DAVID J. MALEBRANCHE, MD, MPH Associate Professor Division of General Medicine Emory University Atlanta, GA
Program Introduction The White House Office of National AIDS Policy. National HIV/AIDS strategy for the United States. July 2010. http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf. Accessed August 17, 2011. http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf 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.
EPIDEMIOLOGY OF HIV/AIDS IN BLACKS AND HISPANICS
AIDS Diagnoses by Race/Ethnicity in the United States and Dependent Areas, a 1985-2009 Year of Diagnosis Diagnoses, % Black/African American White Hispanic/Latino b American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Asian Multiple Races United States and Dependent Areas 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). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race-ethnicity/index.htm. Accessed August 17, 2011.
Diagnoses of HIV and Population by Race/Ethnicity, 2009: 40 States a 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). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race-ethnicity/index.htm. Accessed August 17, 2011. N = 42,011 N = 241,832,054
HIV Diagnoses by Subpopulation 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 MSM 2 HIV diagnoses in men (2009) Black women: 66%; Hispanic/Latino women: 14% 1 HIV diagnoses in women (2009) Black adolescents: 73%, Hispanic/Latino adolescents: 13% 3 HIV diagnoses in adolescents (aged 13 to 19 years: 2008) 1 CDC. HIV surveillance by race/ethnicity (through 2009). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race- ethnicity/index.htm. Accessed August 17, 2011. 2 CDC. HIV among African Americans. September 2010. http://www.cdc.gov/hiv/topics/aa/resources/factsheets/pdf/aa.pdf. Accessed August 17, 2011. 3 CDC. HIV Surveillance in Adolescents and Young Adults (through 2008). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. Accessed August 17, 2011.
HIV Diagnosis Rates for Adults and Adolescents by Race and Gender, 2009 (40 US States) 1 CDC. HIV surveillance by race/ethnicity (through 2009). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race- ethnicity/index.htm. Accessed August 17, 2011. 2 The White House Office of National AIDS Policy. National HIV/AIDS strategy for the United States. July 2010. http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf. Accessed August 17, 2011. Diagnosis rates in MSM (2006) 2 Black: 1710 per 100,000 Hispanic: 716 per 100,000 White: 344 per 100,000
HIV Transmission in Blacks and Hispanics in the United States, 2009 a Black Men b and Women Men: 68% MSM sexual contact Men: 20% Women: 87% Heterosexual contact Men: 9% Women: 13% IDU Hispanic Men and Women Men: 71% MSM sexual contact Men: 14% Women: 83% Heterosexual contact Men: 12% Women:17% IDU 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). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race- ethnicity/index.htm. Accessed August 17, 2011.
Age-adjusted a Average Annual Rate of Death due to HIV, United States, 2003-2007 CDC. HIV mortality (through 2007). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/mortality/index.htm. Accessed August 17, 2011. a Standard: age distribution of year 2000 US population. b Hispanic/Latino can be any race. Deaths per 100,000 Population b
HIV TESTING AND TREATMENT: RECOMMENDATIONS AND REALITY
HIV Testing and Treatment: Reality 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. 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.
ALL patients aged 13 to 64 years in ALL health care settings Routine HIV testing Annually for those at high risk, eg, those who have had unprotected sex since previous test Repeat screening HIV Testing Recommendations CDC. MMWR. 2006;55(RR14):1-17. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed August 17, 2011.
Risk-based HIV Testing Strategies: Missed Opportunities Number and Percentage of Health Care Visits by Late Testers a Who Had Visited a Health Care Facility Before the Date of HIV Diagnosis, South Carolina, 1997-2005 Late testers had an average of 4 health care visits in the years before HIV diagnosis. CDC. MMWR. 2006;55(47):1269-1272. http://www.cdc.gov/mmwr/index2006.htm. Accessed August 17, 2011. Reported diagnosisNumberPercentage Visits with diagnosis likely to prompt an HIV test171121.4 Sexually transmitted disease and related diagnoses1652.1 Symptoms suggestive of acute retroviral syndrome b 119114.9 Diseases possibly related to HIV c 4786.0 Diseases probably related to HIV d 941.2 Intravenous drug use and related behaviors851.1 Visits with diagnosis not likely to prompt an HIV test627778.6 Total visits7988100.0 a N = 1302. Reported in South Carolina during 2001-2005. b Including fever, lymphadenopathy, and rash. c Including peripheral neuropathy, pneumonia, and thrombocytopenia. d Including cerebral toxoplasmosis, pulmonary tuberculosis, and thrush.
