Asians and Pacific Islanders with HIV

							Asians and Pacific Islanders and HIV


             Jason Tokumoto, MD
    Assistant Clinical Professor of Medicine
    University of California at San Francisco
Case Presentation
   KC is a 32 year-old Chinese American gay
    male with AIDS.
   He initially presented to a dermatologist
    because of purplish skin lesions which on
    biopsy proved to be Kaposi’s sarcoma. He
    had these lesions for 6 months before
    seeking care. His CD4 cell count was 30 and
    viral load 200,000.
Case Presentation
   KC became progressively ill despite anti-
    retroviral therapy developing CMV retinitis,
    disseminated MAC, worsening Kaposi’s
    sarcoma despite appropriate treatment.
   In need of increasing care and help but did
    not want to access the services of HIV
    community based organizations.
   Family in New York. Not aware of his HIV
    status. He informed his family he had a “bad
    cancer.”
Case Presentation
   KC decided that he wanted to return to New
    York. His family also wanted him to return
    home so that they could take care of him.
   He and I had several long discussions about
    telling his family about his HIV status since
    they were going to be taking care of him and
    that they should be informed.
   He agreed but wanted me to tell his family.
Case Presentation
   His mother came to San Francisco to take KC
    home.
   She did not speak or understand English so
    an interpreter was used.
   When she saw her son for the first time, she
    was shocked to see the condition he was in.
    She thought it was due to the “bad cancer.”
Case Presentation
   It took 6 months for KC to seek medical care.
   He was not able to disclose his HIV status to
    his family.
   He did not want to access services provided
    by community organizations.
   He could not tell his mother directly that he
    had AIDS.
API Epidemiology, USA—CDC,
December 2000
           AIDS           HIV


Males      4997/640,022   405/98,771


Females    731/134,441    143/39,229
Epidemiology-USA, December 1998
   4,974 APIs with AIDS

       89% men

       79% of these men were gay

       59% foreign born
Epidemiology—USA, December 1998
   Five states, which account for 63% of the API
    population in the USA, reported 78% of the
    cases:
      California        45%
      Hawaii            12%
      New York          15%
      Texas             3%
      Washington        3%
Epidemiology—USA, December 1998
   Incidence rate per 100,000 for 1996-1997:

       Highest rate in Northeast   15.9
       West                        13.8
       South                       10.6
       Midwest                     5.7
Epidemiology-USA
   There are still 40,000 new infections per year.
   20-30% of those infected are unaware that
    they are infected.
   Illegal immigrant from Asia not seeking
    testing because of concern about being
    deported.
Testing of APIs
   Rate of PCP in New York City between 1997-
    1998:
      Caucasians decreased by 50%

      African Americans decreased by 40%

      Latinos decreased by 40%

      APIs increased by 30%

   Because PCP is preventable, why this high
    rate?
Testing of APIs
   Nonseeking of or delay in seeking health care
    may partly explain this high rate.
       Cultural stigma
       Family abandonment/shame
       Perceptions of social norm regarding
        homosexuality
       Belief in Karma(a sense of fatalism)
       Low levels of acculturation
       Possible deportation because of one’s illegal alien
        status
Testing of APIs—APIWC, San Francisco
   1999-APIs accounted for only 9% undergoing
    HIV testing at various public health
    department sites in San Francisco
   APIWC HIV Testing and Training Program
    started offering free HIV testing(OraSure) at
    various events( eg API events—Vietnamese
    TET Festival, gay parade, massage parlors).
    The target population is primarily APIs but no
    one is turned away for testing.
Testing of APIs--APIWC, San Francisco
   Advertising of HIV testing
   During the 1st year (2000-2001), 366 tests
    done(majority were APIs and having their
    first HIV test)
   Of the 366, 8 were HIV positive
Cultural diversity
   In the USA, APIs consists of 49 ethnic groups
    speaking over 100 languages and dialects.
   Although there are some basic similarities
    among these groups, each group is distinct
    and each has it’s unique specific “values.”
   Keeping these cultural factors in mind and
    being sensitive about these factors can help
    to facilitate your care of APIs.
Cultural issues
   Family role
       Often overides individual identity.
       Ones behavior reflect upon one’s ancestors as well
        as the entire family, community and ethnic group.
       Family members are responsible and obligated to
        the family.
       Filial piety—obligation an individual has towards
        ones parents.
Cultural issues
   Family role/Filial piety

