Racial disparities in HIV virologic failure: Do missed visits matter?

Background—Racial/ethnic health care disparities are well described in people living with HIV/ AIDS, although the processes underlying observed disparities are not well elucidated. Methods—A retrospective analysis nested in the UAB 1917 Clinic Cohort observational HIV study evaluated patients between August 2004 and January 2007. Factors associated with appointment nonadherence, a proportion of missed outpatient visits, were evaluated. Next, the role of appointment non-adherence in explaining the relationship between African American race and virologic failure (plasma HIV RNA >50 copies/mL) was examined using a staged multivariable modeling approach. Results—Among 1,221 participants a broad distribution of appointment non-adherence was observed, with 40% of patients missing at least 1 in every 4 scheduled visits. The adjusted odds of appointment non-adherence were 1.85 times higher in African American patients compared to Whites (95%CI=1.61–2.14). Appointment non-adherence was associated with virologic failure (OR 1.78; 95%CI=1.48–2.13), and partially mediated the relationship between African American race and virologic failure. African Americans had 1.56 times the adjusted odds of virologic failure (95% CI=1.19–2.05), which declined to 1.30 (95%CI=0.98–1.72) when controlling for appointment nonadherence, a hypothesized mediator.