Data Show Inequities From the HIV, COVID-19 Pandemics Remain Left to Be Addressed

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Pharmacies can help bring inequities plaguing health care systems to an end to ensure the COVID-19 pandemic does not follow trends of inequity experienced in the HIV pandemic.

Since the beginning of 2020, there have been over 400 million confirmed cases and over 6 million deaths from COVID-19.1 The impact of COVID-19 has been devastating to communities the world over. Chronic health conditions predisposing individuals to complications from COVID-19—such as type 2 diabetes, obesity, and HIV—are more prevalent in minority communities, including African American communities. Correspondingly, death rates from COVID-19 among African Americans have been 2 to 3 times higher than among white individuals.2

The impact of the COVID-19 pandemic on African American communities is reminiscent of the AIDS epidemic. HIV and AIDS have affected 79 million people and claimed almost 36 million lives since the virus was first recognized in the 1980s.3 Almost 40 years later, the 2014 Kaiser Health Tracking Poll reports that African Americans have higher rates of HIV testing (76%) compared to white individuals (50%) and are still disproportionately affected by the HIV epidemic.

African Americans account for almost half of new HIV diagnoses (43%) and AIDS-related deaths (44%), more than any other racial/ethnic group, and the same is evident with COVID-19.4 According to the Understanding Coronavirus in America Study conducted by the University of Southern California, Black Americans are more likely to report wearing masks to prevent transmission of COVID-19 than white Americans (67% and 46%, respectively).5 Rates of social distancing between February to May 2020 were also greater among Black Americans (59%) than white Americans (56%).6 However, Black Americans still have an increased prevalence of complications from COVID-19, including higher rates of mechanical ventilation (23.2% African American, 21.6% white), renal replacement therapy (6.6% African American, 3.4% white), and transfusion (4.6% African American, 3.3% white).10

Evident in the parallels between these 2 pandemics over multiple decades is a general need to identify and address barriers related to health outcomes for African Americans. Non-medical factors, or social determinants of health (SDOH), are key drivers of health outcomes and inequities.11

Among the disparities that remain necessary to address is decreased access to medical care in minority communities. There are higher rates of uninsured populations among Native American (22%), Hispanic (19%), and African American (12%) individuals compared to their white (8%) counterparts.14 Not only do African Americans have less access to the health care system—whether geographically, financially, or otherwise—but they also have lower rates of overall health care engagement (56.9% white, 48.2% African American), higher rates of medication nonadherence (18% white, 42% African American), and lower rates of COVID-19 vaccination (62% white, 57% African American).9,13,15 These statistics cannot determine causation. However, their association has prompted theories that this is evidence of both SDOH and medical mistrust due to historical abuses of African Americans by medical organizations and insitutions.9

These inequities subsequently pose the question of how a pharmacist and pharmacies nationwide can use these findings to address the needs of their African American customers and their community. One suggestion that pharmacists and pharmacy technicians can quickly adopt is establishing rapport with patients. While we recognize that there is not always time in busy pharmacies to build rapport, it can still be accomplished. Increased comfort and familiarity with health care team members can help alleviate medical mistrust and reengage hesitant community members. Some health care team members have even taken to social media to listen to their communities (great examples: Dr. JAM as @JayCdoesID and Dr. Manning as @gradydoctor on Twitter).

Pharmacy upper management can also commit to rebuilding trust with African American communities by setting up systems to provide pharmacy employees time to be engaged, whether through additional health fairs in underserved areas or an increased presence in local schools. Another option identified by Jamie Spears, PharmD and colleagues was that frequent comorbidity and medication education increased adherence to medications.12

Additionally, the CDC considers medication therapy management (MTM) to be a best practice which can improve patient engagement at the pharmacy.2 If a patient has multiple pharmacies or physician specialists on their team, the resulting difficulties can lead to increased levels of frustration for both pharmacies and patients. As reported by Marcum et al., use of multiple pharmacies by a patient is associated with higher rates of nonadherence (32% with multiple-pharmacy use, 29.8% with singe-pharmacy use; p<0.001) and an increase in drug-drug interactions (3.6% with multiple pharmacy use, 3.2% with single pharmacy use).8 One proposal to limit this could be expanded access to medical records for pharmacies that provide MTM, especially for persons living with HIV. This way, pharmacists can provide a more holistic review of a patient’s care.

Currently, the University of North Texas Health Science Center is conducting an ongoing prospective, randomized controlled trial (NCT03437694) funded by the National Institute of Minority Health and Health Disparities (NIMHD) to evaluate the impact of MTM on health outcomes for African Americans living with HIV based on expanded access to their medical records. As a subset of the trial, we evaluated the impact of COVID-19 on SDOH among the study population. Surprisingly, participants reported increased medication adherence post-COVID-19 compared to pre-COVID-19 (81.5% vs. 59.3%; p=0.09) and fewer participants reported financial barriers as a contributing factor for nonadherence post-COVID-19 compared to pre-COVID-19 (14.8% vs. 29.6%; p=0.08).

