The contribution of specific causes of death to sex differences in mortality

OBJECTIVE

Men have higher mortality rates than women for most causes of death. This study was conducted to determine the contribution of specific causes of death to the sex difference in years of potential life lost (YPLL).

METHODS

The authors examined data from the National Health Interview Survey with linked mortality data through 1997. Using survival analysis estimates, a stochastic simulation model to simulate death events for cohorts of white, African American, and Latino adults was created.

RESULTS

YPLL from all causes were greater among men than women. Homicide, motor vehicle accidents, and suicide accounted for 33% of YPLL sex difference among whites, 36% among African Americans, and 52% among Latinos. For all three racial/ethnic groups, cardiovascular disease (principally ischemic heart disease) was the second largest contributor to the sex difference in YPLL (29% among whites, 23% among African Americans, and 25% among Latinos). Lung cancer was also important among whites and African Americans, accounting for 15% and 17% of the sex difference in YPLL from all causes, respectively.

CONCLUSIONS

Ischemic heart disease, lung cancer, and traumatic deaths account for as much as three-quarters of the excess YPLL among men, suggesting that a few modifiable behaviors such as the use of tobacco, alcohol.

Residential segregation and Latino, black and white mortality in New York City

Although racial segregation is associated with health status, few studies have examined this relationship among Latinos. We examined the effect of race/ethnic group concentration of Latinos, blacks and whites on all-cause mortality rates within a highly segregated metropolitan area, New York City (NYC). We linked NYC mortality records from 1999 and 2000 with the 2000 U.S. Census data by zip code area. Age-adjusted mortality rates by race/ethnic concentration were calculated. Linear regression was used to determine the association between population characteristics and mortality. Blacks living in predominantly black areas had lower all-cause mortality rates than blacks living in other areas regardless of gender (1616/100,000 vs. 2014/100,000 for men; 1032/100,000 vs. 1362/100,000 for women). Amongst whites, those living in predominantly white areas had the lowest mortality rates. Latinos living in predominantly Latino areas had lower mortality rates than those in predominantly black areas (1187/100,000 vs.1950/100,000 for men; 760/100,000 vs. 779/100,000 for women). After adjustment for socioeconomic conditions, whites, older blacks, and young Latino men experienced decreasing mortality rates when living in areas with increasing similar race/ethnic concentrations. Increasing residential concentration of blacks is independently associated with lower mortality in older blacks; similarly, increasing residential concentration of Latinos and whites is associated with lower mortality in young Latino men and whites, respectively.

The effect of socioeconomic status on the survival of people receiving care for HIV infection in the United States

HIV-infected people with low socioeconomic status (SES) and people who are members of a racial or ethnic minority have been found to receive fewer services, including treatment with Highly Active Antiretroviral Therapy (HAART), than others. We examined whether these groups also have worse survival than others and the degree to which service use and antiretroviral medications explain these disparities in a prospective cohort study of a national probability sample of 2,864 adults receiving HIV care. The independent variables were wealth (net accumulated financial assets), annual income, educational attainment, employment status (currently working or not working), race/ethnicity, insurance status, use of services, and use of medications at baseline. The main outcome variable was death between January 1996 and December 2000. The analysis was descriptive and multivariate adjusted Cox proportional hazards regression analysis of survival. By December 2000, 20% (13% from HIV, 7% non-HIV causes) of the sample had died. Those with no accumulated financial assets had an 89% greater risk of death (RR=1.89, 95% CI=1.15-3.13) and those with less than a high school education had a 53% greater risk of death (RR=1.53, 95% CI=1.15-2.04 ) than their counterparts, after adjusting for sociodemographic and clinical variables only. Further adjusting for use of services and antiretroviral treatment diminished, but did not eliminate, the elevated relative risk of death for those with low SES by three of the four measures. The finding of markedly elevated relative risks of death for those with HIV infection and low SES is of particular concern given the disproportionate rates of HIV infection in these groups. Effective interventions are needed to improve outcomes for low SES groups with HIV infection.

