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ABSTRACT
In the United States, access to HIV care has remained suboptimal for people of color. To assess racial disparities in HIV testing and knowledge about treatment for HIV/AIDS in the
United States, we analyzed the 2001 Behavioral Risk Factor Surveillance System. We obtained
the percentage of respondents aged 18 to 64 years who: (1) were tested for HIV ever and recently (in the past 12 months) excluding for blood donations and (2) responded true to the
statement, There are medical treatments available that are intended to help a person who is
infected with HIV to live longer. We calculated the difference in rates of HIV testing and
knowledge about treatment between blacks or Latinos compared to whites. Overall, of the
162,962 respondents, 44.7% had been tested for HIV and 12.8% were tested in the past year.
Overall, 86.4% answered true to the statement on treatment for HIV/AIDS. HIV testing rates
were significantly lower among whites (ever, 42.4%; recent, 10.8%) than blacks (ever, 59.7%;
recent, 23.4%) or Latinos (ever 45.6%, recent 14.8%). Compared to knowledge among whites
(89.6%), knowledge level was, lower among blacks (odds ratio [OR] 5 0.58, 95% confidence
interval [CI] 5 0.52, 0.64) and Latinos (OR 5 0.67, 95%CI 5 0.59, 0.75) even after adjusting for
sociodemographics and HIV testing status. The knowledge gap among blacks compared to
whites decreased with increasing income and education. We conclude that knowledge about
the availability of antiretroviral treatment was high overall. Compared to whites, blacks, and
latinos had significantly higher HIV testing rates but significantly lower knowledge about
antiretrovirals.
INTRODUCTION
UNITED STATES , since 1996, overall AIDSrelated deaths have declined and the number
of people living with HIV/AIDS has increased
largely because of the availability and use of antiretroviral drugs.1,2 The probability of survival
of patients who have AIDS varies by access to a
knowledgeable AIDS physician, manifestation of
disease, age, race, transmission risk, and adherN THE
27
28
EBRAHIM ET AL.
METHODS
The Behavioral Risk Factor Surveillance
System (BRFSS), established in 1984, is an ongoing, state-based telephone survey that gathers information about modifiable risk behaviors.11 Designed to produce risk factor estimates
for the noninstituitionalized civilian population 18 years of age or older in each state and
the United States, it provides baseline data for
setting national and state health promotion and
disease prevention objectives. All information
collected in the BRFSS is self-reported. The
questions are asked in English or Spanish. The
estimates from the BRFSS are computed using
sample weighting factors that adjust for differences in the probability of selection and nonresponse. This method is designed to produce
unbiased estimates for the adult population of
29
that had at least 50 respondents in each race category. We used SUDAAN (SUDAAN, Research
Triangle Park, NC) to obtain estimates of standard errors adjusted for the complex sample design. A p value less than 0.05 was considered
statistically significant for all analyses.
RESULTS
The results are based on 162,892 U.S. resident
men and women 18 to 64 years of age (representative of 172 million people) who responded
to the survey in 2001; 1489 respondents for
whom data on knowledge about HIV treatments were missing have been excluded from
TABLE 1.
HIV TESTING
AND
Gender
Male
Female
Race
White
Black
Hispanic
Other
Marital status
Never married
Married
Divorced/widow
Age (years)
1824
2544
4564
Income
,$25K
$2550K
$50K1
Do not know/refused
Education
,High School
High school
Some college
College
Employment
Not employed
Employed
a People
Distribution
respondents (%)
Ever
Recent
50.2
49.8
42.5
46.9
12.6b
13.0
85.6
87.2
Referent
1.16 (1.06, 1.28)
69.9
10.2
13.2
6.6
42.4
59.7
45.6
43.8
10.8
23.4
14.8
13.0
89.6
80.9
78.0
77.4
Referent
0.58 (0.51, 0.66)
0.60 (0.52, 0.70)
0.36 (0.30, 0.43)
34.5
58.4
21.1
45.1
43.2
50.2
17.3
10.6
15.3
85.6
87.2
84.4
Referent
0.90 (0.79, 1.02)
0.89 (0.75, 1.06)
15.4
47.5
37.1
44.0
55.7
30.9
20.0
14.8
7.2
84.2
87.5
85.9
Referent
1.05 (0.91, 1.20)
1.05 (0.91, 1.22)
22.8
31.0
34.3
11.9
46.5
45.9
45.2
36.5
15.9
13.5
11.0
10.6
79.6
87.0
93.2
76.4
Referent
1.27 (1.12, 1.44)
1.91 (1.64, 2.22)
0.65 (0.56, 0.76)
8.8
30.6
28.4
32.1
40.7
41.3
47.2
47.5
13.1
12.6
13.9
11.9
71.1
82.1
90.1
93.3
Referent
1.38 (1.20, 1.60)
2.57 (2.19, 3.02)
3.53 (2.96, 4.21)
25.0
74.8
42.8
45.5
13.3
12.6
83.5
87.6
Referent
0.99 (0.88, 1.11)
who responded True to the statement Treatment is available to help people with HIV/AIDS live longer.
Differences in ever and recent HIV testing rates among population groups were significant (p , 0.05)
except for recent testing by sex.
OR, adjusted odds ratios; adjusted for all the variables in the table and HIV testing; 95% CI 5 95% confidence
intervals.
b Note:
30
EBRAHIM ET AL.
TABLE 2.
