HIV/AIDS

HIV/AIDS

hiv

HIV/AIDS

Highlights


HIV/AIDS in African Americans: A Special Challenge
Down Low (DL) l Group Barriers to HIV Prevention & Control
Challenges of Managing HIV/AIDS & Substance Abuse, Combined
AIDS Blanket Quilt/Names Project: Reminder of the Epidemic’s Destructive Impact
Our Overview of HIV/AIDS
HIV/AIDS has become epidemic in the African American community, and is also disproportionately high in the Hispanic community. With adequate education, and access to high quality care, racial and ethnic minority populations can, with the help of others who care, reverse this epidemic.

“Mainstream America” should care more about the AIDS epidemic in minorities because:

  1. The cost of treating HIV/AIDS is very high, directly and indirectly. An increased societal investment on prevention would, therefore, be a very sound investment;
  2. The intermittent illnesses of some people with AIDS, and the multiple demands of treatment may interfere with productivity in the workplace;
  3. Although treatment with protease inhibitors, and the use of cocktails (multiple drug therapy) has changed AIDS from primarily being a fatal disease, to becoming a chronic disease, there is still no cure and, as with other serious and costly diseases, “Prevention is Always Better Than a Cure“.

The Down Low

The term Down Low is most widely understood to mean keeping some information or activity private, or down low. It is also often used to describe the behavior of men who have sex with other men as well as with women, but do not consider themselves as gay or bisexual. Instead, they may refer to themselves as on the down low, on the DL, or on the low.

Although the practices of bisexual men are not unique to African-American men, the Down Low term is probably most often used regarding African-American men because it reportedly originated in the African-American community. However, there is an unknown, but significant, number of Hispanic and White men who are also on the Down Low/bisexual.

While it is known that some heterosexual women have become infected with HIV through sexual contact with bisexual men, the extent is not really known. For example, some heterosexual women develop HIV infection from bisexual men who also inject drugs.

Because the extent to which being on the Down Low may be related to the significant increase in HIV infection among African-American women in recent years is unknown, much more research is needed regarding this issue. CDC is currently collaborating in the conduct of several projects related to HIV-related risk practices in men, including men who refer to themselves as on the Down Low.

African-American and Hispanic Women are at Much Greater Risk

Today, women account for one-fourth of all new HIV/AIDS diagnoses:

  • Of the 126,964 women living with HIV/AIDS in 2005, 64% were African-American and 15% were Hispanic;
  • Further, the rate of AIDS diagnosis in African-American women was 23 times the rate in white women. Contributing to the very high incidence of HIV/AIDS in African-American, and then Hispanic women, is the fact that an unknown but significant number of their male partners and acquaintances also have sex with men, often without the women’s knowledge. Some of these men do not consider themselves gay or bisexual, and refer to themselves as on the Down Low. The Down Low is discussed further in What It Means, Health Power’s web site glossary.The various challenges for all involved associated with this practice requires that:
    • African-American and Hispanic women become better informed about how to protect themselves from HIV, and act on that knowledge;
    • The public health community, physicians and other health professionals, and researchers give a higher priority to health education, behavioral research, and the availability of support networks and related resources in disproportionately affected communities of color.

    Of the 207,810 men who reported having sex with men (MSM), 32% or one-third of the total was African-American men and 16% were Hispanic. Further, of the MSM who reported injecting drugs, another major risk factor for HIV, 39% were African-American and 14% were Hispanic.

    Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases of the National Institutes of Health and a widely recognized HIV/AIDS expert, has noted in various that Complacency on AIDS is dangerous.

    Further, when asked Who is the face of AIDS in the U.S., his response, has been:

    • o A young African-American woman infected by a partner who she did not know was infected, and had no reason to believe she needed to protect herself.
    • A young African-American man who is bisexual, and because of the stigma associated with being gay, superimposed on the stigma of being infected, does not seek counsel nor appreciate what he needs to do to decrease or eliminate HIV/AIDS in his community.

Now, almost 50% of men with HIV/AIDS are African-American, and in women, almost 60% are in African-American women.

All women of color especially African-American women, who bear the greatest burden from HIV/AIDS, need to be well informed about the Down Low, and to increase their knowledge, skills, and determination to protect themselves. Hopefully, their sense of self worth will be enough to motivate them to do so. However, if not, they will hopefully protect themselves for the good of those they love. . . or in the reverse, for the good of those who love them.

Special Tip: Participation in women’s support groups (even two people can be a group), can help women develop or increase their will and skills in protecting themselves.

