIS: week 96 safety and efficacy of darunavir/r by gender, age and race. 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009). Cape Town, South Africa; July 19-22, Poster CDB072.
Lemly D, Shepherd B, Hulgan T, et al. Race and sex differences in antiretroviral therapy use and mortality among HIV-infected persons in care. J Infect Dis. 2009;199:
Lille-Blanton M, Stone VE, Jones AS, et al. Association of race, substance abuse, and health insurance coverage with use of highly active antiretroviral therapy among HIV-infected women, Am J Public Health. 2010;100:
Ribaudo H, Smith K, Robbins G, et al. Race differences in the efficacy of initial ART on HIV infection in randomized trials undertaken by ACTG. 18th Conference on Retroviruses and Opportunistic Infections (CROI 2011). Boston, MA; February 27-March 2, Abstract 50.
Smith KY, Garcia F, Ryan R. GRACE (Gender, Race and Clinical Experience): outcomes by race at week th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009). San Francisco, CA; September 12-15, Abstract H-918.
Smith KY, Kumar PN, Patel P, et al. Differences in virologic response among African-Americans and females regardless of therapy in the HEAT study. 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009). Cape Town, South Africa; July 19-22, Abstract MOPEB033.
Smith K, Tierney C, Daar E, et al. Association of race/ethnicity and sex on outcomes in ACTG Study A th Conference on Retroviruses and Opportunistic Infections (CROI 2011). Boston, MA; February 27-March 2, Abstract 536.
Now let’s review the clinical data.

35. Race and Sex Differences in HAART Use and Mortality Among Patients in Care
Kaplan-Meier Survival Curve of Time to Death in the Total Cohort, by Race
Retrospective, observational cohort study (N = 2605); 38% black; 24% female
Women, blacks less likely to receive HAART
Race (but not sex) differences in mortality likely associated with HAART use 1 2 3 4 5 6 7 8
0.6
0.7
0.8
0.9
1.0
Survival Probability
Nonblack
Black
This retrospective, observational cohort analysis included 2605 patients in care between 1998 and 2005 at the Comprehensive Care Center (CCC), a Vanderbilt University–affiliated outpatient clinic. At baseline, blacks had a lower median CD4 count and CD4 percentage and a higher median HIV RNA level than nonblacks. Blacks were also less likely to have been exposed to ART or highly active ART (HAART) before their first clinic visit. Analysis revealed significant disparities in HAART utilization and survival according to race and sex among the cohort while in care.:
Women and blacks were less likely to receive HAART than men and nonblacks, respectively; these associations persisted when limited to those with a CD4 count of <200 cells/mm3 at baseline
The crude all-cause mortality rate was higher in blacks than in nonblacks; when data were adjusted for baseline characteristics (including CD4 count), death was associated with black race and female sex. After adjusting for utilization of HAART in care, black race was no longer associated, but female sex remained associated, with an increased risk of death
According to the investigators, these findings suggest that differences in the use of HAART were at least partly responsible for the differences in mortality by race but did not explain differences in mortality by gender.
Reference:
Lemly D, Shepherd B, Hulgan T, et al. Race and sex differences in antiretrovi­ral therapy use and mortality among HIV-infected persons in care. J Infect Dis. 2009;199:
HAART, highly active antiretroviral therapy.
Lemly D, et al. J Infect Dis. 2009;199:

