HIV/AIDS: Hispanic/Latino Disparities and Policy Recommendations Daniel Santibanez, MPH Department of Public Health University of North Florida Donna T. Jones, MS, RD, LD/N MNT Services, Inc. This is part 6 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of Duval County Health Department. For more information or register for the seminars, please call 620-1289.

HIV/AIDS Defined What causes AIDS ? AIDS is the most serious form of an illness caused by a virus called the Human Immunodefiency Virus (HIV). In general, the body attacks and disables the immune system. Over time, with a damaged immune system, the body loses its ability to combat a variety of illnesses, called opportunistic infections (OI’s) or conditions. Challenges by these OI’s and conditions further challenges the immune system. The gradual destruction of the immune system, doesn’t happen the same in everyone. Some can remain well for up to 10-15 years without experiencing the first serious symptoms, while others the destruction of the immune system is very rapid, only a few years.

What causes AIDS ?

AIDS is the most serious form of an illness caused by a virus called the Human Immunodefiency Virus (HIV). In general, the body attacks and disables the immune system. Over time, with a damaged immune system, the body loses its ability to combat a variety of illnesses, called opportunistic infections (OI’s) or conditions. Challenges by these OI’s and conditions further challenges the immune system.

The gradual destruction of the immune system, doesn’t happen the same in everyone. Some can remain well for up to 10-15 years without experiencing the first serious symptoms, while others the destruction of the immune system is very rapid, only a few years.

The Culprit’s Mug-Shot

From Project Inform. For more information, contact the National HIV/AIDS Treatment Hotline, 800-822-7422, or visit our website, www.projectinform.org

Indicator Conditions for Case Definition of AIDS Candidiasis of bronchi, trachea, or lungs Candidiasis, esophageal Cervical cancer, invasive Coccidioidomycosis, disseminated or extrapulmonary Cryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal Cytomegalovirus disease (other than liver, spleen, or lymph nodes) Encephalopathy, HIV-related Herpes simplex, chronic ulcer(s) or bronchitis, pneumonitis, or esophagitis Histoplasmosis, disseminated or extrapulmonary Isosporiasis, chronic intestinal Lymphoma, Burkitt's Kaposi's sarcoma Lymphoma, immunoblastic Lymphoma, primary (in brain) Mycobacterium avium complex or M. kansasii , disseminated or extrapulmonary Mycobacteriumtuberculosis , any site Pneumocystis carinii pneumonia Pneumonia, recurrent Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Toxoplasmosis of brain Wasting syndrome, HIV-related

Candidiasis of bronchi, trachea, or lungs

Candidiasis, esophageal

Cervical cancer, invasive

Coccidioidomycosis, disseminated or extrapulmonary

Cryptococcosis, extrapulmonary

Cryptosporidiosis, chronic intestinal

Cytomegalovirus disease (other than liver, spleen, or lymph nodes)

Encephalopathy, HIV-related

Herpes simplex, chronic ulcer(s) or bronchitis, pneumonitis, or esophagitis

Histoplasmosis, disseminated or extrapulmonary

Isosporiasis, chronic intestinal

Lymphoma, Burkitt's

Kaposi's sarcoma

Lymphoma, immunoblastic

Lymphoma, primary (in brain)

Mycobacterium avium complex or M. kansasii , disseminated or extrapulmonary

Mycobacteriumtuberculosis , any site

Pneumocystis carinii pneumonia

Pneumonia, recurrent

Progressive multifocal leukoencephalopathy

Salmonella septicemia, recurrent

Toxoplasmosis of brain

Wasting syndrome, HIV-related

Classification system for HIV infection

Infection Control/Prevention Abstinence Condoms: Latex or polyurethane condoms Female condoms MTCT: Viramune or AZT Tx during childbirth, avoid breast feeding The transmission of HIV from mother to child is responsible for over 90% of infections among children under the age of 15 Using sterile needles for IVDU Universal Precautions for healthcare workers

Abstinence

Condoms:

Latex or polyurethane condoms

Female condoms

MTCT: Viramune or AZT Tx during childbirth, avoid breast feeding

The transmission of HIV from mother to child is responsible for over 90% of infections among children under the age of 15

Using sterile needles for IVDU

Universal Precautions for healthcare workers

Global approximates 14,000 new HIV infections a day in 2003 More than 95% are in low and middle income countries Almost 2000 are in children under 15 years of age About 12,000 are in persons aged 15 to 49 years, of whom: almost 50% are women about 50% are 15–24 year olds