Oral health findings for HIV-infected adult medical patients from the HIV Cost and Services Utilization Study

BACKGROUND

The HIV Cost and Services Utilization Study (HCSUS) was conducted by a consortium of private and government institutions centered at the RAND Corp. to provide national estimates of adult medical patients who are HIV-positive. This article presents descriptive oral health findings from that study.

METHODS

The National Opinion Research Center (NORC) conducted four interviews of a nationally representative sample of adults with HIV who made a medical visit for regular care in early 1996. This article uses data from the second interview conducted between December 1996 and July 1997. The authors constructed analytical weights for each respondent so the 2,466 interviewees represented a population of 219,700.

RESULTS

Most adult medical patients with HIV rated their oral health as at least "good," but 12 percent (representing a population of 25,300) rated it as "poor." Xerostomia was the most commonly reported symptom (37 percent) to arise in the time since the previous interview. Twenty-nine percent had a dental benefit under Medicaid and 23 percent had private insurance. Eighteen percent had not revealed their HIV status to the dentist they usually saw.

CONCLUSIONS

National data on adult medical patients with HIV provide a context for local or convenience sample studies and can help give direction to public health and public policy programs directed to the oral health needs of this population.

CLINICAL IMPLICATIONS

The attitudes and beliefs of adult HIV patients should be taken into account in the creation of community health education programs and continuing education for dentists. Medicaid programs should include adult dental benefits.

Differences in Cause-Specific Mortality Between Latino and White Adults

BACKGROUND

Understanding differences in cause-specific mortality between Latinos and whites is important for targeting future public health interventions and research aimed at eliminating health disparities.

OBJECTIVES

We sought to determine the contribution of specific causes of death to Latino-white differences in mortality.

RESEARCH DESIGN

Using nationally representative data, we estimated cause-specific mortality risks, which were then used in a simulation model to estimate mortality events for a cohort of persons starting at age 25 and followed until death or age 75.

SUBJECTS

Subjects were 507,820 Latino and white adults, age 25 or older, who participated in the 1986-1994 National Health Interview Surveys.

MEASURES

Outcomes were years of potential life lost before age 75 from specific causes of death and age-specific mortality rate ratios for Latinos compared with whites.

RESULTS

Latinos had higher mortality rates than whites before age 45 and similar mortality rates at older ages. Latino women lost 315 (95% confidence interval [CI], 229-2423) more years of potential life (per 1000 persons before the age of 75) than white women and Latino men lost 595 (95% CI, 513-1675) more years than white men. For both men and women, whites lost substantially more years of potential life than Latinos from lung cancer. Homicide, diabetes, HIV, and liver disease contributed most to the excess years of potential life lost among Latino men, and diabetes and HIV contributed most to the excess years of potential life lost among Latino women.

CONCLUSIONS

To eliminate health disparities between Latinos and whites, future health policy and public health efforts should target diabetes, homicide, HIV, and liver disease among Latinos and lung cancer among whites.

Religiousness and Spirituality Among HIV-Infected Americans

PURPOSE

To describe the demographic and clinical factors associated with the importance of religiousness and spirituality among patients with human immunodeficiency virus (HIV) infection in the United States.

METHODS

Longitudinal study of a nationally representative cohort of 2266 patients receiving care for HIV infection surveyed in 1996 and again in 1998. Measures included 12 items assessing religious affiliation and attendance, the importance of religion and spirituality in life, and religious and spiritual practices. Multi-item religiousness and spirituality scales were constructed.

RESULTS

Eighty percent of respondents reported a religious affiliation. Sixty-five percent affirmed that religion and 85% that spirituality was "somewhat" or "very" important in their lives. A majority indicated that they "sometimes" or "often" rely on religious or spiritual means when making decisions (72%) or confronting problems (65%). Women, nonwhites, and older patients were more religious and spiritual. Residents of regions other than the western United States reported higher religiousness. High school graduates were more religious and spiritual than those with less education. Patients who did not report one of the risk factors assessed for HIV infection had higher religiousness scores than injection drug users (IDUs). Women, nonwhites other than Hispanics, patients older than 45 years of age compared to those between 18 and 34 years of age, and more educated patients reported higher spirituality. Clinical stage was not associated with religiousness or spirituality.

