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Recent HCSUS studies focus on HIV infection in older individuals and women, use of complementary and alternative therapies, and insurance status

The HIV Cost and Services Utilization Survey (HCSUS) was the first study to examine the health status and health care use of a nationally representative sample of adults infected with the human immunodeficiency virus (HIV) that causes AIDS. The core study enrolled 2,864 U.S. men and women who were receiving ongoing medical care in the first 2 months of 1996. Respondents were sampled from 28 urban areas and 24 clusters of rural counties in the continental United States. The study design included an in-person interview (baseline) and two followup interviews at 6 and 12 months after baseline.

HCSUS was supported in part by the Agency for Healthcare Research and Quality (HS08578) and led by Martin F. Shapiro, M.D., Ph.D., of RAND and the University of California, Los Angeles, School of Medicine, and Samuel A. Bozzette, M.D., Ph.D., of RAND and the University of California, San Diego. The following HCSUS studies were published recently.

Crystal, S., Akincigil, A., Sambamoorthi, U., and others (2003). "The diverse older HIV-positive population: A national profile of economic circumstances, social support, and quality of life." Journal of Acquired Immune Deficiency Syndromes 33, pp. S76-S83.

The characteristics and care needs of the older HIV-positive population are very diverse and vary sharply by HIV-exposure route, concludes this study. The goal of the study was to provide a national profile of the socioeconomic circumstances of the middle-aged and older population living with HIV and to evaluate their social support and quality of life across age and HIV-exposure category. Results revealed that older gay men with HIV/AIDS were predominantly white and more likely to have health insurance than their younger counterparts; 38 percent were employed, and 48 percent reported an income of more than $25,000.

Older injection drug users (IDUs) with HIV/AIDS were predominantly black and particularly disadvantaged; only 11 percent were employed, and 74 percent reported incomes of less than $10,000. Older IDUs reported especially low levels of physical functioning and emotional support compared with their younger counterparts, whereas older gay men did not differ significantly from younger gay men in these respects. The researchers note the need to tailor care to the needs of these distinct groups and to develop supportive care interventions for older IDUs.

Sherbourne, C., Forge, N.G., Kung, F-Y., and others (2003). "Personal and psychosocial characteristics associated with psychiatric conditions among women with human immunodeficiency virus." Women's Health Issues 13, pp. 104-110.

About 40 percent of newly diagnosed cases of HIV occur among women, particularly vulnerable, poor, and minority women. This study of 847 women participating in HCSUS found that 55 percent of them showed signs of mood disorders, drug dependence, or heavy drinking. Increased risk for psychiatric conditions among these women was associated with younger age, having AIDS (rather than being HIV-positive but asymptomatic), using avoidant coping strategies, reporting increased conflict with others, prior physical abuse (20 percent), needing income assistance (52 percent), and putting off going to the doctor because of caring for someone else.

Emotional or substance abuse problems were 1.48 times more likely among women with a need for income assistance and 2.2 times more likely among women who put off going to the doctor because they were caring for someone else, compared with other HIV-positive women. These findings suggest the need to address women's need for safety from assaultive partners and the need for special programs for HIV-infected women burdened with having to care for others, conclude the researchers. They screened the women for psychiatric mood disorder using the short form of the University of Michigan's Composite International Diagnostic Interview (CIDI-SF). The screening items for drug use and drug dependence were based on the CIDI, but modified for this study.

Editors Note: Another AHRQ-supported, non-HCSUS study (HS11625) focused on women with HIV. It highlighted the vulnerability of HIV-infected women to substance abuse and noncompliance with antiretroviral therapy during the postpartum period. See Warner, L.A., Wei, W., McSpiritt, E., and others (2003). "Ante- and postpartum substance abuse treatment and antiretroviral therapy among HIV-infected women on Medicaid." Journal of the American Medical Women's Association 58(3), pp. 143-153.

Hsiao, A-F., Wong, M.D., Kanouse, D.E., and others (2003). "Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients." Journal of Acquired Immune Deficiency Syndromes 33, pp. 157-165.

This study found that 53 percent of those HIV-infected adults participating in HCSUS had recently used at least one type of complementary and alternative medicine (CAM), and 3 percent substituted CAM for conventional HIV therapy. HCSUS respondents were asked if they had used any of 15 types of CAM since their baseline interview. These ranged from spiritual healing, herbal medicine, acupuncture, and chiropractic to massage, hypnosis, megavitamins, and underground/unlicensed drugs.

Of the patients who had used CAM, one-fourth of them used CAM that had the potential for adverse effects. For example, St. John's Wort used for depression decreases levels of the antiretroviral drug, indinavir, which could potentially lead to treatment failure and development of HIV drug resistance. Also, one-third of CAM users had not discussed such use with their health care providers. Patients with greater desire for medical information and involvement in medical decisionmaking and those with a negative attitude toward antiretroviral therapy were more likely to use CAM. These findings underscore the need for doctors to openly discuss CAM use with their HIV-infected patients.

Goldman, D.P., Leibowitz, A.A., Joyce, G.F., and others (2003). "Insurance status of HIV-infected adults in the post-HAART era: Evidence from the United States." Applied Economics and Health Policy 2(2), pp. 85-91.