Blacks and Hispanics Have Higher Rates of Undiagnosed HIV Infection CI, confidence interval; HRHC, high-risk heterosexual contact. Campsmith ML, et al. J Acquir Immune Defic Syndr. 2010;53:619-624. By transmission category, the highest rates of undiagnosed infection were seen among men with HRHC, followed by MSM. NumberRate95% CI White Male Female 72,000 62,800 9200 42.2 75.6 10.5 38.3-46.1 68.3-83.0 7.8-13.3 Black/African American Male Female 113,000 77,500 35,700 380.3 556.5 225.7 352.7-407.8 508.0-605.7 196.0-225.4 Hispanic Male Female 41,900 34,700 7200 126.4 201.6 45.2 111.3-141.5 174.9-228.3 32.0-58.4 Asian/Pacific Islander Male Female 4500 3700 800 38.6 66.0 13.2 24.9-52.3 39.2-92.8 6.6-19.9 American Indian/Alaska Native Male Female 1200 848 336 60.4 87.4 33.0 25.1-95.6 46.2-128.6 18.7-47.3 Total232,70094.289.5-98.8 Estimated Number and Rate (per 100,000 Population) of Persons Age 13 Years Living with Undiagnosed HIV Infections, by Race/Ethnicity and Sex, 2006United States
Undiagnosed Persons Contribute Disproportionately to New Infections About 32,000 new HIV infections each year are sexual transmissions Aware: 14,720Unaware: 17,280 More than 1 million persons are living with HIV in the United States (2006) About 75% aware (diagnosed)About 25% unaware (undiagnosed) UAV, unprotected anal and vaginal intercourse. Marks G, et al. AIDS. 2006;20:1447-1450. If all diagnosed + 57% reduction in UAV Sexual transmissions to 7430 31% reduction in new infections: 14,720 + 7430 = 22,150
HIV Treatment Recommendations Initiate combination ART in the following patients CD4 cell count <350 cells/mm 3 or AIDS-defining illness CD4 cell count 350 cells/mm 3 to 500 cells/mm 3 HIVAN or HBV coinfection Pregnant (regardless of CD4 cell count) Combination ART optional in patients with CD4 cell count >500 cells/mm 3 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; 1-166. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed August 17, 2011.
ART Use and Clinical Outcomes in Black and Hispanic Populations Race-specific data are limited and mixed Is nonwhite race independently associated with increased mortality and poor outcomes? Do disparate outcomes reflect racial differences in comorbidities and access to care?
Racial Differences in Key Comorbidities Disproportionately affected by HCV, heart disease, diabetes, obesity, and cancer 1,2 NHANES (2007-2008): HCV infection prevalence 2.6% versus 1.3% for whites 2 Disproportionately affected by HCV, heart disease, diabetes, obesity, and cancer 1,2 NHANES (2007-2008): HCV infection prevalence 2.6% versus 1.3% for whites 2 Blacks Disproportionately affected by diabetes, renal disease, obesity, cervical cancer 3 Hispanics HCV, hepatitis C virus; NHANES, National Health and Nutrition Examination Survey. 1 CDC. Highlights in minority health and health disparities. February 2008. http://www.cdc.gov/omhd/Highlights/2008/HFeb08.htm. 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. http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=54. Accessed August 17, 2011.
Racial Differences in Key Factors That Influence Access and Adherence to Care FactorComment Income Blacks and Hispanics are nearly 3 times as likely to live in poverty 1 Health- insurance coverage 48% of blacks and 59% of Hispanics are either uninsured or covered by Medicaid, compared with 23% of whites 2,3 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 1 Kaiser Family Foundation. Poverty Rate by Race/Ethnicity (2008-2009), U.S. (2009). http://www.statehealthfacts.org/comparebar.jsp?ind=14&cat=1. Accessed August 22, 2011. 2 Kaiser Commission on Medicaid Facts: Medicaids Role for Black Americans. May 2011. http://kff.org/medicaid/upload/8188.pdf. Accessed August 22, 2011. 3 Kaiser Commission on Medicaid Facts: Medicaids Role for Hispanic Americans. May 2011. http://kff.org/medicaid/upload/8189.pdf. Accessed August 22, 2011.