CONCLUSIONS

A large majority of HIV-infected patients in the United States affirm the importance of religiousness and spirituality. These findings support a comprehensive, humanistic approach to the care of HIV-infected patients.

Predictors and consequences of negative physician attitudes toward HIV-infected injection drug users

BACKGROUND

We evaluated physicians' training, experience, and practice characteristics and examined associations between their attitudes toward human immunodeficiency virus (HIV)-infected persons who are injection drug users (IDUs) and quality of care.

METHODS

Cross-sectional surveys were conducted among a probability sample of noninstitutionalized HIV-infected individuals in the United States and their main HIV care physicians. Physician and practice characteristics, training, HIV knowledge, experience, attitudes toward HIV-infected IDUs, stress levels, and satisfaction with practice were assessed. The main quality-of-care measures were patient exposure to highly active antiretroviral therapy, reported problems, satisfaction with care, unmet needs, and perceived access to care.

RESULTS

Nationally, 23.2% of HIV-infected patients had physicians with negative attitudes toward IDUs. Seeing more IDUs, having higher HIV treatment knowledge scores, and treating fewer patients per week were independently associated with more positive attitudes toward IDUs. Injection drug users who were cared for by physicians with negative attitudes had a significantly lower adjusted rate of exposure to highly active antiretroviral therapy by December 1996 (13.5%) than non-IDUs who were cared for by such physicians (36.1%) or IDUs who were cared for by physicians with positive attitudes (32.3%). Physician attitudes were not associated with other problems with care, satisfaction with care, unmet needs, or perceived access to care.

CONCLUSIONS

Negative attitudes may lead to less than optimal care for IDUs and other marginalized populations. Providing education or experience-based exercises or ensuring that clinicians have adequate time to deal with complex problems might result in better attitudes and higher quality of care.

Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses

BACKGROUND

Improving communication and collaboration among doctors and nurses can improve satisfaction among participants and improve patients' satisfaction and quality of care.

OBJECTIVE

To determine the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit.

METHODS

During a 2-year period, an intervention unit was created that differed from the control unit by the addition of a nurse practitioner to each inpatient medical team, the appointment of a hospitalist medical director, and the institution of daily multidisciplinary rounds. Surveys about communication and collaboration were administered to personnel in both units. Physicians were surveyed at the completion of each rotation on the unit; nurses, biannually.

RESULTS

Response rates for house staff (n = 111), attending physicians (n = 45), and nurses (n = 123) were 58%, 69%, and 91%, respectively. Physicians in the intervention group reported greater collaboration with nurses than did physicians in the control group (P < .001); the largest effect was among the residents. Physicians in the intervention group reported better collaboration with the nurse practitioners than with the staff nurses (P < .001). Physicians in the intervention group also reported better communication with fellow physicians than did physicians in the control group (P = .006). Nurses in both groups reported similar levels of communication (P = .59) and collaboration (P = .47) with physicians. Nurses in the intervention group reported better communication with nurse practitioners than with physicians (P < .001).

CONCLUSIONS

The multidisciplinary intervention resulted in better communication and collaboration among the participants.

A national study of the relationship of care site HIV specialization to early adoption of highly active antiretroviral therapy

BACKGROUND

Little is known about characteristics of organizations that predict early adoption of highly active antiretroviral therapy (HAART) for persons with HIV infection.

OBJECTIVES

To describe characteristics of sites where HIV care is provided and to assess site characteristics that predict early adoption of HAART.

DESIGN

Cross-sectional analysis of survey data from patients, HIV physicians, and medical directors.

PATIENTS AND SETTING

Participants in the HIV Cost and Services Utilization Study, a national probability sample of persons with HIV who received outpatient care in the continental United States during 1996.

MAIN OUTCOME MEASURE

Rates of exposure to HAART by December 1996.

