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Black Women in US Less Likely to Get Antiretrovirals, Regardless of Insurance
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48th ICAAC
October 25-28, 2008
Washington, DC
Mark Mascolini
African-American women eligible for antiretroviral therapy were twice more likely than white women to remain untreated in 2002 or 2005, according to findings in the Women's Interagency HIV Study (WIHS) [1]. Neither substance abuse nor lack of medical insurance explained the disparity. Drinking alcohol independently made anti-HIV treatment less likely, and being in the AIDS Drug Assistance Program (ADAP) improved chances of getting treated.
WIHS is an ongoing observational study of US women with HIV or at high risk of HIV infection [2]. Every 6 months WIHS members have a detailed interview, physical and gynecologic exams, and lab tests. This study focused on 1463 women clinically eligible for antiretroviral therapy in 2002 and 1345 women eligible in 2005. The researchers defined eligibility as self-reported current treatment, a CD4 count under 350, or a viral load above 50,000 copies. In the 2002 group, 445 antiretroviral-eligible women (30%) were not being treated, and in the 2005 group, 390 eligible women (29%) remained untreated.
One statistical model used to pin down factors related to lack of antiretroviral therapy looked only at race/ethnicity as an independent variable. A more complicated model weighed the impact of race/ethnicity, substance use, insurance, demographics, clinical indicators, study site, cohort, and ADAP.
In the simple model, in 2002 black women had a doubled risk of not getting antiretrovirals when they needed them compared with whites (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.38 to 2.91). That risk changed little in 2005 (OR 2.06, 95% CI 1.39 to 3.07). In the multivariate model being black made nontreatment 2.38 times more likely in 2002 (95% CI 1.52 to 3.73) and 2.01 times more likely in 2005 (95% CI 1.22 to 3.31).
In 2002 Hispanic ethnicity did not raise the risk of nontreatment in the simple or multivariate model. In 2005 Hispanic women had more than a 50% higher risk of remaining untreated than white women in the simple model (OR 1.57, 95% CI 1.02 to 2.41), though not in the multivariate model. In other words, in 2005 sociodemographic differences explained the treatment disparity between Hispanics and whites.
Compared with not drinking alcohol, heavy drinking nearly tripled the risk of nontreatment in 2002 (OR 2.93, 95% CI 1.53 to 5.43). Heavy drinking did not independently predict nontreatment in 2005, but moderate drinking (OR 1.72, 95% CI 1.10 to 2.70) and light drinking (OR 1.39, 95% CI 1.03 to 1.89) did. Illicit drug use did not affect antiretroviral treatment in 2002 or 2005.
Compared with having Medicaid, having no insurance quadrupled the risk of nontreatment in 2002 (OR 4.17, 95% CI 2.75 to 6.31) and more than doubled the risk in 2005 (OR 2.38, 95% CI 1.52 to 3.73). In contrast, taking advantage of ADAP independently lowered the risk of nontreatment 63% in 2002 and 46% in 2005.
The investigators concluded that "efforts to improve insurance coverage could improve access to HIV medications for women" regardless of race or ethnicity. They believe their results underline the importance of assessing alcohol use as well as illicit drugs.
These disparities in getting antiretrovirals when needed are particularly disturbing because one would expect women in a program like WIHS to have better antiretroviral access as a result of their twice-yearly contact with healthcare professionals. It is possible that women not in WIHS run even a higher risk of nontreatment.
References
1. Lillie-Blanton M, Stone VE, Snow Jones A, et al. Race, drug use and insurance coverage in use of HAART among HIV positive women, 2002-2005. 48th Annual International Conference on Antimicrobial Agents and Chemotherapy (ICAAC). October 25-28, 2008. Washington, DC. Abstract H-444.
2. Women's Interagency HIV Study (WIHS). ClinicalTrials.gov (http://clinicaltrials.gov/show/NCT00000797).
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