BLACK WOMEN ACCOUNT FOR a greater proportion (69%) of US human immunodeficiency virus (HIV) diagnoses than do women of all other racial or ethnic groups.1,2 Black women who are sexually transmitted disease (STD) clinic patients have higher HIV risk deriving from higher prevalences of HIV among STD patients relative to the general public,3 disproportionate rates of HIV infection among blacks,4 and sexual network patterns that may exacerbate black women’s risk for heterosexually acquiring HIV.5
Although routinization of HIV testing is necessary to improve early HIV diagnosis, some proportion of patients declines the tests, and prevalence of undiagnosed infection remains high among decliners.6 Therefore, improving acceptance of readily available testing is necessary to increase the proportions of HIV-infected persons who are diagnosed and begin treatment early.
One factor that may influence rates of clinic-based HIV diagnosis is patient-provider racial concordance. Although findings are mixed, most suggest black patients may have better clinical experiences with patient-provider racial concordance, i.e., seeing providers perceived as black (concordance from henceforward). However, this literature disproportionately focuses on chronic disease and general health care-related outcomes7–10; little is known about concordance and HIV-related outcomes. One cohort study examining this issue among HIV-positive patients found that black patients under the care of white doctors received protease inhibitors on average 119 days later than black patients under the care of black doctors (P <0.001).11
Although HIV prevention efforts increasingly stress providing routine HIV screening to persons who present for clinical care, we are aware of no research that examines relationships between patient-provider racial concordance and uptake of readily available HIV antibody tests. The purpose of this study was to determine whether concordance is associated with black women STD patients obtaining enzyme-linked immunosorbent assay (ELISA) HIV antibody tests, which are routinely offered to all patients presenting for STD diagnosis at many public STD clinics. We hypothesized that concordance would be associated with higher odds of testing.
This cross-sectional secondary analysis was part of a multilevel project examining social determinants of HIV testing among black STD patients (N = 413; 56% women). The research was conducted at a county public STD clinic in a southeastern US city. Although the number of clinicians seeing patients fluctuated, it did not exceed 10 at any given time during the study period. All full-time clinicians were women and approximately 25% were black. Providers see patients on a walk-in, first-come, first-served basis and offer all patients newly seeking STD diagnosis routine ELISA HIV antibody tests with confirmatory Western blot as appropriate. Patients are assigned numeric codes on sign-in by which they are called to be seen by the next available clinician. The study received full approval from the University of North Carolina School of Public Health Institutional Review Board.
Patient eligibility criteria for the parent study were ≥18 years old, self-reported black race, and newly seeking STD diagnosis or screening at the public STD clinic. The parent study’s sample recruitment and key measures are described elsewhere.12 Additional measures on concordance were assessed for every participant enrolled during the second half of the data collection period. Demographic and testing behavior did not vary between participants for whom data on concordance was not collected and the 250 outpatients (55% women) for whom it was collected. Of these, men were excluded in the current study as exploratory analyses indicated factors associated with testing may vary by gender. Final sample size for this study was N = 137 black women presenting for STD diagnosis or screening between April and June 2003.
Patient eligibility was established on sign-in for care. Research staff administered informed consent and participants self-administered the paper questionnaires while seated in the clinic lobby. Questionnaires were quantitative with close-ended items. To ensure anonymity, testing behavior ascertainment was masked to questionnaire data collection. Participants’ names were removed before analyses.
We defined HIV test uptake as visit-specific ELISA and ascertained it from the clinic laboratory’s daily log of diagnostic tests following each participants’ visit. We defined racial concordance as occurring when both self-reported patient race (i.e., racial identity) and other-assessed clinician race (i.e., racial perception) were African American or black. The questionnaire also assessed the following: socioeconomic characteristics such as income and educational attainment; covariates such as HIV knowledge borrowed from the Behavioral Risk Factor Surveillance System (BRFSS); and several clinical encounter factors including patient satisfaction. We derived a 5-item, visit-specific patient satisfaction scale from Marshall and Hays’13 18-item scale on the basis of prior focus groups conducted with indigent, predominately black residents of the STD clinic service area. All scales had high internal validity and test-retest reliability (Cronbach α ≥0.70).
