Racial and Ethnic Disparities in HIV infection

Introduction

Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have a measurable form of disease-specific expertise, such as high HIV patient volume or infectious diseases certification. Although it is known that racial/ethnic minorities generally have worse access to care than do whites, previous work has not examined disparities in the use of physicians with HIV-related expertise.

Discussion

Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have some form of disease-specific expertise, based on evidence from the United States that certain types of board certification and high HIV patient volume (“experience”) are associated with indicators of better quality care such as lower patient mortality, increased use of appropriate medications, and fewer hospitalizations. In one of the first published studies on the effectiveness of HIV expertise, Kitahata et al. categorized physicians into “least, moderate, and most” levels of experience and found that patients of the moderately and most-experienced physicians had progressively lower relative risks of death. Earlier studies found that patients of several types of specialists were prescribed antiretroviral therapy sooner and hospitalized less frequently than were patients of generalists. More recently, tests of physician knowledge showed that infectious diseases certification and high HIV experience were independently associated with responding correctly to questions about the appropriate use of antiretroviral and prophylactic therapy (Smedley et al, pp 23-181).

The importance of physician expertise has also come to the attention of state policymakers, as evidenced by the recent enactment of laws requiring managed care plans to give their HIV-positive enrollees the option to self-refer to specialists. This legislation, however, does not apply to persons who are uninsured or not enrolled in managed care plans. Further, relatively generous insurance coverage does not guarantee that HIV patients will see physicians who are best suited for treating their health problems (Markson et al, pp 35-41). As noted in a recent Institute of Medicine report, racial/ethnic minorities with HIV, regardless of insurance coverage, generally have worse access to care than do whites. African Americans and Latinos in particular have fared poorly on each of the outcomes that evidence suggests is improved by the care of physicians who training or clinical experience would makes them eligible for certification as “HIV specialists.” Specifically, members of these racial/ethnic minority groups have greater odds of dying lower odds of receiving antiretroviral therapy and more frequent hospital admissions compared with whites (Frankel et al, pp 969-92).

Previous research has helped to establish infectious diseases training and clinical experience as defining components of HIV expertise by examining the relationship of these provider characteristics with indicators of health care quality. However, the lack of any studies on racial/ethnic differences in the use of physicians with HIV expertise represents a considerable gap in the health disparities literature (Doescher et al, pp 1156-63). The present study addresses the extent to which the potential benefit of having a physician with HIV-related expertise is realized for all persons in care for HIV in the United ...