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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


HIV in Vulnerable Patients and Underserved Populations


GOAL
To provide infectious disease specialists, psychiatrists, and other physicians with practical information for human immunodeficiency virus (HIV) management in underserved populations such as intravenous drug users, mentally ill, homeless, and those who are in the corrections system.

TARGET AUDIENCE
This activity is designed for infectious disease specialists, psychiatrists, and other physicians who treat patients with HIV.

LEARNING OBJECTIVES
After reading this issue, the participant should be able to:

  • Address specific issues concerning optimal HIV care in disenfranchised patients.
  • Understand the complexities of care and management of HIV in prison populations.
  • Understand methods of improving outcomes in drug addiction clinics.
  • Identify neuropsychiatry disorders associated with HIV.
  • Identify mental illnesses associated with HIV.

ACCREDITATION STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association (AMA) Physicians' Recognition Award. Each physician should only claim those hours of credit that he/she actually spends in this educational activity. Credits are available until the expiration date of May 31, 2004.

This continuing education activity was produced under the supervision of John G. Bartlett, MD, Chief, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland; and Glenn J. Treisman, MD, PhD, Associate Professor, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland.

This program is supported by an unrestricted educational grant from Agouron Pharmaceuticals, Inc and Pfizer, Inc.

Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

The contents of this issue of Advanced Studies in Medicine include articles based on presentations given at a satellite symposium supported by Agouron Pharmaceuticals, Inc and Pfizer, Inc at the 39th Annual Meeting of the Infectious Diseases Society of America held in San Francisco, California, on October 24, 2001. In addition, related poster presentations from the scientific sessions are highlighted.

CHAIRS

    John G. Bartlett, MD
    Chief, Division of Infectious Diseases
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Bartlett reports serving on the HIV advisory boards for Abbott, GlaxoSmithKline, and Merck.

    Glenn J. Treisman, MD, PhD
    Associate Professor, Department of Psychiatry
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Treisman reports receiving honoraria from many pharmaceutical companies.

PARTICIPATING FACULTY

    Marc Fishman, MD
    Assistant Professor
    Department of Psychiatry & Behavioral Sciences
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Fishman reports receiving grant/research support from the Center for Substance Abuse Treatment and other financial and material support from the Maryland Treatment Centers.

    William H. Ruby, MD
    Instructor, Division of Infectious Diseases
    Johns Hopkins University School of Medicine
    • Dr Ruby reports receiving grant/research support and honoraria from and serving as a consultant to Agouron, Bristol-Myers Squibb, Dupont, and GlaxoSmithKline.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

HIV in Vulnerable Patients and Underserved Populations
John G. Bartlett, MD*; and Glenn J. Treisman, MD, PhD

Treating patients with human immunodeficiency (HIV) has changed considerably in the last decade-for both the patient and the HIV health care team-mostly as a result of highly active antiretroviral therapy (HAART). The first protease inhibitors were approved by the Food and Drug Administration in 1996. Within 1 year, the death rate from HIV was cut in half. HIV-infected patients were given more positive prognoses and learned how to live with HIV infection.

The Moore Clinic at Johns Hopkins Hospital parallels those developments in HIV management. Observers have witnessed its growth from a clinic originally operating 1 half-day per week in 1983 to a 11-room, 5-day-per-week clinic serving more than 3000 HIV-infected patients and a staff of more than 150 persons.

The Moore Clinic serves the underserved. Demographics of the population show 80% are African American, 60% have injection drug use as their HIV risk factor, 46% have hepatitis C virus coinfection, and the median income is less than $5,000 per year. Primary care providers follow 50 to 80 patients per half day in the clinic. Additional services are provided by specialists in gastroenterology, neurology, psychiatry, gynecology, obstetrics, ophthalmology, and dermatology.

This issue of Advanced Studies in Medicine addresses some of the barriers to treating HIV in underserved and disenfranchised populations: those who are poor, minorities, uneducated, without health insurance, suffer from drug addiction, and/or are incarcerated. Many of those barriers may be considered "psychiatric" due to the high level of psychiatric disorders in patients seen at HIV clinics across the country, but also because of the high crime rate, poor social support, and demoralization that are the result of circumstances outside of HIV infection that are all too common with these patients. By recognizing, understanding, and addressing those barriers, the chances of positive outcomes are greatly improved.

Dr William H. Ruby addresses the prevalence and challenges of treating HIV in incarcerated populations. The rate of HIV among jail and prison inmates is 5 times the national rate, yet many in decision-making positions do not feel that diverting money to treat incarcerated HIV-infected patients is a priority. Also, because of the complicated regimens associated with state-of-the-art HIV medications such as HAART, consideration must be given to the timing of the prisoner's release and the type of circumstances he or she will be reentering upon release. In addition, Dr Ruby discusses the potential legal issues associated with HIV testing of inmates and segregated housing for those infected with HIV, and the stigma applied to HIV infection among the incarcerated community.

Dr Marc Fishman examines HIV treatment from the perspective of the person suffering from substance abuse. Substance abuse is very common among the underserved HIV population and understanding the mentality of substance abuse can facilitate improved treatment adherence for HIV. As Dr Fishman emphasizes, the societal view of treatment for addiction underestimates the success rate and misrepresents patient attitudes. For the ID specialist, many ID clinics are now becoming substance abuse clinics and vice versa.

Dr Glen J. Treisman explores the psychiatric issues with HIV disease and the way they can hinder optimal care. Using a case study, Dr Treisman discusses the psychiatric illnesses associated with HIV in straightforward terms and presents useful ways that the ID specialist can recognize and treat the most commonly associated psychiatric disorder with HIV infection-depression. He also carefully explains the difference between depression and demoralization and why the treatment approaches are different.

Finally, Dr John G. Bartlett discusses some of the barriers to HIV treatment and the need for flexibility in decisions about when to start therapy and the regimens to use. Such regimens may not match the new federal guidelines, but they may be appropriate for the unique circumstances of the individual patients.

The availability of HAART has brought innumerable treatment successes, halved the death rate due to HIV, and changed the focus of psychiatric counseling in this population away from death and grief toward dealing with a life with HIV infection. While we celebrate this new era of HIV management, the underserved HIV-infected populations continue to warrant careful study and consideration. HAART is most effective in patients who strictly adhere to its regimens. The information presented here offers ID specialists the opportunity to increase their success rate with HIV treatment through a multidisciplinary approach-an approach that has proven effective for other chronic diseases.

*Chief, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland; Associate Professor, Department of Psychiatry, Johns Hopkins University School of Medicine.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.