Use of Highly Active Antiretroviral Therapy in a Cohort of HIV-Seropositive Women

Highly active antiretroviral therapy (HAART) has prolonged life and revolutionized care for patients with HIV/AIDS. However, questions remain about who does and does not have access to HAART. Previous studies have found women underrepresented in HIV/AIDS clinical trials; less knowledgeable than HIV-positive men about the latest antiretroviral therapies; less aware of their eligibility to participate in such trials; and less likely to be recruited for studies by their medical providers.

The purpose of this study was to examine longitudinal trends of antiretroviral therapy use in a cohort of HIV-positive women enrolled in the Women's Interagency HIV Study (WIHS). While previous studies have indicated that women, members of minority groups and other populations of disadvantaged individuals are less likely to receive the most potent antiretroviral therapy, very little is known about which groups of women have access to these regimens. Also needed is a better understanding of how predictors such as education, ethnicity and substance abuse influence access among HIV-positive women. The six WIHS sites are Chicago, Los Angeles, San Francisco, Brooklyn, the Bronx and Washington, D.C.

Examined in this study were 1,690 women who met inclusion criteria. Participants had a median age of 36; 57 percent were African-American; 24 percent were Hispanic/Latina; 19 percent were white. While 41 percent reported a history of injection drug use at their initial visit, only 11 percent reported current drug use. Seventy-four percent of the women reported some type of public health insurance coverage; 12 percent had private insurance coverage; and 14 percent reported no coverage. Fifty-three percent had clinical symptoms related to HIV/AIDS.

In their analysis of patients' use of drug therapy, the researchers identified a number of factors associated with the likelihood of reports of HAART use, after adjustment for the clinical laboratory markers CD4 and viral load. African-American women were less likely to report taking HAART, suggesting potential benefits from special outreach and medical education efforts for this group. Women with histories of injection drug use were also less likely to report HAART use, as were those with recent use of alcohol and street drugs. Such women may be less likely to be offered these therapies because of physicians' perceptions that they are poor risks for adherence, even though they may have discontinued using, or their current use may not preclude medical compliance. Alternatively, these women may have been offered HAART but declined it.

Study participants with private health insurance were significantly more likely to report HAART use, suggesting that women without private health insurance coverage may have reduced access to the most effective treatments for HIV. Women with previous experience in clinical trials were more likely to report HAART use.

In the pre-HAART era, aside from clinical indicators, use of therapy was predicted by a woman's current drug or alcohol use and her experience in previous clinical trials. Different predictors emerged, however, after HAART penetrated this cohort. Given the complexity of regimens, their expense and their reliance on near-perfect adherence for efficacy, the authors report that it is not surprising that new variables emerged, including education, private insurance coverage, absence of drug or alcohol use, and non-African-American racial/ethnic status.

"The challenge residing in this knowledge is that of ensuring that use of HAART is not restricted to women from certain racial/ethnic groups or educational backgrounds or to those with certain types of health insurance coverage or drug use histories. Efforts are clearly called for to educate physicians about the vulnerability of disadvantaged groups of women in regard to receiving less effective HIV therapies. This includes increasing physicians' sensitivity to patients differing cultural beliefs about Western medicine and their previous antiretroviral therapy experiences, as well as the need to involve women's families and significant others in education about HAART," the authors wrote.

"Similarly, intensive and sensitive efforts to educate women about available therapies can help them make informed decisions about whether and when to initiate HAART regimens. This should include efforts that address the concerns of patients who are skeptical about the value of HAART and focus on accommodating treatment preferences, especially those of African Americans, who according to previous research are less likely to express their treatment preferences to physicians."

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