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 Statement This 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 Designation Postgraduate 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 (contd) NURSING CONTINUING MEDICAL EDUCATION Credit Designation This educational activity for 1.5 contact hours is provided by Postgraduate Institute for Medicine. Accreditation Statements Postgraduate 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 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 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 Native Asian 3 Black/African American Hispanic/Latino 2 Native Hawaiian/Other Pacific Islander White

Disproportionate Effect of HIV/AIDS in Black Subpopulations Black women Accounted for 65% of new AIDS cases among women in the US in Reported an HIV incidence rate 14.7 times higher than white women in 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 MSM 3 Black adolescents Black youth accounted for 68% of AIDS cases among those ages in 2007, while making up just 17% of the population 1 1.Kaiser Family Foundation (KFF). The HIV/AIDS epidemic in the United States CDC MMWR. 2008;57(36): CDC. MMWR. 2005;54(24):599.

Epidemiologic Overview: Disproportionate Effect of HIV/AIDS in Hispanic Americans New HIV Infections & US population by Race/Ethnicity, In 2006, Hispanics accounted for approximately 17% of the new HIV infections 1 In 2007, Hispanics accounted for 19% of new AIDS diagnoses 1 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

HIV Prevalence in Select Countries and in Subpopulations in the US 1 1. El Sadr W, et al, N Engl J Med. 2010;362: Prevalence (%) 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 sex 1 HIV Outpatient Study: black race independently associated with 50% higher mortality rate vs whites 2 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: 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 whites 1 Blacks and Hispanics less likely to have health insurance, compared with whites 2 1.DeNavas-Walt. US Census Bureau. Income, Poverty, and Health Insurance Thomas M et al. Health Coverage for Communities of Color, Kaiser Foundation, Insurance Coverage of Nonelderly, by Race/Ethnicity,

Critical Role of Public Funding for HIV/AIDS Care in Communities of Color Medicaid covers ~40% of persons with HIV receiving care in the US 1 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 nationally 2 ~183,000 enrollees nationwide in KFF. Fact Sheet: Ryan White Program, 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 Percentage

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 disease 1-3 Higher rates of hospitalization reported among women, blacks, injection drug users (IDU), and Medicaid and Medicare patients 4 Higher proportion of unrecognized HIV infection among black and Hispanic MSM 5 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 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 epidemic 1 Personal experience of inequitable care by health care system 2 Distrust may lead to suboptimal adherence 3 Blacks and Hispanics on average have higher levels of distrust of physicians than do whites 4 Distrust associated with gender, age, insurance coverage, educational level and income 4 1. Bogart. JAIDS IOM. Unequal Treatment. 2002; 3. Bogart. JAIDS 2010; 4. Armstrong. Am J Pub Health

HIV-Related Stigma Affects Care in Communities of Color Focus group data among low-income black and Hispanic HIV+ patients reveal stigma on multiple levels 1 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 needed 1,2 Particular concern among non-gay-identified MSM 1 1. Sayles. J Urban Health, Malebranche. J Natl Med Assoc

Incarceration Critical to Spread of HIV in Minority Communities 2.3 million incarcerated persons in % were black and 17.9% were Hispanic 1 As many as 17% of all persons with HIV pass through a correctional facility each year 2 Higher rate of incarceration among black men impacts HIV/AIDS rates among women of color 3 1. CDC, Testing Recommendations in Correctional Settings, 2009; 2. NCCHC Position Statement 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 Percentage

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 Enrollment 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 Enrollment

Strategies to Provide Culturally Competent HIV/AIDS Care

Recognize health-related cultural beliefs Understand potential difficulties in cross-cultural encounters 1 Gender Family dynamics Patient beliefs Social environment 1. Carillo JE et al. Ann Intern Med

Strategies to Provide Culturally Competent HIV/AIDS Care Encourage patient-centered communication Minority patients more likely to feel less involved in health care decisions 1 Minority patients report needing more time with clinicians to make health care decisions 2 Patients who report that their provider who knows them as a person more likely to 3 Receive ART Have better adherence to ART Achieve undetectable HIV RNA 1. Cooper-Patrick. JAMA Federman. J Gen Intern Med Beach. J Gen Intern Med

Strategies to Provide Culturally Competent HIV/AIDS Care Having a racially diverse staff has an impact on patient perceptions of care 1 Racial concordance independently associated with time to receipt of ART 2 Where possible, it is recommended that clinics diversify clinical and nonclinical staff to reflect the communities they serve 3 Growing concern about supply of HIV- experienced clinicians 4 1. Cooper. Ann Intern Med King. J Gen Intern Med Washington. J Gen Intern Med Rawlings. XVI Intl 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 Percentage

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

HIV Testing in US Adults and in Communities of Color 1,2 1. KFF. Survey on HIV/AIDS, 2009; 2. KFF. HIV/AIDS Policy Fact Sheet: HIV/AIDS Testing in the United States, June 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 positivity 1 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

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 services 1 Case management, outreach, group visits 2,3 1. Cunningham. J Health Care Poor Underserved Gardner. AIDS Cabral. AIDS Patient Care STDS

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 Percentage

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 backbone DHHS guidelines added recommendation to offer ART to patients with CD4 cell counts between cells/mm 3 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 ART 1,2 Other studies have not identified similar associations, suggesting outcomes reflect disparities in access to care and comorbidities 3,4 1. Anastos. JAIDS Weintrob, JAIDS Jensen-Fangel. CID Silverberg. AIDS

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 N ABC/3TC + LPV/r TDF/FTC + LPV/r

GRACE Trial: Differences in Virologic Outcomes Associated with Race GRACE trial: Virologic response (TLOVR) in the ITT population 1. Smith. ICAAC 2009, abstract H Time, weeks Patients with HIV-1 RNA <50 copies/mL, % % 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 relationship 1 Share with patients evidence of regimens effectiveness (eg, improvements in viral load and CD4 cell counts) 1 1. Stone. J Gen Intern Med

Optimizing ART: Predicting Adherence Is Difficult Clinicians are generally not skilled at predicting patient adherence or judging who is adherent 1,2 However, certain factors have been shown to be associated with poor adherence 3 Substance use Low health literacy Depression Lack of disclosure of HIV status Unstable or chaotic living situation 1. Bangsberg. JAIDS Miller. J Gen Intern Med Golin. J Gen Intern Med

Optimizing ART: Strategies for Helping Patients Adhere Assess patient readiness to start ART 1 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 provider 2 Assess adherence to appointments 3 Improve patient-provider communication 4 1. Enriquez. J Assoc Nurses AIDS Care Bakken. AIDS Patient Care STDs Lucas. Ann Intern Med Schneider. J Gen Intern Med

Optimizing HIV Research in Communities of Color

Improved Minority Representation in Antiretroviral Clinical Trials 1. Collier. N Engl J Med Staszewski NEJM Gulick NEJM Gallant. NEJM Smith. AIDS Squires. IAS 2009, abst MOPEB042.

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 Population Percentage

Research at Moore Clinic, Johns Hopkins University, Baltimore, MD Association between patient perception and clinical outcomes 1 1. Beach. J Gen Intern Med Provider Knows Patient as a Person Percent of Patients

Research at Moore Clinic, Johns Hopkins University, Baltimore, MD Access to care, by proportion of blacks or Hispanics at HIV care site 1 1. Korthuis PT et al, J Gen Intern Med Travel time (minutes) Wait time (minutes) Travel time to HIV Care Site By proportion Black or Hispanic Wait time to see Provider By proportion Black or Hispanic BlackHispanic BlackHispanic

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