““Challenges Facing HIV Positive Challenges Facing HIV Positive Africans in Minnesota and The Africans in Minnesota and The

Way Forward”Way Forward”byby

Omobosola Akinsete, MD, MPHOmobosola Akinsete, MD, MPHHealth Partners/ Hennepin County Health Partners/ Hennepin County

Medical Center/University of MinnesotaMedical Center/University of Minnesota

Presented at the African World AIDS DayEvent, December 9, 2006

Background of HIV in Africans in Background of HIV in Africans in MinnesotaMinnesota

Sub-Saharan AfricaSub-Saharan Africa

70% of people with HIV/AIDS live in 70% of people with HIV/AIDS live in Sub-Saharan AfricaSub-Saharan Africa

Anti-retroviral treatment (ARV) is Anti-retroviral treatment (ARV) is available to 11% of those affected available to 11% of those affected (according to WHO 2005)(according to WHO 2005)

Some Risk Factors for Acquiring Some Risk Factors for Acquiring The Disease in AfricaThe Disease in Africa

Driving Factors for HIV in AfricaDriving Factors for HIV in Africa

Ignorance/denialIgnorance/denial Fear/silenceFear/silence Sexual networksSexual networks Blood and blood Blood and blood

productsproducts Conflict/displace-Conflict/displace-

ment of familiesment of families Migrant workersMigrant workers Commercial sex Commercial sex

workwork

Poverty!!!!- Linked Poverty!!!!- Linked to most other to most other factorsfactors

Cultural/traditional Cultural/traditional practicespractices

Low socioeconomic Low socioeconomic status of womenstatus of women

Limited Limited governmental governmental supportsupport

African-born Residents in the U.S. by State, Census 2000

Source: U.S. Census Bureau, Census 2000 Data

Large African-born Population in Large African-born Population in MinnesotaMinnesota

0

20

40

60

80

100

120

140

NY TX NJ VA FL IL OH WA RI CT TN MO OR WI LA AL SC NE DE SD MS ME ND ID AK MT

State

Num

ber o

f Per

sons

(Tho

usan

ds)

According to the U.S. Census, Minnesota has the 2nd largest population of East Africans

in the nation.

Minnesota (10th largest)

0

100

200

300

400

500

1990 1993 1996 1999 2002 2005Year

No.

of N

ew H

IV/A

IDS

Cas

es &

Dea

ths

0

1000

2000

3000

4000

5000 No. of P

ersons Living w/ H

IV/A

IDS

HIV (non-AIDS) AIDS^ AIDS Deaths* Living HIV/AIDS

HIV/AIDS in Minnesota:HIV/AIDS in Minnesota:Number of New Cases, Prevalent Cases, and Deaths by Number of New Cases, Prevalent Cases, and Deaths by

Year, 1990-2005Year, 1990-2005

*Deaths among AIDS cases, regardless of cause.

^Includes refugees in the HIV+ Resettlement Program diagnosed with AIDS subsequent to their arrival in the United States

0

20

40

60

80

100

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Num

ber o

f Cas

es

Other

Latin America/Car

Asia

Africa

HIV Infections* among Foreign-Born PersonsHIV Infections* among Foreign-Born Persons†† in Minnesota by Year of Diagnosis and Region of Birth, in Minnesota by Year of Diagnosis and Region of Birth,

1990-20051990-2005

Region of Birth#

* HIV or AIDS at first diagnosis† Excludes persons arriving to Minnesota through the HIV+ Refugee Resettlement Program.# Latin America/Car includes Mexico and all Central, South American, and Caribbean countries.

Afr born1%

White88%

Asian3%

Hispanic3%

Amer Ind2%

Afr Amer3%

Afr born16%

Other1%

Hispanic8%

Asian1%Amer Ind

1%

Afr Amer22%

White51%

HIV Infections* Diagnosed in Year 2005 and General HIV Infections* Diagnosed in Year 2005 and General Population in Minnesota by Race/EthnicityPopulation in Minnesota by Race/Ethnicity

HIV Diagnoses(n = 304)

Population†

(n = 4,919,479)

* HIV or AIDS at first diagnosis† Population estimates based on 2000 U.S. Census

data.

n = Number of persons Amer Ind = American IndianAfr Amer = African American (Black, not African-born persons) Afr born = African-born (Black, African-born persons)Data source: Minnesota HIV/AIDS Surveillance System

Unique Features of HIV Epidemic in Unique Features of HIV Epidemic in

Minnesota’s African CommunityMinnesota’s African CommunitySignificant Demographic Diversity

Total Africans living with HIV/AIDS in Total Africans living with HIV/AIDS in 2005: 2005: 587587

Many more are likely undiagnosedMany more are likely undiagnosed

Representing Representing more than 25 different more than 25 different countriescountries and every region of Africa and every region of Africa

Source: Minnesota Department of Health HIV/AIDS Surveillance System

Unique Features of HIV Epidemic in Unique Features of HIV Epidemic in Minnesota’s African CommunityMinnesota’s African Community

Men47% Women

53%

African-born PersonsTotal Number = 587

Men82%

Women18%

Other Minnesota CasesTotal Number = 5,233

Source: Minnesota Department of Health HIV/AIDS Surveillance System, data reflect prevalent cases in 2005

Gender Distribution

Facts about HIV Positive Africans Facts about HIV Positive Africans in Minnesotain Minnesota

Slightly more women then menSlightly more women then men At Hennepin County Medical Center At Hennepin County Medical Center

(HCMC), only 9% of people got routine HIV (HCMC), only 9% of people got routine HIV testtest

86% of them acquired HIV through 86% of them acquired HIV through heterosexual intercourseheterosexual intercourse

Africans Do Not Routinely Africans Do Not Routinely Test for HIVTest for HIV

Present to the clinic later in the Present to the clinic later in the disease and usually with an infection disease and usually with an infection such as TBsuch as TB

Why Do African-born Patients Present Late?Why Do African-born Patients Present Late?

