Does Access to Health Care Impact Survival Time After Diagnosis of AIDS?

Differences in survival time of HIV-infected persons are often attributed to differences in access to health care. While this explanation is logical and supported for other disease processes, there is little evidence in the literature to support the conclusion that better access to health care improves survival probability in people with AIDS. It is important to study the factors that give rise to differences in survival time in the United States so that survival can continue to improve. The recent survival gains, which are often associated with newly available antiretroviral drugs, differ significantly among blacks, whites, men and women. If the factors responsible for these differences can be determined, they may then be modified.

In this article, authors examine perceived access to health care and utilization of health services and their associations with survival after AIDS, controlling for highly active antiretroviral therapy (HAART) status. The authors hypothesized that indicators of access to care and health care (both perceived access to care and health care utilization) were significantly associated with survival.

This study was conducted under the auspices of the Michigan Department of Community Health's HIV/AIDS Surveillance Section, located in Detroit. The databases from two surveillance studies were matched -- the Adult/Adolescent Spectrum of HIV Disease (ASD) project, and the Supplement to HIV and AIDS Surveillance (SHAS) project. Both ASD and SHAS are ongoing multi-site projects located throughout the United States. This study examines data from the two Detroit sites. Candidates for inclusion in this project were at least age 18 at the time of their SHAS interview, had completed a SHAS interview, and had an ASD record.

For this study, participants were divided into two categories, those who were not prescribed HAART and those who have ever been prescribed HAART. Every person in this study fits into one of these two mutually exclusive categories. The health outcome examined was survival time. For the purpose of obtaining a relatively consistent beginning point for each person, survival was measured from the date a person first met the criteria for AIDS to the time of death. Of the 1,550 participants included in the ASD/SHAS matched database between January 1990 and December 1999, this study included the 752 people who met the definition for AIDS, and for whom complete data were available for the variables examined. Approximately 35 percent of participants had received HAART, 72 were black, 78 percent were male, and 54 percent were men who have sex with men.

The authors examined the association between survival after AIDS and indicators of perceived access to health care and utilization of health services. The authors observed that the indicators for utilization of health care and race were significantly associated with survival after AIDS, but that sex, mode of transmission, and perceived access to health care were not significantly associated with survival in the study population. These results affirm the hypothesis posed by other researchers that utilization of health care services was an underlying source of differences in survival previously attributed to race, sex, or mode of transmission. HAART was a significant predictor of survival in both models.

Consistent with the authors' findings, other studies have shown that even among individuals within the health care system, a regular source of health care increases survival time for people living with AIDS. "It is crucial to provide HIV-infected populations with tools that will enable them to adequately access a regular source of health care in a way that will most benefit their health," the authors concluded.

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