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Researchers report recent findings from the HIV Cost and Services Utilization Study

The HIV Cost and Services Utilization Study (HCSUS) is a nationally representative study of 2,864 adults infected with the human immunodeficiency virus (HIV) that causes AIDS who received health care in the United States in 1996. HCSUS was conducted under a cooperative agreement between RAND and 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 Medical School, and Samuel A. Bozzette, of RAND and the University of California, San Diego. Five recent HCSUS studies are summarized here.

London, A.S., Foote-Ardah, C.E., Fleishman, J.A. and Shapiro, M.F. (2003, June). "Use of alternative therapists among people in care for HIV in the United States." American Journal of Public Health 93(6), pp. 980-987.

These researchers found that about 15 percent of people receiving medical care for HIV also use complementary care provided by alternative therapists such as massage therapists, acupuncturists, or herbalists, and that certain patients are more likely to use complementary and alternative medicine (CAM) providers than others. The researchers analyzed baseline HCSUS interviews conducted with 2,754 patients that included questions about use of alternative therapists within the past 6 months. Among those who had used an alternative therapist, 54 percent had fewer than five visits in the past 6 months.

Gays and lesbians were more likely to use alternative providers than heterosexuals. Those whose income was above $40,000 were also more likely to use alternative providers than people with an income below $5,000, as were those who lived in the Northeast and West compared with those who lived in the South. Patients who were depressed were more likely than those who screened negatively for depression to use CAM providers, as were patients who wanted more information about and involvement in their care.

People who believed that antiretroviral therapy was definitely worthwhile were somewhat less likely to have visited an alternative therapist in the past 6 months than people who were not as confident about the medication. Among those who had used an alternative therapist, people who had private insurance had significantly more visits than people who did not have insurance, suggesting that private insurance reduces financial access barriers to some kinds of CAM providers.

Reprints (AHRQ Publication No. 03-R046) are available from the AHRQ Publications Clearinghouse.

Tucker, J.S., Burnam, M.A., Sherbourne, C.D., and others (2003, May). "Substance use and mental health correlates of nonadherence to antiretroviral medications in a sample of patients with human immunodeficiency virus infection." American Journal of Medicine 114, pp. 573-580.

Antiretroviral medication regimens for HIV infection are complex and inconvenient, often produce side effects, and must be taken consistently for long periods of time. Not taking the medications as directed can compromise their long-term effectiveness and lead to development of HIV medication resistance. HIV-infected patients with substance abuse or mental health problems, which are common in HIV patients, are much less likely to comply with antiretroviral medication regimens, according to this study.

The study involved 1,910 HCSUS patients who reported their adherence to antiretroviral medication regimens over a 1-week period in 1997 and 1998. Patients were considered adherent if they missed no medications at all during the week and if all medications were taken exactly as directed "all of the time." Adherence was achieved by nearly half of patients who did not have a probable psychiatric disorder or use illegal drugs. However, only 36 percent of those with a psychiatric problem and 39 percent of those who used illegal drugs reported adherence to their antiretroviral treatment.

Patients suffering from depression, generalized anxiety disorder, or panic disorder were more likely to not adhere to the therapy than those without a psychiatric disorder. Similarly, users of cocaine, marijuana, amphetamines, or sedatives in the previous month were more likely than other patients not to comply with therapy. Finally, compared with patients who did not drink, those who were moderate, heavy, or frequent heavy drinkers were more likely to be nonadherent. These associations could not be explained by demographic, clinical, or treatment factors.

Chan, K.S., Orlando, M., Joyce, G., and others (2003, May). "Combination antiretroviral therapy and improvements in mental health: Results from a nationally representative sample of persons undergoing care for HIV in the United States." Journal of Acquired Immune Deficiency Syndromes 33, pp. 104-111.

An initial assessment of HCSUS patients in 1996 and 1997 indicated that nearly half suffered from a psychiatric problem such as depression or anxiety. However, mental health has improved for many individuals in this group in recent years, coinciding with use of combination ART that substantially lowers HIV-related complications and deaths. This is the first study to document a global improvement in mental health, regardless of treatment profile, in a broadly representative sample of HIV/AIDS patients during the ART era, possibly due to better quality of life and the promise of extended survival. It also shows an ART-specific effect on improved mental health.

