Cultural Competence: Strengthening the Clinicians Role in Delivering Quality HIV Care - PowerPoint Presentation

1. Cultural Competence: Strengthening the Clinicians Role in Delivering Quality HIV Care within Hispanic Adolescent MSM CommunitiesFebruary 9, 2012Updated August 10, 2013Presented by Lisa Hightow-Weidman, MD, MPHClinical Associate ProfessorUniversity of North Carolina at Chapel Hill

2. Learning ObjectivesUnderstand the impact of the epidemic among young Latino men who have sex with men (MSM)Identify critical cultural issues and other considerations related to Latino MSM and HIV infectionProvide an example of a successful HIV prevention intervention with Latino MSMIdentify important priorities for maintaining the health and wellness of young Latino MSM

3. TerminologyMSM embodies a wide range of men with varying social identities related to their sexual and or relationship practices with other men.The term “Latino” is used to denote a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race as men born in the U.S.Youth/young encompasses adolescents and young adults ages 13-24 years.

4. Why is the Latino Community a Major Concern for HIV Prevention?The Latino community is the fastest growing population in the U.S. and the group with the second-highest risk for HIV/AIDS1 Between 2000 and 2010 the Latino population in the U.S. has increased by 43%; from 35.3 million in 2000, to 50.5 million in 201021.The Henry J. Kaiser Family Foundation HIV/AIDS Policy Fact Sheet. Latinos and HIV July 20102. U.S. Bureau of the Census 2012. Available at www.census.gov

5. Projected Latino Population in the US: 2000-2050U.S. Bureau of the Census, Available at www.census.gov

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10. Critical Cultural issues and other considerations related to Latino MSM and HIV infection

11. Health Disparities and Barriers to HIV Prevention and Care for young Latino MSMRisk factors vary by country of originCultural beliefs Substance and alcohol useEngagement in HIV risk behaviors/High rates of STIsLow HIV testing ratesLimited access to health care/HIV treatmentLanguage

12. Behavioral Risk Factors Differ From Country of Birth Among HispanicsCountry of Birth Central/South America (n=814) Cuba (n=145) Mexico (n=1334) Puerto Rico (n=1346) United States (n=2608)AIDS Cases (%)MSMIDUMSM andIDUHigh-RiskHeterosexualContactAIDS Diagnosed in the United States During 2006OtherCDC. HIV/AIDS Surveillance Report, 2006. 2007;18:1-46.49%62%18%59%45%10%9%10%40%22%3%4/4%5%6%36%24%26%36%25%1%0%2%1/1%

13. Experiences of Stigma and DiscriminationDiscrimination toward homosexual behavior, racism and poverty associated with greater rates of sexual risk behaviors among Latino MSMInternalized homophobia associated with increased consumption of drugs and alcohol during sex among Latino MSMJarama, AIDS Behav, 2005; Mizuno, AIDS Behav, 2011; Diaz, AJPH, 2001

14. Experiences of Anti-gay Discrimination Among Young Gay/Bisexual Latino MenHuebner, AJPH, 2004

15. Experiences of Racial and Sexuality-Related Bullying Among Young Latino MSMMultisite study of 351 racial/ethnic HIV+ minority young MSM Hightow-Weidman, AIDS Patient Care and STDs, in press

16. Nuestras VocesNational Latino Gay Men’s Study 19% HIV-positive 912 men recruited in 35 Latino gay barsNew York: n = 309Miami: n = 302Los Angeles: n = 30150% under age 3082% self-identified as gay or homosexual55% some college or more27% unemployed73% immigrant (including from Puerto Rico)41% mostly Spanish-speaking (with friends) Diaz, AJPH, 2001

17. Experiences of Homophobia Made fun of as a childViolence as a childMade fun of as an adultPolice harassmentViolence as an adultAs a child heard gays grow old aloneHad to move away from family Job discriminationHave had to pretend to be straightAs a child felt their gayness hurt familyAs a child heard gays not normal91% (89-94)70% (66-75)64% (59-69)15% (12-18)20% (17-24)29% (25-33)71% (67-75)10% (7-12)50% (45-54)18% (15-21)64% (60-68)Diaz, AJPH, 2001Ever experienced % (95% confidence interval)

18. Cultural Factors Relevant in Lives of Young Latino MSM Machismo: complicated and global concept that defines what is “manly” in the Latino community; may consist of values and behaviors related to masculinity, pride, bravery, and invulnerability Familismo: Strong commitment to family. Acculturation: the exchange of cultural features that results when groups of individuals having different cultures come into continuous first hand contact.

