Managing HIV/AIDS Therapy in Special Populations What are the special needs of African-American patients?
	Enlarged Version of Graphics Below	Dr. Kwakwa (OC): The African-American patient faces many, many barriers to care, some of which are very similar to the barriers to seeking treatment for other chronic illnesses such as hypertension and diabetes as well, and some of which they hold in common with non-African-American communities when it comes to HIV disease. Dr. Kwakwa (VO): They are such barriers as financial barriers, social/cultural barriers, which can be tremendous barriers to seeking care in a timely fashion. The stigma of HIV, although held in common with other communities, is particularly pervasive and deeply held in the African-American community, and along with it, of course, comes the denial of risk, and the lack of recognition of risk that leads to seeking care so late in disease, and this has been confirmed in so many studies-this lack of recognition of risk. Those are only some of the barriers. I will say that one increasingly important barrier in this African-American community, as in others, is the effect of competing subsistence needs. There are so many other issues that people have to take care of and struggle with on a daily basis that the health, or HIV, certainly, is relegated to a position of lower priority, and it is difficult to combat that, it being a chronic disease that is frequently asymptomatic for years at the time.   See Slide Dr. Kwakwa (VO): The provider-specific barriers that the patients perceive-the main one that I can think of that has been shown in some studies is the perception of the African-American patient as perhaps being unable or unwilling in some parts to adhere not only to antiretroviral therapy, but also to treat them to treatment-related recommendations made by the provider. What this leads to, in many cases, is a different kind of treatment, such as delaying antiretroviral therapy, and although this is what we've been taught-not to initiate therapy until the patient is ready-it is important that we institute some more objective measures of patient readiness, because many studies have shown that these subjective assessments really are often incorrect, that race itself is not a predictor of nonadherence on the one hand, and on the other hand that we as clinicians are really the worst predictors of adherence, and really should not be basing clinical judgments on such predictions.   See Slide Dr. Kwakwa (OC): We see that mistrust every day, and operating in a clinic that is staffed mainly by people of color, by African-Americans, Latinos and Latinas, by Africans and Caribbeans-we see manifestations of that mistrust every day. Dr. Kwakwa (VO): Sometimes it's verbalized. Sometimes it's a comment, when you send a patient to a specialist, a subspecialist, and they refuse to go unless you perform the procedure, which you are not able to perform, and sometimes that leads into such discussions. Sometimes it leads to a very difficult time with antiretroviral medications. Taking the medication when the patient is ill, and they see no other option, and then discomfort with the medication running out, when they are not feeling so ill. When it comes to adherence to medication, it's very difficult dealing with this mistrust, because this mistrust leads patients to come in with the perception that they are going to be given plenty of pills that they may or may not need, and the pills are probably going to make them feel a little bit worse than they do already, and that is what in actuality happens.   See Slide Dr. Kwakwa (OC): Sometimes it sort of leads into this perception, and we have found that when we address, or elicit and address, these misperceptions up front, patients tend to do quite a bit better. Dr. Kwakwa (VO): There are no differences in treatment goals, and there really ought to be no differences in adherence goals, regardless of the race or ethnicity of the patient treated. I think that the approach to the African-American patient particularly may be a little bit different. It may be more important to find out what their social support system is, and to really work a little bit harder as a team in the practice setting to support them, however they need that support, whatever form that support may take, as an alternative to maybe delaying or withholding therapy for a little bit longer. The social challenges are definitely a little bit more, and the perceptions may be a little bit different.   See Slide Dr. Kwakwa (OC): When it comes to the genetic polymorphisms that contribute to the differences in drug metabolism such as with MDR1 gene, and the cytochrome P450 subsets, it is a very important issue that has been shown to have clinical relevance in other disease states, such as in transplant medicine, for example, and it's very important that we follow this, as we get more information on HIV disease. Perhaps the drug that has been best studied in this area, again, is efavirenz, and there are other medications that have been studied peripherally, but again, we don't have enough information to base clinical judgments on these polymorphisms. It is interesting, it will be important, but we don't have the tools to know exactly how to use it. Going forward, though, and truly individualizing therapy, I think that will be an important tool to have in our armamentarium. Dr. Kwakwa (VO): A related issue beyond the issue of efficacy of drugs, when we're talking about a drug such as efavirenz, is the side effect profile, which also appears, to some extent, to be dependent on the genetic makeup for some drugs. Again, abacavir has perhaps been the best studied in this area, where the hypersensitivity reaction is much less frequent in people of African descent, apparently because of the lower prevalence of certain HLA haplotypes in this community, and so, that is important information to know, not because you can give abacavir to an African-American patient without worrying about it, but because you know the risk may be lower, although it is never zero, and so, this is an important area of study.   See Slide Dr. Kwakwa (VO): ...One of the most important considerations in the African-American patient when selecting antiretroviral therapy is comorbid conditions, or underlying risk for comorbid conditions such as, perhaps, dyslipidemias, coronary artery disease, certainly, diabetes mellitus, existing hypertension, endstage renal disease or chronic kidney disease, for example. All of those are incredibly important considerations that, as we see the population with HIV continue to age, will become even more important.   See Slide Dr. Kwakwa (OC): There is no single antiretroviral agent that I can say should not be used in the African-American patient, but as with all of the considerations with each agent, we need to weigh the potential risk versus the potential benefit, and with some of the agents that contribute to these comorbid conditions, we may get to the point where the risk may outweigh the benefit for some of our patients. Dr. Kwakwa (VO): The particular medication that comes to mind, for example, is tenofovir. Although there are many studies that show-and my own experience certainly supports the use of tenofovir in the African-American patient-I see many more African-American patients who are at higher risk for developing elevated glomerular filtration rates on tenofovir-containing regimens, for example, because my African-American patients are more likely to be hypertensive, to have diabetes mellitus, to have family histories of kidney disease, and to come in with kidney function that may be borderline at baseline, raising the risk of using tenofovir. It's incredibly important when we're using tenofovir to be aware of the glomerular filtration rate and not just the creatinine, regardless of the race or ethnicity of the patient we are treating.   See Slide Dr. Kwakwa (VO): When it comes to the protease inhibitors and the dyslipidemias that may be associated with them-because African Americans tend to be such an increased risk of coronary artery disease-it is important that we be acutely aware of some of the potential risks of dyslipidemia with these medications, and be very aggressive in preventing them when possible, diagnosing them early, if they should occur, and really managing them very aggressively if and when they do occur.   See Slide
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