RESULTS

Nationally, 79% of patients were treated at sites specializing in HIV care (HIV sites). Over 90% of patients were cared for by physicians who were experts in HIV care, either infectious disease specialists (46%) or general medicine experts (45%). Adjusted rates of exposure to HAART by December 1996 varied from 0.02 to 0.79 across sites (mean rate, 0.33). In multivariable models, HIV specialization (odds ratio [OR], 3.6; P < 0.001), total patient volume of more than 20,000 visits a year (OR, 2.1; P < 0.01), and educational level of the zip code in which the site was located (OR, 1.2 for each 10% increase in college education) were associated with higher rates of exposure to HAART. These effects persisted after adjustment for physician HIV expertise. Site effects were more important than physician effects in explaining rates of exposure to HAART.

CONCLUSION

In 1996 there were wide variations in rates of HAART use by site of care. Low-volume sites that do not specialize in HIV care should take measures to ensure that HIV expertise is available to their patients.

Effect of a Multidisciplinary Intervention on Communication and Collaboration Among Physicians and Nurses

• Background Improving communication and collaboration among doctors and nurses can improve satisfaction among participants and improve patients’ satisfaction and quality of care.

• Objective To determine the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit.

• Methods During a 2-year period, an intervention unit was created that differed from the control unit by the addition of a nurse practitioner to each inpatient medical team, the appointment of a hospitalist medical director, and the institution of daily multidisciplinary rounds. Surveys about communication and collaboration were administered to personnel in both units. Physicians were surveyed at the completion of each rotation on the unit; nurses, biannually.

• Results Response rates for house staff (n = 111), attending physicians (n = 45), and nurses (n = 123) were 58%, 69%, and 91%, respectively. Physicians in the intervention group reported greater collaboration with nurses than did physicians in the control group (P &lt; .001); the largest effect was among the residents. Physicians in the intervention group reported better collaboration with the nurse practitioners than with the staff nurses (P &lt; .001). Physicians in the intervention group also reported better communication with fellow physicians than did physicians in the control group (P = .006). Nurses in both groups reported similar levels of communication (P = .59) and collaboration (P = .47) with physicians. Nurses in the intervention group reported better communication with nurse practitioners than with physicians (P &lt; .001).

• Conclusions The multidisciplinary intervention resulted in better communication and collaboration among the participants.

Does racial concordance between HIV-positive patients and their physicians affect the time to receipt of protease inhibitors?

BACKGROUND

Compared to whites, African Americans have been found to have greater morbidity and mortality from HIV, partly due to their lower use of effective antiretroviral therapy. Why racial disparities in antiretroviral use exist is not completely understood. We examined whether racial concordance (patients and providers having the same race) affects the time of receipt of protease inhibitors.

METHODS

We analyzed data from a prospective, cohort study of a national probability sample of 1,241 adults receiving HIV care with linked data from 287 providers. We examined the association between patient-provider racial concordance and time from when the Food and Drug Administration approved the first protease inhibitor to the time when patients first received a protease inhibitor.

RESULTS

In our unadjusted model, white patients received protease inhibitors much earlier than African-American patients (median 277 days compared to 439 days; P < .0001). Adjusting for patient characteristics only, African-American patients with white providers received protease inhibitors significantly later than African-American patients with African-American providers (median 461 days vs. 342 days respectively; P < .001) and white patients with white providers (median 461 vs. 353 days respectively; P= .002). In this model, no difference was found between African-American patients with African-American providers and white patients with white providers (342 vs. 353 days respectively; P > .20). Adjusting for patients' trust in providers, as well as other patient and provider characteristics in subsequent models, did not account for these differences.

CONCLUSION

Patient-provider racial concordance was associated with time to receipt of protease inhibitor therapy for persons with HIV. Racial concordance should be addressed in programs, policies, and future racial and ethnic health disparity research.

Sociodemographic differences in access to care among Hispanic patients who are HIV infected in the United States

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.

The prevalence of antiretroviral drug resistance in the United States

BACKGROUND

Antiretroviral therapy has dramatically reduced the morbidity and mortality of infection due to HIV. The emergence of drug-resistant virus has limited the usefulness of many drugs.

OBJECTIVE

To determine the prevalence of HIV drug resistance in the population of adults receiving care in the United States.