       Hide or ignore HIV diagnosis
       Fail to seek or adhere to treatment
       Not seek social services
       Isolate from family
Cultural issues
   Shame
      Often used to remind individuals of their

       obligation to their families.

       For many Asians, shame is often
        understood as “losing face.”
Cultural issues
   Shame
       Patient often feels shame about having HIV and
        have disappointed their families and therefore will
        hide their HIV diagnosis.
       Feel unworthy of receiving care.
       To “save face” a patient will try to appear that
        everything is okay and that he/she has no needs.
KC—Family role and shame
   Not able to disclose is HIV status and
    homosexuality because of fear of bringing
    shame to his family.
   KC suspected that he was HIV-infected but
    delayed getting medical care because of fear
    of bringing shame to his family.
Cultural issues
   Avoid expressing one’s feelings
      Discourages direct communication of

       feelings.
      Talking about one’s feelings often viewed

       as a sign of weakness.
Cultural issues
   Avoid expressing one’s feelings

       Can compound a patient’s sense of
        isolation and alienation
KC—avoid expressing one’s feelings

   KC was quite stoic when his mother was
    informed of his HIV status.

   Seeking help was a sign of weakness.
Cultural issues
   Indirect communication

       Express one’s desires through silence or
        non-verbal communication and therefore
        the provider who expects the patient to
        speak up and say what is on his/her mind
        may miss what is being communicated.
Cultural issues
   Language

       Can isolate a patient from seeking medical care

       Use of an intepreter—patient may be reluctant to
        discuss sensitive issues

       Professional medical interpreters may have their
        own cultural biases regarding HIV
Cultural issues
   Deference to Authority

       May see physician as “God”

       May only appear to be compliant in order
        to please their provider

       Can be barrier to self-advocation
Cultural issues
   Taboo Subjects
      Sex, sexuality, homosexuality considered

       taboo in many API cultures
      Emphasis on handling problems associated

       with these subjects privately
      Avoiding these topics with a provider can

       result in medical and social service needs
       not being met
Cultural issues
   Herbs and Drug Therapy
       Southeast Asian Americans often believe
        medications should be given on a short term basis
        with expectation of immediate relief
       Asian Americans more likely to develop side
        effects from psychotropic drugs and to fear that
        antidepressant medication will make them too
        drowsy
       Traditional healing modalities such as
        acupuncture, qi gong may increase their sense of
        well-being
Interventions
   “Culturally sensitive care”


       To develop trust, medical provider should
        proceed slowly

       Validate and even encourage using both
        Western and traditional treatment

       Review possible outcomes of both Western
        and traditional treatment
Interventions
   “Culturally sensitive” care
       A patient’s culture should be seen as a
        potential asset rather than as a barrier

       Link patients to culturally sensitive services

       Educate providers about culturally sensitive
        services
Interventions
   Peer intervention
       Meeting other APIs living with HIV will give a
        sense of not being alone and help to find others
        who share a common cultural background
   Educate patient
       Explaining the medical system and
        provider/patient role can help the patient to learn
        to advocate for his or her self. Teach patients to
        question authority and analyze what they read or
        hear
The Golden Rule
   Buddhism
      “Hurt not others in ways that you yourself would find
        hurtful.”
   Confucianism
      “Do not unto others what you would not have them do unto
        you.”
   Islam
      “No one of you is a believer until he desires for his brother
        that which he desires for himself.”
   Judism
      “What is hateful to you, do not to your fellowman.”

   Christianity
      “Do unto others as you would have them do unto you.”