Improving the Quality of Care Among American Indian Patients: HIV Clinical Update

1
Improving the Quality of Care Among American
Indian Patients HIV Clinical
Update

• Victoria Oxendine, RN,MSN, FNP-C AAHIVS
• New Hanover Regional Medical Center

2
Objectives

• Discuss key testing strategies and
  recommendations
• Identify HIV medications and appropriate usage in
  treating HIV population
• Describe HIV associated co-morbidities and how
  they impact American Indian/Alaska Natives

3
HIV Testing

• Integral to HIV prevention, treatment, and care
  efforts

4
HIV testing
CDC, MMWR, Vol. 55, NO. RR14 September2006. CDC,
MMWR, Vol. 52, NO. 15 April 2003.
5
Key dates in history of HIV testing

• 1981 First AIDS case reported
• 1984 Human Immunodeficiency Virus (HIV)
  identified
• 1985 First test for HIV licensed (ELISA)
• 1987 First Western Blot blood test kit
• 1992 First rapid test
• 1994 First oral fluid test
• 1996 First home urine tests
• 2002 First rapid test using finger prick

Kaiser Family Foundation, Global HIV/AIDS
Timeline, www.kff.org/hivaids/timeline.
6
Key dates in history of HIV testing (cont.)

• 2003 Rapid finger prick test gained CLIA waiver
• 2004 First rapid oral fluid test (also granted
  CLIA waiver)
• 2006 CDC recommends routine HIV screening in
  U.S. health-care settings
• 2007 CDC launches Expanded HIV testing
  Initiative in U.S.
• 2007 WHO/UNAIDS global guidelines recommend
  routine HIV screening in health-care settings

Kaiser Family Foundation, Global HIV/AIDS
Timeline, www.kff.org/hivaids/timeline.
7
Testing Recommendations Requirements
8
Revised CDC Recommendations for HIV Testing in
Healthcare Settings

• Routine voluntary testing for patients ages 13 to
  64 years in healthcare settings
• Not risk-based
• Opt-out testing
• No separate consent for HIV
• Pretest counseling not required
• Repeat HIV testing left to discretion of provider
• Based on patient risk

9
Issues in HIV testing Opt-out testing

• Prevalence of unprotected anal or vaginal sex
  with HIV partners ? by 68 after knowing HIV
  status
• Most testing in US done in primary care settings
  hospital, ER, outpatient
• 22 of all tests
• 27 of all positive tests
• CDC strategy normalize HIV testing by making it
  a routine, voluntary part of care for everyone
  aged 1364
• Overall consent for care to include HIV test
• Individual can decline test (opt-out)
• Goals
• Identify 252312K HIV persons including
  pregnant women who are unaware of serostatus
• Refer for care, reduce transmission and stem US
  epidemic

CDC, MMWR, Vol.55, No. RR14 September 2006.
10
HIV testing recommendations

• NC-HIV testing for pregnant women in first
  third trimesters
• Mandatory in certain cases-blood organ donors,
  military applicants and active duty personnel,
  federal state inmates under certain
  circumstances, newborns in some states
  immigrants

Kaiser Family Foundation, Fact Sheets,
www.kff/hivaids/factsheet.
11
Serostatus Awareness and HIV
Transmission
Accounting for
25 Unaware of Infection
54of New Infections
75Aware of Infection
46 of New Infections
People Livingwith HIV/AIDS(1,039,000-1,185,000)
New Sexual Infections Each Year(32,000)
Marks et al. AIDS. 2006201447.
12
Testing Statistics

• 53 of U.S. adults, ages 18-64, report ever
  having been tested, including 19 w/in last year
• Of the 1 million people living with HIV in the
  U.S., 21 unaware they are infected
• Diagnosed late in illness

Kaiser Family Foundation, Fact Sheets,
www.kff/hivaids/factsheet.
13
Testing Statistics

• Testing sites CDC funded sites, health
  departments, hospitals, private doctor offices,
  and STD clinics

14
Surveillance and testing policies

• HIV/AIDS surveillance
• Confidential vs. Anonymous testing

15
Confidential name-based HIV/AIDS cases by year of
diagnosis, 2004-2007
http//minorityhealth.hhs.gov/templates/content.as
px?ID3026
16
Confidential name-based persons living with
HIV/AIDS by year of diagnosis, 2004-2007
http//minorityhealth.hhs.gov/templates/content.as
px?ID3026
17
Testing Techniques

• HIV ELISA/Western Blot
• Types of Test
• Conventional blood test
• Conventional oral fluid test
• Rapid tests
• Home tests
• Urine test

18
HIV testing issues among American Indians

• 1.5 percent of U.S. population, with hundreds of
  diverse tribes and cultures
• One-half of all American Indians/Alaskan Natives
  live in 10 states
• California, Oklahoma, and Arizona-largest
  population

www.hab.hrsa.gov/population/nativeamericans.htm
19
HIV testing issues among American Indians (cont.)