36. Race, Ethnicity, and HAART in Women, 2005
Using data from the Women’s Interagency HIV Study (WIHS), researchers examined racial/ethnic disparities in HAART use and whether differences are associated with insurance status or substance abuse. The study population (N = 1354) for this analysis was limited to HIV-infected women who self-identified as white (13.7%), African American or black (57.5%), or Hispanic/Latina (28.8%) and were clinically eligible for HAART prior to or at visit 22 in 2005.
Approximately 3 out of 10 women who were eligible for HAART reported not taking HAART
A higher proportion of nonuse was seen among black and Hispanic women than among white women, and among uninsured women than among women covered by Medicaid
Lack of insurance was associated with a higher risk of nonuse in all 3 racial/ethnic groups. Among the uninsured, black and Hispanic women had higher percentages of nonuse than white women
Alcohol use was also associated with nonuse of HAART; however, illicit drug use was not
After controlling for differences in insurance and other confounders, the likelihood of nonuse by black women remained roughly twice that of white women, a disparity that did not persist for Hispanic women
Reference:
Lille-Blanton M, Stone VE, Jones AS, et al. Association of race, substance abuse, and health insurance coverage with use of highly active antiretroviral therapy among HIV-infected women, Am J Public Health. 2010;100:
WIHS, Women‘s Interagency HIV Study. Lille-Blanton M, et al. Am J Public Health. 2010;100:

37. Race and Sex Differences in Virologic Response: the HEAT Study
Proportion of Subjects with HIV-1 RNA <50 copies/mL at Week 96
Percentage
Analysis of response by sex and by race in the HEAT study found that blacks and women had reduced treatment response rates (defined as viral load <50 copies/mL) compared with the overall and subgroup populations through week 96. African-American race, but not female sex, was a significant predictor of virologic failure using a multivariate logistic regression model.
The analysis included 688 patients receiving either abacavir/lamivudine (ABC/3TC) + lopinavir/ritonavir (LPV/r) or tenofovir/emtricitabine (TDF/FTC) + LPV/r: 82% male, 35% black, and 20% Hispanic. No formal assessment of medication compliance was performed.
Reference:
Smith KY, Kumar PN, Patel P, et al. Differences in virologic response among African-Americans and females regardless of therapy in the HEAT study. 5th IAS; July 19-22, 2009; Cape Town, South Africa. Abstract MOPEB033.
3TC, lamivudine; ABC, abacavir; FTC, emtricitabine; HEAT, Head-to-head Epzicom® and Truvada® trial; LPV/r, lopinavir/ritonavir; TDF, tenofovir. Smith KY, et al. 5th IAS. Cape Town, South Africa; July 19-22, Abstract MOPEB033.

38. GRACE Study Virologic Response in the ITT Population at 48 Weeks
Black (n = 264) 8 16 24 32 40 48 10 20 30 50 60 70 80 90
100
Caucasian (n = 65)
Hispanic (n = 96)
61.5
Patients with HIV-1 RNA <50 copies/mL, %
60.0
48.5
GRACE was a multicenter, open-label, Phase 3b study conducted in 65 study sites across the US, Canada and Puerto Rico to evaluate sex-based differences in the efficacy and safety of darunavir/ritonavir (DRV/r)–based therapy plus an investigator-selected optimized background regimen (OBR). The analysis by race was a preplanned secondary objective to evaluate race-based differences of DRV/r-based therapy. A total of 425 patients were included in this analysis: 62% black, 22% Hispanic, and 15% white.
At week 48 in the ITT population, similar response rates were observed in Hispanic and white patients, with lower response rates seen in black patients
Differences in response rates were observed between sexes in the black and Hispanic populations in the ITT analysis; however, when discontinuations for reasons other than virologic failure were censored, response rates were comparable between women and men within each race/ethnic group
Median change in observed CD4+ count from baseline was comparable across races
A lower proportion of black and Hispanic patients were ≥95% adherent (63.3% and 66.7%, respectively) compared with white patients (73.8%)
The investigators suggested that socioeconomic and other differences led to more black patients discontinuing than Hispanic or white patients and the resulting lower response rate in black patients.
Reference:
Smith KY, Garcia F, Ryan R. GRACE (Gender, Race And Clinical Experience): outcomes by race at week th ICAAC; September 12-15, 2009; San Francisco. Abstract H-918.
Time, weeks
GRACE, Gender, Race, and Clinical Experience study; ITT, intention-to-treat.
Smith KY, et al. 49th ICAAC. San Francisco, CA; September 12-15, Abstract H-918.