We conducted multiple logistic regression (backward elimination) to obtain odds ratios (ORs) with 95% confidence intervals (CIs) estimating associations between patient-provider racial concordance and ELISA testing during STD clinic visits. The full model included provider race, patient satisfaction, STD symptoms as the reason for seeking care, demographic characteristics, and HIV prevention-related covariates such as perceived HIV risk. We conducted all analyses using Stata version 8.0 (Stata Corporation, College Station, TX).
Table 1 summarizes sample characteristics. Overall, 61% of the sample (n = 84) accepted an HIV antibody test on the day they were enrolled into the study. Mean age was 28 years (range = 18–55 years, standard deviation = 9.04). One-fourth of participants (n = 35) were seen by black providers. The proportion testing varied by provider race; 80% of sample members seen by black providers but only 55% of those seen by nonblack providers accepted testing during their clinic visit (χ2 = 6.92, df = 1, p = 0.01) Patient satisfaction was high overall.
A strong crude association existed between patient-provider racial concordance and testing (OR = 3.29, 95% CI = 1.32–8.21). This association persisted in the multivariable model (OR = 3.41, 95% CI = 1.28–9.08), which controlled for levels of patient satisfaction, symptoms as the reason for seeking care, income, age and perceived risk of HIV infection.
This study examined whether for at-risk black women STD outpatients, provider race is associated with uptake of available opt-in routine ELISA HIV antibody testing. Because the study was based in a public STD clinic where patients automatically are offered HIV screening regardless of ability to pay, access to testing does not explain the findings. We studied women patients seen by women providers, circumventing potential gender interactions.
As hypothesized, racial concordance was associated with higher odds of testing during clinical visits. These findings are consistent with previous research showing patient-provider racial concordance improves health services utilization,7 quality of clinical encounters,14 and HIV treatment outcomes.11 It did not address continuity of care, which may be important when studying long term care or repeat visits.15
The observed associations may denote patient preferences, cross-cultural communication or distrust of clinicians.14,16 Future research should clarify relationships between these factors, explore potential gender interactions and determine whether concordance is more salient for some subpopulations (such as blacks who distrust nonblack providers) than others.17
Although in previous studies,18,19 relationships between patient satisfaction and racial concordance have been mixed, in this study, patient satisfaction was high and unrelated to testing (OR = 1.00, 95% CI = 0.91–1.11). Dedicated STD clinics provide fewer and less-complicated services than other providers, however, resulting in fewer opportunities to dissatisfy patients.
There are several policy implications. The study provides baseline data on rates of testing that future studies can use to assess the impact of recently recommended opt-out HIV screening20 on rates of diagnosis in this population. The findings also suggest that HIV counseling and testing efforts targeting blacks should aim not only to improve access to tests, but they also should consider how provider characteristics may influence uptake of the available tests. “Pipeline” programs training blacks in HIV prevention may help to improve rates of diagnosis in this population. It also is important to improve test acceptance in racially discordant clinical encounters, for instance, by enhancing cultural competency among providers.21 In this study, no provider tested 100% of the patients they saw, and research shows that prevalence of undiagnosed HIV infection is high among STD patients who do not accept HIV antibody tests.6 Therefore, continued support for HIV outreach and education targeting nontesters is needed.22
This research had several strengths. It focused on ELISA, which remains the most widely used test, and targeted an important priority population, black women. The objective assessment of HIV testing behavior is a better measure than oft-used self-reported testing. Last, it adds to the small but growing infectious disease-related literature on concordance.
Study limitations include the cross-sectional design, which limited our ability to establish that the observed associations are causal. Also, research staff did not directly observe clinical consultations and thus could not assess the quality of interpersonal communication. Future research aims to explicitly examine these additional factors.
In summary, black women STD clinic patients may be more likely to accept routine ELISA HIV antibody tests when testing is offered by black relative to nonblack providers. Improving access to black providers may be one way to improve rates of HIV diagnosis in this population. Identifying testing-related barriers in racially discordant clinical encounters also is important. Future research should use current rates of testing as a baseline to evaluate the new recommendations’20 impacts on test acceptance regardless of provider race.
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