Update: HIV Infection Behavior Then and Now The Time in Between

1
Update HIV InfectionBehavior Then and Now(The
Time in Between)
Ernesto Parra, M.D., M.P.H.

• Clinical Associate Professor
• Department of Family Practice, UTHSCSA

2
Presentation Outline

• Epidemiology of AIDS and HIV
• Characteristics of Latino Patients with HIV
• Consequences of Behavior on Health
• Predictors of Poor Adherence to HAART
• Strategies for Improving Adherence
• Conclusions

3
AIDS Cases Worldwide
Year
AIDS Cases

• 1994.17 Million
• 2005.38.6 Million

UNAIDS 2006
4
38.6 Million People Worldwide Living with
HIV/AIDS at End of 2005
UNAIDS 2006
5
Western Europe 1.8
Eastern Europe Central Asia 3.8
North America 3.1
East Asia 1.8
Caribbean .8
South South-East Asia 19.7
North Africa Middle-East 1.1
Sub Saharan Africa 63
Latin America 4.1
Australia New Zealand .2
38.6 Million People Estimated Living with
HIV/AIDS Worldwide at End of 2005
UNAIDS 2006
6
11,000 New HIV Infections Each Day Worldwide in
2005

• 10,000 (90) are 15-49 years old
• 50 are women
• 50 are 15-24 years old

UNAIDS 2006
7
People Living withAIDS in the United States
Year
AIDS

• 2000.320,177
• 2004.415,193

CDC Surveillance Report 2005
8
AIDS Cases in the United States by 2004
80
73
19
27
0.1
1
Cumulative Total 944,306
During 2004 Total 42,514
CDC Surveillance Report 2005
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Proportion of AIDS Cases, by Race/Ethnicity and
Year of Report, 1985 2004, United States
Percent of Cases
Year of Diagnosis
CDC Surveillance Report 2005
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Ethnic Demographics of HIV/AIDSCases
Newly-Diagnosed in 2004
2
US Population in 2001 N285,863,000
30
21
HIV Cases N33,132
5
47
13
71
2
12
28
20
AIDS Cases N42,514
50
CDC Surveillance Report 2005
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Proportion of Adult AIDS Cases by Exposure
Category and Year of Diagnosis, 1985 2004, U.S.
Percent of Cases
Year of Diagnosis
CDC Surveillance Report 2005
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Number of Persons in U.S. Living with AIDS in
2004 by Gender and Exposure Category
Men Total317,698
Women Total93,566
CDC Surveillance Report 2005
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CDC
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CDC
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An Estimated 40,000 People infected with HIV
During 2004 in the United States

• 110 HIV infections per day
• 70 men
• 47 African American
• 21 Latino

CDC Surveillance Report 2005
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Presentation Outline

• Epidemiology of AIDS and HIV
• Characteristics of Latino Patients with HIV
• Consequences of Behavior on Health
• Predictors of Poor Adherence to HAART
• Strategies for Improving Adherence
• Conclusions

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Mi Hermano

• Victor Risky sexual behavior
• Father Denial, Guilt, Blame, Privacy,
  Protection of family
• Mother Disclosure, Protection of family
• Jose Disclosure
• Antonio Taboo sexuality, safe sex
• Marta Low risk behavior, perinatal
  transmission
• Marisela Abstinence
• Doctor Education on Risk Reduction

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Presentation Outline

• Epidemiology of AIDS and HIV
• Characteristics of Latino Patients with HIV
• Consequences of Behavior on Health
• Predictors of Poor Adherence to HAART
• Strategies for Improving Adherence
• Conclusions

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Cultural Characteristics thatDelay Latinos
Presenting for HIV Care

• Social dynamics and family roles
• Stigma of promiscuity or injecting drug use
• Anticipated violence from spouse or peers
• Inability to acknowledge Infidelity
• Machismo sense of manliness
• Reluctance to acknowledge homosexual behavior
• Hispanic MSM self-identify as heterosexual
• Fatalismo belief person is powerless against
  fate
• Religious conflict may impede seeking care

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Limited Education DelaysLatinos Presenting for
HIV Care

• Language
• One-third of Latinos are mono-lingual in Spanish
• Formal Education
• 43 of Latinos in US have not graduated from high
  school
• Lack Awareness of high-risk behavior1
• Ignorance of what is high-risk behavior2
• Unspoken polygamy and/or IV drug use places sex
  partners at risk without their knowledge3
• Many do not perceive their behavior as at-risk

1. HIV/AIDS in the Latino community,
www.hispanicfederation.org
2. Essien EJ. J Natl Med Assoc. 20094304-312.
3. Pulerwiz J. AIDS Care. 200214789-800
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Economic Barriers DelayLatinos Presenting for
HIV Care

• Poverty and unemployment
• 21.4 of Latinos in US lived in poverty in 20021
• Limited access to healthcare coverage by Latinos
  in 20012
• Uninsured.....33.2
• Medicare....18.9
• Medicaid..6.1

