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
Experiences in Healthcare and
Racial/Ethnic Disparities

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

Underexamined contributor to racial/ethnic
healthcare disparities
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Potential Patient-Level Factors

Discriminatory healthcare experiences
– Perception of poor interpersonal treatment attributed
to stigmatized status(es)

Healthcare provider distrust
– Expectation that provider will act in patient’s best
interest is not met

Reported more often by racial/ethnic minority
patients
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Potential Patient-Level Factors

Inverse association with treatment adherence

Plausible effect on treatment-related attitudes
and beliefs that affect adherence
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Racial/Ethnic Minority Status and
Antiretroviral Therapy Adherence

Poor adherence is common among HIV+ patients

Racial/ethnic minority status is inconsistently
associated with poor adherence

Discrimination and distrust as potential mediators
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Conceptual Model
Racial/
Ethnic
Minority
Status
Discriminatory
Healthcare
Experiences
Healthcare
Provider
Distrust
Antiretroviral
Therapy
Attitudes and
Beliefs
Antiretroviral
Therapy
Adherence
6
HIV Cost and Services Utilization Study

HIV+ individuals over 18 yo receiving care
outside of emergency depts, military, prisons

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)
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Sample Selection
Wave 1 (n = 2864)
Died or Lost (n = 398, 14%)
Wave 2 (n = 2466)
Died or Lost (n = 199, 8%)
Wave 3 (n = 2267)
Not Prescribed
Antiretroviral Therapy (n = 356, 16%)
Prescribed Antiretroviral Therapy (n = 1911)
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Attrition and Selection Biases

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
– Higher viral loads
– Less healthcare
provider distrust
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Methods

Unadjusted bivariate associations

Exploratory and confirmatory factor analyses

Structural equation modeling (MPlus 3.11)
– Fit indices
– Add or delete paths to improve model fit
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Study Measures
Construct
# Items Alpha
Mean†
SD
Discriminatory healthcare experiences*
6
.84
1.2
1.8
Healthcare provider distrust
7
.92
1.5
.60
Psychological burden of medication
8
.85
1.4
.55
Difficulty accessing medication
4
.71
2.2
.39
Difficulty scheduling medication
3
.76
1.9
.78
Weak medication efficacy beliefs
2
.72
1.5
.52
Antiretroviral therapy adherence
5
.82
6.4
.92
*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.
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Examples of Covariates

Sociodemographic
–
–
–
–


Age
Gender
Sexual orientation
Insurance status
Health
– Self-reported physical
and mental health
– Illicit drug use
– Depression symptoms
HIV-specific

– AIDS diagnosis
– Risk exposure
– Number of medications
Psychosocial
– Adherence self-efficacy
– Social support
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Sample Description
Minority (n = 918)
90
80
70
60
50
40
30
20
10
0
White (n = 993)
84*
69 *
54
35 *
33 *
12
Female
28
12
< HS degree
< $25K income
Homosexual
Identity
*p < .001
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Descriptive Statistics
Minority
60
White
50*
48 *
50
40
40
32
30
16
20
14
10
0
Any discrimination
Did not trust
completely or almost
completely
Perfect adherence
*p < .05
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Final Structural Model:
Direct Effects
Discriminator
y
Healthcare
Experiences
-.43
.09
Psychological
Burden of
Medication
.20
Difficulty
Accessing
Medication
.50
- .21
Racial/
Ethnic
Minority
Status
- .36
.56
Difficulty
Scheduling
Medication
.15
.15
Healthcare
Provider
Distrust
.14
.32
.16
- .29
Antiretroviral
Therapy
Adherence
.13
.06
Medication
Efficacy
Beliefs
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Final Structural Model:
Indirect Effects
Discriminator
y
Healthcare
Experiences
-.43
.09
Psychological
Burden of
Medication
.20
Difficulty
Accessing
Medication
.50
Racial/
Ethnic
Minority
Status
.56
.15
Healthcare
Provider
Distrust
.14
.32
.16
-.21
-.36
Difficulty
Scheduling
Medication
.15
-.29
Antiretroviral
Therapy
Adherence
.13
.06
Medication
Efficacy
Beliefs
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Summary of Model
R2 (χ2 = 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
Adequate - good
(CMINDF = 3.37, CFI = .97, TLI = .96,
RMSEA = .04, WRMR = .1.40)
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Discussion

Patient-level factors explained little of relationship
between minority status and adherence

Minority status as contextual factor?
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Discussion

Discrimination and distrust may subtly color
HIV+ patients’ attitudes and beliefs about
antiretroviral therapy, and thus adherence

Distrust as a protective factor?
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Limitations

Data collected 10 years ago

Exposure vs. current experiences with
discrimination

Temporality of measures
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Strengths and Significance

Assessed direct and indirect effects

Tested a potential mechanism of racial/ethnic
disparities in healthcare
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Acknowledgements

Barbara Turner

Giselle Corbie-Smith

Robert DeVellis

Sharon Christ

National Institute of
Allergies and Infectious
Diseases

AHRQ/UNC Cecil G. Sheps
Health Services Research
Center

UNC Graduate School
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Thank You