19. Cultural Factors: MachismoPositive Characteristics Strength and protection of the family“Male honor,” demanding respect from others, sticking to personal beliefsNegative Characteristics Proving masculinity through power and dominance can lead both straight and gay Latino men to engage in risky sex behaviorHigher levels of machismo predicts having a greater number of sex partners Exaggerated hyper-masculinity can be expressed with physical and sexual aggressiveness Latino men may perceive themselves as invulnerable to HIVCDC. Available at: http://www.cdc.gov/hiv/hispanics/challenges.htm ; Jarama, AIDS Behav, 2005.

20. Cultural Factors: FamilismoCan be a strong incentive for some Latino men to reduce unprotected sex with casual partners. Can also be a source of conflict for young Latino MSM, whose families may have a negative view of homosexuality. Many Latino MSM identify themselves as heterosexual and, as a result, may not relate to prevention messages crafted for gay men.Individuals may delay or refuse treatment because of the advice and opinions of familyCDC. Available at: http://www.cdc.gov/hiv/hispanics/challenges.htm

21. Additional ConsiderationsFatalismo: (fatalism) may convince some Latinos that it is in their destiny to be afflicted with HIVLatinos more likely than Whites to think that chronic disease is determined by God and therefore must be accepted and endured as punishment for personal sinsMarianismo: a cultural concept in women that encompasses qualities of chastity, virginity, devotion to home and familyFor some Latinas admitting that their husbands may have infected them through infidelity could possibly be interpreted as domestic failure of their role as wifeStone V, et al. HIV/AIDS in U.S. Communities of Color. Springer; New York, NY: 2009.

22. Acculturation/MigrationGreater acculturation into the U.S. culture has been associated with the adoption of several health-protective behaviors among Latinos, as well as with an increase in behaviors that are risk factors for HIV infection.Latino MSM frequently report coming to the U.S. to escape homonegativity and to achieve greater sexual freedomAmong younger MSM - tendency to engage in high levels of sexual activity during the early period after arrival Bianchi FT, Culture, Health and Sexuality, 2007

23. Migration-related Risk Factors for HIV InfectionConstant mobilityCulturalLinguisticGeographic barriers to health care servicesChange in sexual practicesLimited educationPsychosocial factorsIsolationDiscriminationPovertyChronic underemploymentSubstandard housingOrganista, KC et al. Migrant laborers and AIDS in the United States: A Review of the literature. AIDS Educ. Prev. 1997;9:83-93

24. Examples of HIV Risk Behaviors and PracticesAdoption of new sexual practicesSeeking companionship to compensate for the alienating aspects of migration experienceFewer constraints or social control on behaviorsExposure to previously unknown or unacceptable sexual behaviors and practicesExchange sexual services for money, food or lodging Low levels of knowledge relating to the mechanisms of HIV infection and preventionMultiple partnersLow condom useIncreased alcohol and drug useLimited access to medical care and HIV testingHIV Risk Ten Times Higher for Migrant Farm-workers. Public Health Rep. 1994;109:459

25. STDs by Age, Race/Ethnicity in Men, 1996-200820-24 years25-29 yearsCDC, http://www.cdc.gov/std/stats/

26. CDC: Estimated Prevalence of Undiagnosed HIV Infection in the United States (2006)Campsmith ML, JAIDS. 200921% of 1,106,400 HIV-infected persons in the United States were undiagnosed in 2006.

