Addressing HIV Disparities Among Women of Color

Addressing HIV Disparities Among

Women Of Color In The Southern United States

www.healthhiv.org

Women of Color Living With HIV A

s an increasing number of women in the United

Factors Influencing HIV Rates Among Women

States become infected with HIV, particularly women

Biological Susceptibility

of color, the changing epidemic is challenging established mechanisms for the delivery of primary medi-

Women are more vulnerable to HIV infection due to prolonged mucosal

cal care services. Advances in HIV treatments, and the

exposure to semen containing HIV. Untreated sexually transmitted infections

resultant longer life expectancy for those living with

(STIs) and recurrent yeast infections also increase the biological susceptibil-

the disease, means primary care providers must man-

ity to HIV among women. Interpersonal power inequities in sexual and family

age the chronic medical conditions of patients living

relationships have been posited as an additional explanation for gender

with

differences in HIV infection.5,6

These

HIV

in

addition

developments,

to

providing

along

with

HIV

treatment.1

changes

in

the

types and number of people living with HIV in the U.S.,

Delay of HIV Testing and Late Initiation of Treatment

require a comprehensive, integrated approach to HIV pri-

Diagnosis late in the progression of HIV disease frequently results in opportunistic infections and

mary medical care and treatment.

less robust immune system rebound once treatment has been initiated. Actual and perceived In 2006, an estimated 26% of new HIV infections were in females (up from 18% in 1994). Forty five percent of cases

lack of power in sexual network patterns and family relationships also are thought to be factors

were in African-Americans, 35% in Whites, and 17% in Hispanics. Among women, 60% of new infections were

contributing to women prioritizing the health concerns of others over their own, resulting in

reported in African-American women – despite the fact they make 12% of the US female population – 22% in White

delayed testing, diagnosis, and care. 5,6

women and 16% in Hispanic women.

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The rate of HIV infection among African-American women was almost fifteen

times higher than the rate for White females, and almost three times the rate for Hispanic females.

In 2007, 27% of AIDS clients were women (up from 7% in 1985). Sixty-six percent of these cases were among AfricanAmerican women, 18% among White women, and 14% in Hispanic women. This trend among African-American women is most severe in the Southeastern United States (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Arkansas, Louisiana, New Mexico, Oklahoma, and Texas). Florida, Georgia, and Louisiana led the

Psycho-social Considerations Substance abuse, mental illness, and physical and sexual abuse, disproportionately affect women of color and also lead to high risk behaviors and an increased chance of exposure to, and infection with, HIV.5

nation in HIV/AIDS diagnosis rates among female adults and adolescents in 2007.4

STIs Chlamydia was the most reported infectious disease in the US in 2007, with more than half of all cases occurring in females age 15-24. The rate of Chlamydia in Black females being almost eight times as high as in White females, and three times as high in Hispanic women.7 Due to the fact that Chlamydia can be asymptomatic in females, the diagnosis is often missed.

Statistics are similar for gonorrhea, the second most reported infectious disease in the US in 2007.

Southeastern states having the highest rate of gonorrhea in the nation. Like Chlamydia, gonorrhea increases the likelihood of HIV transmission.7 Cervical and anal human papilloma virus (HPV) infections are higher in women with HIV, as are abnormalities on Pap smears ranging from ASCUS (Atypical Squamous Cell of Undetermined Significance) to HSIL (Highgrade Squamous Intra-epithelial Lesion). Invasive cervical cancer or CIS (Carcinoma In Situ) is also more common in HIV positive women, particularly AfricanAmerican and Hispanic women age 20-34.8,9,10

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HealthHIV Addresses Women Living With HIV

Barriers to Effective Care Among Women Missed Opportunities for Medical Documentation

HealthHIV developed and field-tested “A Workshop to Develop Evidence Based Best Practices for Primary Medical Care of Minority Women with HIV in the Rural South.” The workshop was hosted

