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Care of HIV-Infected Latinos in the United States

A Description of Calls to the National HIV/AIDS Clinicians' Consultation Center

Mahoney, Megan R., MD1; Khamarko, Kevin, MA1; Goldschmidt, Ronald H., MD2

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Journal of the Association of Nurses in AIDS Care: July-August 2008 - Volume 19 - Issue 4 - p 302-310
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Abstract

Latinos are currently the largest federally designated ethnic group in the United States (U.S. Census Bureau, 2006). Increasingly, HIV has disproportionately affected the Latino population in the United States. Although Latinos comprised 14% of the U.S. population in 2004, they accounted for approximately 19% of those diagnosed with HIV/AIDS (Centers for Disease Control and Prevention [CDC], 2007a). Latinos continue to have the second highest annual AIDS case rates among all ethnic/racial groups (CDC, 2007b). Overall, HIV transmission patterns among Latinos are similar to other racial/ethnic groups, with the majority of infections among men attributed to male-to-male sexual contact and the majority of infections among women attributed to high-risk heterosexual sex (CDC, 2007b). The epidemic among Latinos has been shaped by ethnic/cultural differences, migration, immigration policy, socioeconomic status, regional differences, country of origin, and behavioral risk (National Alliance of State and Territorial AIDS Directors, 2003). The CDC (2007c) reported that the majority of cases are concentrated among persons born in the continental United States (32%), Puerto Rico (18%), and Mexico (18%).

The literature on Latino patients has suggested that both cultural and structural barriers to diagnosis and treatment of HIV exist. Flores (2000), and Jimenez and Jimenez (1992) reported that HIV-infected Latinos often face a pervasive stigma that negatively affects their family relationships and support systems. Cultural ostracism is a disincentive to timely diagnosis and treatment of HIV. Structural barriers have been identified, including unfamiliarity with the U.S. health care system, lack of medical insurance, and lack of U.S. citizenship (Bowden, Rhodes, Wilkin, & Jolly, 2006; Garcés, Scarinci, & Harrison, 2006; Jimenez & Jimenez, 1992).

Several studies have reported that (a) Latinos felt disrespected or looked down upon by their providers (Blanchard & Lurie, 2004), (b) Latinos felt discriminated against and that they were treated poorly by providers (Campero, Herrera, Kendall, & Caballero, 2007), (c) Latinos believed they would have received better medical care if they belonged to a different ethnic/racial group, and (d) Latinos believed that medical staff judged them unfairly based on their proficiency in English (Johnson, Saha, Arbelaez, Beach, & Cooper, 2004). One study reported that Latinos with strong beliefs about discrimination were more likely to prefer a Latino provider, and one third of all Latinos preferred a Latino provider (Chen, Fryer, Phillips, Wilson, & Pathman, 2005).

There is a paucity of HIV-specific research on health care providers who work with Latino patient populations. There have been several studies, however, on health care providers who care for minority patients in general. Research on minority patients has suggested that racially concordant patient-provider relationships might be associated with more participation in decision making and better communication between the patient and provider as well as longer doctor visits and greater satisfaction than in racially discordant relationships (Laveist & Nuru-Jeter, 2002; Saha, Taggart, Komaromy, & Bindman, 2000). Although data have shown the clinical benefits of race-concordant provider-patient relationships among HIV-infected African Americans (King, Wong, Shapiro, Landon, & Cunningham, 2004), little is known of the benefits of HIV-infected Latinos having a Latino provider. In one study, Chen et al. (2005) reported that more Latinos with a preference for a racially concordant physician who themselves had a Latino physician were satisfied than patients who preferred a racially concordant physician-patient relationship and did not have a Latino physician (40% vs. 29%). These results, however, did not reach statistical significance.

HIV care often requires consultation because clinicians' experiences with HIV vary, new drugs and drug formulations for HIV are released relatively frequently, and recommendations on antiretroviral treatment (ART) strategies are constantly evolving. Ready access to HIV consultation can support clinicians providing care for HIV-infected individuals. The National HIV Telephone Consultation Service (Warmline) and the National Perinatal HIV Consultation and Referral Service (Perinatal HIV Hotline) are two lines of the National HIV/AIDS Clinicians' Consultation Center, a federally funded program at the University of California, San Francisco, based at San Francisco General Hospital, that provide free and confidential consultation to clinicians across the United States and Puerto Rico.