 

Key research activities:
  • a comprehensive literature review,
  • conduct of 48 focus groups,
  • 92 in-depth interviews,
  • an all-day Grassroots workshop
  • an all-day Leaders and Experts workshop,
  • comparative analysis of selected high profile print and broadcast commercials targeting African-Americans

About the 48 Focus groups conducted with the following African-American groups:

  • adolescents
  • gay and bisexual men and adolescents
  • heterosexual men
  • lesbians
  • prison inmates (current and former)
  • substance users
  • partners of substance users
  • women of childbearing age, including a Caribbean group
  • faith based leaders
  • other leaders and experts

In addition, focus groups were conducted with representatives of community based organizations.

HIV prevention strategies were developed for:

  • each of the above African-American groups;
  • African-American faith leaders and communities;
  • Other African-American leaders;
  • HIV counseling and testing;
  • Community organizations; and
  • Public communication.

Looking Backward to Plan Forward:

Dr. Goodwin considers many of the findings and recommendations of her research still valid, and not adequately pursued. Health Power considers it desirable that a repeat research project, based on the AIDS and African-Americans: It’s Time for Action model, be conducted after updated modifications, as there is a strong case for comparing the findings from that baseline study with where we are today – both as health professionals and as at-risk communities and populations. A summary of the findings from the original research project can be obtained from Dr. Goodwin at njgoodwin@healthpowerforminorities.com. –

Two key tables from the project follow.

12 Barriers to HIV Prevention and Control in
Racial and Ethnic Populations
Barrier Key Strategy/Strategies
1. Preventive health has a decreased priority because of competing needs and/or interests. a. Provide ongoing culturally relevant and “family”* centered direct, print and broadcast information, education and health services, with an emphasis on disease prevention, early detection and control.
* Traditional and non-traditional families.
2. There is widespread distrust of both the medical establishment, and the government. a. Openly discuss in various settings the historical validity of some concerns, such as the legacy of the Tuskegee Study.

b. Use culturally and linguistically appropriate health educators and service providers whenever possible.

c. Emphasize, especially with African-Americans and Hispanics who engage or have engaged in high-risk practices, the increased likelihood of poorer outcomes with delayed testing and treatment.

d. Downplay governmental involvement in direct education and service.

3. There is a prevalent stigma associated with having HIV/AIDS. a. Incorporate sensitive and informed discussion about HIV/AIDS in individual and group discussions involving persons with HIV/AIDS, members of the general population, and mixed audiences involving both groups.
4. Poverty and under-education occur frequently among persons with HIV and AIDS. a. Indicate in appropriate group settings, the high correlation between poverty and poor health status.

b. Encourage and support the informed participation of affected persons in both formal education and self-education, since increased educational achievement is associated with improved economic status and health status.

5. Many persons have inadequate skills in negotiating safer sex and other risk reduction and avoidance situations. a. Conduct skill development workshops that include: multiple sessions, improving self-esteem, and individual and small group situation-specific individual and small group practice exercises.
6. There are not enough ongoing peer and other mutual support opportunities regarding HIV/AIDS risk reduction. a. Develop and facilitate the conduct of a greater number of ongoing HIV/AIDS risk reducing peer and other mutual support opportunities.
7. There is wide opposition to condom use, in part because of concerns about population control. a. Incorporate discussion of concerns about population control in group discussions about condom use as well as the risk reducing benefits of planned condom use.

b. Discuss approaches to infection-free reproduction through pre-conception HIV testing (at two intervals), and condom use during pregnancy unless one is engaged in a monogamous relationship with an uninfected person.

8. Many persons with HIV and AIDS have experienced multiple layers of discrimination related to such factors as:

  • race and/or ethnicity
  • socioeconomic status
  • sexual orientation
  • injection drug use
  • history of incarceration

The result is less responsiveness to prevention and treatment requirements.

a. Discuss, in appropriate individual and group settings, the damaging impact on persons of having experienced multiple levels of discrimination

b. Develop and implement modified approaches in order to achieve adherence with diagnostic and treatment requirements.

9. There is an inadequacy of customized, culturally relevant, user-friendly health information, messages and services related to HIV and AIDS. a. Increase the availability and use of customized, culturally relevant, user-friendly information, messages and services related to HIV and AIDS.
10. There is a prevalence of low individual, family, group, and community esteem. a. Discuss the relationship of individual, family, group and community esteem on lifestyle and health behavior.

b. Develop and conduct, interventions which incorporate esteem building as a significant component.

11. As a result of religious conservatism, there is less faith community involvement than needed. a. Approach various faith leaders and alliances and, in coordination with them, facilitate the development and conduct of needed outreach, educational and advocacy activities, including joint activities with other faith-centered organizations.
12. There is a need for increased community leadership, organization, collaboration and advocacy related to HIV/AIDS. a. Develop and/or increase the level of active and ongoing involvement of community leaders in issues related to HIV/AIDS.

