1. “Challenges Facing HIV Positive Africans in Minnesota and The Way Forward” by Omobosola Akinsete, MD, MPH Health Partners/ Hennepin County Medical Center/University of Minnesota Presented at the African World AIDS Day Event, December 9, 2006

2. Background of HIV in Africans in Minnesota

3. Sub-Saharan Africa 70% of people with HIV/AIDS live in Sub-Saharan Africa 70% of people with HIV/AIDS live in Sub-Saharan Africa Anti-retroviral treatment (ARV) is available to 11% of those affected (according to WHO 2005) Anti-retroviral treatment (ARV) is available to 11% of those affected (according to WHO 2005)

4. Some Risk Factors for Acquiring The Disease in Africa

5. Driving Factors for HIV in Africa Ignorance/denial Ignorance/denial Fear/silence Fear/silence Sexual networks Sexual networks Blood and blood products Blood and blood products Conflict/displace- ment of families Conflict/displace- ment of families Migrant workers Migrant workers Commercial sex work Commercial sex work Poverty!!!!- Linked to most other factors Poverty!!!!- Linked to most other factors Cultural/traditional practices Cultural/traditional practices Low socioeconomic status of women Low socioeconomic status of women Limited governmental support Limited governmental support

6. African-born Residents in the U.S. by State, Census 2000 Source: U.S. Census Bureau, Census 2000 Data Large African-born Population in Minnesota According to the U.S. Census, Minnesota has the 2 nd largest population of East Africans in the nation. Minnesota (10 th largest)

7. HIV/AIDS in Minnesota: Number of New Cases, Prevalent Cases, and Deaths by Year, 1990-2005 *Deaths among AIDS cases, regardless of cause. ^Includes refugees in the HIV+ Resettlement Program diagnosed with AIDS subsequent to their arrival in the United States

8. HIV Infections* among Foreign-Born Persons † in Minnesota by Year of Diagnosis and Region of Birth, 1990-2005 Region of Birth # * HIV or AIDS at first diagnosis † Excludes persons arriving to Minnesota through the HIV+ Refugee Resettlement Program. # Latin America/Car includes Mexico and all Central, South American, and Caribbean countries.

9. HIV Infections* Diagnosed in Year 2005 and General Population in Minnesota by Race/Ethnicity HIV Diagnoses (n = 304) Population † (n = 4,919,479) * HIV or AIDS at first diagnosis † Population estimates based on 2000 U.S. Census data. n = Number of persons Amer Ind = American Indian Afr Amer = African American (Black, not African-born persons) Afr born = African-born (Black, African-born persons) Data source: Minnesota HIV/AIDS Surveillance System

10. Unique Features of HIV Epidemic in Minnesota’s African Community Significant Demographic Diversity Total Africans living with HIV/AIDS in 2005: 587 Total Africans living with HIV/AIDS in 2005: 587 Many more are likely undiagnosed Many more are likely undiagnosed Representing more than 25 different countries and every region of Africa Representing more than 25 different countries and every region of Africa Source: Minnesota Department of Health HIV/AIDS Surveillance System

11. Unique Features of HIV Epidemic in Minnesota’s African Community African-born Persons Total Number = 587 Other Minnesota Cases Total Number = 5,233 Source: Minnesota Department of Health HIV/AIDS Surveillance System, data reflect prevalent cases in 2005 Gender Distribution

12. Facts about HIV Positive Africans in Minnesota Slightly more women then men Slightly more women then men At Hennepin County Medical Center (HCMC), only 9% of people got routine HIV test At Hennepin County Medical Center (HCMC), only 9% of people got routine HIV test 86% of them acquired HIV through heterosexual intercourse 86% of them acquired HIV through heterosexual intercourse

13. Africans Do Not Routinely Test for HIV Present to the clinic later in the disease and usually with an infection such as TB Present to the clinic later in the disease and usually with an infection such as TB

