One type of program doesn’t fit all
As researchers examined the issue of racial disparity in HIV care and treatment, they found that some clinics and states have made progress in reducing disparity through a variety of programs and measures. Through studying various HIV programs in four states, researchers have found that the chief obstacles and solutions vary by region and minority culture, so there probably will never be one model for care that would work for all states and programs. However, they have collected an assortment of strategies that work for some areas and could be used in areas where disparity is a major problem.
"The most promising strategy is to contract with minority community-based organizations (CBOs) to do treatment education and outreach," says Stephen F. Morin, PhD, professor of medicine at the University of California-San Francisco (UCSF) and the AIDS Research Institute in San Francisco. "This has been done for years in New York and has emerged as a major strategy in California," Morin says.
Another strategy is to create a position of regional minority coordinator whose job is to provide treatment education and outreach efforts. This method has been employed by Florida, he explains. In Florida, there also has been an outreach program that has used black universities and colleges and their football games to spread the word about HIV treatment and information, Morin says.
Providers also have been involved with HIV awareness outreach through minority media outlets in California, New York, Texas, and Florida, he points out. The only drawback is that none of these outreach efforts have been studied with regard to outcomes, and researchers have recommended that the Health Resources and Services Administration (HRSA) in Rockville, MD, begin to study these programs to evaluate outcomes, Morin adds.
New York state’s approach to providing Medicaid services for HIV enrollees is another example of a government’s strategy for reducing disparity.
While some states have Medicaid programs that limit enrollment to people who meet both income and disability requirements, meaning that many HIV-infected people would not qualify until they acquired AIDS-defining illnesses, New York’s program is more liberal with no barriers for HIV-infected people who meet the income eligibility, says Guthrie S. Birkhead, MD, MPH, director of the New York State Department of Health AIDS Institute in Albany.
New York’s Medicaid program also provides early, quality care for HIV patients, so even if minorities are disproportionately receiving their HIV treatment through Medicaid, they still are receiving services comparable to those offered to HIV patients with private insurance.
Another way New York has reduced racial disparity is through assembling advisory groups and engaging community organizations and local leaders in efforts to design prevention and treatment programs for minorities. "We make an effort to work with the Centers for Disease Control and Prevention with their directly-funded programs for minorities," Birkhead says. "The community-developed initiative funds organizations in the African-American and Hispanic communities to assess what the needs are and work with us to meet those needs."
In comparing eight clinics that either target Hispanic or African-American populations, investigators found that in some cases, the clinic and clinicians themselves were the ones coming up with ways to reduce disparity in treatment. For example, one HIV physician made certain she was readily available to HIV patients by giving them her beeper number, says T. Anne Richards, MA, research specialist with UCSF. "That was pretty amazing to me — she was really engaged," she says.
Also, a clinic in San Francisco offered HIV patients an array of services that covered more than clinical needs, Richards says. "They looked at a person’s total situation and made a determination on an individual basis of what needed to happen in that person’s life to facilitate HIV care, and then they’d meet weekly to do a case review. So it was an interdisciplinary approach."
The clinic’s methods included collaborating with patients to make them active participants in their HIV clinical decisions. There also was a heavy emphasis on educating patients before they started on antiretroviral medications, she says. "If the patient’s basic life needs weren’t covered, then HIV falls in priority, so the clinic would help them make arrangements for housing and check in with them to make sure the housing situation was conducive to their taking medications."
Since the clinic’s staff were well aware of issues pertaining to their Latino population, they also came up with strategies for helping clients stay on their medications when they left the United States for long periods of time, an issue that might never occur to clinicians who work with a primarily white population.
The San Francisco model also had an effective method for keeping newly diagnosed clients from falling through the cracks. Once a client received a positive HIV serostatus notice, the clinic’s staff would walk the patient to the clinic to make a medical appointment, Richards says.
"That moment of receiving notice of serostatus is one with a lot of fear and anxiety, and it’s a critical time where people will disappear from the system and not show up again until they’re symptomatic," Richards says. "They realized this was a critical time to bridge the gap from testing to treatment."
The San Francisco clinic also encouraged HIV patients to bring their family members and friends into the clinic where they could be involved in decision making and providing the patient support, she says. "This is a real community model of what defines the neighborhood of services. This is not rocket science; it’s simple, practical things."