Transcript Presentation - Vancouver Native Health Society

AN INVESTIGATION OF THE DETERMINANTS OF
ADHERENCE TO HIGHLY ACTIVE ANTI-RETROVIRAL
THERAPY IN ABORIGINAL MEN IN THE DOWNTOWN
EASTSIDE OF VANCOUVER
Meck Chongo, Virginia Russell, Josée Lavoie, Ross Hoffman,
Mamdouh Shubair
University of Northern British Columbia
Agenda
•Background
•Objectives
•Participants & Research
Environment
•Method
•Demographics
•Results – Themes
•Factors
•Support Structures
•History of
Trauma/Residential
Schools
•Conclusions
•Recommendations
•References
Photography by Claire Martin ©
Downtown Eastside
www.clairemartinphotography.com
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Background
•British Columbia (BC) represents approximately 13% of Canada’s population
•18% of Canada’s estimated total HIV-positive population lives in BC (VNHS, 2009)
•~ 1 million Aboriginal peoples
•3.8 percent of total population (Statistics Canada, 2008).
•PHAC estimates  Aboriginal peoples = 8.0 % of Canadian with HIV (2008) &
12.5% of all new HIV infections in 2008
•Overall infection rate in Aboriginal persons that is nearly 3.6 times higher than
among non-Aboriginals (Duncan et al., 2010)
•2011
•~ 11,700 people living with HIV in BC
•~380 incident infections (PHAC, 2011)
•Aboriginals represent ~5% of BC’s population
•Continue to be disproportionately represented, comprising 18% of new AIDS cases
(BCCDC, 2012).
•The eradication of HIV is not yet possible
•Patients must take highly active anti-retroviral therapy (HAART) regularly (Ickovics &
Meade, 2002)
•In BC, HAART is distributed at no cost but HIV-positive Aboriginal persons continue to
have sub-optimal access to HAART (BC-CfE, 2010; Tu et al., 2008)
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Objectives
1.To investigate the
determinants of adherence to
HAART in Aboriginal men in
the downtown eastside
(DTES) of Vancouver
2.To offer culturally-sensitive
recommendations to better
address the effects of the
determinants aimed at
improving adherence and
reducing deaths due to
HIV/AIDS for Aboriginal men in
the DTES.
www.clairemartinphotography.com
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Participants & Research Environment
• Aboriginal men from DTES using
services at the Vancouver Native
Health Society (VNHS)
• 25+ years of age
• Currently enrolled in HAART program
• Vancouver DTES is the poorest urban
area in Canada
• Characterized by highest rates of HIV
• High rates of IDU users and
transmission
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Method
•Vancouver School of Phenomenology
•Hybrid qualitative method developed by
Joan Anderson (Anderson, 1991) was
used
•Describes lived experiences - giving
meaning to individuals’ perception of a
particular phenomenon
•Non-random methods of purposive
sampling and snowballing were used for
recruitment
www.clairemartinphotography.com
•10 in-depth interviews & 1 focus group
with 14 participants were conducted using
open-ended questions and thematic
analysis performed
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Demographics
Range 39 – 56
Age (yrs)
Time HIV
diagnosis
Time on
medication
Marital
status
Mean 47
Mode 43
Range 1987 - 2008
Mode 35 years
Range 2 – 14 years
Mean 7 years
Single/Separated
Married/Cohabiting
27%
Widowed
BC housing
Temp hotel room
Own house/Other
64%
27%
9%
Employment
status
Disability allowance
Seasonal/PT job
Unemployed
50%
32%
18%
Education
level
Some high school
High school
Elementary school
68%
27%
5%
68%
Housing
5%
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Results - Themes
• Results indicated that adherence to HAART in Aboriginal men in
the DTES was affected by:
Patient Factors
Inter-Personal Factors
Support Structures
Medication-Related Factors
www.clairemartinphotography.com
History of
Trauma/Residential Schools
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1. Patient Factors
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Depression
Drug or alcohol abuse
Fear of either dying or being more ill
Procrastination, being too busy or just not caring
Unemployment
Homelessness
Lacking faith & trust in care providers
Memory loss
For example
“When I get into depression, I need supervision to make sure
I take these pills, because when I fall into depression or uh,
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feeling of, “Poor me.” I stop taking the meds”.
