The Effects of Discrimination & Distrust on Racial/Ethnic Disparities in Antiretroviral Therapy Adherence by HIV+ Patients Angela Thrasher, PhD, MPH University of California at San Francisco Jo Anne Earp, PhD Cathy Zimmer, PhD Carol Golin, MD University of North Carolina at Chapel Hill

AcademyHealth Experiences in Healthcare and Racial/Ethnic Disparities Racial/ethnic minority patients often report more difficult interactions with their providers than white patients Racial/ethnic minority patients often report more difficult interactions with their providers than white patients Experience of care may influence access, patterns of use, and healthcare outcomes Experience of care may influence access, patterns of use, and healthcare outcomes Underexamined contributor to racial/ethnic healthcare disparities Underexamined contributor to racial/ethnic healthcare disparities

AcademyHealth Potential Patient-Level Factors Discriminatory healthcare experiences Discriminatory healthcare experiences –Perception of poor interpersonal treatment attributed to stigmatized status(es) Healthcare provider distrust Healthcare provider distrust –Expectation that provider will act in patient’s best interest is not met Reported more often by racial/ethnic minority patients Reported more often by racial/ethnic minority patients

AcademyHealth Potential Patient-Level Factors Inverse association with treatment adherence Inverse association with treatment adherence Plausible effect on treatment-related attitudes and beliefs that affect adherence Plausible effect on treatment-related attitudes and beliefs that affect adherence

AcademyHealth Racial/Ethnic Minority Status and Antiretroviral Therapy Adherence Poor adherence is common among HIV+ patients Poor adherence is common among HIV+ patients Racial/ethnic minority status is inconsistently associated with poor adherence Racial/ethnic minority status is inconsistently associated with poor adherence Discrimination and distrust as potential mediators Discrimination and distrust as potential mediators

6 Conceptual Model Racial/ Ethnic Minority Status Discriminatory Healthcare Experiences Healthcare Provider Distrust Antiretroviral Therapy Attitudes and Beliefs Antiretroviral Therapy Adherence

AcademyHealth HIV Cost and Services Utilization Study HIV+ individuals over 18 yo receiving care outside of emergency depts, military, prisons HIV+ individuals over 18 yo receiving care outside of emergency depts, military, prisons Sampling strategies Sampling strategies –Urban: multi-stage random sampling –Rural: purposive sampling –Weights used to address clustering 3 waves of data collected 6 months apart (96-97) 3 waves of data collected 6 months apart (96-97)

AcademyHealth Sample Selection Wave 1 (n = 2864) Wave 2 (n = 2466) Wave 3 (n = 2267) Prescribed Antiretroviral Therapy (n = 1911) Not Prescribed Antiretroviral Therapy (n = 356, 16%) Died or Lost (n = 199, 8%) Died or Lost (n = 398, 14%)

AcademyHealth Attrition and Selection Biases Completed Waves 1-3 Completed Waves 1-3 –White –Not have an AIDS dx –No use of heroin or cocaine in past year –HIV exposure by heterosexual contact –Higher social support Prescribed Antiretroviral Therapy at Wave 3 Prescribed Antiretroviral Therapy at Wave 3 –Higher viral loads –Less healthcare provider distrust

AcademyHealth Methods Unadjusted bivariate associations Unadjusted bivariate associations Exploratory and confirmatory factor analyses Exploratory and confirmatory factor analyses Structural equation modeling (MPlus 3.11) Structural equation modeling (MPlus 3.11) –Fit indices –Add or delete paths to improve model fit

AcademyHealth Study Measures Construct # Items Alpha Mean † SD Discriminatory healthcare experiences * Healthcare provider distrust Psychological burden of medication Difficulty accessing medication Difficulty scheduling medication Weak medication efficacy beliefs Antiretroviral therapy adherence * Three indicators collected at Wave 1 and three at Wave 2. Indicators for all other measures were collected at Wave 3. † † The range is 1 – 4, except for antiretroviral therapy adherence, which is 1 – 7.

AcademyHealth Examples of Covariates Sociodemographic Sociodemographic –Age –Gender –Sexual orientation –Insurance status HIV-specific HIV-specific –AIDS diagnosis –Risk exposure –Number of medications Health Health –Self-reported physical and mental health –Illicit drug use –Depression symptoms Psychosocial Psychosocial –Adherence self-efficacy –Social support

AcademyHealth Sample Description *p <.001 * * * *

AcademyHealth Descriptive Statistics *p <.05 * *

15 Final Structural Model: Direct Effects Racial/ Ethnic Minority Status Healthcare Provider Distrust Discriminator y Healthcare Experiences Psychological Burden of Medication Difficulty Accessing Medication Difficulty Scheduling Medication Medication Efficacy Beliefs Antiretroviral Therapy Adherence

16 Final Structural Model: Indirect Effects Racial/ Ethnic Minority Status Healthcare Provider Distrust Discriminator y Healthcare Experiences Psychological Burden of Medication Difficulty Accessing Medication Difficulty Scheduling Medication Medication Efficacy Beliefs Antiretroviral Therapy Adherence

AcademyHealth Summary of Model R 2 (χ 2 = 40.48, df = 12, p =.000).49 Total effect of minority status b = -.20 (p <.001) Direct effect of minority status b = -.21 (p <.001) Model fit (CMINDF = 3.37, CFI =.97, TLI =.96, RMSEA =.04, WRMR =.1.40) Adequate - good

AcademyHealth Discussion Patient-level factors explained little of relationship between minority status and adherence Patient-level factors explained little of relationship between minority status and adherence Minority status as contextual factor? Minority status as contextual factor?

AcademyHealth Discussion Discrimination and distrust may subtly color HIV+ patients’ attitudes and beliefs about antiretroviral therapy, and thus adherence Discrimination and distrust may subtly color HIV+ patients’ attitudes and beliefs about antiretroviral therapy, and thus adherence Distrust as a protective factor? Distrust as a protective factor?

AcademyHealth Limitations Data collected 10 years ago Data collected 10 years ago Exposure vs. current experiences with discrimination Exposure vs. current experiences with discrimination Temporality of measures Temporality of measures

AcademyHealth Strengths and Significance Assessed direct and indirect effects Assessed direct and indirect effects Tested a potential mechanism of racial/ethnic disparities in healthcare Tested a potential mechanism of racial/ethnic disparities in healthcare

AcademyHealth Acknowledgements Barbara Turner Barbara Turner Giselle Corbie-Smith Giselle Corbie-Smith Robert DeVellis Robert DeVellis Sharon Christ Sharon Christ National Institute of Allergies and Infectious Diseases National Institute of Allergies and Infectious Diseases AHRQ/UNC Cecil G. Sheps Health Services Research Center AHRQ/UNC Cecil G. Sheps Health Services Research Center UNC Graduate School UNC Graduate School

Thank You