Journal of General Internal Medicine

, Volume 19, Issue 4, pp 366–374 | Cite as

Disparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients

  • Mitchell D. Wong
  • William E. Cunningham
  • Martin F. Shapiro
  • Ronald M. Andersen
  • Paul D. Cleary
  • Naihua Duan
  • Hong Hu Liu
  • Ira B. Wilson
  • Bruce E. Landon
  • Neil S. Wenger
  • the HCSUS Consortium
Populations At Risk


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.

Key words

African Americans health services accessibility HIV Latinos patient compliance 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Hogg RS, Heath KV, Yip B, et al. Improved survival among HIV-infected individuals following initiation of antiretroviral therapy. JAMA. 1998;279:450–4.PubMedCrossRefGoogle Scholar
  2. 2.
    Palella FJ Jr, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV outpatient Study Investigators. N Engl J Med. 1998;338:853–60.PubMedCrossRefGoogle Scholar
  3. 3.
    Forrest DM, Seminari E, Hogg RS, et al. The incidence and spectrum of AIDS-defining illnesses in persons treated with antiretroviral drugs. Clin Infect Dis. 1998;27:1379–85.PubMedGoogle Scholar
  4. 4.
    Lemp GF, Hirozawa AM, Cohen JB, Derish PA, McKinney KC, Hernandez SR. Survival for women and men with AIDS. J Infect Dis. 1992;166:74–9.PubMedGoogle Scholar
  5. 5.
    Poundstone KE, Chaisson RE, Moore RD. Differences in HIV disease progression by injection drug use and by sex in the era of highly active antiretroviral therapy. AIDS. 2001;15:1115–23.PubMedCrossRefGoogle Scholar
  6. 6.
    Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med. 1994;330:763–8.PubMedCrossRefGoogle Scholar
  7. 7.
    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;281:2305–15.PubMedCrossRefGoogle Scholar
  8. 8.
    Moore RD, Hidalgo J, Sugland BW, Chaisson RE. Zidovudine and the natural history of the acquired immunodeficiency syndrome. N Engl J Med. 1991;324:1412–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Stein MD, Piette J, Mor V, et al. Differences in access to zidovudine (AZT) among symptomatic HIV-infected persons. J Gen Intern Med. 1991;6:35–40.PubMedCrossRefGoogle Scholar
  10. 10.
    Strathdee SA, Palepu A, Cornelisse PG, et al. Barriers to use of free antiretroviral therapy in injection drug users. JAMA. 1998;280:547–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Anderson KH, Mitchell JM. Differential access in the receipt of antiretroviral drugs for the treatment of AIDS and its implications for survival. Arch Intern Med. 2000;160:3114–20.PubMedCrossRefGoogle Scholar
  12. 12.
    Andersen R, Bozzette S, Shapiro M, et al. Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. HCSUS Consortium. HIV Cost and Services Utilization Study. Health Serv Res. 2000;35:389–416.PubMedGoogle Scholar
  13. 13.
    Sambamoorthi U, Moynihan PJ, McSpiritt E, Crystal S. Use of protease inhibitors and non-nucleoside reverse transcriptase inhibitors among Medicaid beneficiaries with AIDS. Am J Public Health. 2001;91:1474–81.PubMedCrossRefGoogle Scholar
  14. 14.
    Report of the NIH Panel to Define Principles of Therapy of HIV Infection. Ann Intern Med. 1998;128(12 Part 2):1057–78.Google Scholar
  15. 15.
    Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. Department of Health and Human Services and the Henry J. Kaiser Family Foundation. Ann Intern Med. 1998;128(12 Part 2):1079–100.Google Scholar
  16. 16.
    Panel on Clinical Practices for Treatment of HIV Infection. Guidelines for the Use of Antiretroviral Agents in HIV-1-infected Adults and Adolescents. Department of Health and Human Services. November 10, 2003. Bethesda, MD.Google Scholar
  17. 17.
    Condra JH. Resistance to HIV protease inhibitors. Haemophilia. 1998;4:610–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Molla A, Korneyeva M, Gao Q, et al. Ordered accumulation of mutations in HIV protease confers resistance to ritonavir. Nat Med. 1996;2:760–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Moutouh L, Corbeil J, Richman DD. Recombination leads to the rapid emergence of HIV-1 dually resistant mutants under selective drug pressure. Proc Natl Acad Sci USA. 1996;93:6106–11.PubMedCrossRefGoogle Scholar
  20. 20.
    Haubrich RH, Little SJ, Currier JS, et al. The value of patient-reported adherence to antiretroviral therapy in predicting virologic and immunologic response. California Collaborative Treatment Group. AIDS. 1999;13:1099–107.PubMedCrossRefGoogle Scholar
  21. 21.
    Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133:21–30.PubMedGoogle Scholar
  22. 22.
    Little SJ, Daar ES, D’Aquila RT, et al. Reduced antiretroviral drug susceptibility among patients with primary HIV infection. JAMA. 1999;282:1142–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Bangsberg D, Tulsky JP, Hecht FM, Moss AR. Protease inhibitors in the homeless. JAMA. 1997;278:63–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Eckenwiler L. Justice and access to therapies for AIDS. AIDS Public Policy J. 1999;14:20–5.PubMedGoogle Scholar
  25. 25.
    Lerner BH, Gulick RM, Dubler NN. Rethinking nonadherence. Historical perspectives on triple-drug therapy for HIV disease. Ann Intern Med. 1998;129:573–8.PubMedGoogle Scholar