More than 95% are in low and middle income countries

Almost 2000 are in children under 15 years of age

About 12,000 are in persons aged 15 to 49 years, of whom:

almost 50% are women

about 50% are 15–24 year olds

The AIDS pandemic Adults and children living with HIV/AIDS, end 2002 North America 980,000 Caribbean 440,000 Latin America 1,500,000 North Africa & Middle East 550,000 Sub-Saharan Africa 29,400,000 East Asia & Pacific 1,200,000 S & SE Asia 6,000,000 Australia & New Zealand 15,000 Western Europe 570,000 Eastern Europe & Central Asia 1,200,000 2001-02 increase Source: UNAIDS 3.4% 4.8% 5.6% 11.1% 13.2% 13.5% 15.8% 17.8% 20.8% 29.0%

Age-sex-adjusted percentage of adults aged 18+ who had ever been tested for HIV, January - June 2002 * Estimates are age-sex-adusted to the 2000 U.S. standard population using five age groups: 18-24 years, 25-34 years, 35-44 years, 45-64 years, and 65 years and over 46.7 - 51.7 49.2 Black, non-Hisp 31.4 - 33.4 32.4 White, non-Hisp 33.2 - 37.6 35.4 Hispanic 95% confidence interval Percent* Race/Ethnicity

AIDS Cases by Race/Ethnicity 3,026 196 American Indian/Alaska Native 7,166 497 Asian/Pacific Islander 172,993 8,757 Hispanic 368,169 21,304 Black, not Hispanic 376,834 12,222 White, not Hispanic Cumulative Estimated # of AIDS cases, through 2003 Estimated # of AIDS Cases in 2003 Race or Ethnicity

Top 10 AIDS Reported Cases by State/Territory Maryland 26,918 North Carolina 1,083 Georgia 27,915 New Jersey 1,516 Puerto Rico 28,301 Maryland 1,570 Pennsylvania 29,988 Illinois 1,730 Illinois 30,139 Pennsylvania 1,895 New Jersey 46,703 Georgia 1,907 Texas 62,983 Texas 3,379 Florida 94,725 Florida 4,666 California 133,292 California 5,903 New York 162,446 New York 6,684 State/Territory # of Cumulative AIDS cases through 2003 State/Territory # of AIDS Cases in 2003

Cumulative Adult AIDS Cases Through May 2002 (N=87,682) Comment: The epidemic in Florida has spread out to suburban and rural areas from urban epicenters in Miami-Dade, Broward, Palm Beach, Hillsborough, St. Petersburg, Orange, and Duval counties. Though 55% of the 87,000 AIDS cases are known to have died, the cumulative numbers remind us of the overall burden of the epidemic on the community. Characterized by race/ethnicity, sex, and mode of exposure, it becomes apparent that HIV/AIDS in Florida consists of multiple overlapping, but somewhat distinct, epidemics. Source: HIV/AIDS Reporting System (HARS). CUMULATIVE CASES 0 to 500 501 to 2500 2501 to 5000 Over 5000 6 780 9 50 5 541 42 8384 28 487 1345 70 19 88 126 306 25400 36 145 8 14 71 100 80 664 59 26 33 213 27 1180 30 64 180 122 5014 18 15 79 550 4969 1337 804 328 13790 574 193 266 167 4402 314 1232 112 840 1466 113 1033 268 178 40 1440 13 791 3491

Overview Through May 2002 Florida U.S. Reported AIDS Cases 87,682 822,920 HIV Cases 25,761 182,851 Estimated HIV Prevalence 95,000 850,000-950,000 Whites 30,200 --- Blacks 49,100 --- Hispanics 15,200 --- Others 500 --- Estimated Percent Aware of Serostatus 75% 75% Estimated Annual HIV Incidence 4,000 40,000

Florida U.S.

Reported

AIDS Cases 87,682 822,920

HIV Cases 25,761 182,851

Estimated

HIV Prevalence 95,000 850,000-950,000

Whites 30,200 ---

Blacks 49,100 ---

Hispanics 15,200 ---

Others 500 ---

Estimated Percent

Aware of Serostatus 75% 75%

Estimated Annual

HIV Incidence 4,000 40,000

HIV/AIDS epidemic is a serious threat to the Hispanic/Latino community In addition to being a population seriously affected by HIV, Hispanics continue to face challenges in accessing health care, prevention services, and treatment In 2001, HIV/AIDS was the third leading cause of death among Hispanics men aged 35-44 and the fourth leading cause of death among Hispanic women in the same age group

In addition to being a population seriously affected by HIV, Hispanics continue to face challenges in accessing health care, prevention services, and treatment

In 2001, HIV/AIDS was the third leading cause of death among Hispanics men aged 35-44 and the fourth leading cause of death among Hispanic women in the same age group

Cumulative Effects of HIV Infection and AIDS (through 2002) Although Hispanics make up only about 14% of the population of the U.S. and Puerto Rico, they accounted for 20% of the more than 886,500 AIDS cases diagnosed since the beginning of the epidemic By the end of 2002, nearly 88,000 Hispanics had died with AIDS

AIDS in 2002 The 76,052 Hispanics living with AIDS accounted for 20% of all people in the United States living with AIDS

HIV/AIDS in 2002 From 1999 - 2002, the number of new HIV/AIDS cases increased 26% among Hispanics in 30 surveillance areas

Risk Factors and Barriers to Prevention A number of cultural, socioeconomic, and health related factors help drive the HIV epidemic in the Hispanic community Because Hispanic Americans or their parents have emigrated from many Latin countries or regions, there is no single Hispanic culture in the U.S.