NOTE: See also the key group-specific barriers found for the following groups:

  • gay and lesbian persons
  • heterosexual men
  • heterosexual women
  • prisoners and parolees
  • substance abusers
  • teenagers

Note: While the following barriers were found in the project, it’s important that we emphasize that they did not apply to all persons in any of the groups. Thus, stereotyping is to be avoided. .

Gay and Lesbian Persons

  • Prevalent community stigma regarding persons with these sexual orientations
  • Scarcity of HIV related information and services specific to their needs
  • Few HIV related peer and other mutual support group opportunities

Heterosexual Men

  • Frequent low level of consciousness that non-condom use increases HIV and other STD transmission
  • Tendency by some to dominate their female partners because of either:
    • cultural tradition, and/or
    • having limited power in “mainstream America”
  • Tendency of more men than women not to use the health care delivery system
  • Few HIV related peer or mutual support group opportunities

Heterosexual Women

  • Relative scarcity of eligible men of color influences sexual decision-making
  • Inadequate control in many male-female relationships
  • Fear of potential physical and/or psychological abuse if condom use is insisted on
  • Too few peer or mutual support group opportunities that incorporate HIV related issues

Prisoners and Parolees

  • Official denial that sex occurs in prison, thus eliminating access to condoms
  • Reported widespread availability and use of drugs in prisons
  • Negligible HIV related services to prisoners on release as well as their families or significant others

Substance Abusers (including Users of Alcohol and Non-injection Drugs)

  • Individuals are unlikely to practice safe(r) sex when “high” or “under the influence”
  • Inadequate number of drug treatment slots
  • Inadequate number of needle exchange programs that incorporate drug treatment

Teenagers

  • Teen idleness and hopelessness
  • Inadequate parent (and other adult) teen communication
  • Media messages glamorizing sex, violence and risk taking
  • Too few peer or mutual support group opportunities that incorporate HIV related issues

What can be done, where considered still indicated:

  1. Select (only) one or two barriers based on their local situation and priorities;
  2. Develop strategies for action including sources for financial and other resource support;
  3. Implement the agreed upon plan of action; and
  4. Evaluate and monitor the results. This same approach is advised for the 12 key general barriers also identified in this section by Health Power.

Substance Abuse Combined

Slide Presentation by Norma J. Goodwin, M.D.
President of Health Power



Why Substance and Alcohol Treatment are Key in HIV Care:

  • Illegal drugs and alcohol are risk factors for HIV;
  • Illegal drugs and alcohol interfere with adherence to HIV medications;
  • Illegal drugs and alcohol increase the risk of side effects from medications;
  • Illegal drugs and alcohol reduce the practice of safer sex.
Substance Abuse Screening
All clients, or patients, with HIV should be screened for substance use (alcohol and drugs) at least once a year.

Tips in Assessing Alcohol & Substance Abuse:

  • Heavy smokers often also have alcohol and/or substance dependence.
  • When substance abuse is admitted, ask specific questions about injection drug use
  • Be sure to use non-judgmental language in inquiring about, and discussing substance use.
Effect of Regular Use of Methadone – An Opiate
Causes physical and psychological dependencymeaning a regular user gets withdrawal when it is stopped.

Side Effects of Methadone:

  • Possible worse effect if one has a co-infection, such as HIV, hepatitis, TB and pneumonia;
  • Development of tolerance, meaning one is less responsive to the same dose, over time;
  • Physical dependence;
  • Psychological dependence;
  • Respiratory depressions;
  • Hypertension (low blood pressure);
  • Nausea, vomiting, constipation, sedation, dizziness, edema (swelling)

The most serious side effects of methadone, which can include death, usually occurwith recreational use, and not in methadone maintenance programs.

Key Antiretroviral Therapy Goals

  • Restoring and/or preserving immune function (Keeping CD4 T cells high);
  • Reducing HIV-related illness and death;
  • Limiting the risk of viral resistance, thus preserving future treatment options;
  • Maximum and sustained suppression of viral replication (Keeping the HIV blood level low);
  • Improving the quality of life
  • Integrated care is the best care.
  • Thus, care team members need experience working with individuals with both HIV/AIDS & substance use.
  • Combined (HIV/AIDS and substance abuse) treatment clients have:
    • A greater probability of relapse
    • A greater probability of having cultural variations

Basic Classes of HIV Medications:

  • NRTIs – Nucleoside/nucleotide reverse transcriptase inhibitors or “nukes”
  • NNRTIs – Non-nucleoside reverse transcriptase inhibitors or “non-nukes”
  • PIs – Protease inhibitors
  • EIs – Entry inhibitors (including fusion inhibitors)

When a Person with HIV Can be Diagnosed as Having AIDS:

According to CDC, a person with HIV has AIDS when:

  • He or she has a CD4 cell count of less than 200. The CD4 count measures the strength of the body’s immune (or defense) system. A normal CD4 cell count is 500 or above.
  • He or she develops certain serious conditions related to HIV infection. They are called AIDS-defining illnesses, such as pneumocystis carinii pneumonia or PCP, which is an opportunistic infection, a skin cancer called Kaposi’s sarcoma, cervical dysplasia or cervical cancer, and tuberculosis.
  • Another key test used today in making decisions about treating people with HIV is the viral load. Ideally, it should be undetectable. However, the level at which treatment may be considered is usually more than 55,000 copies/ml.