1.1. Many Africans do not feel at risk of Many Africans do not feel at risk of contracting HIV- low condom use, stable contracting HIV- low condom use, stable relationship, lack of trustrelationship, lack of trust

2.2. Lack of information about servicesLack of information about services3.3. Socioeconomic barriersSocioeconomic barriers4.4. Immigration barriersImmigration barriers5.5. Competing prioritiesCompeting priorities6.6. Psychosocial issues- coping skills, fearPsychosocial issues- coping skills, fear

Barriers Accessing HIV Barriers Accessing HIV ServicesServices

Barriers due to:Barriers due to: Lack of knowledge about servicesLack of knowledge about services Fear of stigmaFear of stigma Language problemsLanguage problems Immigration issuesImmigration issues Lack of insuranceLack of insurance

Challenges Within the Challenges Within the HIV Care SystemHIV Care System

Shock/denialShock/denial Insurance Insurance

issues/povertyissues/poverty Interpreters/miscom-Interpreters/miscom-

municationmunication Competing prioritiesCompeting priorities Cultural issuesCultural issues

StigmaStigma Social isolationSocial isolation Psychosocial issuesPsychosocial issues Complex formsComplex forms Attitudes of providersAttitudes of providers

Many Family Members and Friends Do Not Many Family Members and Friends Do Not Know About The Diagnosis of Each OtherKnow About The Diagnosis of Each Other

Why?Why? ShameShame Fear that they will be left aloneFear that they will be left alone Fear that others will find outFear that others will find out PanicPanic People will think that People will think that

they are bad peoplethey are bad people

StigmaStigma

What causes stigma?What causes stigma? Experience in AfricaExperience in Africa FearFear ShameShame IgnoranceIgnorance Association with AIDS Association with AIDS

and deathand death

Effects of StigmaEffects of Stigma

How does stigma affect patient care?How does stigma affect patient care? Late presentation and diagnosisLate presentation and diagnosis Increased transmissionIncreased transmission Poor adherence to medicationsPoor adherence to medications Isolation of patientsIsolation of patients

Services ProvidedServices Provided

Good HIV and primary careGood HIV and primary care Insurance servicesInsurance services Case managers/social workersCase managers/social workers Support groupsSupport groups Psychological supportPsychological support

How Do Africans in Care Behave?How Do Africans in Care Behave?

Increased knowledgeIncreased knowledge Good adherence to medicationsGood adherence to medications Trust their providersTrust their providers More people willing to come outMore people willing to come out Increased coping skillsIncreased coping skills Relatively normal livesRelatively normal lives ChildrenChildren

20%14%10%

25%29%

49%

19%

37%

00.050.10.150.20.250.30.350.40.450.5

Community forums

Pamphlets

TV/ Nat Lang

Radio/Nat lang

HouseStorytelling

DramaComm. Papers

Best ways to teach people in community about HIV

What Is Needed?What Is Needed? Increased funding of sustainable resources!!!!!!!- Increased funding of sustainable resources!!!!!!!-

Good response from Minnesota Department of Health Good response from Minnesota Department of Health and others - but we need more.and others - but we need more.

Increased education –culturally appropriate, within Increased education –culturally appropriate, within communities, increase numbers of African trained communities, increase numbers of African trained educatorseducators

Involvement of Africans- NGOs, churches/religious Involvement of Africans- NGOs, churches/religious leadersleaders

Counseling/crises centers/hot lineCounseling/crises centers/hot line

What Is Needed (continued)What Is Needed (continued) Incorporate education/counseling into other Incorporate education/counseling into other

health care- OBGYN, Primary carehealth care- OBGYN, Primary care

Education for refugeesEducation for refugees

Screening for all as part of health care and Screening for all as part of health care and decrease stigmadecrease stigma

Interpreters - more/ better trained/discreteInterpreters - more/ better trained/discrete

Information pamphlets in various languages, Information pamphlets in various languages, radio, newspapers and TVradio, newspapers and TV

What Is Needed (continued)What Is Needed (continued)

Case management/social workersCase management/social workers

Support groups for those infected, e.g. SAYFSMSupport groups for those infected, e.g. SAYFSM

Affordable drugs for those infected in AfricaAffordable drugs for those infected in Africa

The Way ForwardThe Way Forward HIV is just a disease!HIV is just a disease!

HIV does not mean you are a bad person!HIV does not mean you are a bad person!

HIV does not show on your face!HIV does not show on your face!

There no cure but there is treatment for HIV!There no cure but there is treatment for HIV!

There is hope for people with HIV!There is hope for people with HIV!

HIV infected people need support from their HIV infected people need support from their community members!community members!

AcknowledgementsAcknowledgements

Tracy SidesTracy Sides Keith HenryKeith Henry Luisa Pessoa-BrandãoLuisa Pessoa-Brandão Charles CartwrightCharles Cartwright Diane HirigoyenDiane Hirigoyen Christy BoraasChristy Boraas Cynthia DaveyCynthia Davey Ellen KaneEllen Kane