A number of cultural, socioeconomic, and health related factors help drive the HIV epidemic in the Hispanic community

Because Hispanic Americans or their parents have emigrated from many Latin countries or regions, there is no single Hispanic culture in the U.S.

Research shows that Hispanics born in different countries have different behavioral risk factors for HIV/AIDS Data suggest that Hispanics born in Puerto Rico are more likely than other Hispanics to contract HIV as a result of injection drug use By contrast, sexual contact with other men is the primary cause of HIV infections among men born in Mexico

Risk Factors and Barriers to Infection Heterosexual Risk Denial Substance Abuse Poverty Sexually Transmitted Diseases

Poverty Of the Hispanic people with HIV/AIDS interviewed in a multi-site study, 47% of Mexican-born men who have sex with men (MSM) and 59% of Puerto Rican-born MSM had annual incomes of less than $10,000 A variety of socioeconomic problems associated with poverty, including limited access to high-quality care, directly or indirectly increase the risk for HIV infection

Of the Hispanic people with HIV/AIDS interviewed in a multi-site study, 47% of Mexican-born men who have sex with men (MSM) and 59% of Puerto Rican-born MSM had annual incomes of less than $10,000

Denial Although many Hispanics are increasingly engaged in the fight against HIV/AIDS, some Hispanics have been slow to join the effort Many Hispanics MSM identify themselves as heterosexual and, and as a result, may not relate to prevention messages crafted for gay men

Although many Hispanics are increasingly engaged in the fight against HIV/AIDS, some Hispanics have been slow to join the effort

Heterosexual Risk Some women, including those who suspect that their partners are at risk for HIV infection, may be reluctant to discuss condom use with their partners out of fear of emotional or physical abuse or the withdrawal of financial support Hispanic women are most likely to be infected with HIV as a result of sex with men

Some women, including those who suspect that their partners are at risk for HIV infection, may be reluctant to discuss condom use with their partners out of fear of emotional or physical abuse or the withdrawal of financial support

Substance Abuse Both casual and chronic substance users are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol Injection drug use continues to be a significant risk factor for Hispanics

Both casual and chronic substance users are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol

Sexually Transmitted Diseases Compared with whites, Hispanics are about twice as likely to have gonorrhea or syphilis Sexually transmitted infections increase the likelihood of HIV transmission

Compared with whites, Hispanics are about twice as likely to have gonorrhea or syphilis

Lack of experience using American medical system In most Central and South American communities, medical services are not always located nearby and pharmacists are permitted to freely dispense many drugs that require prescriptions in the U.S. Therefore, people go to see the doctor only when they are very sick

In most Central and South American communities, medical services are not always located nearby and pharmacists are permitted to freely dispense many drugs that require prescriptions in the U.S.

Many clients did not have access to medical services back home, and need to be educated about the U.S. system as well as basic medical issues. For example, case managers at La Clinica del Pueblo in Washington D.C. spend a great deal of time with clients addressing questions like: “ What is a prescription? A refill?” “How do you take the medications?” La Clinica del Pueblo receives Title I and Title II funds to serve Hispanic men whose exposure category is men who have sex with men. Fewer than 10 percent of La Clinica clients speak fluent English

“ Clients are accustomed to going to the emergency room for drugs when they feel bad. The idea of taking medications when they feel okay is foreign. These individuals don’t understand drug resistance, or their need to see a doctor. In Mexico, individuals get drugs from pharmacists without ever seeing a physician” Barbara Aranda-Naranjo of the South Texas AIDS Center for Children and Families in San Antonio

“ You don’t talk about your disease! You never, in the Hispanic culture, talk about anything where someone will lose face. It is very difficult for these women to be honest with their physician; they think it is safer if no one finds out they are sick.” Barbara Aranda-Naranjo of the South Texas AIDS Center for Children and Families in San Antonio Reluctance to even discuss health problems also is a factor

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Provide additional resources to support services to Latinos, including increased funding to Puerto Rico and states currently experiencing dramatic increases in Latino populations Create, fund, and sustain services tailored to monolingual Spanish speaking and migrant/immigrant Latinos without regard to citizenship states Create and support HIV prevention and care services to Latinos in and transitioning from correctional settings