Basic Principles of HIV Treatment:

Treatment for HIV takes into consideration both the CD4 and viral load levels.

  • Highly Active Anti-Retroviral Treatment (HAART):taking 3 or more drugs at the same time;
  • Preventive medicines to avoid opportunistic infections;
  • Treatment of HIV-related illnesses; and
  • Healthy living practices, including eating healthy, exercise, getting enough sleep, stress management, and avoiding cigarette smoking, alcohol, and street drugs.

Adherence: A Key to Controlling HIV/AIDS

It is very important that people being treated for HIV always take that medications as ordered. Remember, the medications are not as bad as the disease. Also, without adherence, there is an increased chance of developing resistance.

Possible Special Side Effects of Methadone Maintenance on HIV Treatment:

  1. Some HIV medications interact, or mix, with methadone, and require a change in the dosage of methadone or the HIV medicine. Therefore, the treatment of some people on combined therapy requires more frequent lab tests or check-ups.
  2. Because methadone is an opiate, adherence may be more difficult for some individuals who are also on methadone maintenance therapy. They therefore may require more frequent monitoring, as well as more support.
  3. Because of the physical and psychological dependence associated with methadone maintenance, if detoxification is done on a person receiving HIV therapy, it must be carefully done under medical supervision, and with the active support of the entire care team.

Special Tips for Controlling HIV/AIDS:

Always emphasize:

  • Keeping Pressure on the Virus
  • If there’s not enough of the right medicine in the blood:
    HIV can continue to multiply (make copies); and
  • If there’s not enough of the right medicine in the blood:
    Resistance can develop, thus decreasing a person’s treatment options

Another key test used today in making decisions about treating people with HIV is theviral load. Ideally, it should be undetectable. However, the level at which treatment may be considered is more than 55,000 copies/ml. PCR. Treatment for HIV takes into consideration both the CD4 and viral load levels.

  • Highly Active Anti-Retroviral Treatment (HAART):taking 3 or more drugs at the same time;
  • Preventive medicines to avoid opportunistic infections;
  • Treatment of HIV-related illnesses; and
  • Healthy living practices, including eating healthy, exercise, getting enough sleep, stress management, and avoiding cigarette smoking, alcohol, and street drugs.

Adherence: A Key to Controlling HIV/AIDS:

It is very important that people being treated for HIV always take that medications as ordered. Remember, the medications are not as bad as the disease. Also, without adherence, there is an increased chance of developing resistance.

Possible Effect of Methadone Maintenance on HIV Treatment:

Some HIV medications interact, or mix, with methadone, and require a change in the dosage of methadone or the HIV medicine. Therefore, the treatment of some people on combined therapy requires more frequent lab tests or check-ups.

Special Tips for Controlling HIV/AIDS:

Always focus on :

  • Keeping Pressure on the Virus
  • If there’s not enough of the right medicine in the blood:
    • HIV can continue to multiply (make many more copies of the virus);
    • Resistance can develop, thus decreasing ones’ treatment options.

The AIDS Blanket (Quilt) or the Names Project:

Reminder of the HIV/AIDS Epidemic’s Destructive Impact

Perhaps the best known and most touching single symbol of the more than 250,000 people who have died from HIV/AIDS in the United States is the AIDS Blanket or Quilt, also called the AIDS Memorial Blanket.Since the AIDS Blanket was started in 1987, more than 40,000 colorful panels have been created to remember and honor loved ones who have been lost as a result of HIV/AIDS.

Now more than 25 years since the start of the AIDS Epidemic, and although the number of persons dying from HIV/AIDS has decreased markedly as a result of effective combination therapy, there are still over 40,000 new HIV infections each year in the United States. In addition, this incidence has remained the same for the past 10 years. Further, there are more than 750,000 persons in the U.S. today with HIV/AIDS. Of great concern, more than 250,000 people in this country who are infected with HIV don’t know it.

In addition to the information on HIV/AIDS in this section of our web site, a broad mix of related information can be found in “What It Means”, our glossary, such as antibody, CD4 cells, HIV tests,

immune deficiency, Kaposi’s sarcoma, lipodystrophy, lymphatic system, opportunistic infection,

risk, risk factor, and viral load,
Leading additional sources of information on HIV/AIDS are CDC’s National Prevention Information Network (NPIN) and National Center for Health Statistics. Their web sites are only one click away from our Relevant Resources section.