DESIGN AND METHODS

HIV drug susceptibility assays were performed on plasma virus from a random sample representative of the 132500 HIV-infected American adults who had received medical care in early 1996 yet were viremic with > 500 copies/ml of HIV RNA in late 1998. A blood sample was obtained from 1797 patients who comprised a representative sample of the 208900 adults receiving urban care for HIV infection in early 1996 who survived to late 1998. The sampling procedure permitted weighting each evaluated patient to reflect demographic and other characteristics of the target population.

RESULTS

We estimated that 132500 (63%) of the target population had HIV viremia of > 500 copies/ml. Among viremic patients, an estimated 76% had resistance to one or more antiretroviral drugs. The odds of resistance were significantly higher in patients with a history of antiretroviral drug use, advanced HIV disease, higher plasma HIV viral load and lowest CD4 cell count by self-report.

CONCLUSIONS

The frequent selection for drug-resistant virus among viremic patients during the first 3 years of widespread use of potent antiretroviral combination therapy has significant implications for HIV treatment and transmission.

Delays and unmet need for health care among adult primary care patients in a restructured urban public health system

OBJECTIVES

We estimated the prevalence and determinants of delayed and unmet needs for medical care among patients in a restructured public health system.

METHODS

We conducted a stratified cross-sectional probability sample of primary care patients in the Los Angeles County Department of Health Services. Face-to-face interviews were conducted with 1819 adult patients in 6 languages. The response rate was 80%. The study sample was racially/ethnically diverse.

RESULTS

Thirty-three percent reported delaying needed medical care during the preceding 12 months; 25% reported an unmet need for care because of competing priorities; and 46% had either delayed or gone without care.

CONCLUSIONS

Barriers to needed health care continue to exist among patients receiving care through a large safety net system. Competing priorities for basic necessities and lack of insurance contribute importantly to unmet health care needs.

Racial and ethnic differences in patients' preferences for initial care by specialists

PURPOSE

To examine racial and ethnic differences in patients' preferences for initial care by specialists, and to determine whether trust in the physician and health beliefs account for these differences.

METHODS

We conducted a cross-sectional study of 646 patients in the waiting room of three academic-based internal medicine outpatient practices. We asked subjects about their preference to see their primary care provider or a specialist first regarding the actual health problem that had brought them to see their physician as well as regarding three hypothetical scenarios (2 weeks of new-onset exertional chest pain, 2 months of knee pain, and rash for 4 weeks). We examined the relation among patients' preference for initial care by a specialist and their demographic characteristics, global ratings of their primary care physician and health plan, trust in their primary care physician, and other health beliefs and attitudes.

RESULTS

Averaged for the three scenarios and actual health problem, 13% of patients preferred to see a specialist first. Adjusting for all other covariates, blacks (risk ratio [RR] = 0.55; 95% confidence interval [CI]: 0.20 to 0.92) and Asians (RR = 0.46; 95% CI: 0.19 to 0.75) were much less likely to prefer a specialist than were whites. Patients with less confidence in their primary care physician and greater certainty about needed tests and treatments were more likely to prefer a specialist. These variables, however, did not explain the difference in preference for specialist care among blacks, Asians, and whites.

CONCLUSION

Blacks and Asians are less likely than whites to prefer initial care by a specialist. Future studies should examine whether differences in preference for care lead minorities to underutilize appropriate specialty care or lead whites to overuse specialty care.

Symptom-based framework for assessing quality of HIV care

OBJECTIVE

To evaluate HIV quality of care using a symptom-based, patient-centered framework.

METHODS

An expert panel developed 13 quality indicators for three common symptoms: cough with fever and/or shortness of breath; severe or persistent diarrhea; and significant weight loss. A nationally representative probability sample of HIV-infected adults was interviewed between 1996 and 1997.

PARTICIPANTS

were asked about the presence and severity of HIV symptoms during the preceding 6 months, and care received. Variation in adherence to the indicators was assessed by symptom type and patient characteristics.

