1. Arnold School of Public Health Health Services, Policy, and Management 1 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.

2. Arnold School of Public Health Health Services, Policy, and Management 2 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).

3. Arnold School of Public Health Health Services, Policy, and Management 3 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.

4. Arnold School of Public Health Health Services, Policy, and Management 4 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

5. Arnold School of Public Health Health Services, Policy, and Management 5 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%))

6. Arnold School of Public Health Health Services, Policy, and Management 6 Independent Variables Age Gender Race Mode of HIV exposure Household composition Employment status Educational attainment

7. Arnold School of Public Health Health Services, Policy, and Management 7 Independent Variables Insurance status Household income Lowest reported CD4 cell count

8. Arnold School of Public Health Health Services, Policy, and Management 8 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 10,000 copies/ml OR symptomatic HIV or AIDS Handout 1

9. Arnold School of Public Health Health Services, Policy, and Management 9 Dependent Variables Opportunistic 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

10. Arnold School of Public Health Health Services, Policy, and Management 10 Dependent Variables Opportunistic Infections Rx Mycobacterium Avium Complex –Bacterial infections, Mycobacterium avium, Mycobacterium intracellulare Fungal Infections Herpes Simplex Viruses –HSV-1, HSV-2 Immune System Boosters

11. Arnold School of Public Health Health Services, Policy, and Management 11 Analysis Description of Sample National estimates Bivariate analysis Multivariate analysis (Odds Ratio)

12. Arnold School of Public Health Health Services, Policy, and Management 12 Results of Analyses

13. Arnold School of Public Health Health Services, Policy, and Management 13 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

14. Arnold School of Public Health Health Services, Policy, and Management 14 Sample Characteristics of Respondents

15. Arnold School of Public Health Health Services, Policy, and Management 15 Sample Characteristics of Respondents

16. Arnold School of Public Health Health Services, Policy, and Management 16 Sample Characteristics of Respondents

17. Arnold School of Public Health Health Services, Policy, and Management 17 Sample Characteristics of Respondents

18. Arnold School of Public Health Health Services, Policy, and Management 18 Sample Characteristics of Respondents

19. Arnold School of Public Health Health Services, Policy, and Management 19 Sample Characteristics of Respondents

20. Arnold School of Public Health Health Services, Policy, and Management 20 Sample Characteristics of Respondents

21. Arnold School of Public Health Health Services, Policy, and Management 21 Sample Characteristics of Respondents

22. Arnold School of Public Health Health Services, Policy, and Management 22 Sample Characteristics of Respondents

23. Arnold School of Public Health Health Services, Policy, and Management 23 Sample Characteristics of Respondents

24. Arnold School of Public Health Health Services, Policy, and Management 24 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

25. Arnold School of Public Health Health Services, Policy, and Management 25 Weighted Population Estimate (%) of HAART Use by Race/Ethnicity African Americans are less likely to use HAART than other racial/ethnic groups.

26. Arnold School of Public Health Health Services, Policy, and Management 26 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.

27. Arnold School of Public Health Health Services, Policy, and Management 27 Weighted Population Estimate (%) of HAART Use by Employment Status Those who are employed full time, or those who are disabled, are more likely to use HAART.

28. Arnold School of Public Health Health Services, Policy, and Management 28 Weighted Population Estimate (%) of HAART Use by Education Those who are more highly educated are more likely to use HAART.

29. Arnold School of Public Health Health Services, Policy, and Management 29 Weighted Population Estimate (%) of HAART Use by Insurance Status Those persons who have private insurance are more likely to use HAART.

30. Arnold School of Public Health Health Services, Policy, and Management 30 Weighted Population Estimate (%) of HAART Use by Income Those with higher incomes are more likely to use HAART.

31. Arnold School of Public Health Health Services, Policy, and Management 31 Weighted Population Estimate (%) of HAART Use by CD 4 Cell Count Those with lower CD4 counts are more likely to use HAART.

32. Arnold School of Public Health Health Services, Policy, and Management 32 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

33. Arnold School of Public Health Health Services, Policy, and Management 33 Multivariate Logistic Regression Use 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

34. Arnold School of Public Health Health Services, Policy, and Management 34 Multivariate Logistic Regression Use of HAART 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.

35. Arnold School of Public Health Health Services, Policy, and Management 35 Multivariate Logistic Regression Use of HAART –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.

36. Arnold School of Public Health Health Services, Policy, and Management 36 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: CytomegalovirusPneumocystis TuberculosisFungal Infections HerpesImmune System Booster Table 5 - 10

37. Arnold School of Public Health Health Services, Policy, and Management 37 Multivariate Logistic Regression Rx for Opportunistic Diseases 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: –CytomegalovirusTuberculoses –Fungal InfectionsHerpes

38. Arnold School of Public Health Health Services, Policy, and Management 38 Multivariate Logistic Regression Rx for Opportunistic Diseases Third survey (second follow-up) –By the third survey, African Americans were still significantly less likely than Whites to receive drug treatment for: CytomegalovirusTuberculosis Fungal Infections

39. Arnold School of Public Health Health Services, Policy, and Management 39 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.