39. ACTG: Association of Race and Sex with Outcomes
ACTG (5 clinical trials)
Blacks: higher rates of VF, third-agent intolerability, and <100% adherence
Women: higher rates of VF on ATV/r compared with EFV
Initial analysis: black race associated with 60% higher risk of VF
Adjusted analysis: black race associated with 40% higher risk of VF after adjusting for demographic and clinical factors
AIDS Clinical Trials Group (ACTG) A5202 randomized treatment-naïve HIV-infected individuals to receive atazanavir/ritonavir (ATV/r )or efavirenz (EFV) with either tenofovir/emtricitabine (TDF/FTC) or abacavir/lamivudine (ABC/3TC). This analysis evaluated the association of sex and race on outcomes among 1857 participants: 17% female, 40% white, 33% black, and 23% Hispanic. Blacks had lower baseline CD4 and viral load than whites; Hispanics did not statistically differ from whites in these factors.
Black race was associated with increased risk of virologic failure (VF)
Female sex was associated with increased VF while on ATV/r compared with EFV, with differences in safety, tolerability, and adherence not appearing to explain the difference
Blacks had increased risk of third-agent tolerability end point compared with whites.
Week 8 self-reported adherence was high overall (92% with 100% adherence). Blacks were more likely to report <100% adherence than whites
The investigators suggested that the increased risk of VF among blacks was possibly related to lower adherence and higher rate of third-drug tolerability1
A separate analysis reviewed data from ART-naïve white and black participants initiating ART in 5 ACTG trials conducted between 1998 and 2005 (N=2495; 46% black). After adjusting for the potential impact of age, gender, disease status, comorbidities, mode of HIV transmission, depression, self-reported education level, alcohol use, belief in one’s ability to take antiretrovirals regularly, perceived social support, and time-updated self-reported adherence, black race was associated with a 40% higher risk of VF while on initial ART regimens than white race.2
References:
Smith K, Tierney C, Daar E, et al. Association of race/ethnicity and sex on outcomes in ACTG Study A th Conference on Retroviruses and Opportunistic Infections (CROI 2011). Boston, February 27–March 2, Abstract 536.
Ribaudo H, Smith K, Robbins G, et al. Race differences in the efficacy of initial ART on HIV infection in randomized trials undertaken by ACTG. 18th Conference on Retroviruses and Opportunistic Infections (CROI 2011). Boston, February 27–March 2, Abstract 50.
ACTG, AIDS Clinical Trials Group; ATV/r, atazanavir/ritonavir; EFV, efavirenz; VF, virologic failure.
1 Smith K, et al. 18th CROI. Boston, MA; February 27-March 2, Abstract 536.
2 Ribaudo H, et al. 18th CROI. Boston, MA; February 27-March 2, Abstract 50.

40. ARTEMIS: Evaluating the Potential Effects of Gender, Race, and Agea
ARTEMIS (AntiRetroviral Therapy with TMC114 ExaMined In naïve Subjects)
is a randomized, controlled, Phase 3 trial evaluating the efficacy and safety of
once-daily darunavir/ritonavir (DRV/r) 800/100mg versus lopinavir with low-dose ritonavir (LPV/r: 800/200mg total daily dose) in treatment-naïve, HIV-1-infected patients across 26 countries. Subgroup analyses at week 48 demonstrated no clinically meaningful differences due to gender, age, or race. A total of 343 patients were included in the week 96 analysis: 30% female, 23% black, 22% Hispanic, 40% white, 13% Asian, and 1% other.
Virological response at week 96 (percentage of patients with viral load <50 copies/mL) was generally similar across the subgroups; however, black patients had a slightly lower virological response rate (71%) compared with other races
Logistic regression analyses showed that baseline HIV-1 RNA, race, region, and mean adherence as possible explanatory factors did not account for this observed variability. Age was shown to correlate with response, but this finding could not be explained by the analyses that were conducted
Reference:
Fourie J, Flamm J, Rodriquez-French A, et al. ARTEMIS: week 96 safety and efficacy of darunavir/r by gender, age and race. 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention. Cape Town, South Africa, July 19-22, Poster CDB072.
(n = 44)
(n = 80)
(n = 137)
(n = 77)
a The numerical differences that were found between subgroups in the ARTEMIS study were not statistically significant.
ARTEMIS, AntiRetroviral Therapy with TMC114 ExaMined In naïve Subjects; VL, viral load. Fourie J, et al. 5th IAS. Cape Town, South Africa; July 19-22, Poster CDB072.

