Disparities in HIV Treatment and Physician Attitudes About Delaying Protease Inhibitors for Nonadherent Patients

Authors

  • Mitchell D. Wong MD, PhD,

    Corresponding authorSearch for more papers by this author
  • William E. Cunningham MD, MPH,

  • Martin F. Shapiro MD, PhD,

  • Ronald M. Andersen PhD,

  • Paul D. Cleary PhD,

  • Naihua Duan PhD,

  • Hong Hu Liu PhD,

  • Ira B. Wilson MD, MSc,

  • Bruce E. Landon MD, MBA,

  • Neil S. Wenger MD,

  • for the HCSUS Consortium


  • Received from the Division of General Internal Medicine and Health Services Research (MDW, WEC, MFS, HHL, NSW) and School of Public Health (WEC, MFS, RMA), University of California, Los Angeles, Calif; RAND (MFS, NSW), Santa Monica, Calif; Department of Health Care Policy (PDC, BEL), Harvard Medical School, Boston, Mass; Division of Clinical Care Research (IBW), Tufts New England Medical Center, Boston, Mass; and Department of Psychiatry (ND), University of California, Los Angeles, Calif. This paper was presented at the 24th Annual National Meeting for the Society of General Internal Medicine, May 2001, in San Diego, Calif.

Address correspondence and requests for reprints to Dr. Wong: UCLA, Division of General Internal Medicine and Health Services Research, 911 Broxton Plaza, Los Angeles, CA 90095-1736 (e-mail: miwong@mednet.ucla.edu).

Abstract

BACKGROUND:   Current HIV treatment guidelines recommend delaying antiretroviral therapy for nonadherent patients, which some fear may disproportionately affect certain populations and contribute to disparities in care.

OBJECTIVES:   To examine the relationship of physician's attitude toward prescribing protease inhibitors (PIs) to nonadherent patients with disparities in PI use and with health outcomes.

DESIGN:   Prospective cohort study.

PATIENTS AND SETTING:   A national probability sample of HIV-infected adults in the United States and their health care providers was surveyed between January 1996 and January 1998. We analyzed data on 1,717 patients eligible for PI treatment and the 367 providers who cared for them.

MEASUREMENTS:   Providers’ attitude toward prescribing PIs to nonadherent patients, time until patients’ first receipt of PIs, mortality, and physical health status.

MAIN RESULTS:   Eighty-nine percent of providers agreed that patient adherence is important in their decision to prescribe PIs (Selective) while 11% disagreed (Nonselective). Patients who had a Selective provider received PIs later than those with a Nonselective provider (P = .05). Adjusting for patient demographics and health characteristics and provider demographics, HIV knowledge, and experience, Latinos, women, and poor patients received PIs later if their provider had a Selective attitude but as soon as others if their provider had a Nonselective attitude. African-American patients received PIs later than whites, irrespective of their providers’ prescribing attitude. Patients with Selective providers had similar odds of mortality than those with Nonselective providers (odds ratio, 1.1; 95% confidence interval, 0.6 to 2.0), but had slightly worse adjusted physical health status at follow-up (49.1 vs 50.4, respectively; P = .04), after controlling for baseline physical health status and other patient and provider covariates.

CONCLUSIONS:   Most providers consider patient adherence an important factor in their decision to prescribe PIs. This attitude appears to account for the relatively later use of PI treatment among Latinos, women, and the poor. Given the rising HIV infection rates among minorities, women, and the poor, further investigation of this treatment strategy and its impact on HIV resistance and outcomes is warranted.

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