Racial disparities in a variety of HIV treatments and services have been widely documented.11,28
Disparities in the delivery of potent antiretrovirals is particularly important, because these treatments have a profound impact on AIDS mortality, which is disproportionately greater among African Americans.29
Previous studies have not been able to fully explain why racial disparities in antiretroviral medication use exists.8,10–13
However, these studies have primarily focused on patient characteristics, such as income and insurance status, as explanatory factors and have not examined the impact of racial concordance. Others studies have found that racial concordance between patient and physician influences satisfaction and use,14,15,17,30
but have not found differences in treatment for health conditions.31
In the present study, we found that African-American patients with white providers received protease inhibitors later than white patients with white providers and African-American patients with African-American providers. Although white patients with African-American providers appeared to have the shortest time to protease inhibitor use, this group represents such a small fraction of the patients (<0.1%) that we recommend great caution should be exercised in reaching any conclusions about them.
A number of possible explanations for our findings should be considered. Differences in trust and satisfaction may influence a patient's willingness to accept new therapies. We controlled for trust in their medical provider using a 2-item measure and patient ratings of their medical care. These factors did not appear to explain our findings, however. Still, there may be other characteristics of the patient-provider relationship, including aspects of trust not accounted for in our 2-item scale, that might explain the study results. For example, communication may be better in racially concordant doctor-patient relationships, which may improve patients' acceptance of and readiness to take antiretroviral treatment. Recent studies found that African-American patients in racially concordant relationships reported more participation in decision making, as well as longer doctor visits and greater satisfaction, than those in racially discordant relationships.32
Our findings might also result from differences in physician prescribing behavior, which may be unintentional or possibly represent overt racial discrimination. Prior research has demonstrated that physicians are susceptible to having prior biases and stereotypes in assessing African-American intelligence, likelihood of substance abuse, and ability to adhere to regimens, which ultimately may affect their clinical decisions about African Americans.33,34
For example, most physicians delay treatment for patients whom they believe will be nonadherent.35
African-American patients in a white physician's panel may be more likely to be perceived as nonadherent. Ultimately, physicians might then be more likely to delay treatment for African Americans than for whites. We asked providers whether they considered patient adherence in their decision to prescribe protease inhibitors. This factor, however, did not explain our findings.
We report both statistical and clinical limitations of our study. First, we relied on self-reported dates of antiretroviral medications use. The wrong starting date could lead to either an underestimation or overestimation of the time to first protease inhibitor. Self-report of antiretroviral use is reasonably accurate when compared with pharmacy records,36
but the accuracy of dates of use is not known. There is also little reason to believe that errors in self-report would occur differentially by patient and provider race and result in a biased association. Second, we cannot exclude the possibility of selection bias resulting in some unmeasured differences between patients of the same race who are cared for by African-American versus white providers. African-American patients who have specifically chosen to see African-American providers may be more assertive in seeking medical treatments, may be more receptive to new treatments, or have other characteristics that could improve their access to protease inhibitors. Third, prior research analyzing the impact of patient trust in their provider on patient-provider relationships used more extensive scales to measure trust that the 2-item measure that we used. Thus, we may not have completely controlled for patient's trust in their provider. Finally, unmeasured differences between providers who mainly care for white and African-American patients may also exist. Although we controlled for HIV expertise, physician specialty, patient panel characteristics, and practice location, there may be unmeasured regional or philosophical differences in the standard of care that would affect prescribing patterns. In addition, we controlled for patients' belief that antiretrovirals are effective and found this variable had little effect on our results. Finally, there were not enough patients of both races cared for by the same physician to conduct within-physician analysis of differences in treatment.
Although the median delay in time translates to greater than 3 months, the clinical implications are not straightforward. Because of side effects37
and the concern about the development of drug resistance, HIV treatment strategy has moved away from early antiretroviral use and toward a “wait and see” approach when initiating treatment.38,39
Thus, the delay in treatment among African-American patients may have actually benefited them. Still, when respondents were enrolled in our study in 1996, the prevailing opinion among HIV experts was that protease inhibitors are crucial in reducing morbidity and mortality and must be included in the initial regimens of patients who could tolerate them.40
During the time of data collection, treatment delay was documented to result in lower CD4 counts and higher mortality rates.41,42
Thus, regardless of the clinical implications, our study indicates that race concordance influences the delivery of state-of-the-art care.
As for the policy implications of our study, one might conclude that segregating patients to providers based upon race may help eliminate health care disparities. We believe, however, that involuntary racial segregation of patients is inappropriate and unethical. Alternatively, we should strive to better understand and improve the relationship between patients and their physician, paying particular attention to the effects of race concordance. Future research should examine how and why race concordance influences satisfaction and care and whether discrimination in physician behavior plays a role. In addition, our study has important policy implications as we consider how to address the paucity of African-American providers available to African-American patients.43
Patients often select providers based upon specific characteristics, including race and ethnicity. African-American patients should have access to a provider of their own race and ethnicity if they so choose. Unfortunately, African-Americans are less than 5% of the total number of physicians, and recent anti-affirmative action judicial and legislative decisions have negatively impacted African-American medical school admissions.44–46
Therefore, policy changes to increase the supply of African-American physicians and meet patient demand are imperative. These changes are not likely to occur very soon. In the meantime, medical educators should expand cultural competence training for physicians, as outlined by the Institute of Medicine Report and the American and National Medical Associations. Increasing the number of African-American physicians and improving the patient-provider relationship are potentially critical to eliminating disparities in care. Only when African Americans achieve equity in health care can racial health disparities be eliminated.