• Perceived HIV risk
• HIV testing
• Confidentiality
• Misclassified in terms of race/ethnicity on data
  forms

CDC, MMWR, Vol. 52, No. SS07 August,
2003. www.cdc.gov/hiv/resources/factsheets/aian.ht
m
20
HIV Medication Therapy
21
DHHS Recommendations on When to Initiate
Antiretroviral Therapy
Panel on Antiretroviral Guidelines for Adults and
Adolescents. Guidelines for the use of
antiretroviral agents in HIV-1-infected adults
and adolescents. Department of Health and Human
Services. January 29, 2008 1-128. Available at
http//www.aidsinfo.nih.gov/ContentFiles/AdultandA
dolescentGL.pdf. Accessed April 2008.
22
Antiretrovirals 2009

• NRTIs/NtRTIs
• Abacavir
• Didanosine
• Emtricitabine
• Lamivudine
• Stavudine
• Tenofovir
• Zalcitabine
• Zidovudine
• lamivudine/zidovudine
• abacavir/lamivudine
• lamivudine/zidovudine/abacavir
• Emtricitabine/tenofovir

• NNRTIs
• Delavirdine
• Efavirenz
• Nevirapine
• Etravirine

• PIs
• Atazanavir
• Fosamprenavir
• Indinavir
• Lopinavir/ritonavir
• Nelfinavir
• Ritonavir
• Saquinavir
• Tipranavir
• Darunavir
• 3 Drug Combo
• tenofovir/emtricitabine/efavirenz

• Fusion Inhibitor
• Enfuvirtide
• Integrase Inhibitor
• Raltegravir
• Entry Inhibitor
• Maraviroc

From KY Smith, MD, MPH, at 11th RW Program
Clinical Update, IASUSA.
23
(No Transcript)
24
Co-Morbidities in HIV American Indians

• Disparities in risks for chronic diseases
• Only 55 years ago, leading health
  problems-infectious diseases, malnutrition, and
  infant mortality
• Behavioral Risk Factor Surveillance System-4
  years of survey data

www.cdc.gov/mmwr/preview/mmwrhtml/ss5207al.htm
25
Health Status Indicators

• Overall health status
• Self-perceived fair or poor health status in
  AI/AN women-23.8

www.cdc.gov/mmwr/preview/mmwrhtml/ss5207al.htm
26
Health Status Indicators

• Obesity
• WHO guidelines, a body mass index of gt30kg for
  both men and women is considered obese
• Estimated that 65 of population has a BMI gt35
• Fastest growing population is persons gt100s
  overweight

U.S. obesity trends 1985-2007. CDC and Prevention
web site. http//www.cdc.gov/nccdphp/dnpa/obesity
27
(No Transcript)
28
Obesity

• Increased in AI/AN past 30 years
• Contributing factors
• Nutrition diet
• Shift in traditional occupations, occurred in
  early 1900s
• Diets historically high in complex
  carbohydrate/high fiber foods and lower fat,
  replaced by high refined carbohydrates, fat,
  sodium and low fruits vegetables
• Poverty unemployment
• From 1998-2000, average of 25.9, 26.8 lacked
  insurance
• Limit access to purchase healthy food sources
• Promoted reliance on special federal commodity
  programs

http//aspe.hhs.gov/hsp/07/AI-AN-obesity
29
Obesity (cont.)

• Contributing factors
• Psychosocial factors
• Historical trauma and grief, interpersonal,
  non-interpersonal and witnessed such as
  alcohol-related accidents, homicide, and suicide
• Perception of obesity/overweight as a problem
• Major depressive disorder

http//aspe.hhs.gov/hsp/07/AI-AN-obesity
30
Obesity (cont)

• Contributing factors
• Environment vs. genetics
• Physical activity
• Sedentary lifestyles
• Studies showing low physical activities in adults
  and youths residing in reservation-based
  communities
• Lack of facilities, equipment and trained
  physical educational staff

http//aspe.hhs.gov/hsp/07/AI-AN-obesity
31
Obesity

• Consequences
• Physical Health
• Cardiovascular disease
• Hypertension

http//aspe.hhs.gov/hsp/07/AI-AN-obesity
32
Cardiovascular disease

• Heart disease leading cause of death among AI/AN
• Stroke 5th leading cause
• Heart disease death rate-20 greater and stroke
  death rate 14
• Together, accounted for one-quarter of all deaths
  on AI in 2000

Indian Health Service. Trends in Indian Health,
200-2001. Rockville, Maryland U.S. Department of
Health and Human Services, 2004. http//www.cdc.go
v/nchs/hus.htm
33
Obesity

• Consequences
• Diabetes Mellitus
• Increasing among young persons lt35
• From 1994-2004, diagnosis more than doubled from
  6,001 to 12,313(CDC, MMWR, 11/06)
• Greater amongst females than males in all age
  groups
• Chronic Kidney disease-reservation-based dialysis
  units

http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5544a4.
htm
34
Obesity

• Consequences
• Psychosocial
• Social stigmatization
• Discrimination
• Poor body image
• Undesirable dieting practices

http//www/cdc.gov/mmwr/preview/mmwrhtml/ss5207al.
htm
35
Obesity

• Consequences
• Economic
• Direct costs-preventive, diagnostic, and
  treatment services
• Indirect costs-lost wages
• Physical costs-Diabetic, coronary heart disease
  and hypertensive complications

http//www/cdc.gov/mmwr/preview/mmwrhtml/ss5207al.
htm
36
Health Risk Behaviors

• Tobacco use
• Kills 440,000 people in the U.S.
• Rates higher in AI adults than other
  racial/ethnic groups 36
• Important role in American Indian culture
  storytelling, healing, religious and other
  ceremonies, a sacred gift to the earth

http//www.americalegacy.org
37
Health Risk Behaviors

• No physical activity
• Binge drinking
• Drinking driving
• Domestic violence

http//www/cdc.gov/mmwr/preview/mmwrhtml/ss5207al.
htm
38
Screening for Chronic Disease

• High rates of STDs
• Nationally, direct medical costs associated with
  STDs are estimated at 13 billion annually
• 2004, AI nearly 5 times more likely than Whites
  to get chlamydia, 4 times more likely to get
  gonorrhea, and twice as likely to have syphillis
• PAP tests
• More likely to never have had a PAP vs. other
  racial/ethnic groups

http//www.npaihb.org/health_issues/hiv_std_aids w
ww.cdc.gov/hiv/resources/factsheets/aian.htm http
//www/cdc.gov/mmwr/preview/mmwrhtml/ss5207al.htm

39
Screening for Chronic Disease

• Oral Health
• Prevelance in dental caries, both active and
  previous, higher in AI/AN than in the
  U.S.population
• 59 rate of periodontitis, with 32 in advanced
  stages

Goddard, G., Brown, C., Ahmad, A. 2005. Oral
Disease Prevalence among HIV-positive American
Indians in an Urban Clinic. Journal Of
Psychactive Drugs 37 (3) 313-319.
40
Screening for Chronic Disease

• Substance abuse
• Alcoholism
• 50-60 percent genetic risk factor
• Sense of loss of culture
• Boarding school experiences
• Attitudes and Expectancies

Beauvais, F. American Indians and Alcohol.
Alcohol Health Research World. 1998. 22 (4),
253-259.
41
Social Cultural Mores about Sexual Activity

• High rates of STDs
• Two-spirited
• Confidentiality

http//www.npaihb.org/health_issues/hiv_std_aids w
ww.cdc.gov/hiv/resources/factsheets/aian.htm http
//www.ac.wwu.edu/-culture/medicine.htm
42
Awareness of Having Diabetes

• Number of AI/ANs aged lt35 years with diabetes
  diagnosed through HIS health care services
  doubled from 6,001 in 1994 to 12,313 in 2004
• Less likely to report being told they were
  diabetic

www.cdc.gov/mmwr/preview/mmwrhtml/ss5207al.htm
43
Cultural Competence and Prevention

• Tribal coalitions to share wisdom, data,
  resources, identify and address common
  priorities, and develop strategies to reduce
  further incidence of HIV infection
• Support voluntary HIV testing as routine part of
  medical examination