RESULTS

In all, 2864 (71%) patients completed interviews and 920 reported being at least moderately bothered with one of the three symptoms. Of these, 41, 74, and 65% of patients with a symptom of cough, weight loss, or diarrhea, respectively, reported receiving all indicated care. Performance was better for patients with more severe HIV, measured as a CD4 cell count <50 cells/microliter, compared with those with less severe HIV, measured as CD4 cell count >500 cells/microliter (43% versus 60%; P = 0.02). Uninsured patients had worse performance than Medicare patients (45% versus 62%; P = 0.04), but care did not differ by patient's age, gender, ethnicity, HIV risk factor, providers' HIV patient load, or region. Only CD4 count remained significantly associated with performance in the multivariate analyses.

CONCLUSIONS

Symptom-based quality indicators may provide a useful supplement to conventional measures. Patients with HIV reported substantial underuse of services for common, burdensome symptoms. Although adherence to quality indicators was better for patients with more advanced HIV disease, many still received suboptimal care. Vulnerable patient groups generally did not receive worse quality of care, suggesting that symptom-based measures of quality may measure domains that are distinct from those captured by conventional indicators.

Disparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients

BACKGROUND

Current HIV treatment guidelines recommend delaying antiretroviral therapy for nonadherent patients, which some fear may disproportionately affect certain populations and contribute to disparities in care.

OBJECTIVES

To examine the relationship of physician's attitude toward prescribing protease inhibitors (PIs) to nonadherent patients with disparities in PI use and with health outcomes.

DESIGN

Prospective cohort study.

PATIENTS AND SETTING

A national probability sample of HIV-infected adults in the United States and their health care providers was surveyed between January 1996 and January 1998. We analyzed data on 1717 patients eligible for PI treatment and the 367 providers who cared for them.

MEASUREMENTS

Providers' attitude toward prescribing PIs to nonadherent patients, time until patients' first receipt of PIs, mortality, and physical health status.

MAIN RESULTS

Eighty-nine percent of providers agreed that patient adherence is important in their decision to prescribe PIs (Selective) while 11% disagreed (Nonselective). Patients who had a Selective provider received PIs later than those with a Nonselective provider (P =.05). Adjusting for patient demographics and health characteristics and provider demographics, HIV knowledge, and experience, Latinos, women, and poor patients received PIs later if their provider had a Selective attitude but as soon as others if their provider had a Nonselective attitude. African-American patients received PIs later than whites, irrespective of their providers' prescribing attitude. Patients with Selective providers had similar odds of mortality than those with Nonselective providers (odds ratio, 1.1; 95% confidence interval, 0.6 to 2.0), but had slightly worse adjusted physical health status at follow-up (49.1 vs 50.4, respectively; P =.04), after controlling for baseline physical health status and other patient and provider covariates.

CONCLUSIONS

Most providers consider patient adherence an important factor in their decision to prescribe PIs. This attitude appears to account for the relatively later use of PI treatment among Latinos, women, and the poor. Given the rising HIV infection rates among minorities, women, and the poor, further investigation of this treatment strategy and its impact on HIV resistance and outcomes is warranted.

Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence

CONTEXT

Although political violence continues in parts of Central America, South America, and Mexico, little is known about its relationship to the health of Latino immigrants living in the United States.

OBJECTIVE

To determine (1) rates of exposure to political violence among Latino adult primary care patients who have immigrated to the United States from Central America, South America, and Mexico and its impact on mental health and health-related quality of life and (2) frequency of disclosure of political violence to primary care clinicians.

DESIGN, SETTING, AND PARTICIPANTS

Two-stage cluster design survey of a systematic sample of Latino immigrant adults in 3 community-based primary care clinics in Los Angeles, conducted from July 2001 to February 2002.

MAIN OUTCOME MEASURES

Reports of exposure to political violence in home country before immigrating to the United States and communication with clinicians about political violence; self-reported measures of health-related quality of life using the Medical Outcomes Study Short Form 36 (MOS SF-36); symptoms of depression, anxiety, and alcohol disorders using the Primary Care Evaluation of Mental Disorders (PRIME-MD); and symptoms of posttraumatic stress disorder (PTSD) using the PTSD Checklist-Civilian Version (PCL-C).

