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Gaps narrowed in recent years, but still remain
Minorities and people who are on Medicaid or have no health insurance often are not receiving adequate treatment for HIV, a recent study has concluded.1
HIV treatment received by privately insured white homosexual patients is generally better than that received by uninsured, poor, injection drug users and minorities. The disparity between those levels of treatment narrowed during the period from 1996 to 1998, but a gap still exists, concludes researchers from RAND Health Program in Santa Monica, CA, and the HIV Cost and Services Utili zation Consortium, which conducted the study.
"There clearly were differences in the rate at which members of different groups have obtained access to newer therapies," says Martin Shapiro, MD, PhD, professor of medicine at the University of California - Los Angeles and a chief author of the study, which was published in the June 23, 1999, issue of the Journal of the American Medical Association.
The study included three interviews from January 1996 to January 1998 with more than 2,000 people who had received medical care for HIV. Excluded were people whose only treatment came from emergency departments, the military, or prisons. The sampling strategy probably caused an under-representation of people who were not compliant, had very poor access to care, or who are relatively healthy.
Also, the study was based on self-report data, which the researchers acknowledged could have been subject to bias.
Researchers assessed patients’ medical care based on the following six access measures:
• fewer than two office or outpatient visits in the previous six months;
• one or more emergency department visits without associated hospitalization in the previous six months;
• one or more hospitalizations in the previous six months;
• did not receive protease inhibitors (PIs) or nonnucleoside reverse transcriptase inhibitors (NNRTIs) by Dec. 31, 1996, when the person’s CD4 cell count was less than 50 cells per microliter (0.50 times 108 per liter);
• never received antiretroviral therapy when the person’s CD4 cell count was less than 50 cells per microliter;
• did not receive Pneumocystis carinii pneumonia (PCP) prophylaxis in the last six months when the person’s CD4 cell count was less than 20 cells per microliter.
The study found that HIV patients who have health maintenance organization (HMO) insurance were more likely to have received appropriate PCP prophylaxis, but otherwise were treated similarly to those on other private insurance plans.
Quality of care linked to income, education
People in the lowest income groups and people with the least education typically did not receive the best care and latest medications. For example, in the baseline survey, 49% of the patients who hadn’t completed the standard 12 years of education did not receive a PI or NNRTI by the end of 1996. Only 29% of the people who were college graduates had not received those two types of drugs. Likewise, 54% of those without health insurance and 47% of the people on Medicaid had not received the advanced anti retroviral drugs.
By 1998, these numbers had improved. Only 21% of the uninsured, 19% of people on Medic aid, and 19% of high school drop-outs had not received PIs or NNRTIs. The percentage of college graduates not receiving the more advanced drugs dropped to 9%.
Also, between 1996 and 1998, the percentage of people with HMO and private insurance coverage receiving PIs and NNRTIs had increased substantially. In the baseline survey, 34% of people with HMO coverage and 28% of people with private insurance had not received the drugs. By 1998, only 10% of HMO-covered patients and 9% of privately insured patients had not received them.
The study highlights the disparities between the quality of health care among privately insured and Medicaid-insured patients, says Miguelina Maldonado, MSW, director of government relations and policy at the National Minority AIDS Council in Washington, DC.
"People whose source of insurance is Medic aid are not getting the type of care other insured people are getting," Maldonado says. "We need strategies to improve types of care through Med icaid, and we need to address reimbursement for Medicaid so that all people with HIV and AIDS get the level of care recommended by the U.S. public health officials."
Blacks had the worst health care access for five of the six measures. They were the least likely group to receive PCP prophylaxis, with 38% receiving it, and 56% did not receive PI or NNRTI therapy by the end of 1996. In addition, 30% of blacks surveyed visited the emergency room at least once and were hospitalized at least once in the previous six months, and 11% had received no antiretroviral therapy.
Access to drugs improved by 1998
"The initial gap in use of PIs and NNRTIs was very substantial between racial groups and people with different kinds of insurance in 1996," Shapiro says. "Those gaps closed somewhat by early 1998, but still remained significant."
The study found a 24% difference in initial use of PIs and NNRTIs between blacks and whites. But by January 1998, that gap had closed to 8%.
Latinos also fared worse than whites on health care access. They reported the least number of office or outpatient visits (23% had fewer than two within the previous six months), and they had the second-worst access on four other measures in the initial survey. Latinos continued to have poor access to the best medical treatment in the follow-up survey, although — as with the other groups — their statistics improved.
Men who have sex with men apparently had better access to care than did people who had become infected with HIV through injection drug use or heterosexual activity.
The poor, minorities, and other disadvantaged groups waited much longer to try the newest anti retroviral therapies, the study showed. Blacks waited an average of 13.5 months, while whites waited an average of 10.6 months. Uninsured patients waited an average of 13.9 months, and Medicaid beneficiaries waited 12.4 months on average. People with private, fee-for-service insurance waited only 9.4 months. The wait for patients with HMO coverage was slightly more than for private, fee-for-service insurance.
These statistics also showed a gender gap. Women waited an average of 13.5 months for the latest drugs, while men waited an average of 11.2 months.
Researchers concluded that as newer therapies become available, the medical community should question whether these therapies are available to all populations who need them.
"One has to be concerned that as HIV therapy evolves, some groups will continue to have better access to better HIV care than others," Shapiro says. "And we clearly have to find ways to ameliorate those differences."
1. Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: Results from the HIV cost and services utilization study. JAMA 1999; 281:2,305-2,315.