arnold school of public health health services, policy, and management 1 drug treatment disparities...

1Arnold School of Public HealthHealth Services, Policy, and Management

Drug Treatment Disparities Among African Americans

Living with HIV/AIDS

Carleen H. Stoskopf, Sc.D.

William Pearson, Ph.D.

Jong Deuk Baek, Ph.D.

Yunho Jeon, M.S.


Background

• Many studies have identified disparities in health status, health care access, and health care utilization by race/ethnicity.

• In the late 1990s, clinical trials found the high efficacy of Highly Active Antiretroviral Therapy (HAART).

• Researchers found that African Americans were significantly less likely to use newer antiretroviral regimens (e.g., protease inhibitors and NNRTIs).


Background continued

• Several studies found that racial/ethnic minorities were less likely to use drugs for opportunistic diseases than whites (e.g., PCP and TB/MAC prophylaxis).

• This study explores changes in use of HAART and drugs for opportunistic diseases and to determine factors that influence the use of HAART by race/ethnicity.


HIV Cost and Services Utilization Study (HCSUS) data

• Nationally representative sample

• Adults in care for HIV

• Multi-stage design (n = 4,042)– Geographical– Medical provider– Patients


HCSUS data

• Panel study– Baseline: January ’96 - March ’97

• N = 2,864 (71%)

– First follow-up: December ’96 - July ’97• N = 2,466 (61%)

– Second follow-up: August ’97 - January ’98• N = 2,267 (56%))


Independent Variables

• Age

• Gender

• Race

• Mode of HIV exposure

• Household composition

• Employment status

• Educational attainment


Independent Variables

• Insurance status

• Household income

• Lowest reported CD4 cell count


Dependent Variables

• HAART: Coded as a positive response if the person indicated taking HAART in the past six months– Combinations of NRTI plus certain PI or NNRTI

– 99% of the sample met the published eligibility criteria in 1996 for HAART

• CD4 < 500 cells/μl OR HIV RNA > 10,000 copies/ml OR symptomatic HIV or AIDS

• Handout 1


Dependent VariablesOpportunistic Infections Rx

• Cytomegalovirus (CMV)– Common herpes virus causing retinitis and colitis

• Pneumocystic Carinii Pneumonia (PCP)– Infection of the lungs caused by Pneumocystis carinii

• Tuberculosis (TB)– Bacterial infection, Mycobacterium tuberculosis


Dependent VariablesOpportunistic Infections Rx

• Mycobacterium Avium Complex– Bacterial infections, Mycobacterium avium,

Mycobacterium intracellulare

• Fungal Infections

• Herpes Simplex Viruses – HSV-1, HSV-2

• Immune System Boosters


Analysis

• Description of Sample

• National estimates

• Bivariate analysis

• Multivariate analysis (Odds Ratio)


Results of Analyses


Sample Characteristics of Respondents

• Distribution of the sample respondents is consistent for all three surveys

• All sample frequencies decrease across surveys except for Medicare recipients and some CD4 counts.

– Table 1


Age (Baseline)

50+ 11.42%

18-34 34.18%

35-49 54.39%



Gender (Baseline)

Male 77.44%

Female 22.56%



Race (Baseline)

White 49.24%

Blk/Afr.A32.77%

Other 3.22% Hispanic

14.77%



Exposure (Baseline)

Heterosexual

18.42%

Other8.87% IVDA

24.12%

M sx M 48.59%



Living With (Baseline)

With other 47.51%

Female part 5.18%

Male part 31.89%

Spouse 15.42%



Employment (Baseline)

Not work 8.23%

Disabled 47.42% Unemployed

7.08%

Full/part 37.28%



Education (Baseline)

BA, BS 19.26%

Some HS, 24.94%

Some college 28.36%

HS deg 27.44%



Insurance (Baseline)

Medicare 19.16%

No Insurance

19.76%

Private 16.53%

Private (HMO) 15.33%

Medicaid 29.22%



Income (Baseline)

$10000-$25000 25.99%

$5000-$10000 25.82%

$0-$5000 19.72%

>$25000 28.47%



CD 4 Cell Count (Baseline)

0-49 23.59%

>=500 9.49%

200-499 37.45%50-199

29.48%



HAART Use in the Three Consecutive Surveys

• Test of Independence (Chi square)– Proportions of HAART use were dramatically

increased (sample frequencies and estimated population weighted percentages) across all three surveys.

– All independent variables are statistically significant except age in the two follow-ups.