HIV disease is very expensive to treat, with lifetime costs of up to $150,000. Public insurance is the predominant source of health insurance coverage for those in care for HIV in the United States, and that coverage increases as the disease progresses, according to this study. Based on their analysis of HCSUS data, the investigators estimate that almost half the patients in care for HIV are covered by Medicaid or Medicare.

About 20 percent of the HCSUS population reported Medicare coverage in 1996 and 1997 (of which 13 percent were covered by both Medicare and Medicaid). Public coverage was more likely as HIV disease progressed. While 5 percent of asymptomatic and 10 percent of symptomatic patients were covered by Medicare or Medicaid, 20 percent of those who had developed AIDS were dually covered.

To explore the impact of disease severity on insurance coverage, the investigators used HCSUS data to develop a model to adjust for factors (for example, race, sex, HIV exposure route, education, time since diagnosis, and lowest CD4 lymphocyte count) that might affect insurance outcomes. Their findings indicate that the probability of having private insurance falls gradually from about 0.37 with a CD4 count of 700 (the normal count for healthy people is usually 600-1200) to 0.23 as lowest CD4 count approaches zero. On the other hand, the probability of having public insurance rises dramatically from 0.36 to 0.67.

Reprints (AHRQ Publication No. 04-R010) are available from AHRQ Publications Clearinghouse.

Asch, S.M., Kilbourne, A.M., Gifford, A.L., and others (2003, June). "Underdiagnosis of depression in HIV." Journal of General Internal Medicine 18, pp. 450-460.

This study found that over one-third (37 percent) of 1,140 HCSUS patients studied suffered from major depression, a rate of depression similar to victims of heart attack, cancer, or stroke (33-39 percent). Yet, 45 percent of depressed patients did not have a depression diagnosis documented in their medical chart. Undiagnosed depression among people with HIV can lead to poorer adherence to medication regimens; self-medication of depressive symptoms with alcohol or illicit drugs, which can also be associated with poorer HIV treatment adherence; or use of alternative therapies such as St John's Wort, which can reduce the blood level of the protease inhibitor indinavir that is used to treat HIV.

The investigators interviewed patients about their mental health using the Composite International Diagnostic Interview (CIDI) survey. They also collected demographic information, asked patients about their socioeconomic status and HIV disease severity, and reviewed medical record data from 1995 to 1997. Based on the CIDI, 37 percent of patients suffered from major depression, but only 45 percent of them had a diagnosis of depression documented in their medical chart. After adjusting for demographic, socioeconomic, and provider factors likely to affect depression diagnosis, patients with less than a high school education were less likely than those with at least a college education to have their depression diagnosed.

Providers should be more aware of the potential for coexisting depression among HIV-infected patients, particularly less educated patients, and they should use depression screening instruments, conclude the researchers.

Ciccarone, D.H., Kanouse, D.E., Collins, R.L., and others (2003, June). "Sex without disclosure of positive HIV serostatus in a U.S. probability sample of persons receiving medical care for HIV infection." American Journal of Public Health 93(6), pp. 949-954.

It is not uncommon for people who are infected with HIV to engage in risky (unprotected) sex without disclosure of their HIV-positive status. This study found that 42 percent of gay or bisexual men, 19 percent of heterosexual men, and 17 percent of all women said they had unprotected sex without disclosing their HIV status to their partner. Among gay or bisexual men, this practice was predominantly with nonexclusive partners. For gay or bisexual men, 13 percent of serodiscordant partnerships (sex between an HIV-positive and HIV-negative person) involved unprotected anal or vaginal sex without disclosure of HIV status, compared with 9 percent of heterosexual men's and 10 percent of women's serodiscordant partnerships.

About half of the sexually active gay or bisexual men (58 percent), heterosexual men (46 percent), and women (47 percent) had serodiscordant sexual partners during the 6 months before the interview. Most unprotected sex without disclosure in serodiscordant partnerships appeared to involve mutual nondisclosure (that is, with a partner of unknown HIV status). The rate of sex without disclosure found in this sample of HIV-positive individuals suggests that 17,400 gay or bisexual men, 2,000 heterosexual men, and 2,900 women, all of whom were HIV-infected, engaged in unprotected anal or vaginal sex without disclosing their HIV status during the 6-month reporting period.

These numbers are large enough to suggest that substantial numbers of new HIV infections could occur among partners of HIV-positive individuals who do not disclose their status. Prevention efforts designed to promote disclosure and reduce unsafe sex among HIV-positive men and women may yield important public health benefits, conclude the researchers. These findings were based on data on 1,397 HIV-positive individuals from the Risk and Prevention Study subset of HCSUS. The authors examined the prevalence of abstinence, sex only with HIV status disclosure, sex without disclosure, and unprotected anal or vaginal sex without disclosure by risk group.

Editor's Note: Another HCSUS study analyzes patterns of coping among individuals with HIV infection. For more information, see Fleishman, J.A., Sherbourne, C.D., Cleary, P.D., and others (2003, September). "Patterns of coping among persons with HIV infection: Configurations, correlates, and change." American Journal of Community Psychology 32, pp. 187-204.

Reprints (AHRQ Publication No. 04-R009) are available from AHRQ Publications Clearinghouse.

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