The Warmline provides advice to clinicians at all levels of HIV expertise on ART, prophylaxis and treatment of opportunistic infections, and the prevention of HIV transmission. The Perinatal HIV Hotline provides advice on indications and interpretations of standard and rapid HIV testing in pregnancy as well as consultation on ART use in pregnancy, labor and delivery, and the postpartum period. To characterize clinical questions asked about Latino patients and patients of Latino clinicians, Warmline and Perinatal HIV Hotline consultations were analyzed for all calls received between July 1, 2006, and June 30, 2007.

Methods

The Warmline and Perinatal HIV Hotline incorporate methods to collect demographic data about callers and their patients. Data from each consultation were documented in a relational database, with data about clinicians linked to data on the actual call. The caller database consisted of unique clinician records that contain the caller's name, profession, facility type, number of HIV-infected patients in the clinician's practice, and self-reported race/ethnicity. The call database is composed of call records that contain descriptions of each consultation and coding of the call topics covered during the consultation. Whereas there was one unique call topic code assigned to each Warmline consultation, multiple codes were assigned to a single consultation on the Perinatal HIV Hotline. The coding frameworks of call topics for the Warmline and Perinatal HIV Hotline are shown in Table 1. Anonymous information about the patient of interest in each call, including sex, ethnicity/race, age, risk factor and HIV status, was also included in the call database.

Table 1
Table 1:
Warmline and Perinatal HIV Hotline Coding Framework

The University of California, San Francisco, Human Research Protection Program approved the study protocol. All Warmline and Perinatal HIV Hotline calls made between July 1, 2006, and June 30, 2007, were retrieved for the analyses. For multiple calls made about the same patient, coding for the consultation topic from the first call was used. For callers and patients of mixed ethnic/racial heritage, the first listed race/ethnicity was used. Because the Warmline and Perinatal HIV Hotline do not collect patient identifiers such as name or date of birth, two calls made about a patient with the same age, race/ethnicity, sex, HIV risk factors, and HIV provider were considered to be about the same patient. Calls were then sorted to create two datasets: (a) calls about Latino patients (i.e., data on calls about Latino patients and their providers of all ethnic/racial backgrounds), and (b) calls from Latino clinicians (i.e., data on calls made from Latino clinicians and their patients of all ethnic/racial backgrounds). Within each dataset, demographic patient and caller information from Warmline and Perinatal HIV Hotline databases were pooled and presented as such after data on duplicate callers and patients were removed.

Results

Clinician Demographics

Clinicians calling about Latino patients

A total of 172 individual clinicians called the Warmline and Perinatal HIV Hotline about Latino patients during the study timeframe. The majority (69.8%) of callers were physicians. More than half (55.8%) of callers cared for more than 25 HIV-infected patients in their practice. Clinicians who cared for Latino patients represented the following ethnic/racial groups: 58.7% were White, 12.8% were Latino, 7.6% were Asian/Pacific Islander, and 5.8% were African American. See Table 2 for detailed caller demographics.

Table 2
Table 2:
Demographic Information About Clinicians Calling the Warmline and/or Perinatal HIV Hotlinea

Latino clinicians

A total of 58 individual Latino clinicians used the Warmline and Perinatal HIV Hotline during the study timeframe. The majority (69%) of Latino callers were physicians. Approximately one third (36.2%) of callers cared for more than 25 HIV-infected patients in their practice. Latino clinicians most commonly called about African American (28.3%) and Latino (25.2%) patients (see Table 3).

Table 3
Table 3:
Patient Race of Latino Clinicians (N= 127)

A total of 22 Latino clinicians called about Latino patients. Their demographic data were included in both categories (i.e., clinicians calling about Latino patients and Latino clinicians).

Calls About Latino Patients

Warmline consultations

A total of 2,069 calls were made to the Warmline during the study timeframe. Of these calls, 210 (10.1%) were about Latino patients. Among Latino patients, the average patient age was 39.9 years, and 159 (75.7%) patients were male. All Warmline consultation topics were represented with varying frequencies: ART strategies (66.7%), management of HIV-related conditions (14.3%), clinical and laboratory issues (12.9%), testing and counseling (4.3%), primary care and epidemiology (1.4%), and transmission and prevention (.5%). See Table 4 for Warmline call topic information on calls about Latino patients. Warmline call topics from physicians and nurses, including nurse practitioners, are shown in Table 5.

