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The Impact of Competing Subsistence Needs and Barriers on Access to Medical Care for Persons With Human Immunodeficiency Virus Receiving Care in the United States

Cunningham, William E. MD, MPH*†; Andersen, Ronald M. PhD; Katz, Mitchell H. MD; Stein, Michael D. MD§; Turner, Barbara J. MD, MSEd; Crystal, Steve PhD#; Zierler, Sally DrPH, MPH, MEd**; Kuromiya, Kiyoshi††; Morton, Sally C. PhD§§; St. Clair, Patricia BS§§; Bozzette, Samuel A. MD, PhD§§¶¶; Shapiro, Martin F. MD, PhD*§§

Medical Care:
Original Articles
Abstract

Objectives. To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data.

Design. Survey of a nationally representative sample of 2,864 adults receiving HIV care.

Main Independent Variables. Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick.

Main Outcome Measures. Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale.

Results. More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access.

Conclusions. Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

Author Information

*From the Division of General Internal Medicine and Health Services Research, Department of Medicine, School of Medicine, University of California, Los Angeles, California.

From the Department of Health Services, School of Public Health, University of California, Los Angeles, California.

From the Department of Public Health, San Francisco, California.

§From the Division of General Internal Medicine, Rhode Island Hospital, Brown University, Providence, Rhode Island.

¶From the Center for Research in Medical Education and Health Care, Jefferson Medical College, Philadelphia, Pennsylvania.

#From the AIDS Research Group, Rutgers University Institute for Health, New Brunswick, New Jersey.

**From the Department of Community Health, Brown University, Providence, Rhode Island.

††From the Critical Path AIDS Project, Philadelphia, Pennsylvania.

§§From RAND, Health Sciences Program, Santa Monica, California.

¶¶From the Veterans Administration Medical Center, La Jolla, California.

All authors included in this paper are members of the HCSUS Consortium.

The HIV Cost and Services Utilization Study is being conducted under cooperative agreement HS08578 (M. F. Shapiro, PI; S. A. Bozzette, Co-PI) between RAND and the Agency for Health Care Policy and Research.

Substantial additional support for this agreement was provided by the Health Resources and Services Administration, the National Institute for Mental Health, and the National Institute for Drug Abuse.

The opinions expressed in this article represent those of the authors, and not necessarily the opinion of the Agency or the Foundation.

Dr. Cunningham was a Robert Wood Johnson Minority Medical Faculty Development Program fellow and is a Doris Duke Clinical Scientist.

Dr. Bozzette is a Health Services Research and Development Senior Research Associate of the Department of Veterans Affairs.

Address correspondence to: William E. Cunningham, MD, MPH, Room 31-254A, Center for Health Sciences, Department of Health Services, UCLA School of Public Health, 10833 Le Conte Ave., Los Angeles, CA 90095. E-mail: wcunning@medicine.medsch.ucla.edu

Received December 3, 1998; initial review completed March 5, 1999; accepted June 23, 1999.

© 1999 Lippincott Williams & Wilkins, Inc.