摘要：Objectives. This study compared the use of new antiretroviral treatments across sociodemographic subgroups during the 3 years after the introduction of these treatments and examined diffusion of the therapies over time. Methods. Merged surveillance and claims data were used to examine use of protease inhibitors and non-nucleoside reverse transcriptase inhibitors (PI/NNRTIs) among New Jersey Medicaid beneficiaries with AIDS. Results. In 1996, there were sharp disparities in use of PI/NNRTI therapy among racial minorities and injection drug users, even after control for other patient characteristics. These gaps had decreased by 1998. Higher PI/NNRTI treatment rates were also observed among beneficiaries enrolled in a statewide HIV/AIDS-specific home- and community-based Medicaid waiver program. Conclusions. Even within a population of individuals similar in regard to health coverage, there were substantial sociodemographic differences in use of PI/NNRTIs during the early years after their introduction. These differences narrowed as new treatments became standard. Participation in a case-managed Medicaid waiver program seems to be associated with a more appropriate pattern of use. These results suggest a need to address nonfinancial barriers to care. Studies of HIV care have often documented differential access to new drug therapies across sociodemographic subgroups. For example, early access to zidovudine, the first antiviral therapy for HIV disease, was found to be less prevalent among women, members of racial minorities, adolescents and young adults, active injection drug users, and the uninsured. 1 – 4 After the introduction of zidovudine, several years passed before rates of use across demographic subgroups converged. 1 , 5 Since early 1996, combination therapies that include new, more effective antiviral drugs—protease inhibitors (PI) and nonnucleoside reverse transcriptase inhibitors (NNRTI)—have become available for treatment of HIV infection. 6 Some studies suggest that during the years immediately after the introduction of protease inhibitors, women, racial minorities, and injection drug users were significantly less likely to use these new drug therapies. 7 – 11 Also, a handful of published papers—including those from the HIV Cost and Services Utilization Study (HCSUS), which involved a representative sample of the adult US population infected with HIV—have documented a rapid increase in the use of protease inhibitors. 8 , 10 , 12 , 13 In addition, some of these studies have examined diffusion of the new therapies among subgroups defined by sex, race, and other characteristics. 8 , 10 Although these studies have reported a tendency toward a decrease over time in racial and ethnic differences in use of antiretroviral regimens involving protease inhibitors, it has typically been found that African Americans and women continue to lag behind nonminority groups in use of such therapies. 8 , 10 However, the studies were unable to track recent changes in protease inhibitor use owing to data limitations. Messeri and colleagues explored the diffusion issue through 1997, 8 and the HCSUS addressed PI/NNRTI use only through January 1998. 10 In this article, we examine the determinants of PI/NNRTI use over time among persons with AIDS, using more recent data. We analyze claims data from 2089 adults with AIDS who received Medicaid benefits in New Jersey between January 1996 and December 1998. Such an analysis within a single payer source is critical because, despite financial eligibility, disadvantaged subpopulations may differ in their access to outpatient health care services. A number of studies have shown that among persons with AIDS, women, members of racial minorities, and injection drug users receive fewer medical care services than non-drug-using White men, even after insurance differences have been controlled. 2 , 14 , 15 Because New Jersey is among the top-ranking states in regard to number of AIDS cases, it is an important state in which to study this issue. 16 In addition, the state's HIV/AIDS registry data have been merged with Medicaid claims data, allowing for better identification of HIV-infected individuals (in contrast to diagnostic screening approaches to case identification used in other studies). 17 This study estimated crude and adjusted rates of PI/NNRTI use among HIV-infected Medicaid recipients in New Jersey. The objectives included comparing patterns of PI/NNRTI use across demographic subgroups (e.g., sex, race/ethnicity, risk group, and geographic residence), examining diffusion of use over time, and identifying correlates of PI/NNRTI use over time.