  26. 26.
    Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium. N Engl J Med. 1998;339:1897–904.PubMedCrossRefGoogle Scholar
  27. 27.
    Landon BE, Wilson IB, Wenger NS, et al. Specialty training and specialization among physicians who treat HIV/AIDS in the United States. J Gen Intern Med. 2002;17:12–22.PubMedCrossRefGoogle Scholar
  28. 28.
    Gifford AL, Cunningham WE, Heslin KC, et al. Participation in research and access to experimental treatments by HIV-infected patients. N Engl J Med. 2002;346:1373–82.PubMedCrossRefGoogle Scholar
  29. 29.
    Hankins C, Lapointe N, Walmsley S. Participation in clinical trials among women living with HIV in Canada. Canadian Women’s HIV Study Group. CMAJ. 1998;159:1359–65.PubMedGoogle Scholar
  30. 30.
    Stone VE, Mauch MY, Steger K, Janas SF, Craven DE. Race, gender, drug use, and participation in AIDS clinical trials. Lessons from a municipal hospital cohort. J Gen Intern Med. 1997;12:150–7.PubMedGoogle Scholar
  31. 31.
    Cunningham WE, Hays RD, Ettl MK, et al. The prospective effect of access to medical care on health-related quality-of-life outcomes in patients with symptomatic HIV disease. Med Care. 1998;36:295–306.PubMedCrossRefGoogle Scholar
  32. 32.
    Mathews WC, McCutchan JA, Asch S, et al. National estimates of HIV-related symptom prevalence from the HIV Cost and Services Utilization Study. Med Care. 2000;38:750–62.PubMedCrossRefGoogle Scholar
  33. 33.
    Hays RD, Cunningham WE, Sherbourne CD, et al. Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV Cost and Services Utilization Study. Am J Med. 2000;108:714–22.PubMedCrossRefGoogle Scholar
  34. 34.
    Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58:721–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Wittchen HU, Kessler RC, Zhao S, Abelson J. Reliability and clinical validity of UM-CIDI DSM-III-R generalized anxiety disorder. J Psychiatr Res. 1995;29:95–110.PubMedCrossRefGoogle Scholar
  36. 36.
    Liu H, Golin CE, Miller LG, et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Ann Intern Med. 2001;134:968–77.PubMedGoogle Scholar
  37. 37.
    Klein J, Moeschberger M. Survival Analysis Techniques for Censored and Truncated Data. New York, NY: Springer-Verlag; 1997.Google Scholar
  38. 38.
    Huber P. The Behavior of Maximum Likelihood Estimates Under Non-Standard Conditions. Proceedings of the Fifth Berkeley Symposium on Mathematical Statistics Probability. 1967;1:221.Google Scholar
  39. 39.
    Davison AC, Hinkley DV. Bootstrap Methods and Their Application. Cambridge, UK: Cambridge University Press; 1997.Google Scholar
  40. 40.
    Roca B, Gomez CJ, Arnedo A. Adherence, side effects and efficacy of stavudine plus lamivudine plus nelfinavir in treatment-experienced HIV-infected patients. J Infect. 2000;41:50–4.PubMedCrossRefGoogle Scholar
  41. 41.
    Stone VE, Hogan JW, Schuman P, et al. Antiretroviral regimen complexity, self-reported adherence, and HIV patients’ understanding of their regimens: survey of women in the her study. J Acquir Immune Defic Syndr. 2001;28:124–31.PubMedCrossRefGoogle Scholar
  42. 42.
    Wutoh AK, Brown CM, Kumoji EK, et al. Antiretroviral adherence and use of alternative therapies among older HIV-infected adults. J Natl Med Assoc. 2001;93:243–50.PubMedGoogle Scholar
  43. 43.
    Miller LG, Liu H, Hays RD, et al. How well do clinicians estimate patients’ adherence to combination antiretroviral therapy? J Gen Intern Med. 2002;17:1–11.PubMedCrossRefGoogle Scholar
  44. 44.
    Bangsberg DR, Hecht FM, Clague H, et al. Provider assessment of adherence to HIV antiretroviral therapy. J Acquir Immune Defic Syndr. 2001;26:435–42.PubMedGoogle Scholar
  45. 45.
    Escaffre N, Morin M, Bouhnik AD, et al. Injecting drug users’ adherence to HIV antiretroviral treatments: physicians’ beliefs. AIDS Care. 2000;12:723–30.PubMedCrossRefGoogle Scholar
  46. 46.
    Bogart LM, Catz SL, Kelly JA, Benotsch EG. Factors influencing physicians’ judgments of adherence and treatment decisions for patients with HIV disease. Medical Decis Making. 2001;21:28–36.Google Scholar
  47. 47.
    Bangsberg DR, Deeks SG. Is average adherence to HIV antiretroviral therapy enough? J Gen Intern Med. 2002;17:812–3.PubMedCrossRefGoogle Scholar
  48. 48.
    Bangsberg DR, Charlebois ED, Grant RM, et al. High levels of adherence do not prevent accumulation of HIV drug resistance mutations. AIDS. 2003;17:1925–32.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • Mitchell D. Wong
    • 1
  • William E. Cunningham
    • 1
    • 2
  • Martin F. Shapiro
    • 1
    • 2
    • 3
  • Ronald M. Andersen
    • 2
  • Paul D. Cleary
    • 4
  • Naihua Duan
    • 6
  • Hong Hu Liu
    • 1
  • Ira B. Wilson
    • 5
  • Bruce E. Landon
    • 4
  • Neil S. Wenger
    • 1
    • 3
  • the HCSUS Consortium
  1. 1.Division of General Internal Medicine and Health Services ResearchUCLALos Angeles
  2. 2.School of Public HealthUniversity of CaliforniaLos Angeles
  3. 3.RANDSanta Monica
  4. 4.Department of Health Care PolicyHarvard Medical SchoolBoston
  5. 5.Division of Clinical Care ResearchTufts New England Medical CenterBoston
  6. 6.Department of PsychiatryUniversity of CaliforniaLos Angeles

Personalised recommendations