HIV-positive individuals with inadequate outpatient care overwhelmingly minorities and poor

In a first-of-its-kind study, UCLA researchers have shown that segments of the HIV-infected population who have little to no consistent outpatient medical care -- and yet are most in need of such services -- are overwhelmingly minorities, the poor and substance abusers.

Previous studies had shown minorities, the poor and substance users who were receiving routine medical care for the HIV infection, and whose data could therefore be easily captured in healthcare studies, were likelier to be medically underserved and to die more quickly. But Dr. William Cunningham, and the study's lead author, said UCLA researchers tracked HIV-infected people who were not receiving regular care -- and thus more difficult to find. Often this segment showed up in the medical system in emergency situations.

"As we expected, they are much less likely to get routine outpatient care but more likely to get acute care, when they are at their sickest," said Cunningham, who is professor of medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA. "This is just the group that needs to get grassroots outreach service."

For this study, to be published in the November issue of the journal Medical Care, the researchers compared socio-demographic, clinical and health care utilization characteristics of HIV-infected adults from two samples: 1,286 people from the 2001-02 Targeted HIV Outreach and Intervention Initiative (Outreach) and 2,267 who were interviewed in 1998 for the HIV Costs and Services Utilization Study (HCSUS).

Outreach, a multi-site program initiated in 2001 under the Ryan White Care Act, was intended to locate HIV-infected people who are hard to reach and connect them with medical care. HCSUS focused on HIV-positive patients who were receiving care. The 16 Outreach study sites, which were spread throughout the U.S., offered a variety of services such as HIV testing and counseling, social services, case management and direct medical care. They all provided outreach services linking HIV-positive patients with continuous outpatient care. The researchers examined the demographic data, the kinds of medical services the patients used and which services would be the most helpful to them.

According to the study, 59 percent of patients in the Outreach group were black, compared with 32 percent of HIV-infected people who were receiving routine care and were tracked by HCSUS. Also, 20 percent of those from the Outreach sites were Hispanic versus 16 percent from the HCSUS sample; 9 percent were Spanish speakers compared to 2 percent; 75 percent had annual incomes of $10,000 or less compared with 45 percent; and nearly 60% were unemployed, homeless, had no insurance or used heroin or cocaine compared with less than half in the HCSUS study.

Additionally, people from the Outreach group received medical care on an outpatient basis two times or less, but were likelier to have gone to emergency rooms or been hospitalized, during the prior six months. They were also less likely to be on antiretroviral drugs. And surprisingly, these patients were also more likely to have abused alcohol than drugs.

The findings can be used to develop novel interventions specifically tailored to this group, such as mobile HIV testing facilities and bringing HIV treatment to single occupancy hotels, which are typically home to drug abusers, sex workers and other marginalized people.

"Because we did this study, we know better what kind of services to tailor to them," Cunningham said. "They're not the same kind of services that are important to more mainstream patients."

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Other authors in addition to Cunningham are Mitchell D. Wong of UCLA; Nancy L. Sohler of City University of New York; Carol Tobias, Mari-lynn Drainoni, Howard J. Cabral and Judith Bradford of Boston University; Cynthia Davis of Charles R. Drew University in Lynwood, Calif.; Chinazo O. Cunningham of Montefiore Medical Center, New York City, and Lois Eldred of the federal Health Resources and Services Administration.

Funders for the study include the Health Resources and Services Administration; the National Institute of Mental Health; the National Institutes of Health, including its Office of Research on Minority Health; the National Center on Minority Health & Health Disparities; the National Institute of Aging, and the Agency for Health Research and Quality.


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