Medical records that fail to document health issues unique to women with HIV, particularly sexual

in November 2009 by the Southeast Mississippi Rural Health Initiative, one of HealthHIV’s partners

and reproductive health, miss an opportunity to remind providers of additional steps to take to

in a project to support networks of HIV care in areas with high HIV prevalence and large minority

ensure optimal health for female clients. HealthHIV’s clinical assessments at 20 clinics participat-

populations.

ing a project supporting networks of HIV care in areas with high HIV prevelance and large minority populations, show routine gynecological examinations and diagnostic tests for STIs were rarely documented despite the fact it is widely known that concurrency of STIs with HIV increase HIV transmission.11

The workshop design was based on an organizational needs assessment at SeMRHI and addressed specific gaps in practice representative of other local health service delivery sites in the region.

It focused on what has become a national public health imperative, particularly in the South putting the unique needs of women of color, and especially those living with HIV, at the forefront of the healthcare agenda.

Sub-optimal Medical Care Clinicians may not always be aware of adverse effects of certain ARVs during pregnancy, or drug-to-drug interactions between hormonal contraceptives and some ARVs that require dosage adjustments.12 Antiretroviral therapy (ART) adherence can be affected by the therapy’s perceived or actual adverse effects14, poor patient/provider relationship, inability to navigate the complexities of the health system, and fragmentation of care.

Domestic Violence and Gender Inequality Manifestations of power disparities, including domestic violence, specific to women of color with HIV must be addressed. African-American women with abusive primary partners are less likely to use condoms and may experience abuse when requesting they be used. Evidence supports the conclusion that violence is also associated with HIV disclosure, with a number of HIV positive women reporting assaults within six months of disclosure. Adherence to antiretroviral medications may also be affected by threats of domestic violence 13 as well as by competing family

Five core interventions to reduce HIV in minority women were covered in the workplace:

■ Aggressive STI screening

■ Universal HIV testing according to CDC guidelines

■ Effective dual protection (family planning and STI prevention)

■ Optimal treatment of HIV, adherence, and retention in care

■ Known barriers to access to HIV care and treatment

HealthHIV brought together faculty for the Women & HIV workshop, primarily African American women physicians and HIV Specialists who are consultants to HealthHIV. These clinicians provide comprehensive primary care and HIV treatment to minority women in high prevalence areas and have personal and professional experience confronting the challenges of providing such care to minority women on a daily basis. Several of the clinicians are care providers at HealthHIV partner organizations.

priorities such as childbearing and childrearing. Recent studies indicate women are frequently underrepresented in clinical trials of new classes of Antiretrovirals (ARVs) because of their ability to participate.15,16 Difficulties in achieving optimal care originate from a variety of sources including the prevailing

“Thanks to HealthHIV our community is now

socio-economic structure and from within the medical system.

looking closer at the unique challenges faced by women living with HIV.” – Hope Braley, CEO Southeast Mississippi Rural Health Initiative

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HealthHIV Recommendations For Addressing HIV Disparities Among Women Of Color Throughout the Southeastern United States HIV incidence levels have grown alarmingly in women of color. Factors that make women of color more vulnerable to HIV infection and sub-optimal care are found at the socio-economic, health system, provider, and client levels. Additional emphasis

For more information on HIV disparities among women of color in the Southern United States and HealthHIV’s response, email info@healthhiv.org

References

within clinical and care coordination settings are needed when addressing HIV prevention and treatment among women. Organizations and providers can now identify barriers to care among their female clients, implement strategies to fill gaps, and reduce infection rates to improve health at the community and individual levels.

Based on experiences from the HealthHIV Women of Color and HIV workshop, HealthHIV recommends education for primary care clinicians and care coordination staff.

The following topics may be included:

■ The Need for an Approach in the Care & Treatment of Women of Color with HIV

■ Integrating HIV into Primary Medical Care with Focus on Women of Color

■ Primary Medical Care for HIV Positive Women – Comprehensive, Woman-Centered Treatment & Care. Initial Clinical Assessment of Women of Color with HIV Disease

1. “Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2007” Divisions of HIV/AIDS Prevention - National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

Centers for Disease Control and Prevention. February 18, 2009 http://www.cdc.gov/hiv/topics/ surveillance/resources/reports/2007report/table3.htm. Accessed on April 6, 2010.