2. Inter-Personal Factors
Stigma & discrimination led to:
• Fears of being treated with disdain
• Problems with confidentiality
• Feeling unwanted in small communities
• Low self esteem
• High degree of self-destructive behaviour, (e.g., drug
use)
For example:
“I think that, well I know with myself in a real small community
& it was known that I had HIV, I would start to be treated, you
know, with disdain, that I know it would have a great effect on
my ability, especially if I had to go in & get medication - pick it
up daily - I wouldn’t want to go in”.
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3. Support Structures
Psychological & Emotional Pain
Food Programs
Support
Counseling Services
Methadone Maintenance
Programs
Medication Pick Up & Outreach
Alternative/Traditional Medicine
– Ceremonies – Learning Circles
Funding & Services
For example:
“So um, if I wasn’t on methadone, you know, maybe I would miss um,
some days & that [of medication]. But because I gotta come here, you
know, I’m lucky that I have that setting…”
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4. Medication-Related Factors
The development and fear of side effects to
medication
For example:
•
“…I’m scared to take them [ARV
medication] now because they make me
so sick. Like every time I take them I
throw them back up and I’m sick through
the whole night. I can’t sleep”
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5. History of Trauma/Residential Schools
Psychological & Emotional
Pain
Low Self-Esteem
Self Blame
Insecurity
Fear & Resentment
Not Being
Wanted/Accepted
Substance Abuse
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Conclusions
Adherence to HAART in Aboriginal men can be affected by:
• Patient Factors
• Inter-Personal Factors
• Support Structures
• History of Trauma/Residential Schools
• Attendance
• Medication-Related Factors
The findings contribute to the field of HIV/AIDS research by:
• Providing a reasonably comprehensive scheme of
themes that describe, from the perspective of
Aboriginal men living with HIV/AIDS, what affects their
adherence to HAART, and
• Development of recommendations have the potential
to have implications
• Research
• Practice
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PATIENT FACTORS
• Depression
• Alcohol & Drug Addiction
• Fear
• Not Caring
• Procrastination
• Time constraints
• Tradition
INTER-PERSONAL FACTORS
• Poor Patient /
Care Provider
Relationships
Stigma &
Discrimination
• Unemployment
• Homelessness
LOW
ADHERENCE
• Low knowledge about
medication
• Resistance/Interactions
• Memory Loss
Complex Treatment
Side Effects
ANTI-RETROVIRAL
MEDICATION
FACTORS
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•
•
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•
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Figure 1: Interconnectedness between factors (Focus on Low Adherence)
Drug Use
Low Self-Esteem
Self-Blame
Fear
Insecurity
Resentment
SUPPORT STRUCTURE
• Lack of food security
• Decreased social
support
• No Counseling
• No Medication Pick-Up &
Outreach
• No Methadone
Maintenance Treatment
• Unavailability of Funding
& Services
• Not Aboriginal-Centered
HISTORIC
TRAUMA
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Recommendations
ADHERENCE
PATIENT FOCUSED
• Drug problem recognition
• Incorporate Aboriginal
beliefs & practices
• Depression treatment
• Individual treatment
• Education
• Provide employment
COMMUNITY & HEALTH TEAM
FOCUSED
• Stabilize funding for CBO and
ASOs
• Increased Community-initiated
programs
• Incorporation of spirituality in
counselling
• HIV/AIDS and trauma education
• Activism-challenge systemic
barriers
• Social, psychological assistance
• Food security
• Streamline medication pick-up
systems
• Intensify outreach strategies
MEDICATION FOCUSED
• Simplify regimens
• Tailor to patient daily
activities
• Provide reminders
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