Moore R D, Stanton D, Gopalan R, Chaisson R E
Johns Hopkins University School of Medicine, Baltimore, MD 21205.
N Engl J Med. 1994 Mar 17;330(11):763-8. doi: 10.1056/NEJM199403173301107.
Guidelines for drug therapy in human immunodeficiency virus (HIV) disease are based primarily on the stage of the disease. To determine whether sociodemographic characteristics of patients influence drug therapy in practice, we analyzed the use of antiretroviral therapy and prophylactic therapy for Pneumocystis carinii pneumonia (PCP) in an urban population infected with HIV.
All patients presenting for the first time to our HIV clinic from March 1990 through December 1992 were enrolled. Data on sociodemographic and clinical variables and on drug use were collected at the time of presentation and after six months. We asked whether patients with CD4+ cell counts of 500 or less per cubic millimeter were receiving antiretroviral therapy at the time of presentation, and whether patients with CD4+ cell counts of 200 or less per cubic millimeter were receiving PCP prophylaxis.
Among the 838 patients enrolled, 656 (79 percent) were blacks, 167 (20 percent) were non-Hispanic whites, and 15 (2 percent) were Asian or Hispanic descent or were not racially classified. There were no racial differences in the stage of HIV disease at the time of presentation. However, there were racial disparities in the receipt of antiretroviral therapy: 63 percent of eligible whites but only 48 percent of eligible blacks received such therapy (P = 0.003). PCP prophylaxis was received by 82 percent of eligible whites but only 58 percent of eligible blacks (P < 0.001). There were no significant differences in the receipt of drug therapy with respect to age, sex, mode of HIV transmission, type of insurance, income, education, or place of residence. In a logistic-regression analysis, race was the feature most strongly associated with the receipt of drug therapy. When blacks were compared with whites, the adjusted relative odds were 0.59 (95 percent confidence interval, 0.38 to 0.93) for the receipt of an antiretroviral agent and 0.27 (95 percent confidence interval, 0.13 to 0.56) for the receipt of PCP prophylaxis.
Among patients infected with HIV, blacks were significantly less likely than whites to have received antiretroviral therapy or PCP prophylaxis when they were first referred to an HIV clinic. This disparity suggests a need for culturally specific interventions to ensure uniform access to care, including drug therapy, and uniform standards of care.
人类免疫缺陷病毒（HIV）疾病的药物治疗指南主要基于疾病阶段。为了确定患者的社会人口学特征在实际中是否会影响药物治疗，我们分析了城市中感染HIV人群的抗逆转录病毒治疗及卡氏肺孢子虫肺炎（PCP）预防性治疗的使用情况。
纳入1990年3月至1992年12月首次到我们HIV诊所就诊的所有患者。在就诊时及6个月后收集社会人口学和临床变量以及药物使用的数据。我们询问每立方毫米CD4+细胞计数为500或更少的患者在就诊时是否接受抗逆转录病毒治疗，以及每立方毫米CD4+细胞计数为200或更少的患者是否接受PCP预防治疗。
在纳入的838例患者中，656例（79%）为黑人，167例（20%）为非西班牙裔白人，15例（2%）为亚裔或西班牙裔血统或未进行种族分类。就诊时HIV疾病阶段不存在种族差异。然而，在接受抗逆转录病毒治疗方面存在种族差异：63%符合条件的白人接受了此类治疗，而符合条件的黑人中只有48%接受了治疗（P = 0.003）。82%符合条件的白人接受了PCP预防治疗，而符合条件的黑人中只有58%接受了治疗（P < 0.001）。在接受药物治疗方面，年龄、性别、HIV传播方式、保险类型、收入、教育程度或居住地点不存在显著差异。在逻辑回归分析中，种族是与接受药物治疗最密切相关的特征。将黑人与白人相比，接受抗逆转录病毒药物的调整后相对比值为0.59（95%置信区间，0.38至0.93），接受PCP预防治疗的调整后相对比值为0.27（95%置信区间，0.13至0.56）。
在感染HIV的患者中，首次转诊至HIV诊所时，黑人接受抗逆转录病毒治疗或PCP预防治疗的可能性显著低于白人。这种差异表明需要采取针对不同文化的干预措施，以确保包括药物治疗在内的医疗服务可及性统一以及医疗服务标准统一。
