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


OBJECTIVE
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.


METHODS
Prospective cohort study.


METHODS
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 1717 patients eligible for PI treatment and the 367 providers who cared for them.


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


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.
Wong
Mitchell D
MD
Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, California 90095-1736, USA. miwong@mednet.ucla.edu
Cunningham
William E
WE
Shapiro
Martin F
MF
Andersen
Ronald M
RM
Cleary
Paul D
PD
Duan
Naihua
N
Liu
Hong Hu
HH
Wilson
Ira B
IB
Landon
Bruce E
BE
Wenger
Neil S
NS
D000328:Adult; D001291:Attitude of Health Personnel; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D006304:Health Status; D006630:Hispanic or Latino; D006801:Humans; D007182:Income; D008297:Male; D015999:Multivariate Analysis; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D011480:Protease Inhibitors / Q000627:therapeutic use*; D016896:Treatment Outcome; D016312:Treatment Refusal
D011480:Protease Inhibitors