Barriers to Care for People of Color

Core Competency 6: Overcoming Barriers Related to HCV Care

March 2019

Special Focus: People who have Experienced Incarceration

Lesson Objective

Describe barriers to care among people of color Describe the prevalence of HIV among

individuals who have experienced incarceration Discuss the barriers to HIV treatment among

people who have recently experienced incarceration

Identify strategies to address barriers to treatment and prevention among people involved in the criminal justice system

2

Overview of Webinar

HIV and HCV Prevalence and Incidence Sociodemographic Breakdown

New Trends in HIV Incidence HIV among people who inject drugs

Barriers to Care that Exacerbate Health Disparities Sub-Population: Incarceration HIV continuum of Care Barriers Strategies to overcome barriers

3

Estimated HIV Incidence among Persons Aged ≥13 Years, by Race/Ethnicity 2010–2016—United States

Note. Estimates were derived from a CD4 depletion model using HIV surveillance data. Hispanics/Latinos can be of any race.* Difference from the 2010 estimate was deemed statistically significant (P < .05).† Estimates should be used with caution because they do not meet the standard of reliability.

5

Source: CDC, 2018

HCV Disparities

African Americans in the US are twice as likely to be infected with HCV compared to the non-Hispanic-white US population (CDC, 2018)

African Americans are more likely to develop HCV related complications such as hepatocellular carcinoma (Naylor, 2017; Bevhare, 2017)

6

New Trends in HIV Infection

7

New Trends in HIV Infection

8

Beyond the Individual Level

9

Beyond the Individual Level

New Study by Momplaisir, et al. (2018) evaluated variables that were related to racial disparities in HIV among people who inject drugs using HIV Prevention Trial Network 037 data Despite having lower drug risk behavior, all-black

networks disproportionately included HIV+ members. HIV prevention interventions for people who inject drugs need to go beyond individual risk and consider the composition of risk networks.

10

Multi-level factors that affect care

11Berger, et al., 2016

Barriers that Exacerbate Health Disparities Known barriers to care: Lack of health insurance and access to care Stigma (often multi-dimensional)

Specifically for HCV: Cost and lack of coverage for medications

Focus needed on structural inequalities that block access to care

12

13

14

Sub-Population of Focus: People who have Experienced Incarceration

One in seven HIV positive individuals cycle through a correctional setting in any given year (Spaulding, et al., 2009)

HIV among incarcerated populations is 3 times that of the general population (Maruschak, 2017)

Correctional populations represent about 1/3 of total US HCV cases (Varan, 2014)

15

Incarceration and HIV among Black Men

16

HIV Continuum of Care among those who have experienced Incarceration

17

Source: Iroh, et al. 2015

Barriers to Care for those who have experienced incarceration

Access and adherence to ART Intersectional Stigma related to both HIV and

Incarceration Lack of access to addiction treatment Lack of transportation Lack of social support Lack of housing and employment opportunities

18

Social Support

19

Lack of Housing

20

Lack of Employment

21

Structural Barriers Lead to a De-Prioritization of Healthcare

22

Strategies to Overcome Barriers

Need for a multi-level approach Using multi-dimensional intervention that focuses

on access to care Removal of restrictions of rights post-release Move away from mass incarceration to a public

health model of treatment Which is happening, to some degree, in response to

the opioid epidemic

23

References 1. Varan et al.Hepatitis C Seroprevalence Among Prison Inmates Since 2001: Still High but Declining. Public Health Reports, 2014; 129: 187-

195.

2. Iroh, et al. 2015. The HIV Care Cascade Before, During, and After Incarceration: A Systematic Review and Data Synthesis . AJPH.

3. Spaulding, et al. 2009. HIV/AIDS among Inmates of and Releasees from US Correctional Facilities, 2006: Declining Share of Epidemic but Persistent Public Health Opportunity. PlosOne.

4. Maruschak, et al. 2016. HIV in Prisons, 2015 . Bureau of Justice Statistics.

5. Centers for Disease Control and Prevention. HIV Surveillance Report, 2017; vol. 29. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published November 2018. Accessed February 2019.

6. Bonzcar, 2003. Prevalence of Imprisonment in the U.S. Population, 1974-2001. Bureau of Justice Statistics.

7. Prison Policy Reports: https://www.prisonpolicy.org

8. Momplaisir, et al. 2018. Racial inequities in HIV prevalence and composition of risk networks among people who inject drugs in HIV prevention trial network 037. J Acquir Immune Defic Syndro; 76(4): 394-401.

9. Lyss, et al. CROI Abstract 2018

10. Kaiser Family Foundation’s analysis of data available from amfAR’s Opioid & Health Indicators Database

11. Naylor PH, Mutchnick M. Decreasing racial disparity with the combination of ledipasvir-sofosbuvir for the treatment of chronic hepatitis C. Hepat Med. 2017;9:13-16.

12. Devhare PB, Steele R, Di Bisceglie AM, et al. Differential expression of microRNAs in hepatitis C virus-mediated liver disease between African Americans and Caucasians: Implications for racial health disparities. Gene Expr. 2017;17:89-98.

13. Berger, et al. 2016. Barriers and Facilitators to Retaining and Reengaging HIV Clients in Care: A Case Study of North Carolina. Journal of the International Association of Providers of AIDS Care 2016, Vol. 15(6) 486–493

24

Authors and Funders This presentation was prepared by Lauren Brinkley-

Rubinstein, PhD

This presentation is part of a curriculum developed by the AETC Program for the project: Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Co-infected People of Color (HRSA 16-189), funded by the Secretary's Minority AIDS Initiative through the Health Resources and Services Administration HIV/AIDS Bureau.

25

Disclaimer and Permissions

Users are cautioned that because of the rapidly changing medical field, information could become out of date quickly.

The complete HIV/HCV Co-infection: An AETC National Curriculum is available at: https://aidsetc.org/hivhcv

26