Table 4
Table 4:
Warmline and Perinatal HIV Hotline Call Topics Regarding Latino Patientsa
Table 5
Table 5:
Warmline Call Topics by Physicians and Nurses Calling About Latino Patientsa

Perinatal HIV consultations

A total of 291 calls were made to the Perinatal HIV Hotline. Of these calls, 37 (12.7%) were calls about Latino patients. The largest percentage of calls concerned HIV care in pregnancy (36.8%), followed by HIV-exposed infant care (22.8%), HIV testing in pregnancy (17.5%), intrapartum HIV care (15.8%), preconception/contraception concerns (3.5%), and general information (3.5%). See Table 5 for Perinatal HIV call topic information on calls about Latino patients.

Calls From Latino Clinicians

Warmline consultations

Out of a total of 2,069 Warmline calls, 111 (5.4%) were from Latino clinicians during the study timeframe. Warmline call topics for Latino clinicians were represented with varying frequencies: ART strategies (74.8%), clinical and laboratory issues (6.3%), management of HIV-related conditions (7.2%), testing and counseling (5.4%), referrals and references (5.4%), and primary care and epidemiology (.9%) (see Table 6).

Table 6
Table 6:
Warmline and Perinatal HIV Hotline Call Topics Among Latino Cliniciansa

Perinatal HIV consultations

Out of 291 Perinatal HIV calls, 13 (4.5%) were from Latino clinicians. In terms of Perinatal HIV Hotline call topics, the highest percentage of calls concerned HIV care in pregnancy (39.1%), followed by intrapartum HIV care (17.4%), preconception/contraception concerns (17.4%), HIV-exposed infant care (13%), and HIV testing in pregnancy (13%) (see Table 6).

Discussion

The majority of Warmline calls about Latino patients concerned complicated patient care issues such as ART strategies and management of an HIV-related condition rather than topics that often do not require expert consultation such as testing, primary care, and prevention. Accessible expert consultation for complicated cases might be especially relevant when caring for Latino patients in light of evidence that has suggested that HIV-infected Latinos initially present to care at more advanced stages compared with patients of other ethnic/racial backgrounds. Delays both in diagnosis and treatment have been implicated. Lopez-Quintero, Shtarkshall, and Neumark (2005) reported that two thirds of sampled Latinos (n = 4,261) had never been tested for HIV, and 88% of these individuals had no intention of receiving a test in the future. Hodges, Khoshnood, and Stevens (2002) reported that, in a sample of 282 HIV-infected men who had sex with men, Latinos were almost 2.5 times more likely to delay initiation of ART.

The majority of Perinatal HIV Hotline calls about Latino patients concerned the management of the HIV-infected mother and her HIV-exposed infant. Almost one fifth of Perinatal HIV Hotline calls pertained to HIV testing in pregnancy. The volume of these types of calls is expected to increase with further expansion of universal testing in pregnancy nationwide and the advent of the One Test Two Lives campaign that promotes HIV testing in pregnancy (CDC, 2007d). This is particularly important for the Latina community, given that many Latinas are unaware of their risk for HIV until they are tested during pregnancy (Castañeda, 2000). Almost 16% of calls concerned intrapartum HIV care, including consultations on the urgent use of antiretroviral drugs in labor and delivery.

Given the data that have suggested the benefits of cultural sensitivity, language compatibility, and patient-physician race concordance, a separate analysis on Latino clinicians was performed. The majority of Latino Warmline and Perinatal HIV Hotline callers presented cases that involved minorities. This was not surprising given national data that have shown that Latino health care professionals are more likely to work in minority communities (Komaromy, Grumbach, & Drake, 1996). The Latino clinicians who called the center represented a full range of HIV experience, as indicated by their HIV-infected patient loads and their consultation questions, which covered the spectrum of topics.

