摘要：Objectives . This study examined longitudinal trends in use of highly active antiretroviral therapy (HAART) among a cohort of HIV-positive participants in the Women's Interagency HIV Study. Methods . Beginning in 1994, 1690 HIV-positive women reported detailed information about their use of antiretroviral therapy at 6-month study visits. Multivariate logistic and Cox regression analyses were used to estimate the likelihood of antiretroviral therapy and HAART use among women with study visits preceding and following HAART availability. Results . Before the availability of HAART, the cohort's likelihood of any antiretroviral therapy use was associated with clinical indicators (CD4 count, viral load, symptom presence) as well as behavioral factors (abstaining from drug and alcohol use, participating in clinical trials). After HAART became commercially available, newly emerging predictors included college education, private insurance, absence of injection drug use history, and not being African American. Conclusions . After the penetration of HAART into this cohort, additional differences emerged between HAART users and nonusers. These findings can inform public health efforts to enhance women's access to the most effective types of therapy. The use of highly active antiretroviral therapy (HAART) for the treatment of HIV/AIDS has prolonged life and revolutionized patient care. 1 However, questions remain about who does and does not have access to this latest and most potent antiretroviral therapy. Early studies showed that women were less likely than men to use zidovudine and initiated its use later in the course of their HIV disease. 2– 5 More recent studies comparing men's and women's use of HAART confirmed these earlier findings. 6, 7 Women also are underrepresented in HIV/AIDS clinical trials; they are less knowledgeable than HIV-positive men about the latest antiretroviral drug therapies, less aware of their eligibility to participate in such trials, and less likely to be recruited into such studies by their medical providers. 8– 10 Additional research has revealed significantly lower rates of use of zidovudine among members of racial and ethnic minorities, especially African Americans, 11, 12 as well as less use of protease inhibitors and nonnucleoside reverse transcriptase inhibitors (NNRTIs). 1, 6 Moreover, several studies have revealed disproportionately lower rates of antiretroviral therapy use among current or past drug or alcohol users, 2, 4, 9 especially those with a history of injection drug use. 13, 14 Poverty and other resource constraints have been associated as well with a lower likelihood of use. 15, 16 Other factors appear to enhance rather than hinder access to antiretroviral therapy for HIV. Several studies have shown that having health insurance coverage (vs being uninsured) increases the likelihood of use of combination antiretroviral therapy. 1, 6 In addition, having a college education appears to be positively associated with use of both earlier forms of antiretroviral therapy 17 and the latest multidrug regimens. 1 Finally, given guidelines recommending the use of HAART among individuals at certain CD4 and viral load levels, 18 it is not surprising that patients with CD4 cell counts below 500 are significantly more likely to be receiving combination antiretroviral therapy. 6, 13 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, a multicenter investigation of the natural history of HIV disease in women. 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 do and do not have access to these multidrug regimens. Also needed is a better understanding of how predictors such as education, ethnicity, and substance abuse influence access among HIV-positive women. To explore these issues, this study addressed 4 major research questions: (1) What were the predictors of antiretroviral therapy use among a cohort of HIV-positive women in the pre-HAART era? (2) After the introduction of HAART, what proportions of the cohort members reported HAART use as well as any use of antiretroviral therapy? (3) What was the pattern of HAART penetration into the cohort over time as protease inhibitors and NNRTIs became available? and (4) What factors were significantly associated with HAART use, and were they different from those influencing the cohort's earlier use of antiretroviral therapy?
