AN INVESTIGATION OF THE DETERMINANTS OF ADHERENCE TO HIGHLY ACTIVE ANTIRETROVIRAL THERAPY IN ABORIGINAL MEN IN THE DOWNTOWN EASTSIDE OF VANCOUVER Meck Chongo, Virginia Russell, Jose 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 2 Background British Columbia (BC) represents approximately 13% of Canadas population 18% of Canadas 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 BCs 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) 3
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 4 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 www.clairemartinphotography.c om 5 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
6 Demographics Age (yrs) Range 39 56 Time HIV diagnosis Time on medication Marital status Mode 35 years Range 2 14 years Mean 7 years Single/Separated BC housing 64% Employment
status Disability allowance Education level Some high school 50% 68% Mode 43 Range 1987 - 2008 68% Housing Mean 47 Married/Cohabiting 27% Widowed Temp hotel room
27% Own house/Other 9% Seasonal/PT job 32% Unemployed High school 27% Elementary school 5% 18% 5% 7 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 History of Trauma/Residential Schools www.clairemartinphotogra phy.com 8 1. Patient Factors 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, feeling of, Poor me. I stop taking the meds. 9 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 wouldnt want to go in. 10 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 wasnt on methadone, you know, maybe I would miss um, some days & that [of medication]. But because I gotta come here, you know, Im lucky that I have11 that setting 4. Medication-Related Factors The development and fear of side effects to medication
For example: Im 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 Im sick through the whole night. I cant sleep www.clairemartinphotography.com 12 5. History of Trauma/Residential Schools Psychological & Emotional Pain Low Self-Esteem Self Blame Insecurity Fear & Resentment Not Being Wanted/Accepted
Substance Abuse 13 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 www.clairemartinphotography.com 14 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 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 15 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 16
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