Introduction

Charles B. Hicks, MD Professor of Medicine

Associate Director, Duke AIDS Research and Treatment Center Duke University Medical Center

Durham, NC

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

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

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.

Accreditation Statement (cont’d)

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 Center’s 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

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

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

Grant Support

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

Epidemiology of HIV in the US: Disproportionate Impact of HIV in

Communities of Color

Percentages of AIDS Cases and Population by Race/Ethnicity, Reported in 2007—50 States and DC

1. Includes 411 persons of unknown race or multiple races.2. Hispanics/Latinos can be of any race.3. Includes Asian and Pacific Islander legacy cases.

American Indian/Alaska NativeAsian3

Black/African American

Hispanic/Latino2

Native Hawaiian/Other Pacific IslanderWhite

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

1. Kaiser Family Foundation (KFF). The HIV/AIDS epidemic in the United States. 2009. 2. CDC MMWR. 2008;57(36):986. 3. CDC. MMWR. 2005;54(24):599.

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.

HIV Prevalence in Select Countries and in Subpopulations in the US1

1. El Sadr W, et al, N Engl J Med. 2010;362:967-970.

Pre

vale

nce

(%

)

Population

Disparities in Access to Care

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%, P<.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. 2009;199:991-998.2. Palella. CROI 2008, abstract 530.

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

1. DeNavas-Walt. US Census Bureau. Income, Poverty, and Health Insurance. 2008. 2. Thomas M et al. Health Coverage for Communities of Color, Kaiser Foundation, 2009.

Insurance Coverage of Nonelderly, by Race/Ethnicity, 20082

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 ~20%2 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.

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

1. KFF. Fact Sheet: Ryan White Program, 2009. 2. KFF. Fact Sheet: ADAPs, 2009.

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

Population

Per

cen

tag

e

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

Overcoming Challenges and Barriers to Care in Communities of Color

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. 2005;54(24):599.

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.

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.

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.

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

Population

Per

cen

tag

e

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.

Free World Bound: Texas ADAP Male Enrollment by Race/Ethnicity

En

roll

men

t

Year

Kirven D. Poster at Ryan White CARE Act All-Title National Meeting, Washington, DC, August 2008.

Free World Bound: Texas ADAP Female Enrollment by Race/Ethnicity

Year

Kirven D. Poster at Ryan White CARE Act All-Title National Meeting, Washington, DC, August 2008.

En

roll

men

t

Strategies to Provide Culturally Competent HIV/AIDS Care

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.

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.

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 Int’l AIDS Conference, 2006; Abst MoPe0643.

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

Population

Per

cen

tag

e

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

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

Optimizing HIV Testing and Treatment in Communities of Color

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. 2006;55(RR14):1-17. 2. KFF. HIV/AIDS Policy Fact Sheet: HIV/AIDS Testing in the United States, June 2009.

HIV Testing in US Adults and in Communities of Color1,2

1. KFF. Survey on HIV/AIDS, 2009; 2. KFF. HIV/AIDS Policy Fact Sheet: HIV/AIDS Testing in the United States, June 2009.

Percent of non-elderly, ages 18-64, who say they have been tested for HIV

48%

53%

73%

60%

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

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%

OASIS Clinic: Results of Traditional Intake and Focused Intervention

Facilitating the Link Between HIV Testing and Care

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.

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

Population

Per

cen

tag

e

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

Optimizing Treatment with ART in Communities of Color

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.

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.

HEAT Trial: Differences in Virologic Outcomes Associated with Race

1. Smith. IAS 2009, abstract MOPEB033.

HEAT trial: Proportion of Subjects with HIV-1 RNA <50 c/mL at Week 96; ITT

NABC/3TC + LPV/r 343 119 143 73 8TDF/FTC + LPV/r 345 124 147 62 12

GRACE Trial: Differences in Virologic Outcomes Associated with Race

GRACE trial: Virologic response (TLOVR) in the ITT population

1. Smith. ICAAC 2009, abstract H918.

0 8 16 24 32 40 48

Time, weeks

Pat

ien

ts w

ith

HIV

-1 R

NA

<

50 c

op

ies/

mL

, %

0

10

20

30

40

50

60

70

80

90

100

48.5%

Black (n=264)Caucasian (n=65)Hispanic (n=96)

60.0%

61.5%

Facilitating Treatment Initiation

• Strategies to facilitate successful initiation and continuation of ART Cultivate trust in patient-provider relationship1

Share with patients evidence of regimen’s effectiveness (eg, improvements in viral load and CD4 cell counts)1

1. Stone. J Gen Intern Med. 1998.

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.

Optimizing ART: Strategies for Helping Patients Adhere

• Assess patient readiness to start ART1

Inquire about patient’s feelings of readiness and about belief in medication effectiveness

Get to know patient’s 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.

Optimizing HIV Research in Communities of Color

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.

Research for Patients With HIV in Communities of Color, Moore Clinic, Baltimore, MD

• Outpatient HIV clinic (~3800 patients), serving Baltimore’s 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

Population

Per

cen

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e

Research at Moore Clinic, Johns Hopkins University, Baltimore, MD

Association between patient perception and clinical outcomes1

1. Beach. J Gen Intern Med. 2006.

Provider Knows Patient as a Person

Per

cen

t o

f P

atie

nts

0 .2 .4 .6 .8

0 .2 .4 .6 .8

40

35

30

25

20

45

40

35

30

25

20

45

0 .2 .4 .6 .8

0 .2 .4 .6 .8

40

35

30

25

20

45

40

35

30

25

20

45

Research at Moore Clinic, Johns Hopkins University, Baltimore, MD

Access to care, by proportion of blacks or Hispanics at HIV care site1

1. Korthuis PT et al, J Gen Intern Med 2006.

Tra

vel t

ime

(m

inu

tes)

Wa

it tim

e (

min

ute

s)

Travel time to HIV Care SiteBy proportion Black or Hispanic

Wait time to see ProviderBy proportion Black or Hispanic

Black Hispanic Black Hispanic

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

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