Racial Differences in Key Factors That Influence Access and Adherence to Care (contd) 1 DHHS: Health Resources and Services Administration. Guide for HIV/AIDS Clinical Care. 2011. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/. Accessed August 22, 2011. 2 DHHS. Bureau of Justice Statistics. Prisoners in 2009. December 2010. http://bjs.ojp.usdoj.gov/index.cfm?ty=pbse&sid=40. Accessed August 22, 2011. FactorComment 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 behaviors 1 Incarceration Nonwhites incarcerated at significantly higher rates than whites 2
Income 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 basic needs 12.9 million blacks 16.7 million Hispanics $11,000/year (individual) $22,000/year (family of 4) Kaiser Family Foundation. Poverty rate by race/ethnicity, states (2008-2009), U.S. (2009). http://www.statehealthfacts.org/comparebar.jsp?ind=14&cat=1. Accessed August 17, 2011.
Health-insurance Coverage Black Americans: 2009 1 Hispanic Americans: 2009 2 1 Kaiser Commission on Medicaid Facts: Medicaids Role for Black Americans. May 2011. http://kff.org/medicaid/upload/8188.pdf. Accessed August 22, 2011. 2 Kaiser Commission on Medicaid Facts: Medicaids Role for Hispanic Americans. May 2011. http://kff.org/medicaid/upload/8189.pdf. Accessed August 22, 2011. Total = 37 millionTotal = 49 million
Cultural/Language Barriers 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 Cultural barriers 1 Limit access to health information and patient-provider communication Language barriers 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.
Cultural/Language Barriers Physicians by Race/Ethnicity, 2008 2 1 American Medical Association. Total physicians by race/ethnicity2008. http://www.ama-assn.org/ama/pub/about-ama/our- people/member-groups-sections/minority-affairs-consortium/physician-statistics/total-physicians-raceethnicity.page#. Accessed August 22, 2011.
Immigration and Migration a Hispanics/Latinos can be of any race. CDC. HIV Surveillance by Race/Ethnicity (through 2009). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race-ethnicity/index.htm. Accessed August 17, 2011. Diagnoses of HIV Infection Among Adult and Adolescent Hispanics/Latinos a, by Sex and Country of Birth, 200940 States and 5 US Dependent Areas Males N = 1625 N = 6615 Females
HIV Diagnoses by Race and Place of Birth: Massachusetts, 2006-2008 Total Diagnoses, % NH, non-Hispanic. Massachusetts Department of Public Health Office of HIV/AIDS. http://www.mass.gov/Eeohhs2/docs/dph/aids/2010_profiles/tables_born_outside_us.pdf. Accessed August 22, 2011.
Non US Born People Diagnosed with HIV Infection by Gender and Region of Birth: Massachusetts, 2006-2008 Data Source: MDPH HIV/AIDS Surveillance Program. (percentages may not add up to 100% due to rounding); data aas of 1/1/10.. Region of BirthMale N% Female N% State Total N % Caribbean Basin8224803416228 Central and South America 11032231013323 Central and South Asia931<1102 N Africa & Middle East21002<1 N America & Europe351042397 Pacific Rim21002<1 Southeast Asia13463193 Sub-Saharan Africa83241164919934 Unspecified7283153 Total343100238100581100
Distrust of the Health Care System Historical treatment 1 Personal experiences of unequal treatment 2 HIV/AIDS conspiracy theories 1 1 Aziz M, Smith KY. Clin Infect Dis. 2011;52(suppl):S231-S237. 2 Sayles JN, et al. J Urban Health. 2007;84:814-828. 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 cant tell them I am taking HIV medications. In the ER they dont want to be bothered with you, and they will tell you anything to send you back to your own physician.
