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July 2004, Vol 94, No. 7 | American Journal of Public Health 1119-1121
© 2004 American Public Health Association

RESEARCH AND PRACTICE

Sociodemographic Differences in Access to Care Among Hispanic Patients Who Are HIV Infected in the United States

Leo S. Morales, MD, PhD, William E. Cunningham, MD, MPH, Frank H. Galvan, PhD, Ronald M. Andersen, PhD, Terry T. Nakazono, MA and Martin F. Shapiro, MD, PhD

Leo S. Morales, William E. Cunningham, Ronald M. Andersen, Terry T. Nakazono, and Martin F. Shapiro are with the University of California at Los Angeles. Leo S. Morales and Martin F. Shapiro are also with RAND Health, Santa Monica, Calif. Frank H. Galvan is with the Charles R. Drew University of Medicine and Science, Los Angeles, Calif.

Correspondence: Requests for reprints should be sent to Leo S. Morales, MD, PhD, UCLA Medicine/GIM, 911 Broxton Ave, Los Angeles, CA 90024 (e-mail: morales{at}rand.org).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

This study evaluated associations between sociodemographic factors and access to care, use of highly active antiretroviral therapy, and patients’ ratings of care among Hispanic patients who are HIV infected; we used data from the HIV Cost and Services Utilization Study. Gender, insurance, mode of exposure, and geographic region were associated with access to medical care. Researchers and policymakers should consider sociodemographic factors among Hispanic patients who are HIV positive when designing and prioritizing interventions to improve access to care.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Hispanic patients who are HIV infected have worse access to care than do White patients.1,2 Strategies to remedy this problem necessitate learning the extent to which access to care varies among Hispanic subgroups, so that interventions can be tailored and the most vulnerable population prioritized. In this study, we examined sociodemographic differences in access to medical and dental care, receipt of highly active antiretroviral therapy, and patients’ evaluations of care.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
Subjects
We studied Hispanic patients who completed the HIV Cost and Services Utilization Study baseline survey. The HIV Cost and Services Utilization Study was a representative study of adults who are HIV positive receiving care in the United States.1,3,4

Regression Analyses
Dependent variables. We examined 9 dichotomous indicators of access to care, including an access scale (dichotomized at mean),5 having a usual source of care at HIV diagnosis, having 3 or more outpatient visits in the 6 months before interview, having any emergency department visits not associated with hospitalizations in the 6 months before interview, receiving highly active antiretroviral therapy before December 1996, and receiving highly active antiretroviral therapy by the second follow-up HIV Cost and Services Utilization Study survey.6 Patients’ evaluations of care were assessed by a single rating item (excellent vs very good to poor). Access to dental care was assessed by indicators of having a usual source of dental care and having trouble obtaining needed dental care.7

Independent variables. Independent variables were age, gender, educational attainment, income, insurance status, mode of exposure to HIV, geographic location, acculturation,8–11 survey language, and US citizenship.

Estimation. We estimated 9 logistic regressions, controlling for independent variables and CD4 cell count. All analyses were weighted to account for sampling and survey nonresponse.12


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Sample Characteristics
The 415 Hispanics included in the HIV Cost and Services Utilization Study represent an estimated 34 180 (95% Confidence Interval = 18 613, 49 747) Hispanics infected with HIV who were receiving care at the time of the baseline survey in the United States (Table 1Go). Of the Hispanic patients who were HIV infected, 49% were aged 31 to 40 years, 72% were male, 44% had not completed high school, 23% had an annual income of less than $5000, and 25% were uninsured. Forty percent were exposed to HIV by male-to-male sex, 38% were located in the Northeast, 83% were US citizens, 85% answered the English survey, and 58% were highly acculturated.


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  		TABLE 1—— Sociodemographic Characteristics of Hispanics in the HIV Cost and Services Utilization Study
 
Descriptive Results
Of the Hispanic patients who were HIV infected, 64% had a usual source of care at HIV diagnosis, 34% rated their care as excellent, 72% had 3 or more outpatient visits, and 74% had no emergency department visits without hospitalizations. Seventy-four percent were taking highly active antiretroviral therapy by the second follow-up survey, an increase from 34% by the end of 1996. Fifty-four percent had a usual source of dental care, and 80% had no trouble obtaining needed dental care.

Regression Results
Worse access to care was associated with being male, having no insurance, and receiving care in the South (Table 2Go). Having no usual source of care at HIV diagnosis was associated with being male and being exposed to HIV by drug use and heterosexual sex. Having 3 or fewer outpatient visits was associated with being male and being exposed to HIV by heterosexual sex. Having 1 or more emergency department visits without hospitalization was associated with being female. Receiving less than excellent care was less likely in the South. Not taking highly active antiretroviral therapy by the second follow-up survey was associated with being female and receiving care in the Northeast. Not having a usual source of dental care was associated with US citizenship. Difficulty obtaining needed dental care was associated with being less acculturated and receiving care in the South.