RESULTS

A total of 638 (69%) of 919 eligible patients participated. The nonresponse rates did not differ by age, sex, recruitment sites, or clinic sessions. In weighted analyses, 54% of participants reported political violence experiences in their home countries, including 8% who reported torture. Of those exposed to political violence, 36% had symptoms of depression and 18% had symptoms of PTSD vs 20% and 8%, respectively, among those not exposed to political violence. Controlling for age, sex, country, years lived in the United States, acculturation, income, health insurance status, and recruitment site in a subsample of 512 participants (56%), those who reported political violence exposure were more likely to meet symptom criteria for PTSD (adjusted odds ratio [AOR], 3.4; 95% confidence interval [CI], 1.4-8.4) and to have symptoms of depression (AOR, 2.8; 95% CI, 1.4-5.4) and symptoms of panic disorder (AOR, 4.8; 95% CI, 1.6-14.4) than participants not reporting political violence. Those exposed to political violence reported more chronic pain and role limitations due to physical problems, as well as worse physical functioning and lower perceptions of general health than those who were not exposed to political violence. Only 3% of the 267 patients who had experienced political violence reported ever telling a clinician about it after immigrating; none reported their current physician asking about political violence.

CONCLUSION

Latino immigrants in primary care in Los Angeles have a high prevalence of exposure to political violence before immigrating to the United States and associated impairments in mental health and health-related quality of life.

Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients

BACKGROUND

HIV-infected patients commonly use complementary and alternative medicine (CAM), but it is not known how often CAM is used as a complement or as a substitute for conventional HIV therapy.

OBJECTIVES

To evaluate the prevalence and factors associated with CAM use with potential for adverse effects and CAM substitution for conventional HIV medication.

DESIGN AND PARTICIPANTS

Cross-sectional survey of U.S. national probability sample of HIV-infected patients (2,466 adults) in care from December 1996 to July 1997.

MAIN OUTCOME VARIABLES

Any CAM use, CAM use with potential for adverse effects, and use of CAM as a substitute for conventional HIV therapy. Substitution was defined as replacement of some or all conventional HIV medications with CAM.

RESULTS

Fifty-three percent of patients had recently used at least one type of CAM. One quarter of patients used CAM with the potential for adverse effects, and one-third had not discussed such use with their health care provider. Patients with a greater desire for medical information and involvement in medical decision making and with a negative attitude toward antiretrovirals were more likely to use CAM. Three percent of patients substituted CAM for conventional HIV therapy. They were more likely to desire involvement in medical decision-making (odds ratio, 1.8; 95% confidence interval, 1.0-3.2) and to have a negative attitude toward antiretrovirals (odds ratio, 7.8; 95% confidence interval, 3.0-19.0).

CONCLUSIONS

Physicians should openly ask HIV-infected patients about CAM use to prevent adverse effects and to identify CAM substitution for conventional HIV therapy.

Use of alternative therapists among people in care for HIV in the United States

OBJECTIVES

This study examined the influence of sociodemographic, clinical, and attitudinal variables on the use of alternative therapists by people in care for HIV.

METHODS

Bivariate and multivariate analyses of baseline data from the nationally representative HIV Cost and Services Utilization Study were conducted.

RESULTS

Overall, 15.4% had used an alternative therapist, and among users, 53.9% had fewer than 5 visits in the past 6 months. Use was higher for people who were gay/lesbian, had incomes above 40,000 dollars, lived in the Northeast and West, were depressed, and wanted more information about and more decisionmaking involvement in their care. Among users, number of visits was associated with age, education, sexual orientation, insurance status, and CD4 count.

CONCLUSIONS

Among people receiving medical care for HIV, use of complementary care provided by alternative therapists is associated with several sociodemographic, clinical, and attitudinal variables. Evaluation of the coordination of provider-based alternative and standard medical care is needed.

Underdiagnosis of depression in HIV: who are we missing?

OBJECTIVE

To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV.

DESIGN

Cross-sectional survey.

PATIENTS/PARTICIPANTS

National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data.

MEASUREMENTS AND MAIN RESULTS

We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P <.05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P <.01) and those with >or=3 outpatient visits (P <.05) compared to <3 visits were less likely to have their depression diagnosis missed by providers.

CONCLUSIONS

Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients.