Date

March 2009

Document Type

Thesis

Degree Name

M.P.H.

Department

Dept. of Public Health and Preventive Medicine

Institution

Oregon Health & Science University

Abstract

Background- HIV is a complex disease that affects a large number of people throughout the world. HIV care is improving, and physicians are becoming specialized in this area. HIV care requires knowledge of complex medication regimens as well as simultaneous management of co-morbidities. Patients in rural areas may be less likely to receive this type of specialized care. It is currently unknown whether rural residence affects clinical outcomes in HIV-positive patients. Objectives- The goal of this study was to determine if rural residence or time for a patient to reach their main HIV care provider adversely affects CD4 count. Methods- To assess the effect of living in a rural area on health outcomes, a cross-sectional study was employed using information from the Center for Disease Control’s Medical Monitoring Project. Personal interviews and chart abstractions were done for 296 patients in Oregon who were sampled between January 1st and April 30th, 2007. Patients were selected through a two-stage sampling scheme and additional patients were over-sampled from rural areas. Odds of having a CD4 count ≥ 350 cells/mm3 were compared among patients living in rural and non-rural areas. Additionally, the relationship between the time it takes to reach the HIV care provider, as defined as greater than 1 hour or less than or equal to 1 hour, and having a CD4 count ≥ 350 cells/mm3 were assessed. Univariate and multivariate logistic regression were used to examine these relationships. Results- There was a significant difference between the odds ratios for having a high CD4 count of women and men when comparing rural to non-rural. The odds of having a higher CD4 count was 51.2% less in rural men compared with non-rural men, though only significantly at the p<.10 level (p=.067). Women in rural areas had an increased odds of having a higher CD4 count than those in non-rural areas. The odds for women in rural areas was 10.163 times that of those living in non-rural areas (p=0.020). There was a moderately significant interaction between lowest ever CD4 count and time to provider (p=0.077). Patients living within an hour of their provider had an increased odds (by 41.9%) of having a CD4 count greater than or equal to 350 cells/μL when the lowest CD4 count increased by 50 cells/μL. This odds ratio was significant (p<.001). Patients living greater than an hour from their provider had an increased odds (by 10.5%) of having a CD4 count greater than or equal to 350 cells/μL when the lowest CD4 count increased by 50 cells/μL, though this was not significant (p=0.231). Conclusion- In this study, rural residence had a complex effect on magnitude of recent CD4. There is a trend for men who live in rural areas to have a CD4 count below 350 cells/μL. The trend for women is to have a CD4 count ≥ 350 cells/μL in rural areas. Patients had an increased odds of having a CD4 count ≥ 350 cells/μL if they had a greater lowest ever CD4 count. The odds of having a CD4 count ≥ 350 cells/μL was increased less for patients living more than an hour away than for those living less than or equal to an hour away.

Identifier

doi:10.6083/M4JH3J5Z

School

School of Medicine

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