Barriers to HIV care and Antiretroviral Treatment (ART) among HIV-infected

Crack Users in the United States

Christine Bell 1 Gabriel Cardenas 2 Tanisha Sullivan 1 Tamy Kuper 2 Lauren Gooden 2 Jessica Kaplan 1 Elizabeth Scharf 1 Allan Rodriguez 2 Carlos del Rio 1 Lisa Metsch 2

1 1 Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, and Emory CFAR and the Department of Epidemiology2 University of Miami Miller School of Medicine, Department of Epidemiology and Public Health and Medicine and U. Miami D-CFAR.

Background

About 1 in 4 persons living with HIV are not regularly About 1 in 4 persons living with HIV are not regularly attending HIV primary careattending HIV primary care

HIV-infected drug users are less likely to utilize HIV HIV-infected drug users are less likely to utilize HIV primary care and receive HAARTprimary care and receive HAART

HIV-infected drug users also have higher rates of HIV-infected drug users also have higher rates of hospitalization and are more likely to leave the hospitalization and are more likely to leave the hospital against medical advice hospital against medical advice

Use of crack cocaine continues to flourish in many Use of crack cocaine continues to flourish in many inner-cities in the U.S.inner-cities in the U.S.

Study objectives

To describe barriers to HIV care and To describe barriers to HIV care and antiretroviral treatment among HIV infected antiretroviral treatment among HIV infected crack users hospitalized in Grady Memorial crack users hospitalized in Grady Memorial Hospital (Atlanta) and Jackson Memorial Hospital (Atlanta) and Jackson Memorial Hospital (Miami). Hospital (Miami).

To assess factors associated with To assess factors associated with everever having having had an HIV primary care providerhad an HIV primary care provider

To assess association with To assess association with everever having received having received Antiretroviral Treatment (ART)Antiretroviral Treatment (ART)

MethodsMethods Structured interviewsStructured interviews were conducted with HIV-infected were conducted with HIV-infected

crack users who were admitted to two inner city hospitals in crack users who were admitted to two inner city hospitals in the US between August 2006 – January 2008. the US between August 2006 – January 2008.

Interview eligibility criteriaInterview eligibility criteria Hospitalized HIV patient at GMH or JMH were screened prior Hospitalized HIV patient at GMH or JMH were screened prior

to interview to establish:to interview to establish:1) 1) Sexual intercourse in the past 6 monthsSexual intercourse in the past 6 months2) 2) Crack-cocaine use in the past yearCrack-cocaine use in the past year

Data AnalysisData AnalysisLogistic regression analyses were used to identify significant Logistic regression analyses were used to identify significant associations among the variables.associations among the variables.

IRB approvalIRB approval was obtained from Emory IRB and Miami IRB was obtained from Emory IRB and Miami IRB and full informed consent was obtained from study and full informed consent was obtained from study participants before interview.participants before interview.

Demographic characteristics of study participantsAtlanta: Grady HospitalAtlanta: Grady Hospital 141 study participants141 study participants 55% female, 45% male55% female, 45% male 92% Black, 8% Other92% Black, 8% Other Average age: 44 years oldAverage age: 44 years old

Miami: Jackson HospitalMiami: Jackson Hospital 80 study participants80 study participants 48% female, 52% male48% female, 52% male 86% Black, 14% Other86% Black, 14% Other Average age: 43 years oldAverage age: 43 years old

OverallOverall < $5000 annual income: 70%< $5000 annual income: 70% > 5 yrs since HIV diagnosis: 69%> 5 yrs since HIV diagnosis: 69% Homeless: 49%Homeless: 49%

Jackson Jackson Memorial Memorial HospitalHospital

Grady Grady Memorial Memorial HospitalHospital

History of HIV care and treatmentHistory of HIV care and treatment

No

Yes

No

Have you ever gone to a doctor or clinic for HIV care?** Low Income Population (N=150)

Study variable Odds Ratio, 95% Confidence Interval

Atlanta* 0.118 (0.036, 0.383)

Female* 0.394 (0.151, 1.03)

40 or older* 0.679 (0.254, 1.812)

Black/African American* 0.838 (0.197, 3.568)

Ever participated in drug treatment 4.151 (1.666, 10.344)

Receives disability funding 5.053 (1.443, 17.693)

*Variables forced into model**After adjusting for site, gender, age, and ethnicity

Variables not found to have a significantassociation with going to HIV care in our data*

Education levelEducation level ■■ Attitude toward HIV Attitude toward HIV carecare

Provider responsivenessProvider responsiveness ■■ Level of crack/alcohol Level of crack/alcohol

consumption consumption Putting off HIV care due to drugs/alcoholPutting off HIV care due to drugs/alcohol ■■ Housing stability Housing stability Unprotected sex in previous 6 monthsUnprotected sex in previous 6 months ■■ Level of depression Level of depression Referral to a case managerReferral to a case manager ■■ Having children Having children Social supportSocial support History of incarcerationHistory of incarceration Level of HIV knowledgeLevel of HIV knowledge

*Variables not selected by backward stepwise at the 0.05 significance level to *Variables not selected by backward stepwise at the 0.05 significance level to be associated in multivariate form with the dependent variable.be associated in multivariate form with the dependent variable.

