While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
People with HIV/AIDS may be particularly susceptible to health problems caused by opioid analgesics, yet the medications are commonly prescribed, reports Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2009-2012) Jennifer E. Edelman, MD, MHS. Recent work by RWJF Investigator in Health Policy Research (2009-2014) Celeste Watkins-Hayes, PhD, reveals that women living with the disease may struggle mightily to develop strategies to care for their health and remain financially stable. Both studies are the latest contributions from RWJF grantees addressing the HIV/AIDS epidemic—an effort that began 28 years ago.
High-Risk Pain Medication
Finding an effective treatment for the chronic pain (often caused by neuropathy) experienced by people with AIDS can be a challenge. “For this reason, it’s very common for providers to prescribe opioid analgesics such as hydrocodone or oxycodone,” said Edelman, an assistant professor of medicine at the Yale School of Medicine. “Our research looked at how often these medications were prescribed to a large sample of HIV-infected and uninfected veterans.”
Edelman and her team reported their findings in the article “Receipt of Opioid Analgesics by HIV-Infected and Uninfected Patients” in the January 13 print edition of the Journal of General Internal Medicine. “Using the Veterans Aging Cohort Study, we found slightly more HIV-positive patients (31%) were given opioid analgesics than uninfected patients (28%),” Edelman said. The HIV-positive patients in the study were also more likely to receive a higher mean daily dose of morphine equivalent drugs (41 mg. as opposed to 37 mg.) than uninfected patients.
Opioid pain relievers may suppress the immune system.” -Jennifer Edelman, MD
Opioid analgesics may be highly effective at relieving pain, but ongoing use carries a host of potential risks, particularly for people living with HIV/AIDS. “Some data suggest that opioid pain relievers may suppress the immune system, while increasing the risk of cardiovascular disease and bone disease—all of which are especially concerning for HIV-infected patients,” Edelman explained. “People living with HIV/AIDS are also more likely than others to have a history of substance abuse, increasing their risk of developing additional addiction issues when taking opioids.”
Edelman’s ultimate message is that “standardized approaches, including careful assessment of the risks of opioid analgesics, are needed when managing pain in HIV-infected patients.”
Supporting Women with HIV/AIDS
Watkins-Hayes, an associate professor of sociology and African American studies and a fellow at the Institute for Policy Research at Northwestern University, looked at “the social processes that undergird the decisions made by HIV-positive women. How they take care of their health, make ends meet and, in some cases, maintain employment,” she said.
Her findings, from a series of studies, are reported on her website Health, Hardship, Renewal: A Research Study of Women Living with HIV/AIDS. “We found that women with HIV/AIDS may have poor access to care, be at high risk for substance abuse or face other issues that make it more difficult to manage the disease,” Watkins-Hayes said.
“Nonprofit institutions offer critical support to many women. They provide valuable information about health status. Give women a framework for living with HIV/AIDS, resources to manage their health, and a network of people to help them cope,” Watkins-Hayes said.
“Middle-income women have less institutional involvement and that may make it more difficult for them to cope. They tend to have smaller support networks comprised of family members, pastors or therapists,” Watkins-Hayes said. These private networks may make it tougher for women to deal with HIV/AIDS because fewer people are aware of their status and therefore offering them support.
For policy-makers, Watkins-Hayes emphasizes the importance of maintaining the social services and nonprofit organization safety net that many funders may consider unnecessary now that HIV/AIDS is considered a chronic disease. “The danger is that AIDS will now be seen like any other illness, but it is not like any other illness. It still carries a significant social stigma and people who are not properly supported are less likely to practice safe sex,” she advised.
Building on the RWJF Legacy
Wrestling with the challenges of HIV/AIDS as a long-term, chronic illness seemed unimaginable when RWJF began funding community-based HIV/AIDS case management programs in the 1980s.
As the growing epidemic shocked the nation, RWJF was reluctant to invest in addressing specific diseases, let alone one that came with the controversy that accompanied HIV/AIDS in the America of 1985. “I was frankly astounded—pleased, but astounded—when we went into AIDS,” exclaimed then RWJF President Frank Karel, telling the story in the anthology The Foundation and AIDS: Behind the Curve but Leading the Way.
Starting with a four-year demonstration project in 11 communities and an investment of $17.2 million, the Foundation eventually became the largest source of funds for nonprofit HIV/AIDS organizations. By 1990, the Foundation had awarded more than 100 AIDS-related grants, totaling more than $45 million.
Most of those early programs are now supported by government, but the lessons learned in those days have helped to inform RWJF grantees like Edelman and Watkins-Hayes who are now charting the course for new types of HIV/AIDS treatment and support.
Edelman’s upcoming research will assess the impact of opioid analgesics on health outcomes among HIV-infected patients. “I have the Clinical Scholars program to thank for my training and the support needed to do this work, in addition to outstanding mentorship,” she said.
Watkins-Hayes credited the RWJF Investigator Awards in Health Policy Research program “conference feedback for being extremely helpful to my project research and design.” She is working on a book about her research and will continue to develop policy recommendations to maintain support networks for women with HIV/AIDS.
Read Edelman's study, "Receipt of Opioid Analgesics by HIV-Infected and Uninfected Patients."
For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.
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