Terry T. Nakazono

Violence victimization after HIV infection in a US probability sample of adult patients in primary care.

OBJECTIVES This study estimated the proportion of HIV-infected adults who have been assaulted by a partner or someone important to them since their HIV diagnosis and the extent to which they reported HIV-seropositive status as a cause of the violence. METHODS Study participants were from a nationally representative probability sample of 2864 HIV-infected adults who were receiving medical care and were enrolled in the HIV Costs and Service Utilization Study. All interviews (91% in person, 9% by telephone) were conducted with computer-assisted personal interviewing instruments. Interviews began in January 1996 and ended 15 months later. RESULTS Overall, 20.5% of the women, 11.5% of the men who reported having sex with men, and 7.5% of the heterosexual men reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes. CONCLUSIONS HIV-related care is an appropriate setting for routine assessment of violence. Programs to cross-train staff in antiviolence agencies and HIV care facilities need to be developed for men and women with HIV infection.

Prevalence and predictors of Highly active antiretroviral therapy use in patients with HIV infection in the United States

Background: Highly active antiretroviral therapy (HAART) became standard for HIV in 1996. Studies at that time showed that most people infected with HIV had initiated HAART, but that members of minority groups and poor people had lower HAART use. It is not known whether high levels of HAART use have been sustained or whether socioeconomic and racial disparities have diminished over time. Objectives: To determine the proportion of patients who had received and were receiving HAART by January 1998, and to evaluate predictors of HAART receipt. Design and Participants: Prospective cohort study of a national probability sample of 2267 adults receiving HIV care who completed baseline, first follow‐up, and second follow‐up interviews from January 1996 to January 1998. Main outcome variables: Proportion currently using HAART at second follow‐up (August 1997 to January 1998), contrasted with the cumulative proportions using HAART at any time before January 1998 and before December 1996. Analyses: Bivariate and multiple logistic regression analysis of population characteristics predicting current use of HAART at the time of the second follow‐up interview. Results: The proportion of patients ever having received HAART increased from 37% in December 1996 to 71% by January 1998, but only 53% of people were receiving HAART at the time of the second follow‐up interview. Differences between sociodemographic groups in ever using HAART narrowed after 1996. In bivariate analysis, several groups remained significantly less likely to be using HAART at the time of the second follow‐up interview: blacks, male and female drug users, female heterosexuals, people with less education, those uninsured and insured by Medicaid, those in the Northeast, and those with CD4 counts of ≥500 cells/&mgr;l (all p < .05). Using multiple logistic regression analysis, low CD4 count (for CD4 <50 cells/&mgr;l: odds ratio [OR], 3.20; p < .001) remained a significant predictor of current HAART use at the time of the second follow‐up interview, but lack of insurance (OR, 0.71; p < .05) predicted not receiving HAART. Conclusions: The proportion of persons under HIV care in the United States who had ever received HAART increased to over 70% of the affected population by January 1998 and the disparities in use between groups narrowed but did not disappear. However, nearly half of those eligible for HAART according to the U.S. Department of Health and Human Services guidelines were not actually receiving it nearly 2 years after these medications were first introduced. Strategies to promote the initiation and continuation of HAART are needed for those without contraindications and those who can tolerate it.

Oral Health Beliefs in Diverse Populations

Using data from population-based samples of adults participating in the ICS-II USA study, and using principal components analysis, we constructed oral health belief measures corresponding to the Health Belief Model (HBM) dimensions. Tests of validity and reliability were performed. Scales measuring perceived benefit of preventive practices and seriousness of oral disease had the highest validity and reliability. We used multiple regression analysis to examine sociodemographic predictors of perceived benefits of preventive practices. Race-ethnicity and age cohort were significant predictors among Baltimore and San Antonio adults. White adults and middle-aged persons in both research locations were more likely to believe in the benefit of preventive practices. Female gender, higher educational attainment, and better self-rated health were significant indicators of more positive oral health beliefs in every research location. Results also characterize persons who place lower value on preventive practices (i.e., males, less-educated persons, and those reporting poorer self-rated health). The design of effective dental public health messages and outreach efforts requires an analysis of the individuals health orientation and the factors influencing oral health beliefs. Oral health education interventions designed to improve health beliefs should contain an evaluation component for assessing the impact of education on health practices and oral health status.

Role of community risk factors and resources on breast carcinoma stage at diagnosis

The current study investigated the individual and community determinants of breast carcinoma stage at diagnosis (BCSAD) using multiple data sources merged with cancer registry data. The literature review yielded 5 studies that analyzed cancer registry data merged with community‐level variables (1995–2004).

Screening for cervical cancer in HIV-infected women receiving care in the United States.