Have you ever taken medications for your HIV?** (N=189)

Study variable Odds Ratio, 95% Confidence Interval

Atlanta* 0.347 (0.147, 0.816)

Female* 0.64 (0.292, 1.399)

40 or older* 1.733 (0.747, 4.023)

Black/African American* 0.757 (0.232, 2.475)

> 5 years since HIV diagnosis 5.729 (2.544, 12.903)

Been helped into HIV care 2.291 (1.039, 5.05)

Ever participated in drug treatment 3.711 (1.619, 5.05)

*Variables forced into model**After adjusting for site, gender, age, and ethnicity

Variables not found to have a significant association with taking HIV medications in our data*

Education levelEducation level ■■ Having childrenHaving children IncomeIncome ■ ■ Self-efficacy for taking HIV Self-efficacy for taking HIV

medsmeds Putting off HIV care because of Putting off HIV care because of ■ ■ Attitude for taking HIV medsAttitude for taking HIV meds

drugs/alcohol drugs/alcohol ■ ■ Level of depressionLevel of depression Unprotected sex in previous 6 monthsUnprotected sex in previous 6 months Referral to a case manager upon diagnosisReferral to a case manager upon diagnosis Social supportSocial support EmpowermentEmpowerment Level of crack/alcohol consumptionLevel of crack/alcohol consumption Housing stabilityHousing stability

*Variables not selected by backward stepwise at the 0.05 significance level to *Variables not selected by backward stepwise at the 0.05 significance level to be associated in multivariate form with the dependent variable.be associated in multivariate form with the dependent variable.

Study LimitationsStudy Limitations Self reportSelf report

HIV, sexual, drug and social histories provided by study HIV, sexual, drug and social histories provided by study participants were assumed to be accurateparticipants were assumed to be accurate

Interview biasInterview bias

It is possible that participants provided answers that were It is possible that participants provided answers that were most pleasing or acceptable to interviewermost pleasing or acceptable to interviewer

Other factors related to use of care and treatmentOther factors related to use of care and treatment

There may be other factors related to utilization of HIV care There may be other factors related to utilization of HIV care and treatment among HIV crack users not covered in and treatment among HIV crack users not covered in structured interviews. Interview data has not yet been structured interviews. Interview data has not yet been corroborated with medical chart abstraction.corroborated with medical chart abstraction.

Implications for HIV public health policy

In order to bring HIV infected crack users into primary HIV In order to bring HIV infected crack users into primary HIV care, to keep them in care and to allow them to benefit from care, to keep them in care and to allow them to benefit from prevention and treatment interventions…prevention and treatment interventions…

Policy developmentPolicy development: : A multifaceted intervention is needed that includes:A multifaceted intervention is needed that includes:

HIV care managementHIV care management Substance abuse treatment and,Substance abuse treatment and, Strategies to improve socioeconomic stabilityStrategies to improve socioeconomic stability

Project HOPEProject HOPE: HHospital Visit is an ospital Visit is an OOpportunity for pportunity for PPrevention and revention and EEngagement with HIV-positive Crack Users ngagement with HIV-positive Crack Users

AcknowledgementsAcknowledgementsAtlanta Site Funding

Carlos del Rio, MD, Co-PI NIH/NIDA (RO1 DA017612) Richard Rothenberg, M.D., Investigator NIH/NIAID (P30 AI050409) Tanisha Sullivan, Project Director Emory Center for AIDS Research (CFAR) Jessica Kaplan, Interviewer NIH/NIAID (1P30 AI023961) Elizabeth Scharf, Interviewer University of Miami Developmental Mary Yohannan, Facilitator Center for AIDS Research (DCFAR) Ossie Williams, Outreach Worker

Miami Site Lisa Metsch PhD, PI Allan Rodriguez, MD, Co-PI Toye Brewer, MD, Co-I Margaret Pereyra, PhD, Co-I Shari Messinger, PhD, Biostat Lauren Gooden, MPH, Project Director Gabriel Cardenas, MPH, Data Manager Tamy Kuper, BA Project Director/ Interviewer Ginny Locascio, LPN, Facilitator Cheryl Riles, Interviewer Richard Walker, Outreach Worker