27. Young Men’s Survey (1994-2000):Prevalence and Unrecognized HIV InfectionMacKellar DA, JAIDS. 2005. Conducted in Baltimore, Dallas, Los Angeles, Miami, New York, and Seattle.WhiteHispanicBlack10% of 5649 Young MSM Tested Were HIV Positive 77% Were Unaware They Were HIV Infected Unaware of HIV Infection Aware of HIV Infection75%WhiteHispanicBlack75%91%56%64%91%15 to 22 Years of Age23 to 29 Years of Age

28. Prevalence and Awareness of HIV Infection Among Men Who Have Sex With Men — 21 Cities, United States, 2008CDC, 2010

29. Latinos enter HIV care later than both blacks and whitesProportion of patients by race/ethnicity presenting with CD4 counts <350 cells/µl by period entering care. Categorized by CD4 count distribution. A. Dennis, et al, Clinical Infect Dis. 2011

30. Advanced Disease at Diagnosis Delayed presentation, which is common among Latino patients1, results in Disproportionately high number with AIDS2High baseline viral loadImpaired immune status3Increased morbidity, hospitalization for OIs Increased mortality1. Suplemental HIV Surveillance Study Project. Los Angeles County, Department of Heatlh Services, January 2000 2. Turner et al, Delayed Medical Care After Diagnosis of Persons Infected with HIV. Arch of Int Med 16, 2000 3. Swindells S. AIDS. 2002;16:1832-1834.

31. Barriers to Health Care U.S. health system is confusing: Understanding insurance and ways to pay for healthcareLanguage for monolingual Spanish speakersNames: some Latinos use two or more last names and sometimes they are hyphenated Time away from work: Economic lossUrgent comes before importantUndocumented status: Fear of being reported by healthcare staffBowden, et al. Hispanic Journal of Behavioral Sciences 2006.

32. Behavioral Interventions for young Latino MSM

33. Lack of Culturally Relevant HIV Prevention Interventions for Latino MSMPaucity of data examining HIV prevention within Latinos in general and within Latino MSM in particularOnly one reported RCT that addressed an HIV prevention intervention directed specifically at Latino MSM1Interventions focused on MSM in general are less effective for Latino MSM21Carballo-Dieguez, AIDS Care, 2005; 2Johnson, Cochrane Review, 2008

34. “¡Cuídate!! (Take Care of Yourself)”Helped reduce risky sexual behaviors among Latino adolescents (55% male), even a year after students attended the training.The intervention consists of six 60-minute modules delivered to small, mixed-gender groups. ¡Cuídate! incorporates salient aspects of Latino culture, including familismo and gender-role expectations like machismo. These cultural beliefs are used to frame abstinence and condom use as culturally accepted and effective ways to prevent sexually transmitted diseases, including HIV.

35. Case Presentation

36. Case Study: PedroPedro is a 19-year-old youth from Mexico. He is a seasonal worker who spends months each year in the US working as a day laborer. He has a girlfriend and a 2 month old son in Mexico. He sends financial support to his family when he can. 

37. Case: continuedWhen in the United States, he lives with 2 male roommates, one of whom he has sex with from time to time. His girlfriend and family in Mexico and most of his friends are unaware of his sexual relationships with men. He is afraid to face rejection from his family. Pedro has not been tested for HIV and he is concerned about his status.Is Pedro at risk for HIV? How should the provider discuss this with him?

38. Factors That Impede Routine HIV Testing:Key Patient-Based IssuesLack of knowledge about HIV/AIDS and new treatmentsFear of knowing they have the diseaseHIV-related stigma and discriminationFinancial reasons that extend beyond testing and include costs related to follow-up health care, medications, and possible job lossCultural attitudesBelieving that this could never happen to themMistrust of health care providersDrug useMental illnessDaniels P, et al. J Natl Med Assoc. 2004;96:1107-1108.

39. Case: continuedPedro tests positive for HIV infection and is referred to an HIV providerWhat are some things to consider that might be barriers for Pedro to keep that appointment?

40. Barriers to Engaging and Staying in CareLinguistic Issues – English, Spanish, Portuguese, etc. Access to Care and HIV TestingUnder/uninsured – lack of citizenship, job characteristics, povertyEducation – 50% Latinos not completing high schoolTransportation, no childcare, excessive waiting times, can’t miss work Constructs of Culture and GenderReligious beliefsGender rolesFatalistic views of life – “que sera, que sera”Stigma – greater than in U.S. cultureBias of Health Care Provider

41. Care and Treatment for Latinos Personalismo. Preference for relationships with others that reflect a certain familiarity and warmth.May be more likely to trust and collaborate with someone with whom they had pleasant conversations. Simpatia. The importance of polite and cordial social relations. (central cultural value and social expectation). Shuns assertiveness, direct negative responses and criticism.

