摘要：Objectives. We identified race-associated differences in survival among HIV-positive US veterans to examine possible etiologies for these differences. Methods. We used national administrative data to compare survival by race and used data from the Veterans Aging Cohort 3-Site Study (VACS 3) to compare patients’ health status, clinical management, and adherence to medication by race. Results. Nationally, minority veterans had higher mortality rates than did white veterans with HIV. Minority veterans had poorer health than white veterans with HIV. No significant differences were found in clinical management or adherence. Conclusions. HIV-positive minority veterans experience poorer survival than white veterans. This difference may derive from differences in comorbidities and in the severity of illness of HIV-related disease. Racial disparities in processes of care and health outcomes are of growing concern in the United States. Despite improvement in overall health, disparities persist between minority and White patients in the burden of illness and death experienced. 1 A major challenge for the reduction and eventual elimination of racial disparities is understanding their etiologies. Possible etiologies to consider include severity of the patient’s HIV and comorbid illness at first presentation for care, the clinical services received, and the patient’s level of participation in treatment. Veterans receiving treatment for HIV infection represent a unique and scientifically important group for the study of racial disparities in health care. First, the Department of Veterans Affairs (VA) Healthcare System provides an opportunity to study racial disparities in health without having to control for health insurance status, because all veterans have essentially the same level of health insurance coverage. 2 Second, comprehensive data on diagnoses and survival are available at the national level, which provides a dataset large enough to allow observation of racial disparities in survival and to allow measurement of their magnitude. Third, veterans in care are predominantly minority patients with lower-than-average incomes. 3 As such, veterans with HIV represent an especially vulnerable population. Fourth, since the advent of highly active antiretroviral therapy (HAART), outcomes in those with HIV are highly dependent on the processes of care (access to HAART and prophylaxis for opportunistic infection). 4 Finally, by use of in-depth clinical data available from the Veterans Aging Cohort 3-Site Study (VACS 3), it becomes possible to assess a patient’s baseline severity of HIV and comorbid illness and HIV-related medication use and adherence and to determine whether these variables also vary by race. We used national VA administrative data to examine differences in survival by race in HIV-positive veterans. We then used in-depth clinical data from VACS 3 to explore explanations for racial disparities in survival. Potential etiologies examined included health status at study entry, use of clinic services, clinical management, and adherence to HIV-related medications.