1. US Census Bureau. The Hispanic Population in
the US 3/2002. Issued 6/2003
2. US Census Bureau. Health Insurance Coverage
2001. Issued 9/2002
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Cultural Characteristics thatImpede Latinos
Receive HIV Care

• Mistrust of healthcare providers
• Lack of Latino healthcare workers
• Non-Spanish speaking provider/support staff
• Misuse of healthcare services
• Abandon health-belief model of continuity care
• May seek intermittent symptom-associated care
• Utilize urgent or emergency care services
• Suspend health services for alternative care
• Dont tend to doctor shop with HIV diagnosis

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Presentation Outline

• Epidemiology of AIDS and HIV
• Characteristics of Latino Patients with HIV
• Consequences of Behavior on Health
• Predictors of Poor Adherence to HAART
• Strategies for Improving Adherence
• Conclusions

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Advanced Disease at Diagnosis

• Delayed presentation among Latino patients1
  result in
• Disproportionately high number with AIDS
• High baseline viral load
• Impaired immune status2,3
• Increased morbidity, hospitalization for OIs
• Increased mortality4
• Reduced response to HAART treatment

1. Hodges JC XIV International AIDS Conference
2002 Abs. MoPeb3269 2. Paris R. XIV International
AIDS Conference 2002 Abs. TuPeC4702 3. Swindells
S. AIDS. 2002161832-1834 4. Oshaugnesy MV. XIV
International AIDS Conference 2002 Abs. TuPeC4753
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Poor Adherence to HAART Leads to Viral
Resistance

• Adherence to HAART Viral load lt400 at 6
  months
• gt95 Adherence 78
• 90 95
  45
• 80 90
  33
• 70 80
  29
• lt70
  18

Ann Intern Med 200013321
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Poor Adherence Compromises Health

• Incomplete adherence to HAART
• Rapid resistance to HAART
• Limited HAART regimens
• Illness

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Presentation Outline

• Epidemiology of AIDS and HIV
• Characteristics of Latino Patients with HIV
• Consequences of Behavior on Health
• Predictors of Poor Adherence to HAART
• Strategies for Improving Adherence
• Conclusions

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Predictors of Poor Adherence to HAART

• Cultural Attitudes and Health Beliefs
• Homophobia thats a gay disease
• Machismo - risk-maximizing behavior
• Passivity - I dont feel sick
• Social Problems
• No housing
• No food
• No utilities
• No refrigerator

Bamberger JD, AJPH, 90(5)699-701, 2000
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Predictors of Poor Adherence to HAART (Cont.)

• Behavior
• Alcohol abuse
• Injecting drug use
• Intermittent incarceration
• Missed clinic appointments
• Severity of illness
• Overwhelming caregiver duties
• Competing activities childcare, work, family
  events

Pratt RJ, et al.,HIV Clinical Trials.2(2)146-59,
2001
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Predictors of Poor Adherence to HAART (Cont.)

• Mental Health
• Depression
• Bipolar disorder
• Health Provider
• Poor communication
• Poor relationship
• Burnout

Bakken S. AIDS Patient Care, 14(4)189-97,
2000 Van Servellen G. WJ Nurse Res, 27(8)1023-39
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Predictors of Poor Adherence to HAART (Cont.)

• Medication side effects
• Nausea
• Fatigue
• Drowsiness
• Anemia
• Drug interactions
• Medication Dosing
• Difficult dosing schedule
• Pill burden

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Strategies for Improving Patient Adherence

• Educate to reduce misconceptions about HIV
  infection and AIDS
• Engage social service assistance to secure
  housing, utilities, food, transportation, and
  medications
• Identify available ancillary health care for
  addiction and psychiatric care

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Strategies for Improving Patient Adherence

• Educate about desired outcome
• Counsel about dangers of poor adherence
• Monitor adherence behavior
• Provide environmental cues for dosing
• Provide positive feedback for clinical success
• Emphasize self-reliance
• Use twice-a-day or once-a day regimens
• Use fewest number of pills

AIDS Therapy, 2nd Ed.20002
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Presentation Outline

• Epidemiology of AIDS and HIV
• Characteristics of Latino Patients with HIV
• Consequences of Behavior on Health
• Predictors of Poor Adherence to HAART
• Strategies for Improving Adherence
• Conclusions

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Summary

• HIV infection continues to rise unabated
  worldwide
• HIV infection has disproportionately impacted
• minority communities in the U.S
• Latinos with HIV infection often present late for
  care
• Physicians need to be mindful of cultural and
  social barriers to care
• Creative strategies are needed to reduce
• barriers to care and improve adherence to
  therapy

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Newest Medication for HIV
Atripla

• Once-a-Day Medication for HIV

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ABC News Report, October 5, 2006

• Insurance Institute for Highway Safety study
  reported
• Side-impact air bags and new stability
  control
• feature on cars can reduce driver deaths by
  37
• However, Purdue University study finds
• Auto fatality rates are rising
• This study suggest that
• People tend to compensate for advanced
• safety featuresby driving more aggressively
• Author of study concludes
• If we could find some way to modify the
  human behavior, then these features would truly
  be effective

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Known
HIV
Unknown