Provider-level correlates of suboptimal HIV care: Stigma and under-prescribing of antiretroviral thearpy to injection drug users

Background: HIV-infected injection drug users (IDUs) tend to under-utilize antiretroviral therapy (ART). We investigated characteristics of HIV care providers associated with hesitancy to prescribe ART to medically-eligible IDUs. Methods: Clinicians in Maryland and Virginia who prescribed antiretroviral medications during 2009 were identified using pharmacy data available through a private marketing firm. Participants were invited to complete an online questionnaire regarding their practice characteristics, prescribing habits, attitudes and beliefs. Respondents indicated whether they were “likely” or “unlikely” to prescribe ART in a series of hypothetical clinical scenarios involving patients with CD4+ lymphocyte counts of various levels (200, 350 or 500 cells/µl) and varying intensity of drug use. Multiple logistic regression was used to calculate adjusted odds ratios (AORs) for the association between provider characteristics and self-reported unwillingness to prescribe ART. Results: Of 369 providers who responded to the survey, 71% were physicians trained in infectious diseases, 20% were in primary care specialties, and 8% were non-physicians. In multivariate analysis, factors associated with unwillingness to prescribe HAART to medically eligible IDUs included reporting negative attitudes towards drug users (AOR 2.5, 95% C.I. 1.6 – 4.2) and serving a patient population with prevalence of IDU >10% (1.8, 1.1 – 3.0). No differences in prescribing behavior were observed by specialty type, practice location (urban vs. rural), or years of clinical experience. Conclusions: Attitudes and beliefs of health care providers may contribute to under-prescription of ART for IDUs. Efforts to reduce disparities in HIV care should address stigmatization of drug users in health care settings.