14. Why Do African-born Patients Present Late? 1. Many Africans do not feel at risk of contracting HIV- low condom use, stable relationship, lack of trust 2. Lack of information about services 3. Socioeconomic barriers 4. Immigration barriers 5. Competing priorities 6. Psychosocial issues- coping skills, fear

15. Barriers Accessing HIV Services Barriers due to: Lack of knowledge about services Lack of knowledge about services Fear of stigma Fear of stigma Language problems Language problems Immigration issues Immigration issues Lack of insurance Lack of insurance

16. Challenges Within the HIV Care System Shock/denial Shock/denial Insurance issues/poverty Insurance issues/poverty Interpreters/miscom- munication Interpreters/miscom- munication Competing priorities Competing priorities Cultural issues Cultural issues Stigma Stigma Social isolation Social isolation Psychosocial issues Psychosocial issues Complex forms Complex forms Attitudes of providers Attitudes of providers

17. Many Family Members and Friends Do Not Know About The Diagnosis of Each Other Why? Shame Shame Fear that they will be left alone Fear that they will be left alone Fear that others will find out Fear that others will find out Panic Panic People will think that People will think that they are bad people they are bad people

18. Stigma What causes stigma? Experience in Africa Experience in Africa Fear Fear Shame Shame Ignorance Ignorance Association with AIDS Association with AIDS and death and death

19. Effects of Stigma How does stigma affect patient care? Late presentation and diagnosis Late presentation and diagnosis Increased transmission Increased transmission Poor adherence to medications Poor adherence to medications Isolation of patients Isolation of patients

20. Services Provided Good HIV and primary care Good HIV and primary care Insurance services Insurance services Case managers/social workers Case managers/social workers Support groups Support groups Psychological support Psychological support

21. How Do Africans in Care Behave? Increased knowledge Increased knowledge Good adherence to medications Good adherence to medications Trust their providers Trust their providers More people willing to come out More people willing to come out Increased coping skills Increased coping skills Relatively normal lives Relatively normal lives Children Children

23. What Is Needed? Increased funding of sustainable resources!!!!!!!- Good response from Minnesota Department of Health and others - but we need more. Increased funding of sustainable resources!!!!!!!- Good response from Minnesota Department of Health and others - but we need more. Increased education –culturally appropriate, within communities, increase numbers of African trained educators Increased education –culturally appropriate, within communities, increase numbers of African trained educators Involvement of Africans- NGOs, churches/religious leaders Involvement of Africans- NGOs, churches/religious leaders Counseling/crises centers/hot line Counseling/crises centers/hot line

24. What Is Needed (continued) Incorporate education/counseling into other health care- OBGYN, Primary care Incorporate education/counseling into other health care- OBGYN, Primary care Education for refugees Education for refugees Screening for all as part of health care and decrease stigma Screening for all as part of health care and decrease stigma Interpreters - more/ better trained/discrete Interpreters - more/ better trained/discrete Information pamphlets in various languages, radio, newspapers and TV Information pamphlets in various languages, radio, newspapers and TV

25. What Is Needed (continued) Case management/social workers Case management/social workers Support groups for those infected, e.g. SAYFSM Support groups for those infected, e.g. SAYFSM Affordable drugs for those infected in Africa Affordable drugs for those infected in Africa

26. The Way Forward HIV is just a disease! HIV is just a disease! HIV does not mean you are a bad person! HIV does not mean you are a bad person! HIV does not show on your face! HIV does not show on your face! There no cure but there is treatment for HIV! There no cure but there is treatment for HIV! There is hope for people with HIV! There is hope for people with HIV! HIV infected people need support from their community members! HIV infected people need support from their community members!

27. Acknowledgements Tracy Sides Tracy Sides Keith Henry Keith Henry Luisa Pessoa-Brandão Luisa Pessoa-Brandão Charles Cartwright Charles Cartwright Diane Hirigoyen Diane Hirigoyen Christy Boraas Christy Boraas Cynthia Davey Cynthia Davey Ellen Kane Ellen Kane