As illustrated in the sample Warmline and Perinatal HIV Hotline calls (see Figures 1 and 2), the Warmline and Perinatal HIV Hotline received calls concerning undocumented residents and immigration issues. Because the current federal immigration policy excludes persons known to have HIV infection from obtaining legal residency in the United States, these cases are often not reported to the CDC (Castañeda, 2000; Rios-Ellis et al., 2007). Although the Warmline and Perinatal HIV Hotline consultants do not collect information on the citizenship status of patients, one can predict that there is considerable variation in insurance coverage among Latino patients. Callahan, Hickson, and Cooper (2006) reported that insurance coverage differed based on Latino subpopulation and citizenship status. Levy et al. (2007) reported that immigrants (79% of immigrants were Latino immigrants) had lower initial CD4+ T cell counts at diagnosis than U.S.-born patients (287 cells/mm3 vs. 333 cells/mm3), were more likely to have an opportunistic infection at HIV diagnosis (29.8% vs. 17.2%), and were more likely to be hospitalized at HIV diagnosis (20.2% vs. 12.5%). Of these variables, only immigrant status was statistically significant and associated with delayed presentation.

Figure 1. Sample warmline call.
Figure 1. Sample warmline call.
Figure 2. Sample perinatal HIV hotline call.
Figure 2. Sample perinatal HIV hotline call.

This study has several limitations that should be kept in mind when interpreting the results. Two patients of the same provider with identical demographics might have been counted as one patient, which could have led to the underrepresentation of patients of clinicians with large patient loads and patients of a more common racial/ethnic descent. Although calls about Latino patients contribute a significant proportion of calls to the Warmline and Perinatal HIV Hotline, the percentage of those calls is lower than the national percentage of Latinos with HIV. Whereas this study captured all callers to a busy, established, free national HIV consultation service, callers cannot be considered representative of all clinicians caring for HIV-infected patients.

Recommendations for the care of HIV-infected minorities have been published. Shedlin and Shulman (2004) and Warda (2000) recommended that providers serving the Latino community attempt to understand the context of their Latino patients' lives, work on relating to them, build rapport, and above all listen to Latino patients' circumstances and develop clinical recommendations that will work for them. In an article on the HIV care of minority patients, Stone (2004) recommended: (a) becoming familiar with the particular health-related cultural beliefs and practices of the predominant ethnic community, (b) enhancing communication by spending more time listening to minority patients and by using medical interpreters, (c) diversifying the clinical staff in the practice setting, (d) becoming aware of the data regarding disparities in the receipt of ART and using strategies in the clinical setting to overcome barriers to treatment, (e) using strategies to enhance adherence, and (f) recruiting more minority patients into clinical trials. Cultural competency materials for HIV providers are available from a number of sources, including the AIDS Education and Training Centers National Resource Center (AIDS Education and Training Centers, 2006).

Ready access to clinical consultation can be crucial to providing excellent care, especially for clinicians with limited HIV care experience and clinicians caring for patients receiving ART. This study contributes to the growing body of literature targeting providers who care for HIV-infected Latino patients. The free consultative services provided by Warmline and Perinatal HIV Hotline staff can be particularly helpful for those working in the Latino community. These consultations can complement culturally and linguistically appropriate HIV prevention, screening, and disease management services for clinicians caring for this important population.

Clinical Considerations

  • HIV care often requires consultation because clinicians' experiences with HIV vary, new drugs and drug formulations for HIV are released relatively frequently, and recommendations on ART strategies are constantly evolving. Ready accessibility to HIV consultation can be essential to patient care.
  • The National HIV Telephone Consultation Service (Warmline) at (800) 933-3413 and the National Perinatal HIV Consultation and Referral Service (Perinatal HIV Hotline) at (888) 448-8765 are free resources for HIV care providers in the nursing and medical care of Latinos.
  • The Warmline provides advice about ART, prophylaxis and treatment of opportunistic infections, and the prevention of HIV transmission to clinicians at all levels of HIV expertise.
  • The Perinatal HIV Hotline provides advice about indications for and interpretations of standard and rapid HIV testing in pregnancy as well as consultation on ART use in pregnancy, labor and delivery, and the postpartum period.

Acknowledgment

Supported in part by a grant from the AIDS Education and Training Centers, HIV/AIDS Bureau, Health Resources and Services Administration (H4AHA 01082-03) and the Centers for Disease Control and Prevention. The contents of the manuscript are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies.

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Keywords:

AIDS; health care providers; HIV; Latino/Hispanic

© 2008Elsevier, Inc.