Stigma My whole stigma thing was that it was a straight-up gay disease. You got it, man; you must have screwed some dude. Heterosexual man Its assumed that if a woman is HIV-positive, she... either shot drugs or she was a slut, and theres just no other way. Heterosexual woman Being an ethnic minority in the gay community seems like a piece of cake compared to what HIV status is now. Homosexual man Sayles JN, et al. J Urban Health. 2007;84:814-828.
Substance Abuse and Depression Increased mortality 1 Impaired quality of life 1 Decreased adherence to ART 1 Increased risk behaviors 1 Substance abuse and depression are common comorbid conditions with HIV 1,2 1 DHHS. Guide for HIV/AIDS Clinical Care. 2011. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/. Accessed August 22, 2011. 2 Bing EG, et al. Arch Gen Psych. 2001;58:721-728.
Incarceration Estimated Number of Sentenced Prisoners, Federal or State, 2009 US Department of Justice. Bureau of Justice Statistics. Prisoners in 2009. December 2010. http://bjs.ojp.usdoj.gov/index.cfm?ty=pbse&sid=40. Accessed August 22, 2011. 60% of male inmates were Black or Hispanic 43% of female prisoners were Black or Hispanic
Incarceration and HIV: Co-epidemics Highly prevalent among inmates 1 Substance abuse, mental-health disorders Sharing syringes Multiple sex partners, unprotected sex High-risk behaviors A reported 1.5% of inmates have HIV/AIDS 2 HCV incidence is 10 times higher among inmates 1 Incarceration, infectious disease Nearly 730,000 inmates were released from the nations prisons in 2009 3 1 DHHS. Guide for HIV/AIDS Clinical Care. 2011. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/. Accessed August 22, 2011. 2 Maruschak LM. HIV in Prisons, 2007-08. http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=1747>. Accessed August 22, 2011. 3 US Department of Justice. Bureau of Justice Statistics. Prisoners in 2009. December 2010. http://bjs.ojp.usdoj.gov/index.cfm?ty=pbse&sid=40. Accessed August 22, 2011.
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, 2009. 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;199:991-998. 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, 2005. Am J Public Health. 2010;100:1493-1499. 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, 2011. Abstract 50. Smith KY, Garcia F, Ryan R. GRACE (Gender, Race and Clinical Experience): outcomes by race at week 48. 49th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009). San Francisco, CA; September 12-15, 2009. 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, 2009. Abstract MOPEB033. Smith K, Tierney C, Daar E, et al. Association of race/ethnicity and sex on outcomes in ACTG Study A5202. 18th Conference on Retroviruses and Opportunistic Infections (CROI 2011). Boston, MA; February 27-March 2, 2011. Abstract 536.
Race and Sex Differences in HAART Use and Mortality Among Patients in Care 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 Kaplan-Meier Survival Curve of Time to Death in the Total Cohort, by Race HAART, highly active antiretroviral therapy. Lemly D, et al. J Infect Dis. 2009;199:991-998. 012345678 0.6 0.7 0.8 0.9 1.0 Survival Probability Nonblack Black
Race, Ethnicity, and HAART in Women, 2005 WIHS, Womens Interagency HIV Study. Lille-Blanton M, et al. Am J Public Health. 2010;100:1493-1499.
Race and Sex Differences in Virologic Response: the HEAT Study 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, 2009. Abstract MOPEB033. Proportion of Subjects with HIV-1 RNA <50 copies/mL at Week 96 Percentage
GRACE Study GRACE, Gender, Race, and Clinical Experience study; ITT, intention-to-treat. Smith KY, et al. 49th ICAAC. San Francisco, CA; September 12-15, 2009. Abstract H-918. Virologic Response in the ITT Population at 48 Weeks Time, weeks Patients with HIV-1 RNA <50 copies/mL, % 801624324048 0 10 20 30 40 50 60 70 80 90 100 Hispanic (n = 96) Black (n = 264) Caucasian (n = 65) 61.5 60.0 48.5
ACTG: Association of Race and Sex with Outcomes ACTG A5202 1 Blacks: higher rates of VF, third-agent intolerability, and <100% adherence Women: higher rates of VF on ATV/r compared with EFV ACTG (5 clinical trials) 1998-2005 2 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 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, 2011. Abstract 536. 2 Ribaudo H, et al. 18th CROI. Boston, MA; February 27-March 2, 2011. Abstract 50.
