Disparities in healthcare quality among black patients with HIV/AIDS: Exploring differences between foreign-born and United States native subgroups

Foreign-born persons represent an increasing subgroup of Black/African-American patients receiving care for HIV/AIDS in Massachusetts and other states. In other health conditions, immigrants have been shown to have advantages, yet none of the HIV/AIDS disparity research has considered nativity. Using the Behavioral Model of healthcare utilization, this study used medical record data on 357 HIV/AIDS patients identified as "Black" who received treatment in publicly-funded clinics from 1999 through 2002 to compare foreign-born (36%) with US-born patients (64%) on important predisposing, enabling and need factors and examine how these relate to four measures of HIV care quality.; Immigrants were found to differ significantly from US natives on several predisposing and patient-level enabling factors but not on contextual clinic factors or clinical need. Over the 4-year study period, 29% of Blacks overall had inconsistent medical visits, 33% had gaps in laboratory monitoring, 22% missed recommended medications and 32% had hospitalizations after their first year in care. In an adjusted hierarchical model, nativity was independently associated with receipt of recommended HIV medications. Immigrants were less likely to miss medications than US natives (adjusted odds ratio 0.41, 95% CI 0.17-0.99). Available medical record notations indicated patient refusal was a minor factor, suggesting that other unmeasured patient, provider or system factors may be involved. No significant nativity-based differences were found for the other quality measures.; To better understand the "intersectionality" of multiple potential disadvantages (i.e., nativity, race/ethnicity and language), a second analysis examined the full cohort (N=1528). Sub-groups defined by nativity were more consistently different than those defined by race or language on 3 of 4 measures of quality.; These findings illuminate potential pitfalls of grouping immigrant and native populations into the ill-defined racial category of "African American" or "Black". Prior research showing lower use of HIV medications for Blacks compared to Whites without controlling for nativity should be re-evaluated, since the true disparities for US-born African Americans/Blacks may have been underestimated. Future health researchers should be alerted to the critical need to capture information on nativity when conducting health services and epidemiologic research for particular populations.