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Access to life-sustaining anti-HIV drugs is slowly improving for poor and uninsured patients

In 1996, when the "AIDS cocktail" drugs—protease inhibitors—were first approved, uninsured people with HIV disease waited up to 4-1/2 months longer, on average, than privately insured patients to begin life-sustaining medication, according to a new national study sponsored by the Agency for Health Care Policy and Research. The study also found that HIV patients covered by Medicaid waited 3 months longer than privately insured patients to start protease-inhibitor therapy, blacks started nearly 3 months after whites, and women began about 2 months later than men, on average.

But the findings of this study also contain some encouraging news—the glaring disparities uncovered at the beginning of 1996 have narrowed considerably. By the beginning of 1998, Latinos no longer lagged behind white Anglo HIV patients in five of six indicators used to determine the adequacy or inadequacy of care, and although Medicaid, uninsured, and black patients continued to lag behind their counterparts in several of the measures, the differences were not as pronounced as before. The disparity between female and male HIV patients, however, remained essentially unchanged.

The findings are from the HIV Cost and Services Utilization Study (HCSUS)—conducted by RAND of Santa Monica, CA, through a cooperative agreement with AHCPR—and are based on data from a national sample of patients representing the nation's 231,400 HIV-infected people receiving care for their disease, who were interviewed in 1996, 1997, and early 1998. The interviews focused on six indicators of access to quality care—receipt of any antiretroviral therapy; initiating, by the end of 1996, treatment with the recently developed "AIDS cocktails," which incorporate protease inhibitor or non-nucleoside reverse transcriptase inhibitor drugs; taking drugs to prevent Pneumocystis carinii pneumonia (PCP)— major killer of HIV-weakened patients; making at least two outpatient visits; not being hospitalized; and not visiting the emergency room (ER) for a problem that did not result in hospitalization.

In early 1996, 7 of every 10 HIV patients failed to meet at least one of the six standards of access to quality care for which they were eligible. Within the 6 months prior to that first interview, 15 percent of the patients had seen their doctors fewer than two times—the number of visits considered adequate for good continuity of care, 23 percent made at least one ER visit for a problem not leading directly to hospitalization, and 19 percent had been hospitalized at least once.

Also in 1996, Medicaid and uninsured patients, along with blacks and Latinos, were found to be less likely than other HIV patients to visit the doctors managing their disease often enough for good continuity of care, and they were more likely to have gone to an ER for problems not leading directly to hospitalization. Black, female, and Medicaid patients were more likely than other patients to have been admitted to a hospital for HIV-related reasons. Although appropriate ambulatory care does not guarantee that HIV patients will never need to use ERs or be hospitalized for their condition, it reduces the likelihood significantly.

In addition, 30 percent of patients with CD4 cell counts of less than 200 had not taken drugs to prevent PCP, and 41 percent whose CD4 cell counts were less than 500 had not started either protease-inhibitor or non-nucleoside reverse transcriptase inhibitor therapy by the end of 1996. According to Martin F. Shapiro, M.D., the lead author of the study and co-project director of HCSUS, the overall proportion of HIV patients in compliance with all six standards for which they were eligible had risen to 47 percent by January 1998. Also by early 1998, the percentage who had started either protease inhibitor or non-nucleoside reverse transcriptase inhibitor therapy had climbed to 85 percent among those with CD4 counts of less than 500. In addition, ER use and hospitalization rates fell. The percentage of patients not taking medication to prevent PCP declined, although only moderately, from 30 percent to 26 percent.

Moreover, the disparity between black and white patients in initiating use of newly developed HIV medications decreased from 24 percent to 8 percent, while the gulf between uninsured and Medicaid patients on the one hand, and privately insured patients on the other, declined by about half.

For more information, see "Variations in the care of HIV-infected adults in the United States: Results from the HIV Cost and Services Utilization Study," by Dr. Shapiro, Sally C. Morton, Ph.D., Daniel F. McCaffrey, Ph.D., and others, in the June 23, 1999, Journal of the American Medical Association, pp. 2305-2315. Reprints (AHCPR Publication No. 99-R053) are available from AHCPR.

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