RACE/ETHNIC DIFFERENCES
Gender
Male
Female
Marital status
Married
Divorced/widowed
Never married
Age (years)
1824
2544
4564
Income
,$25K
$2550K
$50K1
Do not know/refused
Education
,High School
High school
Some college
College
Employment
Employed
Not employed
Geographic region
Northeast
Midwest
South
West
History of HIV testing
Never
Ever
Tested recently
IN
HIV TESTING
AND
Actual difference
compared to whites
Actual difference
compared to whites
Whites
Blacks
Latinos
Whites
Blacks
Latinos
40.9
43.8
17.7
16.8
20.9a
7.7
88.9
90.3
28.6
28.8
211.9
211.2
41.3
48.1
41.9
17.7
9.6
20.0
4.5
2.2a
0.7a
90.0
87.6
89.6
27.0
28.3
29.9
211.6
29.2
212.2
42.5
54.9
28.0
18.5
14.1
18.3
20.2a
23.4
8.3
88.2
91.1
88.4
29.2
28.8
28.4
213.6
211.5
210.8
44.5
43.1
43.5
32.8
14.7
18.2
20.6
17.3
21.6a
3.2
9.5
10.8
84.3
89.2
94.2
80.9
27.1
25.6
23.2
213.2
211.1
26.9
22.9
212.7
41.4
37.7
43.6
45.9
11.6
19.1
20.6
17.7
25.2
9.1
9.3
11.3
75.1
84.5
91.9
95.3
29.6
28.9
24.6
23.8
26.1
25.8
26.1
26.4
43.2
39.9
18.6
15.3
1.9a
7.5
90.5
87.1
27.4
210.3
211.5
210.7
39.8
37.6
44.9
46.7
22.5
21.2
14.7
10.9
13.8
9.0
0.8a
24.5
90.4
89.9
87.3
92.2
24.3
26.6
28.5
211.3
214.7
27.2
28.7
214.4
87.1
93.0
92.1
214.6
26.4
26.1
216.0
26.7
27.1
a Actual differences compared to whites for blacks or Latinos within each population group were significant
( p , 0.05) both for HIV testing and knowledge, except when marked.
(2) indicates lower rates among blacks and Latinos compared to whites. Other rates are higher than whites.
31
Knowledge gap compared to whites was generally similar for men and women both among
blacks and Latinos; thus only aggregate data
for men and women are presented in Table 2.
Among sociodemographic subgroups, both
among blacks and Latinos, knowledge gap
about treatment for HIV/AIDS compared to
whites was the smallest among people who had
an annual household income above $50,000
and highest among those who never had an
HIV test (Table 2). Among blacks, knowledge
gap compared to whites narrowed with increasing education and income. However,
among Latinos, such a pattern was noted only
for income.
FIG. 1.
Percentage of blacks and Latinos who knew that treatment exists for HIV/AIDS, 2001.
32
EBRAHIM ET AL.
DISCUSSION
This first population-based U.S. data on
knowledge about treatment for AIDS indicates
high knowledge level in the general population.
This rate is about the same as that reported for
Sweden, the only other developed country that
has reported such data.13 Despite higher rates of
HIV testing among blacks and Hispanics compared to whites shown by this study and in previous reports, we found that knowledge about
the availability of antiretroviral treatment was
significantly lower among blacks and Latinos,
compared to whites. The reported increase in the
percentage of people who were ever tested, from
the mid-1980s (1987; 5%) through the mid-1990s
(19951996; 38%42%),10 appears to have leveled
off (44.7% in 2001 in our study). The low percentage of people ever tested for HIV for 1998
(30%) reported based on the National Health Interview Survey could be caused by inclusion of
responses from older people in that analysis
(39% of the respondents were aged 50 years or
older).14 The percentage of people who have
been tested in the past year is within the 9%17%
rates reported by various national surveys in the
1990s.10
The populations groups identified in our
study as having low rates of knowledge about
treatment for HIV/AIDS (people of color, low
socioeconomic status) are also known to have
less knowledge and utilization of many other
health services including influenza vaccination, cancer screening, cardiovascular care, sexually transmitted disease (STD) services, and
prenatal care.15,16 The differences between socially disadvantaged and advantaged population groups may have been even wider if the
BRFSS data collection methods had allowed for
inclusion of population groups such as people
without telephones and people who are instituitionalized. The data from the BRFSS are subject to social desirability bias, coverage, and reporting errors that affect survey data. People
who exhibit HIV risk behaviors may be more
knowledgeable about HIV/AIDS treatment
than the general population and such risk information is not collected by the BRFSS. Notwithstanding these examples of sampling bias,
our data shed light on a fundamental aspect of
HIV/AIDS care utilization: knowledge that
treatment for HIV/AIDS exists.
33
lence may not perceive themselves to be at increased risk for HIV, and therefore are not inclined to seek HIV testing. However, low levels of education, associated with low levels of
HIV testing in our study and other studies,14 is
also associated with low levels of and knowledge about treatment for HIV. Drawing from
these findings and experiences in advancing
HIV prevention among most affected population groups, initiatives aimed at increasing access to antiretrovirals should make greater efforts to inform blacks, Latinos, and people with
low level of education about the availability of
antiretroviral treatments through innovative,
varied, and culturally sensitive educational
strategies. Current national policy emphasis on
and commitment to the reduction of racial disparities in access to HIV/AIDS treatment, including existing efforts to remove economic
barriers to HIV/AIDS treatment, can help narrow the knowledge gap.
ACKNOWLEDGMENTS
9.
10.
11.
12.
13.
14.
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