The emergence of highly active antiretroviral therapy (HAART) has substantially reduced HIV or AIDS that is associated by morbidity and mortality among the African American population as noted by such optimism concerning the benefits of medications has been tempered by evidence suggesting that occasional nonadherence can greatly diminish the benefits of treatment and may lead to serious personal and public health consequences mostly affecting the African American women (Smith, Rapkin, Morrison and Kammerman, 1997) For one, Kaiser (2005) asserted that within a global sense, nearly half of 40 million people living with HIV are female majority African American, there adheres to AIDS percentage satiations  rising steadily from 11 % in 1990 to 26 % in 2003 from data found in CDC (1991; 2004). The outcome then, accounted for about 30 percent of African American (CDC, 2004).


            Indeed, African American women comprise major group having AIDS and antiretroviral therapy were strongly indicated that has transformed the course of HIV into such treatable, chronic illness (Patterson et al., 2000) as leading to strong impact of the disease, Kaiser, (2005) indicated that AIDS is now major cause of death in African American women from age range of 24 years old to 34 years old. The CDC estimates that between 120,000 and 160,000 of adult and adolescent women, and 1 in 160 African American women are HIV-infected. According to CDC (2003) that, the mode of HIV transmission are heterosexual contact and injection drug use, sex and substance use are intermingled such that the actual source of infection is difficult to identify. In addition, some HIV+ African American women might also voluntarily exchange sex for financial or material goods such as housing, food, or clothing in order to survive (Barken et al., 1998; Levine, 1999; Wohl et al., 1998).


            Moreover, one recent study dome by Sharpe et al., (2004) have found that HIV+African American women who used drugs were less likely than nonusers to take their antiretroviral medicines exactly as prescribed, that will impact African American’s ability to take medications and use risk reduction behaviors consistently. There interventions to promote adherence to medications and/or risk reduction behaviors should specifically address these needs and the unique characteristics of this population. Then, Patterson et al. (2000) reported that African American with such HAART behavior mostly women must endure side effects such as vomiting, headaches, changes in body image, In clinical practice, the authors have noted that HIV+ African American women will resist therapy because of the numerous pills as well as complicated dosing schedules.


            Roberts and Mann (2000) verified the observations as there is fear of violence for disclosing her HIV+ status may also put a woman at high risk for non-adherence to HAART process and how adherence is manifested.   Furthermore, proponents Sankar, Luborsky, Schuman and Roberts (2002), have conducted a study on adherence discourse among African-American women taking ART as they used in-depth interviews to identify sources of influence used by 15 African-American women to describe their adherence behavior. The women were asked to provide information on self-reported adherence and sources of authority or reference groups in adherence practice. The results showed that sources of influence that encouraged adherence included physician, quasi-scientific rationale, belief that the drugs work, religiosity and faith, the belief in the power of positive thinking and individual responsibility and the outcomes amiably showed adherence rate of 69 in percentage range.


            Another study (Conigliaro, Gordon, McGinnis and Rabeneck, 2003) identified excessive alcohol use among 33 % of their sample of 881 sero-positive African American veterans and that 20 % of their sample labeled as hazardous drinkers and the 33% labeled as binge drinkers were more likely to have detectable viral loads than those without drinking problems. Although physiological effects of consuming alcohol may contribute to African American patients taking doses missing anti-retroviral doses and drinking may result in individuals forgetting about their medications, it appears at least promising to investigate the potential role that beliefs about drinking alcohol and taking ART may play in adherence practice.