– Table 2


Weighted Population Estimate (%) of HAART Use by Race/Ethnicity

0%

25%

50%

75%

100%

White 33.16% 47.88% 65.35%

African American 9.82% 24.15% 50.95%

Hispanic 20.56% 38.68% 60.40%

Other 27.41% 50.67% 61.78%

Baseline 1st Follow-up 2nd Follow-up

• African Americans are less likely to use HAART than other racial/ethnic groups.


0%

25%

50%

75%

100%

Male 26.00% 41.96% 62.33%

Female 14.77% 28.38% 51.45%


Weighted Population Estimate (%) of HAART Use by Gender

• Females are less likely to use HAART than males, but the gap closes over the three surveys.


Weighted Population Estimate (%) of HAART Use by Employment Status

0%

25%

50%

75%

100%

Full/ part 26.36% 43.63% 61.80%

Unemployed 4.68% 22.77% 44.66%

Disabled 25.97% 38.75% 61.74%

Not work 12.08% 29.87% 52.58%


• Those who are employed full time, or those who are disabled, are more likely to use HAART.


Weighted Population Estimate (%) of HAART Use by Education

0%

25%

50%

75%

100%

Some HS, 13.40% 26.63% 53.96%

HS deg 23.87% 36.85% 57.89%

Some college 25.04% 41.11% 60.27%

BA, BS 33.59% 53.98% 69.21%


• Those who are more highly educated are more likely to use HAART.


Weighted Population Estimate (%) of HAART Use by Insurance Status

0%

25%

50%

75%

100%

No Insurance 10.09% 32.25% 55.49%

Medicaid 17.40% 32.57% 54.74%

Private (HMO) 29.94% 43.64% 64.96%

Private 40.49% 56.22% 68.19%

Medicare 26.65% 36.67% 60.00%


• Those persons who have private insurance are more likely to use HAART.


Weighted Population Estimate (%) of HAART Use by Income

0%

25%

50%

75%

100%

$0-5000 11.16% 30.27% 49.84%

$5000-10000 19.36% 31.09% 57.68%

$10000-25000 22.84% 38.64% 59.63%

>$25000 36.28% 51.68% 68.55%


• Those with higher incomes are more likely to use HAART.


Weighted Population Estimate (%) of HAART Use by CD 4 Cell Count

0%

25%

50%

75%

100%

>=500 8.38% 15.77% 31.68%

200-499 14.44% 30.08% 52.31%

50-199 30.60% 47.93% 67.24%

0-49 34.94% 48.97% 67.80%


• Those with lower CD4 counts are more likely to use HAART.


Rx for Opportunistic Diseases in the Three Consecutive Surveys

• Test of Independence (Chi square) for Race/Ethnicity– African Americans are the least likely group to use

drugs for opportunistic diseases.– This finding is true across all three surveys, except

for TB treatment in the second follow-up survey.

– Table 3


Multivariate Logistic RegressionUse of HAART

• The multivariate logistic Regression allows for controlling the influence of the various independent variables.

• Race (being African American) is consistently statistically significant across all three surveys. When compared to Whites, AA are significantly less likely to have used HAART in the last six months.– Odds ratios are 0.32, 0.54, and 0.70, respectively

– Table 4



• Other significant findings include:– Men having sex with men are more likely to use

HAART at the second follow-up– Those who are unemployed or not working are less

likely to use HAART at the baseline survey, those not working are still less likely to use HAART at the first follow-up.



– As compared to the uninsured, those with Medicaid, private insurance, private HMO, or Medicare were significantly more likely to be receiving HAART at the baseline survey.

– At the second survey (first follow-up) only those with private insurance had a statistically significant advantage

– As expected, those with the lowest CD4 counts were significantly more likely to receive HAART therapy.


Multivariate Logistic Regression Rx for Opportunistic Diseases

Baseline Survey

African Americans were significantly less likely than Whites to receive drug treatment for these disease categories:

Cytomegalovirus Pneumocystis

Tuberculosis Fungal Infections

Herpes Immune System Booster

Table 5 - 10



• Second survey (first follow-up)– At the second survey, African Americans were

significantly less likely to receive drug treatment for all disease except pneumocystis. These include:

– Cytomegalovirus Tuberculoses– Fungal Infections Herpes



• Third survey (second follow-up)– By the third survey, African Americans were still

significantly less likely than Whites to receive drug treatment for:

Cytomegalovirus Tuberculosis

Fungal Infections


Conclusions

• African Americans were consistently less likely to receive appropriate treatment for HIV/AIDS and other infections associated with this disease as HAART was introduced.

• Over time, the racial disparities in HAART use decrease, but statistical differences remain between African Americans and Whites.

arnold school of public health health services, policy, and management 1 drug treatment disparities...

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