HIV/AIDS in Special Population Groups in Texas

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  • The MPOWER Package
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  • Hispanics are the largest and fastest growing minority in Texas, increasing by 12% from 2000 to 2007 According to the US Census Bureau , Hispanics constituted 15% of the US population as of July 2007. The Texas Data Center and the Office of the State Demographer project that by 2020, the Texas Hispanic population will outnumber the White population A large majority of Texas Hispanics are Mexican/Mexican American, according to the Pew Hispanic Center-85% of the Hispanic population in Texas are of Mexican origin. (http://pewhispanic.org/)
  • The Hispanic population in Texas is growing at increasing rates. In 1980, the Hispanic population of Texas was just under 3 million. By 2040 will become the majority in Texas… it is estimated that there will be 18.8 million Hispanics in Texas. The percentage of Hispanics is projected to increase from 21 percent in 1980 to 53 percent of the population by 2040 . These changes are being driven both by high immigration rates and high birth rates.
  • Read Slide: In 2007: Over 1,200 newly diagnosed HIV cases were reported among Hispanics (accounting for 29% of all the new HIV/AIDS diagnoses) Approximately 15,000 Hispanic persons were living with HIV (accounting for 25% of all the persons living with HIV/AIDS in Texas) Over 800 Hispanics progressed to AIDS
  • This dot map is a visual display of the residence county of diagnosis for Hispanics living with HIV/AIDS in Texas in 2007. Additional information: Dots are placed randomly in the county of the individuals residence at diagnosis.
  • This slide represents the number of AIDS cases diagnosed among Hispanics and what proportion of the cases diagnosed Hispanics represented from 1990-2007. The bars indicate the number of cases by year (left axis) and the line represents the proportion of all diagnosed cases that Hispanics made up (right axis). Although the number of AIDS cases diagnosed has remained relatively stable over the last several years among Hispanics, the RED line indicates that Hispanics represent an increasingly large proportion of newly diagnosed AIDS cases over time.
  • Proportion of newly diagnosed AIDS cases that each racial/ethnic group represents over time Over time, the proportion of AIDS cases made up by whites has declined, whereas, Hispanics are representing an increasingly larger proportion of newly diagnosed cases. For the first time In Texas in 2007, the proportion of newly diagnosed AIDS cases among Hispanics surpassed the proportion of cases made up by Whites. This trend differs from what we’re observing nationally… where the proportion of AIDS cases represented by whites still exceeds that of Hispanics.
  • Because there are advances in HIV treatments it is alarming to see an increasing proportion of AIDS cases among Hispanics when we saw decreasing or stable proportions among the other race/ethic categories We know that two main underlying reasons individuals progress from HIV to AIDS are they are not testing or testing less frequently and unaware of their status and/or they are getting into care later The consequences of not knowing your status are that you may unknowingly infect others or unknowingly become co-infected with other STIs and/or drug-resistant strains of HIV Getting into care later can result in quicker progression to AIDS and poor outcomes including death This increasing proportion of AIDS cases among Hispanics led us to explore our available data to develop a picture of HIV Testing and Treatment Among Hispanics in Texas
  • In order to better understand testing and treatment practices among Hispanic persons in Texas, we began by examining all available data sources and comparing the results from these data sources. The data sources we reviewed were: Read slide
  • The first data source we examined was the 2007 BRFSS. BRFSS is a population based random digit dialed survey. BRFSS enables us to calculate general population-based estimates on HIV testing. In 2007, the BRFSS contained questions about HIV testing.