Provide additional resources to support services to Latinos, including increased funding to Puerto Rico and states currently experiencing dramatic increases in Latino populations

Create, fund, and sustain services tailored to monolingual Spanish speaking and migrant/immigrant Latinos without regard to citizenship states

Create and support HIV prevention and care services to Latinos in and transitioning from correctional settings

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Work to improve the coordination of services within and between states/territories and local jurisdictions

Work to improve the coordination of services within and between states/territories and local jurisdictions

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Combine Ryan White Care Act and AIDS Drug Assistance Program (RWCA/ADAP) with state and local resources to expand prescription drug and medical services for uninsured Latinos

Combine Ryan White Care Act and AIDS Drug Assistance Program (RWCA/ADAP) with state and local resources to expand prescription drug and medical services for uninsured Latinos

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Support increased funding for the National Minority HIV/AIDS initiative (MHAI) In its fourth year, the MHAI is a critical tool in the national efforts to eliminate HIV/AIDS related health disparities among racial and ethnic groups

Support increased funding for the National Minority HIV/AIDS initiative (MHAI)

In its fourth year, the MHAI is a critical tool in the national efforts to eliminate HIV/AIDS related health disparities among racial and ethnic groups

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Develop resource allocation methodologies that are consistent with, and that anticipate, local need States, territories, and local health departments should work in close collaboration with planning bodies to ensure that resource allocation are proportionate with systematically demonstrated need

Develop resource allocation methodologies that are consistent with, and that anticipate, local need

States, territories, and local health departments should work in close collaboration with planning bodies to ensure that resource allocation are proportionate with systematically demonstrated need

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Support basic HIV/AIDS educational efforts targeting Latinos Information about HIV/AIDS including modes of exposure, strategies for preventing HIV infection, the natural history of the disease, the importance of early detection and early treatment, and current treatment approaches should be broadly disseminated and constantly updated

Support basic HIV/AIDS educational efforts targeting Latinos

Information about HIV/AIDS including modes of exposure, strategies for preventing HIV infection, the natural history of the disease, the importance of early detection and early treatment, and current treatment approaches should be broadly disseminated and constantly updated

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Create public information and awareness campaigns that educate Latinos about their rights and entitlements as well as the availability and location of services locally

Create public information and awareness campaigns that educate Latinos about their rights and entitlements as well as the availability and location of services locally

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Build and support local, community based-capacity

Build and support local, community based-capacity

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Establish and uphold the highest standards for culturally competent care

Establish and uphold the highest standards for culturally competent care

Work to improve access to prevention, care, and treatment services for Latinos regardless of their immigration or citizen status Provide and support cultural competency training

Provide and support cultural competency training

Organize and mobilize Latinos Encourage and support coalition work within Latino communities and between Latinos and other people of color

Encourage and support coalition work within Latino communities and between Latinos and other people of color

Keys for Provider Success Organizations caring for Hispanics living with HIV disease should link clients with programs that help them address their economic circumstances In some populations, linkages to employment services, transportation services, and counseling may be essential

Organizations caring for Hispanics living with HIV disease should link clients with programs that help them address their economic circumstances

In some populations, linkages to employment services, transportation services, and counseling may be essential

Keys for Provider Success Critical is the integration of substance abuse prevention and AIDS treatment, and actively addressing the role of homophobia and marianismo in health care utilization and prevention methods The Hispanic cultural attitude of machismo and marianismo reinforces female passivity and male dominance and virility, and can reduce safe sex practices and negatively influence treatment utilization

Critical is the integration of substance abuse prevention and AIDS treatment, and actively addressing the role of homophobia and marianismo in health care utilization and prevention methods

Providers should… Collaborate with organizations that have already established trust with the community to build a network of services Aggressively educate the community about testing the treatment Implement educational campaigns in the preferred language of the population Assure that all case managers and physicians are bi-lingual and bi-cultural Provide translation services

Collaborate with organizations that have already established trust with the community to build a network of services

Aggressively educate the community about testing the treatment

Implement educational campaigns in the preferred language of the population

Assure that all case managers and physicians are bi-lingual and bi-cultural

Provide translation services

Providers should… Help clients access support services including support groups Integrate social services with AIDS treatment in order to help patients comply with regimens, return for appointments, eat nutritiously, and maintain their overall health Recognize that HIV status affects individuals’ legal status and/or desire to normalize their legal status

Help clients access support services including support groups

Integrate social services with AIDS treatment in order to help patients comply with regimens, return for appointments, eat nutritiously, and maintain their overall health

Recognize that HIV status affects individuals’ legal status and/or desire to normalize their legal status

Thank You! Daniel Santibanez [email_address] This is part 6 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of Duval County Health Department. For more information or register for the seminars, please call 620-1289.