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Clinical management of African-American patients
Number one issue is inherited resistance
When HIV clinicians manage the care of African-American patients with HIV/AIDS they must consider several issues that often crop up with this population, a long-time HIV physician says.
"The number one issue for me in terms of what dictates what agents to use is inherited resistance," says Ellen Tedaldi, MD, director of the HIV program at Temple University in Philadelphia, PA. Tedaldi has worked with HIV patients since 1984, and she recently spoke about clinical management of HIV infection at the 2009 National Conference on African-Americans and AIDS, held Feb. 23-24 in Philadelphia, PA.
"We still have 10 to 15% of newly-diagnosed patients who may be resistant to one or two of the current agents," Tedaldi says.
"The other consideration is because of late diagnosis," she adds. "If you're also treating patients for a related HIV complication, the question comes in about timing: When do you start them on specific HIV therapy relative to the treatment of opportunistic infections or complications?"
The new opportunistic infections (OIs) treatment guidelines, published March 24, 2009. in the Morbidity and Mortality Weekly Report (MMWR), offer some new recommendations, Tedaldi notes.
Treatment guidelines are not ethnic specific, but HIV clinicians often will see African-American patients with late presentation of the disease, and so the OI recommendations are pertinent to their care, she adds.
Also, most of the women patients Tedaldi and most HIV clinicians see are African-Americans of childbearing years, and for this population clinicians will need to consider the potential for an unplanned pregnancy which could impact which drug to use.
Clinicians generally should discuss with patients the potential for having higher rates of symptoms when they start antiretroviral therapy, Tedaldi suggests.
"It's more of a challenge to get through the initial period of starting treatment because they're often symptomatic and sick," she explains.
And patients will be taking both antiretroviral medications and pills for their OIs, she adds.
Another challenge involves the patient's psychological care, particularly in terms of disclosure and support systems, Tedaldi says.
"We have an on-site case manager and have a team approach, so usually a patient works with both a physician and a nurse practitioner, as well as the case manager," Tedaldi explains. "We try to provide an initial support team for that patient, especially if they're struggling with the beginning of the diagnosis and disclosure to partners and family."
HIV clinicians working with African-American populations also should be aware of a rise in HIV diagnoses among men who have sex with men (MSM), Tedaldi notes.
"The group we see with an incredible increase in diagnoses is men who have sex with men in the African-American community," she says. "I can see in my own clinic the rate of sexually-transmitted diseases (STDs) in the last year or so has increased."
Two factors contribute to this trend: "The digital divide doesn't exist," Tedaldi says. "Cell phones, internet connections, text messaging, allow people to call someone, text them, go on-line and meet up."
The other contributing factor is social networking among an insulated black MSM group that also copes with social stigma within their larger African American community, she adds.
For women infected with HIV, contributing factors include mental health issues and early trauma experiences, Tedaldi says.
"The women deal with sexual or domestic trauma, and one of the secondary consequences is there are a lot of mental health issues and resulting behavioral issues that lead to their being infected with HIV," she adds.