Stories of Success in HIV

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(No Transcript)
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Introduction

• Charles B. Hicks, MD
• Professor of Medicine
• Associate Director, Duke AIDS Research and
  Treatment Center
• Duke University Medical Center
• Durham, NC

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Agenda

• Disparities in HIV/AIDS Care and Communities of
  Color
• Overcoming Challenges and Barriers to Care in
  Communities of Color
• Strategies to Provide Culturally Competent
  HIV/AIDS Care
• Strategies to Optimize Testing and Treatment in
  Patients with HIV in Communities of Color

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Learning Objectives

• After completing this program, participants will
  be better able to
• Describe the disproportionate impact that HIV has
  had in communities of color
• Evaluate successful approaches in screening and
  linkage to care in communities of color
• Outline how to implement strategies for screening
  and linkage to care in their own clinical
  practices
• Discuss how the cultural and socioeconomic status
  of minority patients impacts their access to HIV
  testing and access to care
• Develop trusting and productive patient-provider
  relationships in order to expand HIV testing and
  access to care

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Accreditation Statement

• PHYSICIAN CONTINUING MEDICAL EDUCATION
• Accreditation StatementThis activity has been
  planned and implemented in accordance with the
  Essential Areas and policies of the Accreditation
  Council for Continuing Medical Education (ACCME)
  through the joint sponsorship of Postgraduate
  Institute for Medicine (PIM) and
  HealthmattersCME. PIM is accredited by the ACCME
  to provide continuing medical education to
  physicians.
• Credit DesignationPostgraduate Institute for
  Medicine designates this educational activity for
  a maximum of 1.5 AMA PRA Category 1 Credit(s).
  Physicians should only claim credit commensurate
  with the extent of their participation in the
  activity.

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Accreditation Statement (contd)

• NURSING CONTINUING MEDICAL EDUCATION
• Credit DesignationThis educational activity for
  1.5 contact hours is provided by Postgraduate
  Institute for Medicine.
• Accreditation StatementsPostgraduate Institute
  for Medicine is accredited as a provider of
  continuing nursing education by the American
  Nurses Credentialing Centers Commission on
  Accreditation.
• California Board of Registered Nursing
  Postgraduate Institute for Medicine is approved
  by the California Board of Registered Nursing,
  Provider Number 13485 for 1.7 contact hours.
• To receive Continuing Education Credit for this
  program, please complete the evaluation in your
  meeting folder and return to the meeting
  organizer in the back of the room

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Disclosures of Relevant Financial Relationships

• David Barker, MD, MPH, FACP
• Consulting Fees Virco
• Contracted Research Gilead Sciences, Merck Co,
  Pfizer Inc, Virco
• Edwin DeJesus, MD, FACP
• Consulting Fees Bristol-Myers Squibb, Gilead
  Sciences, GlaxoSmithKline, Merck Co, Tibotec
  Therapeutics, Vertex Pharmaceuticals
• Contracted Research Abbott Laboratories,
  Achillion Pharmaceuticals, Avexa, Boehringer
  Ingelheim, Bristol-Myers Squibb, Gilead Sciences,
  GlaxoSmithKline, Hoffman LaRoche Laboratories,
  Merck Co, Pfizer Inc, Schering Plough, TaiMed
  Biologics, Tibotec Therapeutics, Tobira
  Therapeutics, Pharmaceuticals
• Fees for Non-CME Services Gilead Sciences, Merck
  Co, Tibotec Therapeutics, Virco

W. David Hardy, MD Consulting Fees Gilead
Sciences, GlaxoSmithKline, Merck Co, Monogram
Biosciences, Inc, Pfizer Inc, Tibotec
Therapeutics, ViiV Healthcare Contracted
Research Bionor Immuno, Gilead Sciences, Pfizer
Inc, Tibotec Therapeutics Stock Merck Co
Charles B. Hicks, MD Consulting Fees
Bristol-Myers Squibb, Gilead Sciences,
GlaxoSmithKline, Merck Co, Myriad Genetics,
Inc, Tibotec Therapeutics Contracted Research
Bristol-Myers Squibb, Gilead Sciences,
GlaxoSmithKline, Merck Co, Pfizer Inc,
Schering-Plough, Tibotec Therapeutics
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Disclosures of Relevant Financial Relationships

• Sally L. Hodder, MD
• Contracted Research Bristol-Myers Squibb, Gilead
  Sciences, Tibotec Therapeutics
• Consulting Fees Boehringer Ingelheim,
  Bristol-Myers Squibb, Gilead Sciences, Tibotec
  Therapeutics
• Fees for Non-CME Services Bristol-Myers Squibb
• Stock Merck Co
• Wilbert Jordan, MD, MPH
• Contracted Research Gilead Sciences, Hoffman
  LaRoche Laboratories
• Fees for Non-CME Services Bristol-Myers Squibb,
  Gilead Sciences

Claudia Martorell, MD, MPH, AAHIVS, FACP
Contracted Research Bristol-Myers Squibb,
Gilead Sciences, GlaxoSmithKline, Merck Co,
Tibotec Therapeutics Fees for Non-CME Services
Bristol-Myers Squibb, Gilead Sciences,
GlaxoSmithKline, Tibotec Therapeutics M. Keith
Rawlings, MD Consulting Fees Abbott
Laboratories, Bristol-Myers Squibb, Gilead
Sciences, GlaxoSmithKline, Tibotec Therapeutics
Fees for Non-CME Services Abbott Laboratories,
Bristol-Myers Squibb, Gilead Sciences,
GlaxoSmithKline, Tibotec Therapeutics
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Grant Support

• This program is supported by an independent
  educational grant from Gilead Sciences Medical
  Affairs.

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Epidemiology of HIV in the US Disproportionate
Impact of HIV in Communities of Color
11
Percentages of AIDS Cases and Population by
Race/Ethnicity, Reported in 200750 States and DC
Hispanic/Latino2 Native Hawaiian/Other Pacific
Islander White
American Indian/Alaska Native Asian3 Black/African
American

• Includes 411 persons of unknown race or multiple
  races.
• Hispanics/Latinos can be of any race.
• Includes Asian and Pacific Islander legacy cases.

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Disproportionate Effect of HIV/AIDS in Black
Subpopulations

• Black women
• Accounted for 65 of new AIDS cases among women
  in the US in 20071
• Reported an HIV incidence rate 14.7 times higher
  than white women in 20062
• Black MSM
• In a study of five large US cities in 2005, 46
  of black MSM (men having sex with men) were
  infected with HIV, compared with 21 of white and
  17 of Latino MSM3
• Black adolescents
• Black youth accounted for 68 of AIDS cases among
  those ages 13-19 in 2007, while making up just
  17 of the population1

• Kaiser Family Foundation (KFF). The HIV/AIDS
  epidemic in the United States. 2009.
• CDC MMWR. 200857(36)986.
• CDC. MMWR. 200554(24)599.

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Epidemiologic Overview Disproportionate Effect
of HIV/AIDS in Hispanic Americans

• New HIV Infections US population by
  Race/Ethnicity, 20061

• In 2006, Hispanics accounted for approximately
  17 of the new HIV infections1
• In 2007, Hispanics accounted for 19 of new AIDS
  diagnoses1
• In 2007, the annual AIDS case rate among
  Hispanics was 3 times that of whites (20.4 vs
  6.1)1

1. KFF. The HIV/AIDS epidemic in the United
States. 2009.
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HIV Prevalence in Select Countries and in
Subpopulations in the US1
Prevalence ()
Population
1. El Sadr W, et al, N Engl J Med.
2010362967-970.
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Disparities in Access to Care
16
Disparities in Access to Care Impact on Clinical
Outcomes

• Recent cohort study found blacks spent
  significantly smaller proportion of time on
  antiretroviral therapy (ART) than whites (47 vs
  76, Plt.001)1
• Mortality associated with black race and female
  sex1
• HIV Outpatient Study black race independently
  associated with 50 higher mortality rate vs
  whites2
• Non-care-related factors may have an impact
• Socioeconomic factors
• Concomitant diseases and factors may be more
  common among minorities (HCV, CHD, substance use)

1. Lemly. J Infect Dis. 2009199991-998. 2.
Palella. CROI 2008, abstract 530.
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Disparities in Access to Care Reflect Disparities
in Income and Insurance Coverage

• Blacks and Hispanics are approximately 3 times
  more likely to live in poverty than whites1
• Blacks and Hispanics less likely to have health
  insurance, compared with whites2

Insurance Coverage of Nonelderly, by
Race/Ethnicity, 20082

• DeNavas-Walt. US Census Bureau. Income, Poverty,
  and Health Insurance. 2008.
• Thomas M et al. Health Coverage for Communities
  of Color, Kaiser Foundation, 2009.

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Critical Role of Public Funding for HIV/AIDS Care
in Communities of Color

• Medicaid covers 40 of persons with HIV
  receiving care in the US1
• Medicare covers 202
• Majority (93) are under age 65 and qualify
  because they are disabled
• More likely to be male, disabled, younger than
  65, black, and living in an urban area than other
  Medicare recipients

1. KFF. Fact Sheet Medicaid and HIV/AIDS, 2009
2. KFF. Fact Sheet Medicare and HIV/AIDS, 2009.
19
Critical Role of Public Funding for HIV/AIDS Care
in Communities of Color

• Ryan White Program funds provide services for
  500,000 people with HIV (fill gaps in Medicaid,
  Medicare, and other insurance)1
• Mostly low income and uninsured (33) or
  underinsured (56)
• 72 are people of color
• The AIDS Drug Assistance Programs (ADAPs)
• Provide HIV medications to roughly one-third of
  patients receiving care for HIV nationally2
• 183,000 enrollees nationwide in 20082

• KFF. Fact Sheet Ryan White Program, 2009.
• KFF. Fact Sheet ADAPs, 2009.

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Ruth M. Rothstein CORE Center, Chicago, Illinois

• Public HIV clinic of Cook County Hospital
• Approximately 6000 patients, and growing
• 97-98 publicly insured
• Receives 55 of its funding from a variety of
  sources, including the Ryan White Program

Percentage
Population
21
Meeting the Challenge of Paying for and Securing
Medications CORE Center

• Despite having an onsite pharmacy, the CORE
  Center cannot dispense meds to ADAP patients and
  be reimbursed (Illinois ADAP is mail-order only)
• Therefore, 90 of patients use mail order for
  meds, which can be a problem for those who lack
  secure housing
• The CORE Center allows ADAP and other mail order
  pharmacies to send meds to CORE, where they are
  held for patients
• This work-around benefits patients and saves the
  county health system 5.5 million a year
• County expenditures on meds decreased from 17
  million in 2000 to 4.5 million in 2008

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Overcoming Challenges and Barriers to Care in
Communities of Color
23
Earlier Access to HIV Testing and Care Is Needed

• Data indicate minority patients more likely to
  enter care later in their HIV disease1-3
• Higher rates of hospitalization reported among
  women, blacks, injection drug users (IDU), and
  Medicaid and Medicare patients4
• Higher proportion of unrecognized HIV infection
  among black and Hispanic MSM5

1. Lemly D et al, J Infect Dis 2009 2. Keruly
JC, et al, Clin Infect Dis 2007 3. Losina E et
al, Clin Infect Dis 2009 4. Fleishman JA et al.
Med Care 2005. 5. CDC. MMWR. 200554(24)599.
24
Minority Patients May Be More Likely to Distrust
Health Care System

• Distrust may be based on
• History of research abuses in their communities
• Misinformation about origin of HIV epidemic1
• Personal experience of inequitable care by health
  care system2
• Distrust may lead to suboptimal adherence3
• Blacks and Hispanics on average have higher
  levels of distrust of physicians than do whites4
• Distrust associated with gender, age, insurance
  coverage, educational level and income4

1. Bogart. JAIDS. 2005. 2. IOM. Unequal
Treatment. 2002 3. Bogart. JAIDS 2010 4.
Armstrong. Am J Pub Health. 2007.
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HIV-Related Stigma Affects Care in Communities of
Color

• Focus group data among low-income black and
  Hispanic HIV patients reveal stigma on multiple
  levels1
• Blame about acquiring HIV and how it was acquired
• Gender stereotypes
• Perceived sexual orientation
• Many patients report stigma in health care
  setting
• May lead patients to avoid accessing HIV
  screening or care until it is urgently needed1,2
• Particular concern among non-gay-identified MSM1

1. Sayles. J Urban Health, 2007. 2. Malebranche.
J Natl Med Assoc. 2004.
26
Incarceration Critical to Spread of HIV in
Minority Communities

• 2.3 million incarcerated persons in 2007
• 35.4 were black and 17.9 were Hispanic1
• As many as 17 of all persons with HIV pass
  through a correctional facility each year2
• Higher rate of incarceration among black men
  impacts HIV/AIDS rates among women of color3

1. CDC, Testing Recommendations in Correctional
Settings, 2009 2. NCCHC Position Statement.
2005. 3. Johnson. UC Berkeley, 2005.
27
AIDS Arms Inc Free World Bound Program, Dallas,
TX

• AIDS Arms Inc provides case management for
  patients with HIV (2900 patients)
• Primarily Ryan White funded
• Developed Free World Bound (FWB) program for
  former inmates

Percentage
Population
28
Free World Bound (FWB) Program, Dallas, TX

• Federally funded program to increase enrollment
  of HIV ethnic minorities into Texas ADAP
  post-prison
• Prevent interruptions in ARV
• Goal to enroll 80 of individuals entering the
  Dallas area post-incarceration
• Led to marked increase in enrollment for both men
  and women
• Program increased from working in 2 prisons to 32
  prisons across Texas in 5 years

Kirven D. Poster at Ryan White CARE Act All-Title
National Meeting, Washington, DC, August 2008.
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Free World Bound Texas ADAP Male Enrollment by
Race/Ethnicity
Enrollment
Year
Kirven D. Poster at Ryan White CARE Act All-Title
National Meeting, Washington, DC, August 2008.
30
Free World Bound Texas ADAP Female Enrollment by
Race/Ethnicity
Enrollment
Year
Kirven D. Poster at Ryan White CARE Act All-Title
National Meeting, Washington, DC, August 2008.
31
Strategies to Provide Culturally Competent
HIV/AIDS Care
32
Strategies to Provide Culturally Competent
HIV/AIDS Care

• Recognize health-related cultural beliefs
• Understand potential difficulties in
  cross-cultural encounters1
• Gender
• Family dynamics
• Patient beliefs
• Social environment

1. Carillo JE et al. Ann Intern Med. 1999.
33
Strategies to Provide Culturally Competent
HIV/AIDS Care

• Encourage patient-centered communication
• Minority patients more likely to feel less
  involved in health care decisions1
• Minority patients report needing more time with
  clinicians to make health care decisions2
• Patients who report that their provider who knows
  them as a person more likely to3
• Receive ART
• Have better adherence to ART
• Achieve undetectable HIV RNA

1. Cooper-Patrick. JAMA. 1999. 2. Federman. J Gen
Intern Med. 2001. 3. Beach. J Gen Intern Med.
2006.
34
Strategies to Provide Culturally Competent
HIV/AIDS Care

• Having a racially diverse staff has an impact on
  patient perceptions of care1
• Racial concordance independently associated with
  time to receipt of ART2
• Where possible, it is recommended that clinics
  diversify clinical and nonclinical staff to
  reflect the communities they serve3
• Growing concern about supply of HIV-experienced
  clinicians4

1. Cooper. Ann Intern Med. 2003. 2. King. J Gen
Intern Med. 2004. 3. Washington. J Gen Intern
Med. 2008. 4. Rawlings. XVI Intl AIDS
Conference, 2006 Abst MoPe0643.
35
Infectious Diseases Clinic and Research
Institute, Springfield, MA

• Large clinical practice with access to HIV
  clinical research
• Fully bilingual (English/Spanish)
• Focus on culturally competent care for patients
  with HIV, hepatitis, and infectious diseases

Percentage
Population
36
Infectious Diseases Clinic and Research
Institute, Springfield, MA

• Large proportion of HIV transmission among males
  in western Massachusetts related to IDU
• Provide clinical care for HIV/HCV coinfection
• Research Institute initiated to provide access to
  clinical research
• Need to address patient perceptions of research
  by explaining it carefully to them
• Do not offer research to all patients
• Trial participation based on community needs

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Infectious Diseases Clinic and Research
Institute, Springfield, MA

• Fully bilingual staff improves access to care
• Accommodate patient needs
• Importance of bedside manner
• Provide scheduling flexibility
• Protect patient privacy concerns
• Address substance abuse
• Provide case management and get to know the
  community

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Optimizing HIV Testing and Treatment in
Communities of Color
39
HIV Testing CDC Efforts to Identify More Persons
with HIV

• In 2006, the CDC issued new recommendations for
  routine opt-out HIV screening in all health care
  settings1
• Increase reach of HIV screening
• Identify more people living with HIV
• In 2009 it was estimated that 21 of the more
  than 1 million persons with HIV in the US were
  unaware of their infection2

1. CDC. MMWR. 200655(RR14)1-17. 2. KFF.
HIV/AIDS Policy Fact Sheet HIV/AIDS Testing in
the United States, June 2009.
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HIV Testing in US Adults and in Communities of
Color1,2
Percent of non-elderly, ages 18-64, who say they
have been tested for HIV
53
48
73
60
1. KFF. Survey on HIV/AIDS, 2009 2. KFF.
HIV/AIDS Policy Fact Sheet HIV/AIDS Testing in
the United States, June 2009.
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Innovations in HIV Testing, OASIS Clinic, Los
Angeles, CA

• The Outpatient Alternative Services Intervention
  System (OASIS) Clinic in Los Angeles offers
  comprehensive HIV/AIDS testing and clinical
  services to patients without regard to their
  ability to pay
• HIV testing
• Early intervention
• Outpatient treatment
• Chemotherapy
• Focused intervention and partner notification
  program

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OASIS Clinic Focused Intervention Program

• Focused intervention and partner notification
  program
• Provide incentives for patients to bring in
  friends and partners who may be HIV positive for
  screening
• Has detected a high rate of HIV infection among
  those tested through this intervention
• 28 overall HIV positivity1
• Transgender 45 positive rate
• Formerly incarcerated 32
• MSM 22

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OASIS Clinic Results of Traditional Intake and
Focused Intervention
44
Facilitating the Link Between HIV Testing and Care
45
Facilitating the Link Between HIV Testing and Care

• A critical step in the effort to address the
  needs of people of color infected with HIV is to
  ensure that a diagnosis of HIV infection leads to
  entry into HIV care
• For patients outside the traditional health care
  system, support services have a positive effect
  on their use of medical services1
• Case management, outreach, group visits2,3

1. Cunningham. J Health Care Poor Underserved.
2008. 2. Gardner. AIDS. 2005. 3. Cabral. AIDS
Patient Care STDS. 2007.
46
Optimizing Access to Treatment, Orlando
Immunology Center, Orlando, FL

• Orlando Immunology Center (OIC) is a private
  clinic with no public funding
• Large HIV and HCV patient populations (3600 and
  700 patients)
• 5 full-time HIV providers and one case manager
• Research department conducts Phase I to IV
  clinical trials

Percentage
Population
47
Continuity of Care, Orlando Immunology Clinic

• Facilitating link between testing and care
• Establish immediate face-to-face contact with
  clinician for those who test HIV positive at OIC
• OIC has agreement with local community center
  serving gays/lesbians/transgenders to accept
  referrals following HIV testing
• Maintaining continuity of care
• Provide services to patients through changes in
  insurance status
• Support patients with case management to connect
  patients to needed services

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Optimizing Treatment with ART in Communities of
Color
49
Optimizing Treatment with ART in Minority
Patients with HIV

• Treatment recommendations for patients with HIV
  in communities of color are not fundamentally
  different from those for the general HIV
  population
• One anchor drug with dual nucleoside backbone1
• 2009 DHHS guidelines added recommendation to
  offer ART to patients with CD4 cell counts
  between 350-500 cells/mm3

1. US DHHS HIV Treatment Guidelines, 2009.
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Data on Association Between Race and Clinical
Outcomes

• The literature provides mixed evidence that
  treatment choice should be determined by racial
  background
• Some cohort data have found associations between
  black race and lower response to ART1,2
• Other studies have not identified similar
  associations, suggesting outcomes reflect
  disparities in access to care and comorbidities3,4

1. Anastos. JAIDS. 2005. 2. Weintrob, JAIDS.
2009. 3. Jensen-Fangel. CID. 2002. 4. Silverberg.
AIDS. 2006.
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HEAT Trial Differences in Virologic Outcomes
Associated with Race
HEAT trial Proportion of Subjects with HIV-1
RNA lt50 c/mL at Week 96 ITT
N ABC/3TC LPV/r 343 119 143 73 8 TDF/FTC
LPV/r 345 124 147 62 12
1. Smith. IAS 2009, abstract MOPEB033.
52
GRACE Trial Differences in Virologic Outcomes
Associated with Race
GRACE trial Virologic response (TLOVR) in the
ITT population
1. Smith. ICAAC 2009, abstract H918.
53
Facilitating Treatment Initiation

• Strategies to facilitate successful initiation
  and continuation of ART
• Cultivate trust in patient-provider relationship1
• Share with patients evidence of regimens
  effectiveness (eg, improvements in viral load and
  CD4 cell counts)1

1. Stone. J Gen Intern Med. 1998.
54
Optimizing ART Predicting Adherence Is Difficult

• Clinicians are generally not skilled at
  predicting patient adherence or judging who is
  adherent1,2
• However, certain factors have been shown to be
  associated with poor adherence3
• Substance use
• Low health literacy
• Depression
• Lack of disclosure of HIV status
• Unstable or chaotic living situation

1. Bangsberg. JAIDS. 2001. 2. Miller. J Gen
Intern Med. 2002. 3. Golin. J Gen Intern Med.
2002.
55
Optimizing ART Strategies for Helping Patients
Adhere

• Assess patient readiness to start ART1
• Inquire about patients feelings of readiness and
  about belief in medication effectiveness
• Get to know patients social situation and
  availability of psychosocial support
• Improve patient engagement with provider2
• Assess adherence to appointments3
• Improve patient-provider communication4

1. Enriquez. J Assoc Nurses AIDS Care. 2004. 2.
Bakken. AIDS Patient Care STDs. 2000. 3. Lucas.
Ann Intern Med .1999. 4. Schneider. J Gen Intern
Med. 2004.
56
Optimizing HIV Research in Communities of Color
57
Improved Minority Representation in
Antiretroviral Clinical Trials
1. Collier. N Engl J Med. 1996. 2. Staszewski
NEJM 1997. 3. Gulick NEJM 2004. 4. Gallant. NEJM.
2006. 5. Smith. AIDS. 2009. 6. Squires. IAS 2009,
abst MOPEB042.
58
Research for Patients With HIV in Communities of
Color, Moore Clinic, Baltimore, MD

• Outpatient HIV clinic (3800 patients), serving
  Baltimores largely black population
• 35 of patients IDU
• Large hepatitis C clinic due to high prevalence
  of IDU in Baltimore
• Large HIV database that supports research in
  clinical care among communities of color

Percentage
Population
59
Research at Moore Clinic, Johns Hopkins
University, Baltimore, MD
Association between patient perception and
clinical outcomes1
Percent of Patients
Provider Knows Patient as a Person
1. Beach. J Gen Intern Med. 2006.
60
Research at Moore Clinic, Johns Hopkins
University, Baltimore, MD
Access to care, by proportion of blacks or
Hispanics at HIV care site1
Travel time to HIV Care Site By proportion Black
or Hispanic
Wait time to see Provider By proportion Black or
Hispanic
Travel time (minutes)
Wait time (minutes)
Black
Hispanic
Black
Hispanic
1. Korthuis PT et al, J Gen Intern Med 2006.
61
Stories of Success in HIV Summary

• Disproportionate effect of HIV/AIDS in
  communities of color is a key health care
  challenge facing minority communities
• Providers in communities of color face many
  challenges
• Socioeconomic disparities, including poverty and
  lack of insurance, and associated comorbidities,
  dsignificantly impact access to care
• Cultural diversity requires culturally competent
  care to address needs of individual communities

62
Stories of Success in HIV Summary

• Literature and experience demonstrate strategies
  to improve HIV care in communities of color
• Partner with other providers and AIDS service
  organizations to improve linkage to care and
  provide a range of necessary services
• Develop programs that meet the needs of local
  patient populations