42. Case: continuedPedro makes it to the HIV clinicAt his first visitHIV-1 RNA was 88,500 copies/mL CD4+ cell is 280 cells/mm3What are some important things to consider at that first visit?Should Pedro start medications?

43. Patient EncounterEye contact – demonstrates respectFacial Expression – an unexaggerated, friendly smileGestures – stand up, walk to, & greet patientTouch – greet with handshake and offer handshake upon completion of the encounterVoice Intonation – speaking loudly will not increase understandingAddressing Latino Patients – the use of titlesThe Use of Interpreters

44. Assess Readiness for HAARTKey issues to explore with the patientAre they ready to begin HAARTCan they take and adhere to the prescribed HAART regimenDo they believe the medications are effective and can make a differenceEvaluate for depression and active substance abuseEvaluate for heath literacy levelBecome familiar with the patient’s social situation, stability of social and living situation, psychosocial supports and key people in their lifeLogistical aspectsMedication organizersStone V, et al. HIV/AIDS in U.S. Communities of Color. Springer; New York, NY: 2009.

45. Provide Culturally Competent HIV CareIdentify the patient’s core cultural issuesExplore the meaning of the illness to the patientExplore the patient’s social contextLife controlChange in environmentLiteracy and languageSupport systemsNegotiate across patient-physician culture to develop a treatment plan that is mutually agreeableStone V, et al. HIV/AIDS in U.S. Communities of Color. Springer; New York, NY: 2009. Carrillo JE, et al. Ann Intern Med. 1999;130:829-834. Stone VE. Clin Infect Dis. 2004;38:400-404.

46. Provide Culturally Competent HIV CareBuild trust and optimize patient-provider encounterBe aware of health-related cultural beliefs, including stigma, within the predominant minority groups in your practiceBe comfortable and skilled in eliciting personal and cultural views and perspective of each individual patient and applying a cultural competency framework for each visitStone V, et al. HIV/AIDS in U.S. Communities of Color. Springer; New York, NY: 2009.

47. Alternative Medicine/Traditional HealersBased on family traditions, various religions, and the balance nature. Common illnesses are usually treated by, or at the advice of , a family caregiver – typically a female caregiver. Acculturation\Americanization tends to lead to a hybrid of conventional and traditional medicine.Cuaranderos (Spiritual Healers)Santeros (Magic Practitioners) Yerberos (Herbalist)Supplies , amulets, dietary supplements can be purchased in the community at stores called “Botanicas”.Source: Ortiz, et al. The Annals of Pharmacotherapy 2007

48. Cultural Competency and HIV Care Awareness and acceptance of differencesAwareness of your own cultural valuesAwareness of dynamics of differencesDevelopment of cultural knowledgeAbility to work within other’s cultural contextHealthy self-conceptFree from ethnocentric judgment1. Donini- Lenhoff FG et al. Increasing awareness and implementation of cultural competence principles in health education professions education. J. Allied Health. 2000;29:241-245.; 2. Robins LS et al. Improving cultural awareness and sensitivity training in medical school. Academic Med. 1998;73 (10 suppl): S31-S34.

49. Summary (1)Latino/ a / Hispanic people are a heterogeneous group.Cultural beliefs may affect one’s risk for HIV infection and one’s choices for health care if infected.Migration and immigration can be an isolating experience and may lead to HIV risk behavior.

50. Summary (2)Gay and Bisexual Latino’s experience a unique set of cultural challenges when faced with HIV. Barriers to care may not be apparent. Open up a discussion about fears or challenges associated with HIV care.Traditional medicine can be a complement or a determent to HIV care. Take interest in family traditions centered around health and healing.

51. AETC-NMC Curriculum Review Committee Cultural Competence: Strengthening the Clinicians Role in Delivering Quality HIV Care within Hispanic Adolescent MSM CommunitiesGoulda Downer, Ph.D., RD, LN, CNS - Principle Investigator/Project Director (AETC-NMC) Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN I. Jean Davis, PhD, DC,PA Denise Bailey, MEd.

52. 1840 7th Street NW, 2nd FloorWashington, DC 20001202-865-8146 (Office)202-667-1382 (Fax)Goulda Downer, Ph.D., RD, LN, CNS Principal Investigator/Project Director (AETC-NMC)www.aetcnmc.orgHRSA Grant Number: U2THA19645