ARTEMIS: Evaluating the Potential Effects of Gender, Race, and Age a 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, 2009. Poster CDB072. (n = 44)(n = 80)(n = 137)(n = 77)
IMPROVING HIV CARE IN BLACK AND HISPANIC COMMUNITIES
Opportunities and Strategies Gardner EM, et al. Clin Infect Dis. 2011;52:793-800. 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 Engaged in HIV care Not in HIV care
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
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 Ask about sexual activity/relationship status as part of routine visit Educate patients regarding risk factors (behaviors) and HIV-test utility Improving HIV Testing Integrate HIV testing into routine clinical practice and encourage ALL patients to be tested Determine need for repeat testing on an individual basis Qaseem A, et al. Ann Intern Med. 2009;150:125-131.
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 Jordan WC. Clin Infect Dis. 2007;45(suppl 4):S275-S280. Mean CD4 Cell Count, Cells/mm 3 Men Women Focused Interviews Traditional Methods Partner Services Traditional Methods
HIV-testing Expansion Initiative Expand HIV testing across 17 facilities, including acute-care hospitals and community diagnostic and treatment centers Goal 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 Implementation Number of HIV tests increased from about 50,000 to 188,573 3857 individuals newly diagnosed with HIV Results (FY2006–FY2010) FY, fiscal year. Hamilton T, Casey E. The Forum for Collaborative HIV Research 2010 HIV Summit. Poster #18.
Improving Linkage to Care for Newly Diagnosed Patients Rapid results with patient on site 1 Expedited access to on-site mental-health and substance-abuse services 1 Multidisciplinary team to identify and address the potential barriers, emotional and practical 1 Active, direct linkage: provide appointments (not referrals), patient navigators, sustained follow-up 1,2 1 Christopoulos KA, et al. Clin Infect Dis. 2011;52(suppl2):S214-S221. 2 Gardner EM, et al. Clin Infect Dis. 2011;52:793-800. Strategies
ARTAS: Linkage Case Management ARTAS-I (2001-2003) RCT comparing brief case- management intervention versus passive referral in research settings 78% in case management linked to care within 6 months versus 60% in passive referral ARTAS-II (2005-2006) Evaluated ARTAS-I case- management intervention in diverse real-world settings 79% visited an HIV provider at least once within the first 6 months 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;47:597-606.
LTC team discloses confirmatory result in HIV clinic LTC team does intake, medical assessment LTC team provides care until handoff to PCP ED Linkage to Care Model: PHAST Lab identifies initial positive rapid test M-F (8 AM-5 PM): Lab pages LTC team LTC team meets patient in ED for disclosure Nights/weekends: Lab leaves voicemail for LTC team LTC team verifies ED gave result and confirmatory appointment 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, 2010. Poster PE0433.
Improving Patient Engagement and Retention in Care Provide culturally competent, patient-centered care in safe, supportive treatment environments 1 Diversify staff and/or include peer counselors to identify and address cultural/language barriers 2,3 Provide access to support services on site 2 Follow up on and re-engage patients who drop out of care or engage in care intermittently 1,2 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;52:793-800. Strategies
Project CONNECT Mugavero MJ. IAS-USA. Topics in HIV Medicine. http://www.iasusa.org/pub/topics/2008/issue5/156.pdf. Accessed August 22, 2011. Patient calls to establish HIV care Initial appointment: 31% no-show rate Project CONNECT orientation visit Initial appointment: 19% no-show rate
Project ACCEPT Outcomes 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 Opportunities 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 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;23:128-144.
Chicago Housing for Health Partnership CCHP (n = 54) Usual Care (n = 51)P Value Survival with intact immunity 26 (55%)16 (34%).04 CD4 cell count (mean cells/mm 3 ) 271246 Undetectable VL 36%19%.051 Housing First Strategy: Homeless individuals are best stabilized through housing regardless of the personal challenges they may experience. HIV substudy: selected outcomes at 1 year 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.
Maintenance in Care Program Reduce HIV-related morbidity by engaging patients who are out of care or at risk of dropping out of care Goal 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 Objectives Nieves-deLaPaz J. Breaking down the barriers to care. The Forum for Collaborative HIV Research 2010 HIV Summit. Poster #109.
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.