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

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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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Author information

Authors and Affiliations

  1. Division of General Internal Medicine and Health Services Research, UCLA, 911 Broxton Plaza, 90095-1736, Los Angeles, CA

    Mitchell D. Wong MD, PhD, William E. Cunningham MD, MPH, Martin F. Shapiro MD, PhD, Hong Hu Liu PhD & Neil S. Wenger MD

  2. School of Public Health, University of California, Los Angeles, Calif

    William E. Cunningham MD, MPH, Martin F. Shapiro MD, PhD & Ronald M. Andersen PhD

  3. RAND, Santa Monica, Calif

    Martin F. Shapiro MD, PhD & Neil S. Wenger MD

  4. Department of Health Care Policy, Harvard Medical School, Boston, Mass

    Paul D. Cleary PhD & Bruce E. Landon MD, MBA

  5. Division of Clinical Care Research, Tufts New England Medical Center, Boston, Mass

    Ira B. Wilson MD, MSc

  6. Department of Psychiatry, University of California, Los Angeles, Calif

    Naihua Duan PhD

Authors
  1. Mitchell D. Wong MD, PhD
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  2. William E. Cunningham MD, MPH
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  3. Martin F. Shapiro MD, PhD
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  6. Naihua Duan PhD
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  7. Hong Hu Liu PhD
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  8. Ira B. Wilson MD, MSc
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  9. Bruce E. Landon MD, MBA
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  10. Neil S. Wenger MD
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the HCSUS Consortium

Corresponding author

Correspondence to Mitchell D. Wong MD, PhD.

Additional information

This paper was presented at the 24th Annual National Meeting for the Society of General Internal Medicine, May 2001, in San Diego, Calif.

This research is supported by grants from the Agency for Healthcare Research and Quality, The Robert Wood Johnson Foundation, the Universitywide AIDS Research Program, and by the Health Resources Service Administration through a National Research Service Award.

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Wong, M.D., Cunningham, W.E., Shapiro, M.F. et al. Disparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients. J GEN INTERN MED 19, 366–374 (2004). https://doi.org/10.1111/j.1525-1497.2004.30429.x

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  • DOI: https://doi.org/10.1111/j.1525-1497.2004.30429.x

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