  • In 2007, we found that Hispanic persons were less likely to report ever having tested for HIV when compared to black persons. Hispanic persons were also less likely to report having tested for HIV in the past year when compared to black persons. POINT OUT NUMBERS IN TABLE The proportion of Hispanic persons having ever tested for HIV or having tested in the last year was nearly the same as the proportions for white persons. POINT OUT NUMBERS IN TABLE Additional Notes: no statistically significant difference between Hispanics and white for the “tested in past year” percentage The percentages are within each race group: i.e. of all black persons surveyed 64% said they had an HIV test ever, 36% said they had never had an HIV test
  • Hispanic persons were more likely to report that the last facility they received an HIV test was a clinic as compared to white and black persons who were more likely to report having been tested in private doctors office or at an HMO. REVIEW SLIDE
  • The second data source we examined was the Texas HIV/AIDS surveillance data Texas has been conducting AIDS surveillance since 1983 and in 1999, HIV became reportable by name. The key demographics collected are patient demographic characteristics, the mode of transmission, opportunistic infections, and virologic and immunologic status. In conjunction with core surveillance activities, Texas also implemented EPS to reduce perinatal HIV transmission and to evaluate perinatal prevention efforts For this presentation, we evaluated HIV/AIDS surveillance data for cases diagnosed through 2007
  • As can be seen in this graph a greater proportion of Hispanics, compared to Whites and Blacks, progressed to AIDS within one year of their HIV diagnosis. POINT OUT NUMBERS IN Graph *Percentages do not add up to 100% because cases with unknown progression time frame are excluded
  • We also noticed differences in progression from HIV to AIDS among Hispanics who were foreign born versus those who were born in the US. A greater proportion of Hispanics who were foreign born progressed to AIDS within 1 year of their HIV diagnosis. POINT OUT NUMBERS IN SLIDE Among Foreign Born Hispanic Persons who progressed to AIDS within 1 year of HIV diagnosis, >70% of the cases had a country of origin of Mexico. Additional Notes: We also looked at progression to AIDS among Hispanics in the border, metro, and non-metro areas and there were not major differences among the three groups. (Progression to AIDS within 1 year of diagnosis among Hispanic persons: Border-39%, Metro 41%, Non-Metro-40%)
  • Next we looked at our enhanced perinatal surveillance data which includes detailed information on HIV positive mothers and exposed babies This chart shows the proportion of HIV positive women who delivered an HIV-exposed infant by race. As you can see the patterns have stayed the same over the years with Black women representing over 60% of HIV positive women who deliver an HIV exposed infant Hispanic women represent on average 21% of all the HIV positive women delivering an HIV exposed infant, White women represent on average less than 14% of all HIV positive women who deliver an HIV exposed infant while women of other races (not Black, Hispanic or White) represent on average 5% of all HIV positive women delivering an HIV-exposed infant.
  • In 2007. Hispanics did not represent the highest proportion of HIV positive women delivering an exposed infant, as seen on the previous slide, however they did represent the largest proportion of HIV+ women delivering an infected infant, as seen in this graph. POINT OUT NUMBERS IN GRAPH
  • We also see slight differences among racial/ethnic groups when looking at factors that help prevent the transmission of HIV from the mother to the infant. This data is for HIV positive women delivering an infected infant from 2003-2007. As many of you know it is recommended that all women who are pregnant receive an HIV test during their pregnancy. For the period of 2003-2007, 38% (6 in 16) Hispanic women were diagnosed with HIV at or after delivery and 25% (6 in 25) Black women and 38% (3 in 8) White women were diagnosed at or after delivery. Hispanic and White women delivering an infected infant were more likely to be diagnosed at or after delivery when compared to black women. Receipt of antiretroviral therapy at the recommended intervals is also important in helping to prevent transmission of HIV from the mother to the child. ARV therapy is recommended at three intervals including pregnancy, labor and delivery and neonatally by the child. From 2003-2007, 29% (4 in 14) Hispanic women received antiretroviral (ARV) therapy at the 3 recommended intervals whereas 52% (13 in 25) Black women and 50% (4 in 8) White women received ARV therapy at the 3 recommended intervals. Hispanic women delivering an infected infant were more likely to not receive ARV therapy at the 3 recommended intervals when compared to Black and White women.