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  		TABLE 2—— Subgroup Differences in Odds Ratios Among Hispanic Patients for Access to Medical and Dental Care, After Control for All Independent Variables and CD4 Cell Count
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
In contrast to prior findings, women in this study reported better access to care than did men.1 Women had a 67% lower adjusted odds ratio than men of not having a usual source of care at HIV diagnosis. Not having a usual source of care at HIV diagnosis has been associated with delays in care, subsequent hospitalizations, and decreased use of antiretrovirals.2,13,14 Hispanic persons exposed to HIV by drug use and heterosexual sex also were at increased risk for not having had a usual source of care at HIV diagnosis. These results suggest that Hispanic men and Hispanic patients exposed to HIV by drug use and heterosexual sex should receive special attention when interventions to improve access to care for Hispanic patients who are HIV infected are considered.

We were surprised by the weak associations between access to care and acculturation, survey language, and citizenship status. Language was not significantly associated with any access variable, and acculturation and citizenship status were significant in only 1 regression each. Future research should seek to explain these findings.

This study had limitations. First, data limitations prevented us from identifying the national origin of the Hispanic patients. This limitation was somewhat mitigated by the inclusion of geographic regions that were roughly correlated with concentrations of Hispanic populations of some national origins.15 Second, Hispanic patients may have been less well represented in the HIV Cost and Services Utilization Study than were other racial/ethnic groups. The HIV Cost and Services Utilization Study sampled noninstitutionalized persons receiving care for HIV, whereas Hispanic persons are overrepresented among the incarcerated and the uninsured (thus, not receiving care).4

This study should alert policymakers and researchers to important sociodemographic subgroup differences among Hispanic patients who are HIV positive. Future research should avoid the inclusion of Hispanic patients without characterizing Hispanic subgroups; otherwise, these studies risk obscuring important subgroup variations.


   Footnotes
 
Contributors
L. S. Morales and W. E. Cunningham led the analysis for this study, with assistance from F. H. Galvan, R. M. Andersen, and T. T. Nakazono. L. S. Morales led the writing of this brief. M. F. Shapiro and W. E. Cunningham conceived the study and supervised all aspects of its implementation. All of the authors helped to conceptualize ideas and interpret findings and reviewed drafts of the brief.

Human Participant Protection
The RAND institutional review board reviewed all procedures, forms, and materials used in this study. Subjects were asked for informed consent for participation in the study.

Peer Reviewed

Accepted for publication June 1, 2003.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in care of HIV-infected adults. JAMA. 1999;281:2305–2315.[Abstract/Free Full Text]

2. Turner BJ, Cunningham WE, Duan N, et al. Delayed medical care after diagnosis in a US probability sample of persons infected with human immunodeficiency virus. Arch Intern Med. 2000;160:2614–2622.[Abstract/Free Full Text]

3. Frankel MR, Shapiro MF, Duan N, et al. National probability samples in studies of low-prevalence diseases, part II: designing and implementing the HIV Cost and Services Utilization Study sample. Health Serv Res. 1999;34(5 pt 1):969–992.

4. Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. N Engl J Med. 1998;339:1897–1904.[Abstract/Free Full Text]

5. Cunningham WE, Hays RD, Ettl MK, et al. The prospective effect of access to medical care on health-related quality-of-life outcomes in patients with symptomatic HIV disease. Med Care. 1998;36:295–306.[ISI][Medline]

6. Cunningham WE, Markson LE, Andersen RM, et al. Prevalence and predictors of highly active antiretroviral therapy use in persons with HIV infection in the US. J Acquir Immune Defic Syndr. 2000;25:115–123.

7. Wilson IB, Ding L, Hays RD, Shapiro MF, Bozzette SA, Cleary PD. HIV patients’ experiences with inpatient and outpatient care: results of a national survey. Med Care. 2002;40:1149–1160.[ISI][Medline]

8. Marin BV, Flores E. Acculturation, sexual behavior, and alcohol use among Latinas. Int J Addict. 1994;29:1101–1114.[ISI][Medline]

9. Marin G, Perez-Stable EJ, Marin BV. Cigarette smoking among San Francisco Hispanics: the role of acculturation and gender. Am J Public Health. 1989;79:196–198.[Abstract/Free Full Text]

10. Perez-Stable EJ, Marin G, Marin BV, Katz MH. Depressive symptoms and cigarette smoking among Latinos in San Francisco. Am J Public Health. 1990;80:1500–1502.[Abstract/Free Full Text]

11. Marin G, Sabogal F, Marin BV, et al. Development of a short acculturation scale for Hispanics. Hisp J Behav Sci. 1987;9:183–205.[Abstract]

12. Shapiro MF, Berk ML, Berry SH, et al. National probability samples in studies of low-prevalence diseases, part I: perspectives and lessons from the HIV Cost and Services Utilization Study. Health Serv Res. 1999;34(5 pt 1):951–968.

13. Turner BJ, McKee L, Fanning T, Markson LE. AIDS specialist versus generalist ambulatory care for advanced HIV infection and impact of hospital use. Med Care. 1994;32:902–916.[ISI][Medline]

14. Turner BJ, Markson LE, McKee LJ, Houchens R, Fanning T. Health care delivery, zidovudine use, and survival of women and men with AIDS. J Acquir Immune Defic Syndr. 1994;7:1250–1262.

15. Guzman B. The Hispanic population: Census 2000 brief. Available at: http://www.census.gov/prod/2001pubs/c2kbr01-3.pdf. Accessed May 24, 2001.





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