May 20, 2002
In 1990, a clinical database was established at John Hopkins HIV Clinic designed to capture comprehensive longitudinal data on patients attending its clinical practice. The database includes demographic, psychosocial, and clinical information at entry to the practice and any subsequent changes in these variables during follow-up. Demographic and other variables on patients were kept if the patients were enrolled in the Johns Hopkins HIV Clinic from April 1, 1996, through March 31, 1999; had encounters in the system of at least 2 visits and for at least 90 days and had a CD4 count of = 500 cells/mm3 or fewer or an HIV-1 RNA load of >20,000 copies/mL or greater at their first visit. The goal was to include only patients who were potentially eligible for HAART under prevailing guidelines.
Demographic variables included age, sex, race/ethnicity, HIV risk behavior, level of education, and residence. Clinical variables were psychiatric diagnoses, CD4 cell count, HIV-1 RNA viral load, and prescribed antiretroviral therapies. Payer status was assessed through visit registration data. Uninsured patients were defined as those who present for care and have no insurance or have lost their Medical Assistance eligibility. Other, more detailed data on types of insurance were entered. About 12 percent of the patients were enrolled in clinical trials in which they received HAART therapy. Data from 959 HIV-infected patients were analyzed. The population was predominately male (70%), African-American (78%), and had intravenous drug use as the major risk factor of HIV (47%). HAART was received by 66 percent of patients. There were 163 patients (17%) who were commercial/privately insured; 278 (28%) were government insured, 247 (26%) were uninsured, and 271 (29%) were partially insured.
HAART was significantly less likely to be received by women, non-white patients, injection drug users, patients with less than a high school education, patients from Baltimore city, patients who do not have a psychiatric diagnosis, patients with a high CD4 count, and patients with a lower HIV-1 RNA load. Commercially/privately insured patients were more likely than Medicaid partially insured patients or uninsured patients to receive HAART. Medicaid and partially insured patients were more likely than uninsured patients to receive the regimen. Missed visits were more common among patients who did not receive HAART.
The data from the clinic indicate that early differences in HAART use have, however, narrowed over time. The disparities in receipt of HAART by insurers in 1996 and early 1997 in HCSUS and among the clinic patients were no longer present among the 1998-1999 patients. According to the authors, "This encouraging finding demonstrates that effective, yet expensive, medical care can become available to all patients if socioeconomic barriers are removed."