  • The third data source we examined and explored was the HIV Incidence Surveillance data HIV Incidence Surveillance is used to provide an estimates of the number of newly acquired HIV infections The HIV incidence estimate is generated using STARHS tests results and HIV testing history data for newly reported HIV cases The Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) test is a test that distinguishes between recent and long-standing HIV infection on a population level The STARHS test is performed on remnant serum specimens from confirmed HIV antibody positive tests Testing history data and ARV use data is gathered through patient interview and chart abstraction from patients that are newly diagnosed with HIV For this presentation we reviewed incidence data from cases diagnosed in 2007 and reported as of May 2009
  • Based on the HIV incidence surveillance data it was estimated that there were over 5,000 newly acquired HIV infections in Texas in 2008 which is greater than the number of cases diagnosed in 2008 In 2008. Hispanic persons accounted for 30% of these newly acquired HIV infections
  • In 2008 we found that Hispanic persons were more likely to be undiagnosed in their infection year. As you can see among the Hispanic population, 58% of the newly infected cases in 2008 were undiagnosed in 2008, compared to 52% of Blacks and 47% white/other Although the Hispanic population represents only 1/3 of the newly infected cases in 2007, they have the largest proportion of cases undiagnosed in their infection year.
  • The final data source we examined was the 2005 and 2007 Medical Monitoring Project data MMP collects information about people living with HIV who are receiving medical care in Texas The data is collected from patient interviews and medical record abstractions The 2005 and 2007 MMP data were used to evaluate delay in starting care among Hispanic persons
  • In 2005 and 2007, we saw that Hispanic persons were more likely to delay starting care for more than three months. Among those in care 21% of HIV-positive Hispanic persons delayed starting care for more than 3 months, compared to 13% of whites and 8% of African Americans. 2005 and 2007 total number of patients interviewed = 232. Hispanic = 70 (30.6%), White = 98 (n=42.8%), and Black = 52 (n=22.7%). (race and ethnicity info was available for 229 patients)
  • Read Slide
  • As part of Texas’ response to this emerging challenge a qualitative study was conducted between June and September 2008 to identify barriers to testing and care among the Hispanic Male Community in Texas. READ Slide Extra information on methodology in case questions are asked: CPG requested the survey to be done. Members of groups and key informant interviews were recruited by CPG members and staff from community groups and CBOs.
  • Slide 28: Read Slide.
  • Read Slide

Transcript

  • 1. Douglas A. Shehan University of Texas Southwestern Medical Center -In collaboration with Texas Department of State Health Services- 17 th Texas HIV/STD Conference, May 2010 Our Emerging Challenge: HIV Testing and Treatment Among Hispanics in Texas
  • 2. Outline: HIV Testing & Treatment Among Hispanics
    • Overview: The Hispanic population in Texas and our emerging HIV challenge
    • Exploring the Data
      • Data Sources
      • Emerging Patterns
    • Summary
  • 3. Growing Hispanic Population in Texas
    • Hispanics are the largest and fastest-growing minority in Texas
        • From 2000 to 2007 this population grew by 12%
        • In 2007 Hispanics represented 37% of Texans
    • By 2020, the Hispanic population is expected to outnumber the White population in Texas.
    Source: The Texas Data Center and the Office of the State Demographer
  • 4. Growing Hispanic Population in Texas Projected Texas Population by Specified Race/Ethnicity 1980 to 2040 Source: The Texas Data Center and the Office of the State Demographer Race/Ethnicity Population by Year 1980 Population millions (% of the population) 2040 Projected Population millions (% of the population) Hispanic 3.0 (21%) 18.8 (53%) Black 1.7 (12%) 3.4 (10%) White 9.4 (66%) 11.5 (32%)
  • 5. Emerging Challenge: HIV/AIDS Among Hispanic Persons in TX
    • Advances in HIV treatments have slowed the progression of HIV infection to AIDS and have led to dramatic decreases in deaths among persons with AIDS, yet the HIV/AIDS epidemic is a increasing problem among Hispanics in Texas.
    • In 2007:
      • Over 1,200 Hispanics were newly diagnosed with HIV/AIDS
      • Approximately 15,000 Hispanics were known to be living with HIV
      • Over 800 Hispanics were diagnosed with AIDS
  • 6. Emerging Challenge: HIV/AIDS Among Hispanic Persons in TX Hispanics living with HIV/AIDS in Texas 2007
  • 7. Increasing Proportion of AIDS Cases among Hispanics in TX
    • Number and Proportion of AIDS Cases Among Hispanics in Texas, 1990-2007
  • 8. Increasing Proportion of AIDS Cases among Hispanics in TX
    • Proportion of AIDS Cases by Race/Ethnicity Texas, 1990-2007
    Black Hispanic White Other
  • 9. Emerging Challenge: Increasing Proportion of AIDS Cases
    • Reasons the proportion of AIDS cases may be increasing among Hispanics in Texas
      • Not testing or testing less frequently
      • Getting into care later
    • Consequences
      • May unknowingly infect others
      • May unknowingly become co-infected with other STIs and/or drug-resistant strains of HIV
      • Quicker progression to AIDS
      • Could lead to poor health outcomes including death
  • 10. Exploring our Data: Data Sources
    • Examined and compared available Texas surveillance data to assess HIV testing and treatment among Hispanic persons in Texas
    • Descriptive analyses of data from:
      • Behavioral Risk Factor Surveillance System (BRFSS)
      • Texas HIV/AIDS surveillance
      • Enhanced Perinatal Surveillance (EPS)
      • HIV Incidence Surveillance (HIS)
      • Medical Monitoring Project (MMP)
      • Texas’ Response: Hispanic Male Community Assessment
  • 11. Behavioral Risk Factor Surveillance System (BRFSS)
    • Annual random-digit-dialed telephone survey
    • Administered in collaboration with the Centers for Disease Control and Prevention (CDC)
    • The 2007 Texas BRFSS administered questions about HIV testing history to 12,261 persons aged 18 to 64
    • Survey data were weighted:
      • by demographic characteristics
      • to account for differences in selection probabilities
  • 12. BRFSS: HIV Testing Behavior Ever Tested for HIV among persons aged 18-64 years, Texas, 2007 Race/Ethnicity HIV Testing History Ever Tested Tested in Past Year Hispanic 41% 15% Black 64% 28% White 41% 10%
  • 13. BRFSS: Testing Facility
    • Type of Facility where Last HIV Test was Received, Texas, 2007
  • 14. Texas HIV/AIDS Surveillance
    • In Texas, AIDS has been a reportable condition since 1983, and HIV became reportable by name in 1999
    • Key HIV/AIDS surveillance data collected include:
      • Demographic characteristics (sex, race/ethnicity, age, locality)
      • Mode of transmission
      • Opportunistic infections
      • Virologic and immunologic status
      • Enhanced perinatal surveillance data elements
    • Evaluated HIV/AIDS surveillance data of cases diagnosed through 2007 and reported as of May 2009
  • 15. Surveillance: Progression to AIDS w/in 1 Year of Dx, 2007 Progression to AIDS within 1 Year of HIV Diagnosis, Texas 2007
  • 16. Surveillance: Progression to AIDS w/in 1 Year of Dx, 2007 Progression to AIDS within 1 Year of HIV Diagnosis Among Hispanic Persons, by Country of Origin, Texas 2007 Country of Origin * Persons with unknown country of birth were excluded from analysis
  • 17. EPS: HIV+ Women Delivering, Texas 1999-2008
    • Proportion of HIV+ Women Delivering by Race/Ethnicity, Texas, 1999-2008
    Black Hispanic White Unknown/Other
  • 18. EPS: HIV+ Women Delivering, Texas 2007
    • Proportion of HIV+ Women Delivering an infected infant by Race/Ethnicity, Texas, 2007
  • 19. EPS: HIV+ Women Delivering an Infected Infant, 2003-2007
    • 38% of Hispanic women were diagnosed at or after delivery
      • 25% of Black women and 38% of White women were diagnosed at or after delivery
    • 29% of Hispanic women received antiretroviral (ARV) therapy at the three recommended intervals
      • 52% of Black women and 50% of White women received ARV therapy at the three recommended intervals
  • 20. HIV Incidence Surveillance (HIS)
    • HIS provides estimates of the number of newly acquired HIV infections
    • The HIV incidence estimate is generated using:
      • STARHS (Serologic Testing Algorithm for Recent HIV Seroconversion) tests results
        • A test that distinguishes between recent and long-standing HIV infection on a population level
      • HIV testing history data
    • Evaluated HIV incidence data on cases diagnosed in 2008 and reported by early 2010
  • 21.
    • Based on the HIS data the Texas Department of State Health Services estimates that there were over 5,000 newly acquired HIV infections in Texas in 2008
    • The Hispanic population accounted for 30% of these newly acquired HIV infections
      • The Black population accounted for 38%
      • The White/Other population accounted for 32%
    Incidence Surveillance: 2008 Incidence Estimate
  • 22. Incidence Surveillance: 2008 Incidence Estimate Race/Ethnicity Estimated Percentages Newly infected in 2008 and not diagnosed in 2008 Hispanic 58% Black 52% White/Other 47% Overall 52%
  • 23. Texas Medical Monitoring Project (MMP)
    • Texas MMP collects information about people living with HIV receiving medical care in Texas
    • Data acquired from 232 patient interviews and medical record abstractions
    • 2005 and 2007 Texas MMP data were used to evaluate delay in starting care (excludes Houston data)
  • 24. MMP: Delay in Starting Care, 2005 & 2007 Percentage of persons starting care more than 3 months after diagnosis
  • 25. MMP: Reason Hispanic Persons Start Care Later
    • Top reasons cited for not starting care:
    • Didn’t want to think about being HIV positive
    • Felt good/didn’t want to go
    • Was unable to get an earlier appointment
  • 26. Texas’ Response: Hispanic Male Community Assessment
    • Qualitative study to identify barriers to testing and care
    • Conducted between June and September 2008
    • Assessment involved key informant interviews and focus groups in East Texas, El Paso, the Valley and San Antonio
      • Eight focus groups
      • Three key informant interviews
  • 27. Findings: Hispanic Male Community Assessment
    • Barriers to testing and care:
      • Location/business hours of testing sites
      • Little advertisement of available services
      • Stigma associated with HIV and other STIs
      • Cost of healthcare
    • Other social/cultural barriers to testing and treatment:
      • Machismo (too “manly” to get sick)
      • Discussion of sexual topics taboo in the Latino community
  • 28. Summary
    • Hispanics are the largest and fastest growing minority in Texas
    • The HIV/AIDS epidemic is a growing among Hispanics in Texas with an increasing proportion of AIDS cases among Hispanics
    • When compared to other racial/ethnic populations in Texas, the Hispanic population is:
      • More likely to be unaware of their HIV status
      • Less likely to have reported testing in the last year or ever tested
      • More likely to delay starting care after diagnosis
      • More likely to progress to AIDS within 1 year of HIV diagnosis
    • Effective measures need to be implemented to increase HIV testing and earlier access to treatment among Hispanics in Texas
  • 29. Acknowledgments
    • Presentation co-authors/contributors:
      • Texas Department of State Health Services
        • Elvia Ledezma, MPH
        • Jennifer Chase, MSPH
        • Jonathon Poe, MSSW
        • Margaret Hawthorne, MPH
        • Miranda Leathers Fanning, MPH
        • Nita Ngo, MPH
        • Sharon Riley, MA
        • Tammy Sajak, MPH
      • University of Texas Southwestern Medical Center
        • Douglas A. Shehan
  • 30. Questions?
    • Contact Information:
      • [email_address]