Objective: We examined the sociodemographic, clinical and provider factors associated with screening for cervical cancer among HIV‐infected women. Methods: We studied a national sample representing 43,490 women receiving treatment of HIV infection who completed first follow‐up surveys of the HIV Cost and Service Utilization Study (HCSUS). All women were asked, “In the past 12 months, have you had a Pap test?” Women reporting an abnormal Pap test result were asked whether they had been told antibiotics could cure abnormal cells, and whether they were scheduled for another Pap test or for a colposcopy within 3 months. Results: Of the population represented, 81% had had a Pap test in the past 12 months. Women who reported having a gynecologist and primary care physician at the same clinical site were almost twice as likely (odds ratio, 1.9; 95% confidence interval, 1.3‐3.0) as other women to report Pap testing. Among women who reported abnormal Pap test results and were not told antibiotics could cure abnormal cells, 95% were scheduled for a repeat Pap test or colposcopy, but 15% of the women had not received their repeat Pap test or colposcopy. Conclusion: Although Pap test rates and appropriate referral for abnormal findings were high among HIV‐tested women, many women with initially abnormal Pap test results did not actually receive follow‐up Pap testing or colposcopy. Providing gynecologic care at the same site as primary HIV care would likely improve delivery of needed gynecologic care for women.

Access to Medical Care Reported by Asians and Pacific Islanders in a West Coast Physician Group Association

This study examines access to medical care for Asians and Pacific Islanders in the United States, using a survey of patients receiving care provided by a physician group practice association concentrated on the West Coast. Asians and Pacific Islanders who had used their health plan in the past year had worse access to health care than whites, blacks, Hispanics, and Native American or other ethnicities. The odds that Asians reported that they had adequate access ranged from about one quarter to three quarters that of whites, depending on the measure. Cultural differences and associated communication problems may explain the access problems experienced by Asians. Interventions need to be developed to address the problems with access to services, and better translation services may play an important role in improving access to care for Asians. Future studies need to clarify why Asians were more vulnerable to the access problems examined than other ethnic groups that might experience similar barriers.

The effect of hospital experience on mortality among patients hospitalized with acquired immunodeficiency syndrome in California

BACKGROUND Several studies in the 1980s suggested that mortality rates for patients hospitalized with the acquired immunodeficiency syndrome (AIDS) were lower in hospitals that cared for greater numbers of AIDS patients. We sought to determine whether this observation persisted in the mid-1990s in California. SUBJECTS AND METHODS We performed an analysis of hospital discharge data for 7,901 adults discharged with human immunodeficiency virus (HIV) or AIDS-related diagnoses from all acute care hospitals (n = 333) in California during 1994. The main outcome measure was in-hospital mortality, adjusted for severity of illness, comorbidity, prior hospitalizations, and other patient and hospital characteristics. RESULTS Among 7,901 persons hospitalized with AIDS, the unadjusted inpatient mortality was 9.0%. The adjusted mortality rate varied significantly (P <0.0001) from 12.4% among institutions with the lowest quartile of AIDS experience to 10.3%, 6.3%, and 7.6% by quartile of greater AIDS experience. Increasing severity of illness, comorbidity, and previous hospitalizations were also significant predictors of increased mortality. Sex, race, and insurance status were not associated with hospital mortality. CONCLUSIONS Hospital mortality for AIDS patients was greater among less experienced hospitals. The difference in mortality rate was equivalent to more than four additional deaths per 100 patients with AIDS admitted to the least experienced hospitals. This finding was not explained by severity of illness, comorbidity, or other case-mix variables.

Evaluating the Effect of Usual Source of Dental Care on Access to Dental Services: Comparisons among Diverse Populations

Data collected from the International Collaborative Study of Oral Health Outcomes USA (ICS-II) research locations were used to evaluate the relationship between having a usual source of dental care (USDC) and access to dental services. The robustness of the USDC effect after reducing simultaneity bias was tested in the population-based samples using sensitivity analysis. Logistic regression results provided evidence that USDC was the strongest and most consistent predictor of a dental visit in the past 12 months regardless of geographic location, dental care delivery system, or cultural diversity of the population. Even after removing cases that had a USDC for less than 1 or 2 years, the effect remained. From a policy perspective, USDC remains critical to understanding and explaining dental care utilization patterns. The findings suggest the need for designing interventions to increase the availability of a regular provider among vulnerable populations.

Effect of Violence on Utilization of Services and Access to Care in Persons with HIV

We analyzed the HIV Costs and Service Utilization Study data to determine the association of violence, assessed at baseline, with utilization of and access to health care at follow-up, among gay/bisexual male, heterosexual female, and heterosexual male HIV/AIDS patients. In multivariate analyses, male gay/bisexual violence victims had increased odds of reporting emergency department visits (odds ratio [OR], 1.74; 95% confidence interval [95% CI], 1.20 to 2.52), going without needed medical care because of expense (OR, 1.83; 95% CI, 1.06 to 3.18), and having poor ability to access medical specialists (OR, 1.96; 95% CI, 1.05 to 3.67). Further research is required to understand the association of violence with health care among gay/bisexual men with HIV/AIDS.

Do Black and White Adults Use the Same Sources of Information about Aids Prevention

Although AIDS prevention campaigns need to target population segments that are at highest risk to be effective, little is known about how various sources of AIDS information vary by race, education, and age. To determine the most common communication channels for AIDS information reported by Blacks and Whites, the authors interviewed 1,769 adults in Baltimore, Maryland, to obtain data on nine common sources of information about AIDS and analyzed their reports by race, age, and education. Television and newspapers were the most common sources but varied little across groups. National and local public health agencies, as well as medical doctors and dentists, were more commonly reported by Blacks than by Whites. Religious organizations were much more commonly reported by Blacks than by Whites. Public health organizations working collaboratively with religious organizations and health care providers might be more effective in developing AIDS prevention strategies than has been considered previously.