41. IMPROVING HIV CARE IN BLACK AND HISPANIC COMMUNITIES

42. Opportunities and Strategies
Not in HIV care
Engaged in HIV care
Unaware of HIV infection
Aware of HIV infection (not in care)
Receiving some medical care but not HIV care
Entered HIV care but lost to follow-up
Cyclical or intermittent user of HIV care
Fully engaged in HIV care
Multiple opportunities exist along the continuum of HIV care to improve testing, linkage to care, engagement in care, and retention in care. This section provides a forum for discussing strategies targeting these opportunities.
Reference:
Gardner EM, McLees MP, Steiner JF, del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:
Gardner EM, et al. Clin Infect Dis. 2011;52:

43. Who Should Get an HIV Test?
Nicole C.
36 years old, married, 2 children, full-time paralegal
History of postpartum depression, family history of migraine
Current complaint: headaches
Calvin J.
21 years old, single, full-time business student
Nonsmoker, moderate alcohol use, no illicit drug use
Current complaint: flulike symptoms
Martha S.
62 years old, widow, homemaker, nonsmoker, nondrinker
Overweight, hypertension controlled by medications, family history of diabetes
Annual checkup; no current complaint
Each patient is new to your practice. Based only on the information provided on screen, who should be offered an HIV test? Do you need additional information to decide whether to offer an HIV test?
[Correct response: All 3 patients should be offered an HIV test. If time allows, role-play one of the scenarios with a participant: “Have you ever had an HIV test?” If no: “HIV testing is recommended for everyone who is sexually active. Can we do the test as part of your routine bloodwork today?” If yes, assess need to repeat testing. Be prepared to respond to objections or concerns.]

44. Improving HIV Testing
Integrate HIV testing into routine clinical practice and encourage ALL patients to be tested
Ask ALL patients if they have had an HIV test (risk-based screening has failed to identify a substantial proportion of persons with HIV early in the disease)
If no prior HIV test, recommend as part of routine screening labs
Think about responses to patient questions and objections
Determine how you will deliver test results
Initial screening
The rationale behind universal HIV testing is that risk-based screening has not been effective: patients may be unaware of partner risk behaviors or may not perceive their own behavior as risky. In contrast, universal strategies such as those used in pregnant women and to screen the blood supply have been very effective. Patient acceptance is high when HIV testing is incorporated into routine medical care. Clinicians don’t worry about offending patients when recommending other routine screening tests according to clinical practice guidelines, so offer HIV testing the same way. Considering how you will respond to patients’ questions and concerns can prepare health care providers to manage the situation if it occurs.
[If time allows, ask participants what patient concerns or objections they have heard or anticipate, and role-play to demonstrate how you would respond.]
Determining the need for repeat screening:
The CDC recommends repeat screening at least annually in patients at high risk. Most adults disclose high-risk behaviors when asked by a physician. Questions should be specific and related to behaviors because patients may not perceive themselves to be at risk. For example, a patient who had unprotected sex one time 6 months ago may not perceive that he is at risk because he had an HIV test the next day.
Reference:
Qaseem A, et al. Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med. 2009;150:
Determine need for repeat testing on an individual basis
Ask about sexual activity/relationship status as part of routine visit
Educate patients regarding risk factors (behaviors) and HIV-test utility
Qaseem A, et al. Ann Intern Med. 2009;150:

45. OASIS Clinic: HIV Outreach Program
Focused intervention
28 OASIS HIV-positive MSM identified 45 peers at risk for HIV infection
28 of the 45 peers tested positive
17 of the 28 were previously unaware of their infection
Mean CD4 Cell Count, Cells/mm3
The OASIS Clinic is a full-service HIV clinic founded in 1984 and located in inner-city Los Angeles. The clinic’s comprehensive HIV-associated outreach program involves 3 components: traditional partner notification; focused intervention in which patients engaged in care bring individuals they consider to be at high risk for HIV infection to the clinic for counseling and testing; and an outreach component targeting underserved populations (eg, homeless individuals, black MSM whose sexual orientation is confidential, transgender individuals, and runaway youth).
The partner notification program has been particularly successful in identifying partners of HIV-positive women, while the focused intervention program has been most useful at identifying MSM who are unaware of their positive HIV serostatus. One focused intervention at OASIS involved 28 clinic patients, who identified 45 peers they considered to be at high-risk. Of these individuals, 28 tested positive for HIV, and 17 were previously unaware of their infection.
Data from OASIS demonstrate substantially higher CD4 counts for both men and women with newly diagnosed HIV infection who were identified via the partner-notification and focused intervention programs compared with those who were diagnosed after presenting to the clinic independently of outreach services (ie, by traditional methods).
Reference:
Jordan WC. Reaching lost-to-care populations. Clin Infect Dis. 2007;45(Suppl 4):S275-S280.
Traditional Methods
Partner Services
Traditional Methods
Focused Interviews
Women
Men
Jordan WC. Clin Infect Dis. 2007;45(suppl 4):S275-S280.

46. HIV-testing Expansion Initiative
Goal
Expand HIV testing across 17 facilities, including acute-care hospitals and community diagnostic and treatment centers
Implementation
Site-specific plans based on evaluation of patient flow and processes for consent, offering test, administering test, and providing results
Targets established and linked to financial incentives
In response to the revised CDC HIV testing recommendations in 2006, the New York City Health and Hospitals Corporation (HHC) established the HIV Testing Expansion Initiative (HTEI) across 17 HHC facilities, representing the largest single HIV testing campaign within a US public hospital system. Planning support and partial funding were provided for implementation, HIV testing targets were established, and financial incentives were distributed based on target achievement. Facilities were required to provide testing in outpatient, inpatient, and emergency settings and to report testing activity on a monthly basis. Facilities established individual implementation plans based on site-specific factors and needs. Facilities included large and small acute care hospitals as well as community diagnostic and treatment centers.
Reference:
Hamilton T, Casey E. Successful HIV testing models from a large public hospital system. The Forum for Collaborative HIV Research 2010 HIV Summit. Poster #18.
Results (FY2006–FY2010)
Number of HIV tests increased from about 50,000 to 188,573
3857 individuals newly diagnosed with HIV
FY, fiscal year.
Hamilton T, Casey E. The Forum for Collaborative HIV Research 2010 HIV Summit. Poster #18.

47. Improving Linkage to Care for Newly Diagnosed Patients
Strategies
Rapid results with patient on site1
Expedited access to on-site mental-health and substance-abuse services1
Multidisciplinary team to identify and address the potential barriers, emotional and practical1
Active, direct linkage: provide appointments (not referrals), patient navigators, sustained follow-up1,2
Improving linkage to care not only benefits patients directly, but also plays an important role in prevention. This finding was confirmed by the recent results from HPTN 052, which demonstrated the efficacy of treatment as prevention. Successful linkage to care interventions address both the emotional (eg, fear of medication side effects, stigma) and practical barriers (eg, transportation, family/work responsibilities, finances) that may prevent individuals who receive an HIV diagnosis from entering treatment.
References:
Christopoulos KA, Das M, Colfax GN. Linkage and retention in HIV care among men who have sex with men in the United States. Clin Infect Dis. 2011;52(Suppl2):S214-S222.
Gardner EM, McLees MP, Steiner JF, et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:
1 Christopoulos KA, et al. Clin Infect Dis. 2011;52(suppl2):S214-S221.
2 Gardner EM, et al. Clin Infect Dis. 2011;52:

48. ARTAS: Linkage Case Management
ARTAS-I ( )
ARTAS-II ( )
RCT comparing brief case-management intervention versus passive referral in research settings
Evaluated ARTAS-I case-management intervention in diverse real-world settings
78% in case management linked to care within 6 months versus 60% in passive referral
79% visited an HIV provider at least once within the first 6 months
The Antiretroviral Treatment Access Study-I (ARTAS-I) was a randomized controlled trial. It compared a brief strengths-based case management intervention with passive (standard of care) referral to facilitate early entry into care of individuals recently diagnosed with HIV. Participants in the standard-of-care arm received information about HIV and local resources along with a referral to a local HIV medical care provider. Participants in the intervention arm received up to 5 sessions with a case manager over 90 days in order to facilitate linkage to HIV medical care. Successful linkage was defined as attending at least one HIV medical care visit within the first 6 months after enrollment; 78% in the case management arm versus 60% in the standard-of-care arm were linked to HIV medical care within 6 months.
ARTAS-I was conducted by experienced investigators in university-affiliated research settings; ARTAS-II (N=626) evaluated whether the case management intervention could be implemented effectively in real-world settings, such as state and local health departments or community-based organizations. The study population was 72% male, 70% black, 12% Hispanic, and 54% heterosexual; 62% reported annual household income ≤$10,000. Overall, 79% of participants visited an HIV provider within the first 6 months. The median number of face-to-face sessions was 2; median time spent per client on all case management activities was 5.8 hours (range: 0 to 36.7 hours). Among patients who had not entered care or had entered care but missed one or more appointments in the past 6 months, the most common barrier to care was “I felt well or had no symptoms,” reported by 70% and 58%, respectively.
Reference:
Craw JA, Gardner LI, Marks G, et al. Brief strengths-based case management promotes entry into HIV medical care. J Acquir Immune Defic Syndr. 2008;47:
“I felt well or had no symptoms”– reported by 70% not in care and 58% in care who missed ≥1 appointment
ARTAS, Antiretroviral Treatment Access Study; RCT, randomized controlled trial. Craw JA, et al. J Acquir Immune Defic Syndr. 2008;47:

49. ED Linkage to Care Model: PHAST
M-F (8 AM-5 PM): Lab pages LTC team
LTC team meets patient in ED for disclosure
Lab identifies initial positive rapid test
Nights/weekends: Lab leaves voic for LTC team
LTC team verifies ED gave result and confirmatory appointment
The Emergency Department (ED) is an important site for the diagnosis of HIV infection, especially for those who may not receive regular medical care elsewhere. However, many ED HIV testing programs focus on HIV case identification rather than subsequent care initiation. The San Francisco General Hospital ED and HIV clinic created a program to ensure all patients diagnosed with HIV in the ED receive the services of a multidisciplinary HIV clinic–based linkage to care team. The Positive Health Access to Services and Treatment (PHAST) team includes a nurse practitioner (NP), registered nurse (RN), and social work (SW) associate.
From February 2007 to March 2009, there were 59 new HIV diagnoses in the ED
Eight patients died during postdiagnosis hospitalization or were discharged to long-term care facilities; 2 patients lived out of state; and 1 patient was already engaged at a clinic with HIV care; 48 patients were referred for outpatient follow-up
Within 6.5 months of diagnosis, 47 (98%) attended an HIV clinic visit, and 43 (90%) followed up at a subsequent HIV primary care visit
Reference:
Christopoulos K, Geng E, Jones D, et al. A model linkage to care program for rapid HIV testing in the emergency department. XVIII International AIDS Conference; July 18-23, 2010; Vienna, Austria. Poster PE0433.
LTC team discloses confirmatory result in HIV clinic
LTC team does intake, medical assessment
LTC team provides care until handoff to PCP
ED, emergency department; LTC, linkage to care; PCP, primary care provider; PHAST, Positive Health Access to Services and Treatment;. Christopoulos K, et al. XVIII International AIDS Conference. Vienna, Austria; July 18-23, Poster PE0433.