Interestingly, the results also demonstrated a statistically significant difference in participants feeling safer where they resided or slept post-COVID-19 compared to pre-COVID-19 (88.9% vs. 70.4%; p=0.04). While the cause for these changes were not assessed, it is plausible to hypothesize that pandemic-related programs such as rent and mortgage moratoriums and housing protections provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act contributed to this increased feeling of safety and financial relief despite the poorer outcomes and decreased utilization of health care services. Futhermore, the increase in self-reported adherence could be attributed to the lack of social activity and increase in time spent at home, resulting in fewer distractions and better management of health.

As the most accessible and frequently visited health care team members, pharmacists and pharmacy technicians can help to identify and address the health care access barriers present in their communities.7 Additionally, more focus on the development and continuation of initiatives aimed at direct involvement in overcoming those barriers are essential to ending this public health crisis.

HIV has been disproportionally affecting African Americans for 40 years.16 It is time for pharmacies to step up so that COVID-19 doesn’t follow this same trend of inequity for another 40 years.

REFERENCES

  1. WHO Coronavirus (COVID-19) Dashboard. who.org. Updated March 24, 2022. Accessed March 15, 2022. https://covid19.who.int/.
  2. Hill L, Artiga S. Covid-19 Cases and Deaths by Race/Ethnicity: Current Data and Changes Over Time. kff.org. Published February 22, 2022. Accessed March 15, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-cases-and-deaths-by-race-ethnicity-current-data-and-changes-over-time/.
  3. Community Pharmacists and Medication Therapy Management. cdc.gov. Published August 27, 2021. Accessed March 20, 2022. https://www.cdc.gov/dhdsp/pubs/guides/best-practices/pharmacist-mtm.htm.
  4. Global HIV & AIDS Statistics - Fact Sheet. unaids.org. Published December 1, 2021. Accessed March 15, 2022. https://www.unaids.org/en/resources/fact-sheet.
  5. Key J. Half of U.S. Adults Don’t Wear Masks When in Close Contact With Non-Household Members. Dornsife.usc.edu. Published January21, 2021. Accessed March 20, 2022. https://dornsife.usc.edu/news/stories/3388/half-of-u-s-adults-dont-wear-masks-when-in-close-contact-with-no/.
  6. Huang V, Sutermaster S, Caplan Y, Kemp H, Schmutz D, Sgaier SK. Social distancing across vulnerability, race, politics, and employment: how different Americans changed behaviors before and after major COVID-19 policy announcements. medRxiv. Preprint posted online June 8, 2020. doi.org/10.1101/2020.06.04.20119131
  7. Manolakis PG, Skelton JB. Pharmacists' Contributions to Primary Care in The United States Collaborating to Address Unmet Patient Care Needs: The Emerging Role For Pharmacists to Address The Shortage Of Primary Care Providers. Am J Pharm Educ. 2010;74(10):S7. doi:10.5688/aj7410s7
  8. Marcum ZA, Driessen J, Thorpe CT, Gellad WF, Donohue JM. Effect of Multiple Pharmacy Use on Medication Adherence and Drug-Drug Interactions in Older Adults With Medicare Part D. J Am Geriatr Soc. 2014;62(2):244-252. doi:10.1111/jgs.12645
  9. Ndugga N, Hill L, Artiga S, Haldar S. Latest Data on Covid-19 Vaccinations by Race/Ethnicity. kff.org. Published March 9, 2022. Accessed March 20, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-by-race-ethnicity/.
  10. Rodriguez F, Solomon N, de Lemos JA, et al. Racial And Ethnic Differences In Presentation And Outcomes for Patients Hospitalized with COVID-19: Findings from the American Heart Association’s COVID-19 Cardiovascular Disease Registry. Circulation. 2021;143(24):2332-2342. doi:10.1161/circulationaha.120.052278
  11. Social Determinants of Health - Healthy People 2030. health.gov. Accessed April 24, 2022. https://health.gov/healthypeople/objectives-and-data/social-determinants-health.
  12. Spears J, Erkens J, Misquitta C, Cutler T, Stebbins M. A Pharmacist-Led, Patient-Centered Program Incorporating Motivational Interviewing for Behavior Change to Improve Adherence Rates and Star Ratings in a Medicare Plan. J Manag Care Spec Pharm. 2020;26(1):35-41. doi:10.18553/jmcp.2020.26.1.35
  13. Sun K, Eudy AM, Criscione‐Schreiber LG, et al. Racial Disparities in Medication Adherence Between African American and Caucasian Patients With Systemic Lupus Erythematosus and Their Associated Factors. ACR Open Rheumatology. 2020;2(7):430-437. doi:10.1002/acr2.11160
  14. Tai DBG, Shah A, Doubeni CA, Sia IG, Wieland ML. The Disproportionate Impact of COVID-19 on Racial and Ethnic Minorities in The United States. Clin Infect Dis. 2021;72(4):703-706. doi:10.1093/cid/ciaa815
  15. Webb FJ, Khubchandani J, Striley CW, Cottler LB. Black-White Differences in Willingness to Participate and Perceptions About Health Research: Results from the Population-Based HealthStreet Study [published correction appears in J Immigr Minor Health. 2018 May 9;:]. J Immigr Minor Health. 2019;21(2):299-305. doi:10.1007/s10903-018-0729-2
  16. Black Americans and HIV/AIDS: The Basics. kff.org. Published February 7, 2020. Accessed March 15, 2022. https://www.kff.org/hivaids/fact-sheet/black-americans-and-hivaids-the-basics/.