            However, Conigliaro et al., (2003) assessed the nature and content of beliefs of sero-positive African Americans taking ART and the clinicians who treat them concerning the advisability of consuming alcohol while on ART and to determine if and how these beliefs affect adherence practice. The study focuses on African Americans taking ART because African American ethnicity has been associated with alcohol-related adherence problems (Conigliaro et al., 2003) and because African Americans have higher infection rate than whites and higher morbidity and mortality rates than sero-positive whites (McGinnis, Sharma, and Skanderson, 2003). In particular, African American men aged 40 to 49 have the highest rate of infection in the US (Brown, 2005) and that research on African American drinking patterns (Herd, 1985) has identified history of temperance and rejection of alcohol. The rejection associated with definitions of moral adult behavior and not the pharmaco-kinetic models that underlie the beliefs identified by people as can’t possibly say if the models articulated here are held by non African Americans and findings were shared with the attending physicians at each clinic, both of which now integrate discussions of alcohol and ART interactions and adherence into their training programs.


            The optimizing access to HAART and ensuring consistent use of HAART are among the most important challenges with respect to antiretroviral treatment of African Americans with HIV/AIDS. Research domains now have an increasing amount of data that demonstrate that today’s most potent antiretroviral agents and regimens are highly potent and efficacious in African American patients. More data are still needed comparing the most commonly used regimens in terms of efficacy and toxicity. Nonetheless, there should become familiar with currently available data and make informed choices in partnership within the African American patients about the HAART regimens that are most likely to optimize their outcome while minimizing their toxicities. (Centers for Disease Control and Prevention, 2001).  


            There are significant challenges in investigating racial and ethnic differences, race in HIV-1 disease represent risk marker, with higher prevalence of HIV-1 infection in African Americans with direct etiologic relationship to HIV-1 disease progression or response to antiretroviral therapy mechanisms. Based on findings the African American women would exhibit poorer response to HAART even after adjustment for socio-demographic factors, continuation of HAART, and self-reported adherence. There were 961 participants which included 573 (59.6%) African American, 184 (19.2%) white, and 204 (21.2%) Hispanic women, specifically, the African American women were older, less educated, initiated HAART and were more likely to report pre-HAART use of cigarettes and cocaine and found out that, the African American women were less likely to survive (70.0%) compared with white (80.0%) and Hispanic women (76.5%). (Fellay, Marzolini, Meaden et al., 2002; Kahn, Zhang, Cross, et al., 2002)


Ideally, there were also investigations about relationship of race with response to HIV-1 treatment among 961 women initiating HAART; white women had more favorable virologic, immunologic, and clinical responses to HAART. Although discontinuation of therapy may be secondary to toxicity that results from specific genetic determinants of drug metabolism and transport, both depression and therapy discontinuation are potentially mutable that treating depression and ascertaining and addressing reasons for treatment discontinuation could substantially improve outcomes in African American women.


 


 


            Several studies have demonstrated that African Americans experience higher toxicity and higher rates of discontinuing therapy. For example, the adherence was associated with better responses to the said study but adherence did not vary by race as the ascertainment of adherence did not completely describe differences by race or that such differences are less marked in African American women. (Fellay, Marzolini, Meaden et al., 2002; Kahn, Zhang, Cross, et al., 2002) As reviewed, certain determined differences in drug transport or metabolism may carry clinical significance and the large majority of studies of the efficacy and tolerability of antiretroviral regimens as performed in populations of certain population groups. The trend toward poorer outcomes in African American women, especially AIDS-related deaths, deserves further investigation with longer follow-up in this and other cohorts, to confirm that there is not significant difference by race. Also important for HIV-1-infected African American is the diagnosis and treatment of depression and exploration and rectification of the factors related to HAART discontinuation, as these may be contributing substantially to poorer health status, including death, among HIV-infected African American women.


 


 


 


            Meanwhile, poor HIV+ African American women as well as more affluent men like the ones belong to the third sex benefit from group-based but important gender and socio-cultural differences must be taken into account in developing protocols. Adherence to highly active antiretroviral therapy, coupled with good health behavior, can contain HIV/AIDS in most instances. (Samet et al., 1992).   Aside, the poor HAART adherence coupled with poor health behavior can lead to drug resistance and infection of partners with virulent mutated strains. Thus, presence of behavioral medicine approaches to management and secondary prevention of HIV/AIDS are needed. Thus, the adherence to antiretroviral treatment is a dynamic process; modifiable risk factors are associated with increasing and decreasing adherence, suggesting specific interventions.


