摘要：Objectives. We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women's Interagency HIV Study (WIHS). Methods. Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N = 1354). Results. Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not. Conclusions. These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS. The epidemic of HIV/AIDS among women reflects a convergence of medical and social policy issues—including race, substance use, and sexual behavior—that are difficult to disentangle and address. Since the introduction of highly active antiretroviral therapy (HAART) as the standard of care in 1996, mortality rates from AIDS and its complications have declined dramatically. 1 However, the decline in AIDS deaths between 1993 and 2001 occurred at a much slower rate among African American men and women than among White men and women. 2 One possible explanation for the slower rate of decline is differences in access to quality medical care. In addition, there is growing evidence of lower use of HAART by women of color compared with other women. 3 Shapiro et al. 4 analyzed data from the HIV Cost and Services Utilization Study, the only nationally representative study of US adults receiving care for HIV infection, and reported that African Americans were less likely than were Whites with similar CD4 counts to obtain combination drug therapy in 1998, 2 years after HAART became the standard of care for HIV infection. However, in a subsequent study that also analyzed HIV Cost and Services Utilization Study data, Cunningham et al. 5 reported that racial/ethnic identity was not associated with receipt of HAART when they used a series of nested multivariate models that adjusted for factors that had been found to explain race-associated effects in earlier analyses. In their final analytic model, only insurance coverage and CD4 count were statistically significant predictors of HAART use. At least 2 studies 3 , 6 have provided evidence that HIV-infected African American women are less likely than HIV-infected White women to receive HAART, and several national studies have indicated that African Americans fare worse than Whites on a number of recognized standards of HIV care. 4 , 5 , 7 The same studies have also documented significant disparities in HAART use among illicit drug users. These studies assessed the independent effects of race, illicit substance abuse, and insurance coverage on use of medical care by people with HIV/AIDS. Studies of HIV-infected women have reported mixed findings regarding the roles of race/ethnicity and substance use in receipt of HAART when insurance status is taken into account. Analyzing data from the Women's Interagency HIV Study (WIHS), Cohen et al. 3 and Cook et al. 6 reported that women who were either African American or illicit drug users were less likely to report using HAART than were their counterparts who were White or nondrug users, respectively. However, the studies' findings differed on how Hispanic women fared relative to White women and on the effects of insurance coverage on receipt of HAART. Although these studies have substantially contributed to understanding factors associated with receipt of HAART, considerable gaps in knowledge still exist. We investigated the hypothesis that the combination of race/ethnicity and insurance status represents a greater risk than either factor alone for nonuse of HAART and that the association is more complex than the simple “main” effects used in previous research. We believe that continuing to track patterns of HIV care and clinically indicated HAART use, in particular, is important for gauging progress in reducing disparities in care and for informing HIV treatment policies and clinical practices.
