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DAVID J. MALEBRANCHE, MD, MPH
Associate Professor
Division of General Medicine
Emory University
Atlanta, GA
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.”
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.
EPIDEMIOLOGY OF HIV/AIDS IN
BLACKS AND HISPANICS
AIDS Diagnoses by Race/Ethnicity in the United
States and Dependent Areas,a 1985-2009
United States and Dependent Areas
Diagnoses, %
White
Black/African American
Hispanic/Latinob
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska
Native
Multiple Races
Year of Diagnosis
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 Statesa
N = 42,011
a Alabama,
N = 241,832,054
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.
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
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). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/raceethnicity/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)
Diagnosis rates in MSM (2006)2
•Black: 1710 per 100,000
•Hispanic: 716 per 100,000
•White: 344 per 100,000
1
CDC. HIV surveillance by race/ethnicity (through 2009). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/raceethnicity/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.
HIV Transmission in Blacks and
Hispanics in the United States, 2009a
Black Menb and Women
Hispanic Men and Women
MSM sexual
contact
• Men: 68%
MSM sexual
contact
• Men: 71%
Heterosexual
contact
• Men: 20%
• Women: 87%
Heterosexual
contact
• Men: 14%
• Women: 83%
IDU
• Men: 9%
• Women: 13%
IDU
• Men: 12%
• Women:17%
a Forty
US states and 5 US-dependent areas.
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/raceethnicity/index.htm. Accessed August 17, 2011.
b
Deaths per 100,000 Population
Age-adjusteda Average Annual Rate of
Death due to HIV, United States,
2003-2007
a
b
Standard: age distribution of year 2000 US population.
Hispanic/Latino can be any race.
CDC. HIV mortality (through 2007). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/mortality/index.htm.
Accessed August 17, 2011.
b
HIV TESTING AND TREATMENT:
RECOMMENDATIONS AND REALITY
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.”
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.
HIV Testing Recommendations
Repeat
screening
• ALL patients aged 13
to 64 years in ALL
health care settings
• Annually for those at
high risk, eg, those
who have had
unprotected sex since
previous test
Routine HIV
testing
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
Testersa Who Had Visited a Health Care Facility Before the
Date of HIV Diagnosis, South Carolina, 1997-2005
Reported diagnosis
Number
Visits with diagnosis likely to prompt an HIV test
Late
testers had
an average
of 4 health
care visits
in the
years
before HIV
diagnosis.
Percentage
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
aN
= 1302. Reported in South Carolina during 2001-2005.
fever, lymphadenopathy, and rash.
c Including peripheral neuropathy, pneumonia, and thrombocytopenia.
d Including cerebral toxoplasmosis, pulmonary tuberculosis, and thrush.
b Including
CDC. MMWR. 2006;55(47):1269-1272. http://www.cdc.gov/mmwr/index2006.htm. Accessed August 17, 2011.
Blacks and Hispanics Have Higher Rates
of Undiagnosed HIV Infection
By transmission
category, the
highest rates of
undiagnosed
infection were
seen among
men with HRHC,
followed by
MSM.
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
Number
Rate
95% CI
72,000
62,800
9200
42.2
75.6
10.5
38.3-46.1
68.3-83.0
7.8-13.3
113,000
77,500
35,700
380.3
556.5
225.7
352.7-407.8
508.0-605.7
196.0-225.4
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
232,700
94.2
89.5-98.8
White
Male
Female
Black/African American
Male
Female
Hispanic
Male
Female
Total
CI, confidence interval; HRHC, high-risk heterosexual contact.
Campsmith ML, et al. J Acquir Immune Defic Syndr. 2010;53:619-624.
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:
14,720 + 7430 = 22,150
UAV, unprotected anal and vaginal intercourse.
Marks G, et al. AIDS. 2006;20:1447-1450.
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
• 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-1infected 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
Blacks
• Disproportionately affected by HCV, heart
disease, diabetes, obesity, and cancer1,2
• NHANES (2007-2008): HCV infection prevalence
2.6% versus 1.3% for whites2
Hispanics
• Disproportionately affected by diabetes, renal
disease, obesity, cervical cancer3
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
1
Factor
Comment
Income
Blacks and Hispanics are nearly 3 times as likely to live in
poverty1
Healthinsurance
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
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: Medicaid’s Role for Black Americans. May 2011.
http://kff.org/medicaid/upload/8188.pdf. Accessed August 22, 2011.
3 Kaiser Commission on Medicaid Facts: Medicaid’s 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 (cont’d)
1
Factor
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
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.
$11,000/year (individual)
$22,000/year (family of 4)
Income
In the setting of poverty, HIV testing and
treatment may be sacrificed to competing
demands for basic needs
In 2009, 35% of blacks and
34% of Hispanics in the
United States lived below
the federal poverty line
12.9
million
blacks
16.7
million
Hispanics
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: 20091
Total = 37 million
Hispanic Americans: 20092
Total = 49 million
Kaiser Commission on Medicaid Facts: Medicaid’s Role for Black Americans. May 2011.
http://kff.org/medicaid/upload/8188.pdf. Accessed August 22, 2011.
2 Kaiser Commission on Medicaid Facts: Medicaid’s Role for Hispanic Americans. May 2011.
http://kff.org/medicaid/upload/8189.pdf. Accessed August 22, 2011.
1
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
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, 20082
1
American Medical Association. Total physicians by race/ethnicity—2008. http://www.ama-assn.org/ama/pub/about-ama/ourpeople/member-groups-sections/minority-affairs-consortium/physician-statistics/total-physicians-raceethnicity.page#. Accessed
August 22, 2011.
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
N = 6615
a
Females
N = 1625
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.
Total Diagnoses, %
HIV Diagnoses by Race and Place of
Birth: Massachusetts, 2006-2008
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
Region of Birth
Male
N
%
Female
N
%
State
Total %
N
Caribbean Basin
82
24
80
34
162
28
Central and South
America
110
32
23
10
133
23
Central and South Asia
9
3
1
<1
10
2
N Africa & Middle East
2
1
0
0
2
<1
N America & Europe
35
10
4
2
39
7
Pacific Rim
2
1
0
0
2
<1
Southeast Asia
13
4
6
3
19
3
Sub-Saharan Africa
83
24
116
49
199
34
Unspecified
7
2
8
3
15
3
Total
343
100
238
100
581
100
Data Source: MDPH HIV/AIDS Surveillance Program . (percentages may not add up to 100% due to rounding); data aas of
1/1/10..
Distrust of the Health Care System
Historical
treatment1
HIV/AIDS
conspiracy
theories1
1
2
Personal
experiences
of unequal
treatment2
Aziz M, Smith KY. Clin Infect Dis. 2011;52(suppl):S231-S237.
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 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.”
Stigma
Heterosexual 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.”
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;84:814-828.
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
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
60% of male
inmates were
Black or Hispanic
43% of female
prisoners were
Black or Hispanic
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.
Incarceration and HIV: Co-epidemics
• Highly prevalent
among inmates1
Substance abuse,
mental-health
disorders
High-risk behaviors
• Sharing syringes
• Multiple sex
partners,
unprotected sex
• A reported 1.5% of
inmates have
HIV/AIDS2
• HCV incidence is 10
times higher among
inmates1
Incarceration,
infectious disease
Nearly 730,000 inmates
were released from the
nation’s prisons in 20093
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
Kaplan-Meier Survival Curve of Time
to Death in the Total Cohort, by Race
• Retrospective,
observational
cohort study (N =
2605); 38% black;
24% female
• Race (but not sex)
differences in
mortality likely
associated with
HAART use
Survival Probability
• Women, blacks
less likely to
receive HAART
1.0
0.9
0.8
0.7
Nonblack
Black
0.6
0
HAART, highly active antiretroviral therapy.
Lemly D, et al. J Infect Dis. 2009;199:991-998.
1
2
3
4
5
6
7
8
Race, Ethnicity, and HAART in Women,
2005
WIHS, Women‘s 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
Percentage
Proportion of Subjects with HIV-1 RNA <50 copies/mL at Week 96
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.
GRACE Study
Patients with HIV-1 RNA
<50 copies/mL, %
Virologic Response in the ITT Population at 48 Weeks
Black (n = 264)
Caucasian (n = 65)
Hispanic (n = 96)
100
90
80
70
61.5
60.0
48.5
60
50
40
30
20
10
0
0
8
16
24
32
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, 2009. Abstract H-918.
40
48
ACTG: Association of Race and Sex with
Outcomes
ACTG A52021
ACTG (5 clinical trials)
1998-20052
• Blacks: higher rates of VF,
third-agent intolerability, and
<100% adherence
• Initial analysis: black race
associated with 60% higher
risk of VF
• Women: higher rates of VF on
ATV/r compared with EFV
• 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 Agea
(n = 44)
a
(n = 80)
(n = 137)
(n = 77)
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.
IMPROVING HIV CARE IN BLACK AND
HISPANIC COMMUNITIES
Opportunities and Strategies
Not in HIV care
Unaware of
HIV infection
Aware of
HIV infection
(not in care)
Engaged in HIV care
Receiving
some
medical care
but not
HIV care
Gardner EM, et al. Clin Infect Dis. 2011;52:793-800.
Entered HIV
care but
lost to
follow-up
Cyclical or
intermittent
user
of HIV care
Fully engaged
in HIV care
Who Should Get an HIV Test?
Nicole C.
Calvin J.
Martha S.
• 36 years old, married,
2 children, full-time
paralegal
• History of postpartum
depression, family
history of migraine
• Current complaint:
headaches
• 21 years old, single,
full-time business
student
• Nonsmoker, moderate
alcohol use, no illicit
drug use
• Current complaint:
flulike symptoms
• 62 years old, widow,
homemaker,
nonsmoker, nondrinker
• Overweight,
hypertension controlled
by medications, family
history of diabetes
• Annual checkup; no
current complaint
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
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;150:125-131.
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
OASIS Clinic: HIV Outreach Program
Jordan WC. Clin Infect Dis. 2007;45(suppl 4):S275-S280.
Traditional Partner
Methods Services
Traditional Focused
Methods Interviews
Women
Men
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
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.
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
1
2
Christopoulos KA, et al. Clin Infect Dis. 2011;52(suppl2):S214-S221.
Gardner EM, et al. Clin Infect Dis. 2011;52:793-800.
ARTAS: Linkage Case Management
ARTAS-I (2001-2003)
ARTAS-II (2005-2006)
RCT comparing brief casemanagement intervention versus
passive referral in research settings
Evaluated ARTAS-I casemanagement 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
“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.
ED Linkage to Care Model: PHAST
Lab identifies
initial positive
rapid test
LTC team
discloses
confirmatory
result in HIV clinic
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
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, 2010. Poster PE0433.
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
1
Aziz M, Smith KY. Clin Infect Dis. 2011;52(suppl):S231-S237.
Christopoulos KA, et al. Clin Infect Dis. 2011;52(suppl2):S214-S221.
3 Gardner EM, et al. Clin Infect Dis. 2011;52:793-800.
2
Project CONNECT
Patient calls to
establish HIV care
Initial appointment:
31% no-show rate
Project CONNECT
orientation visit
Initial appointment:
19% no-show rate
Mugavero MJ. IAS-USA. Topics in HIV Medicine. http://www.iasusa.org/pub/topics/2008/issue5/156.pdf. Accessed
August 22, 2011.
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
HIV substudy: selected outcomes at 1 year
CCHP
(n = 54)
Usual
Care
(n = 51)
P Value
26 (55%)
16 (34%)
.04
CD4 cell count
(mean
cells/mm3)
271
246
—
Undetectable
VL
36%
19%
.051
Survival with
intact
immunity
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.
Housing First
Strategy:
Homeless
individuals are best
stabilized through
housing regardless
of the personal
challenges they
may experience.
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, substanceabuse treatment, housing, etc
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.