To test whether mental health improvement among HIV-infected patients was directly related to ART or global optimism about HIV prognosis, these researchers examined the change in psychiatric symptoms among 2,466 HIV-infected people participating in HCSUS from a baseline (January 1996 to April 1997) to the first followup interview about 8 months later. They examined changes in psychiatric symptoms as a function of changes in CD4 counts (with higher counts indicating a stronger immune system), treatments for opportunistic infections (more common with advanced HIV disease), and HIV physical symptoms. They examined these changes separately in patients who maintained ART, initiated ART, never received ART, or changed to a less recommended drug regimen during the study.

Overall, the proportion of the sample screening positive for four psychiatric disorders (major depression, prolonged mild depression or dysthymia, generalized anxiety disorder, and panic attacks) declined from 48 percent to 37 percent at the followup interview. The reduction in psychiatric symptoms was comparable across all treatment groups, suggesting a global effect. However, in patients who initiated ART, fewer psychiatric symptoms were significantly related to all three markers of physical health: higher CD4 counts, fewer opportunistic infection treatments, and reduced HIV symptoms, suggesting a treatment effect. In contrast, for those who stopped taking ART or never received it during the study period, a decrease in psychiatric symptoms was primarily related to reductions in HIV symptoms.

Galvan, F.H., Burnam, M.A., and Bing, E.G. (2003, May). "Co-occurring psychiatric symptoms and drug dependence or heavy drinking among HIV-positive people." Journal of Psychoactive Drugs Suppl 1, pp. 153-160.

Based on data from 2,864 HCSUS participants, one-third of people receiving care for HIV in the United States in 1996 had psychiatric symptoms without drug dependence or heavy drinking problems in the previous year. About 6 percent had either or both drug dependence symptoms or heavy drinking without psychiatric symptoms. Overall, 13 percent had co-occurring psychiatric symptoms and either or both drug dependence symptoms or heavy drinking. Sixty-nine percent of those with a substance abuse problem also had psychiatric symptoms, and 27 percent of those with psychiatric symptoms also had a substance abuse problem.

The odds of having a coexisting condition were higher for males, heterosexuals, and people with more HIV-related symptoms. The odds were lower for people living with AIDS, blacks, people who were gay or sexually abstinent, those living with a spouse, those aged 50 or older, and those with private insurance.

Dobalian, A., Andersen, R.M., Stein, J.A., and others (2003, Spring). "The impact of HIV on oral health and subsequent use of dental services." Journal of Public Health Dentistry 63(2), pp. 78-85.

More than one-third of HIV-infected people develop oral lesions. Untreated oral disease can interfere with talking, chewing, and swallowing and lead to weight loss and malnutrition. This HCSUS study is the first study to examine the relationship between the need for dental care and potentially competing mental and physical health needs of people who have HIV. The researchers found that people who have more HIV-related symptoms and a diagnosis of AIDS have a greater need for dental care than those who have fewer symptoms and do not have AIDS. However, more pressing needs for physical and mental health services limit their access to dental services.

Health care providers need to give more attention to the oral health needs of people who have HIV and are in poor physical and mental health. Also, concerns about adequate treatment of the physical health needs of people with HIV should not preclude attention to dental needs, conclude the researchers. They examined differences in oral health and access to dental services among 2,864 HCSUS participants. They also studied predisposing characteristics (sex, education, age, race/ethnicity, and mode of HIV exposure), enabling factors (income, dental insurance, a usual source of dental care, and receipt of highly active antiretroviral therapy by December 1996), and need factors (AIDS diagnosis and intensity of HIV symptoms) associated with use of dental services.

More education, dental insurance, having a usual source of dental care, and poor oral health predicted a higher probability of having a dental visit. Blacks, Hispanics, those exposed to HIV through drug use or heterosexual contact, and those in poor physical health were less likely to visit the dentist. Of those who visited dental professionals, older people, those with dental insurance, and those in worse oral health had more visits. Blacks and people with mental health problems had fewer visits.

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