50. Improving Patient Engagement and Retention in Care
Strategies
Provide culturally competent, patient-centered care in safe, supportive treatment environments1
Diversify staff and/or include peer counselors to identify and address cultural/language barriers2,3
Provide access to support services on site2
Follow up on and re-engage patients who drop out of care or engage in care intermittently1,2
Successful HIV treatment requires engagement and sustained retention in care; however, some research suggests that approximately 50% of people who have been diagnosed with HIV are not engaged in regular care.1 Efforts to improve engagement and retention in care start with focusing on the quality of the patient’s interactions with the provider and clinic staff.2 Culturally competent care requires both awareness of cultural differences and provision of health care services that respect and respond to the diverse health beliefs, practices, and cultural and linguistic needs of patients.3
References:
Gardner EM, McLees MP, Steiner JF, et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:
Christopoulos KA, Das M, Colfax GN. Linkage and retention in HIV care among men who have sex with men in the United States. Clin Infect Dis. 2011;52(Suppl2):S214-S222.
Aziz M, Smith KY. Challenges and success in linking HIV-infected women to care in the United States. Clin Infect Dis. 2011;52(Suppl2):S231-S237.
1 Aziz M, Smith KY. Clin Infect Dis. 2011;52(suppl):S231-S237.
2 Christopoulos KA, et al. Clin Infect Dis. 2011;52(suppl2):S214-S221.
3 Gardner EM, et al. Clin Infect Dis. 2011;52:

51. Project CONNECT Patient calls to establish HIV care
Initial appointment: 31% no-show rate
Project CONNECT orientation visit
Initial appointment: 19% no-show rate
The Client-Oriented New Patient Navigation to Encourage Connection to Treatment (Project CONNECT) is a new patient navigation program launched at the University of Alabama at Birmingham 1917 HIV Clinic in January It responded to a study reporting a 31% new patient ‘‘no-show’’ rate among patients calling to establish HIV care. Nonwhite race, female sex, and longer delays from the time of the initial call to the scheduled appointment were more likely to become no-shows. Project CONNECT provides a patient-focused orientation visit within 5 days of the initial call, during which a trained staff member interacts with patients who are establishing care to help identify and troubleshoot anticipated barriers to sustained engagement in HIV care. Following implementation of the program, the proportion of no-shows decreased from 31% to 19%.
Reference:
Mugavero MJ. Improving engagement in HIV care: what can we do? IAS-USA. Topics in HIV Medicine. Accessed August 22, 2011.
Mugavero MJ. IAS-USA. Topics in HIV Medicine. Accessed August 22, 2011.

52. Project ACCEPT Outcomes Opportunities
Improved knowledge about HIV transmission and disease process
Assisted youth in learning to accept their diagnosis
Developed social connections
Improved symptoms of clinical depression among males
Include flexibility in structure
Target medical-education sessions to participants diagnosed within 6 months of starting the program
Include more information related to sexuality and relationships
Project ACCEPT (Adolescents Coping, Connecting, Empowering, and Protecting Together) is a 12-session behavioral intervention developed for youth (aged 16-24) newly diagnosed with HIV. The ACCEPT intervention includes individual and group sessions, providing both individualized attention as well as group support. Individual sessions were designed to build rapport, prepare the participants for the groups, and address psychological needs. Group sessions were designed to be interactive; each group session was led by a facilitator with a mental health background and a peer facilitator living with HIV.
A pilot study of the program included 50 participants recently diagnosed with HIV and enrolled from 4 sites selected through the Adolescent Medicine Trials Network (ATN). The majority of participants identified as African American (78%) and/or Hispanic (20%); 22 were female and 28 male. Quantitative and qualitative data demonstrated
high rates of participation and high levels of satisfaction with the program,
improved levels of HIV knowledge that were sustained over time, and improvements in peer and formal social support.
Reference:
Hosek SG, Lemos D, Harper GW, Telander K. Evaluating the acceptability and feasibility of project ACCEPT: an intervention for youth newly diagnosed with HIV. AIDS Educ Prev. 2011;23:
“Most useful for me was the group activity with picking a person you have not told. It was good practice for when I do tell my mom.”
ACCEPT, Adolescents Coping, Connecting, Empowering, and Protecting Together. Hosek SG, et al. AIDS Educ Prev. 2011;23:

53. Chicago Housing for Health Partnership
HIV substudy: selected outcomes at 1 year
CCHP
(n = 54)
Usual Care
(n = 51)
P Value
Survival with intact immunity
26 (55%)
16 (34%)
.04
CD4 cell count (mean cells/mm3)
271
246 —
Undetectable VL
36%
19%
.051
Housing First Strategy:
Homeless individuals are best stabilized through housing regardless of the personal challenges they may experience.
The Chicago Housing for Health Partnership (CHHP) was developed to provide housing and intensive case management to homeless people with chronic illnesses who are being discharged from a hospital. The program is based on the Housing First theory, which states that homeless people are best stabilized through housing regardless of the personal challenges they may experience.
The health impact of this approach for homeless people with HIV was evaluated in a randomized controlled study. HIV-positive homeless inpatients (N=105) at a public hospital were enrolled and randomized to usual care or CHHP intervention offering permanent housing with intensive case management.
The primary outcome was survival with intact immunity, defined as CD4 count ≤200 cells/mm3 and viral load <100,000 copies/mL. Secondary outcomes were viral loads, undetectable viral loads, and CD4 counts
Of 54 CHHP intervention participants, 35 (65%) reached permanent housing in program housing agencies
After one year, 55% of the intervention and 34% of the usual care groups were alive and had intact immunity; 17 CHHP intervention (36%) and 9 usual care (19%) participants had undetectable viral loads. There were no statistical differences in CD4 counts
Based on results, researchers concluded that for every 5 patients offered the intervention and every 3.25 patients provided housing, one additional patient will be alive with intact immunity
Reference:
Buchanan D, Kee R, Sadowski LS, and Garcia D. The health impact of supportive housing for HIV-positive homeless patients: A randomized controlled trial. Am J Public Health. 2009;99(Suppl 3):S675-S680.
For every 5 patients offered this intervention and every 3.25 patients provided housing, one additional patient will be alive with intact immunity
CCHP, Chicago Housing for Health Partnership.
Buchanan D, et al. Am J Public Health. 2009;99(suppl 3):S675-S680.

54. Maintenance in Care Program
Goal
Reduce HIV-related morbidity by engaging patients who are out of care or at risk of dropping out of care
Objectives
Connect patient with HIV provider within 60 days
If patient is not engaged in care at 90 days, connect patient with appropriate support services: mental-health care, substance-abuse treatment, housing, etc
Founded in New York City in 1988, the Harlem United Community AIDS Center, Inc. (HU) provides HIV care for medically underserved communities in Central and East Harlem. The Maintenance in Care (MIC) program is an outreach-based intervention developed by HU to assist patients with HIV who have either been out of care for 90 days or longer (with a history of sporadic care attendance) or are at risk of dropping out of care owing to adverse circumstances (eg, imminent homelessness) or comorbidities (eg, mental health or substance abuse disorders). Services include assessment of need, development of a goal-driven plan demonstrating need for action, and accompaniment and other strategies for getting patients to scheduled appointments. Strategies for hard to engage patients include building a relationship by taking time to listen to what the patient is saying, acknowledging the patient’s fears, and keeping promises (eg, honoring identified methods of contacting the patient). From March 2009 to February 2010, 39 of 48 patients lost to follow-up returned to care (81%), and 795 of 880 patients at risk of dropping out of care were maintained in care (90%).
Reference:
Nieves-deLaPaz J. Breaking down the barriers to care. The Forum for Collaborative HIV Research 2010 HIV Summit. Poster #109.
Nieves-deLaPaz J. Breaking down the barriers to care. The Forum for Collaborative HIV Research 2010 HIV Summit. Poster #109. 

55. Conclusion
“Great disparities remain in access to care and treatment for racial/ethnic minorities with HIV. How to address these disparities is the immediate challenge.”
El-Sadr W, et al. J Acquir Immune Defic Syndr. 2010;55(suppl2):S63.