2. “U.S. HIV and AIDS cases reported through December 1995” HIV/AIDS Surveillance Report. US Department of Health and Human Services. 1995 http://www.cdc.gov/hiv/topics/surveillance/ resources/reports/pdf/hivsur72.pdf. Accessed April 6, 2010.

3. “HIV/AIDS Surveillance in Women.” Divisions of HIV/AIDS - Prevention National Center for HIV/ AIDS, Viral Hepatitis, STD, and TB Prevention. Centers for Disease Control and Prevention. May 5, 2009. http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/index.htm. Accessed April 6, 2010.

4. “HIV/AIDS among Women.” Divisions of HIV/AIDS Prevention -National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Centers for Disease Control and Prevention. August 3, 2008. http://www.cdc.gov/hiv/topics/women/resources/factsheets/women.htm. Accessed April 6, 2010.

5. Bozzette SA, Joyce G, McCaffrey DF, Leibowitz AA, Morton SC, Berry SH, Rastegar A, Timberlake D, Shapiro MF, Goldman DP. RAND Health. Access to HIV Care: Initial Results from the HIV Cost and Services Utilization Study, RB-4530, 2000.

6. Squires K. HIV in Women: Still a Challenge. 13th IAC; 2000; Durban, South Africa. Abstract TuOr54.

■ Strategies to Increase Access, Adherence, & Retention in Care for Women with HIV

7. Pardo MA, Ruiz MT, Gimeno A, Navarro L, Garcia A, Tarazona MV, Aznar MT. Gender bias in clinical trials of AIDS drugs [abstract]. Int Conf AIDS. 2002. WePeB5964.

■ Reproductive Intentions, Contraception: Women of Color with HIV/AIDS

8. Gender bias in clinical trials of AIDS drugs. International Conference on AIDS.Int Conf AIDS. 2002 Jul 7-12; 14: abstract no. WePeB5964.

■ STIs & HIV: A Missed Opportunity for HIV Prevention?

■ Special Gynecologic Considerations

9. “Trends in Reportable Sexually Transmitted Diseases in the United States, 2007: National Surveillance Data for Chlamydia, Gonorrhea, and Syphilis.” Divisions of HIV/AIDS Prevention - National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Centers for Disease Control and Prevention. January 6, 2009 http://www.cdc.gov/STD/stats07/trends.htm. Accessed April 6, 2010

in Women Living with HIV/AIDS

10. CDC HIV/AIDS Fact Sheet. Revised August, 2008.

11. CDC, MMWR, August 4, 2006, Vol. 55, No. RR-11. Sexually Transmitted Treatment Guidelines, 2006.

■ Implementing the 2006 CDC HIV

12. Aberg, J.A., Kaplan, J.E., Libman, H., Emmanuel, P., Anderson, J.R., Stone, V.E., et al. (2009). Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 Update by the HIV Medicine Association of the Infectious Disease Society of America. Clinical Infectious Disease, 49, 651-681.

Testing Recommendations Locally: Are We Reaching Women of Color?

13. Moore, K.M. personal communication, SNHC by EPMC, CAEAR Foundation 2008.

■ Medical Case Management,

14. Anastos, K. Good News for Women Living with HIV. The Journal of Infectious Diseases 2007;196:971– 97315 Manfrin-Ledet, Porche. The State of Science: Violence and HIV Infection in Women. J ASSOC NURSES IN AIDS CARE, 14 (6), 2003, 56-684.

Mental Health & Women of Color with HIV

■ Unique Nutritional Considerations for Women of Color with HIV

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www.healthhiv.org 2000 S Street, NW | Washington DC | 202-232-6749 | info@healthhiv.org

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