            Another study presented by Johnston, Abmad, Smith and Rose (1998) from urban hospital patients, 34 percent African American of those who chose not to take one or all medications, 21 percent believed that the medication did not work for them, whereas 43 percent believed it caused harm. African Americans may be especially likely to mistrust the role of doctors or other health care providers in AIDS care (Herek and Capitanio, 1994). The noncompliance has to be associated with concern about interactions between HIV medications and street drugs. In one study (Samet et al., 1992), 71 percent of 217 prison inmates who were eligible to take antiretrovirals thought the medications could harm those with cocaine in their bodies as there tend to have poorer adherence to HIV medication (Samet et al., 1992). 


 


            Henceforth, on the other side several African American homeless individuals maintain HAART therapy for higher proportion of months following treatment initiation. There assumes lower levels of HAART use among racial minorities have been documented in a variety of cultural settings. However, few studies have considered HAART-naive populations over time and few have considered the homeless. Among HIV-infected homeless adults initiating HAART, African American individuals are more likely to sustain therapy during the first 18 months. (Cook, Cohen, Burke et al., 2002; Barrón et al., 2004) While non-African Americans may incur lower proportion of months on treatment in the beginning, they have an increasing proportion after several months, indicating that non-African Americans may be more likely to stop therapy after initiation and more likely to resume after treatment interruption.


            There are differing trends between racial groups also suggest that analyses based on stops or breaks as an end point are not completely describing treatment patterns. Thus, as compared to whites, African Americans were more likely to visit the emergency department and less likely to have mental health, home health and dental visits and have few outpatient and substance abuse treatment visits; and had more inpatient nights. Whites used prescription drugs more than African Americans but antiretrovirals were equally used. Lower access to HAART for African-American patients is new phenomenon, not a continuation of pre-HAART patterns, while the undesirable patterns of emergency and outpatient provider resource utilization in the HAART and as a continuation of pre-HAART patterns (Castilla, del Romero, Hernando, Garcia and Rodriguez, 2005).


            It can be that, majority of the African-American women are specifically tailored to incorporate social norms and values; this is beneficial to targeted outreach for any group. Some critics argue that quality, content and intensity varies in different programs, as a result there efficiency is unclear. However, programs provide much needed education, awareness and support for African Americans which are all beneficial. Although long-term effectiveness of these HIV/AIDS programs is not apparent, the initiative programs have taken is positive and can ultimately help the African American community and aid in decreasing AIDS cases. (Cook, Cohen, Burke et al., 2002; Barrón et al., 2004)


            Generally, several investigators from the Women’s Interagency HIV Study have found out that discontinuing HAART and to certain extent, points of depression as associated with poor response to antiretroviral therapy as there concerns about drug metabolism in African Americans may be affected by race and literacy and there might be unfavorable impact on the success of anti-HIV treatment if noted. (Anastos, 2005)  In addition, relevant studies have suggested that behavioral characteristics may possibly differ between racial groups and could also impact on the effectiveness of HAART. Then, the investigators from WIHS study indicated that African American women, who are more likely to have natural polymorphism that can affect the success of HAART, would have poorer response to HAART even after adjusting for social factors and issues such as HAART continuation and adherence. (Anastos, 2005)


 


            The African American women can be older, less well educated, started HAART later and were more likely to report pre-HAART use of alcohol, cigarettes and illicit drugs as compared to other women. Therefore, there were more likely as African American women may have low income, be depressed and using less antiretroviral therapy after starting treatment with it as was explained largely by HAART discontinuation and some comments have been beneficial to the underlying African American population with HAART adherence behavior. (Anastos, 2005)


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