Disparities in Hospitalizations Among HIV Positive Individuals for Native Hawaiians and Asians Compared to Whites in Hawai‘i

Abstract

Hospitalizations of those living with HIV are expensive and often indicate failures in access to, or retention in, primary care. Higher rates of hospitalizations among individuals with HIV have been reported in some US ethnic minorities, yet little information is available for Native Hawaiians and Asian subgroups. All hospitalizations in Hawai‘i of individuals aged ≥13 years from December 2006–December 2010 were considered. Hospitalizations of individuals with HIV were identified using ICD-9 diagnosis codes of 042 and V08; 613 hospitalizations with an HIV diagnostic code were found. Using Hawaii State Department of Health 2010 data, estimated rates of hospitalizations among HIV positive individuals by race/ethnicity among the 2,600 Hawai‘i residents living with HIV were calculated along with estimated rate ratios (using Whites as the reference group). Multivariable adjusted estimated rate ratios (aRR) were calculated with negative binomial models, adjusting for age, sex, and payer type. Demographic and clinical differences among hospitalized patients with HIV were also compared by race/ethnicity. Native Hawaiians (aRR: 3.21; 95%CI: 2.11–4.88), Japanese (aRR: 2.27; 95%CI: 1.38–3.72), and Filipinos (aRR: 1.62; 95%CI: 1.01–2.59) living with HIV all had higher likelihood of a hospitalization compared to Whites, even when controlling for age, sex, and payer. Chinese did not vary significantly from Whites. Also of note, the average age of HIV positive individuals who were hospitalized varied significantly across groups (P-value < .001), with Native Hawaiians as the youngest (45 years), followed by Filipinos (47 years), Whites (49 years), Chinese (50 years) and Japanese (54 years). Disparities appear to exist in hospitalizations among HIV positive individuals for Native Hawaiians and Asian subgroups. Further research is warranted to investigate the reasons for these health disparities.

Introduction

HIV disproportionately impacts racial/ethnic minority groups in the United States (US).^1,2 Racial/ethnic disparities are specifically seen in HIV-related hospitalizations with minorities having higher hospitalizations rates than non-Hispanic whites.^3,4 Hospitalizations among HIV positive individuals often indicate failure in access to, or retention in, primary care and contribute substantially to the overall cost burden for HIV. For instance, in 2005, national HIV hospitalization costs were 3.2 billion dollars.⁵

Currently, little research on HIV hospitalizations has considered Asian Americans or Native Hawaiians. Yet Asian Americans make up 5% of the US population (over 15.5 million) and are one of the fastest growing racial/ethnic groups in the US.⁶ Native Hawaiians include more than half a million individuals in the US and experience notable health disparities in many chronic and infectious diseases.^7,8 Native Hawaiians also are more likely to have socio-demographic risk factors, such as poverty, that contribute to poorer health outcomes.⁷ Existing evidence suggests that important disparities in hospitalizations among HIV positive individuals might exist among these diverse, understudied and often underserved populations.⁹

Access to high-quality, culturally relevant primary care is limited among many Asian American, Native Hawaiians, and other Pacific Islander (AA/NHOPI) groups who may also face linguistic, economic and legal barriers to HIV prevention, testing, services, and ongoing care.^9,10 These barriers are manifest across the spectrum of HIV services and may lead to sicker individuals and higher rates of HIV-related inpatient utilization. AA/NHOPI populations are less likely to be tested for HIV compared to other racial/ethnic groups at similar risk.^9,11 At-risk AA/NHOPI groups are diagnosed with HIV at a later stage of disease than similar populations of other race/ethnicities.¹² AA/NHOPIs are less likely to use HIV case management, housing assistance, day/respite care, food/nutrition services, substance abuse treatment, and health education services compared to other racial/ethnic groups.¹

The research on HIV health disparities in hospitalizations that has considered AA/NHOPI groups typically combines diverse AA/NHOPI subgroups into one category.¹³ This obscures disparities among distinct populations.^14–17 In particular, the poorer health access and outcomes of some subgroups, such as Native Hawaiians, are often obscured by the stronger health profile of others, such as the Japanese.^15–17

Native Hawaiians may be at particular risk for HIV inpatient disparities. Western health care services may not provide sufficient access to care and/or culturally appropriate care for disease management, which may impact introduction of, and adherence to, effective HIV therapeutics, such as highly active anti-retroviral therapy (HAART).¹⁸ This may lead to greater use of the more costly inpatient services and to poorer outcomes of those hospitalizations, such as longer lengths of stays, more expensive visits, and more hospitalizations that end in death. A recent state-wide needs assessment done in Hawai‘i found evidence that differences are likely to be seen across AA/NHOPI group and that these are likely to lead to disparities in inpatient care.¹⁹ Specifically, Asian and Pacific Islanders (not including Native Hawaiians) were less likely to be in regular care than other ethnicities, while Native Hawaiians were more likely to have skipped their HAART medications.¹⁹

The National HIV/AIDS Strategy included eliminating health disparities as one of its three primary goals.²⁰ This study fills in critical evidence gaps to help meet this goal by investigating characteristics and disparities in hospitalizations among HIV positive individuals for Asian American subgroups and Native Hawaiians using data from all hospitalizations in Hawai‘i between December 2006 and December 2010. Our specific study goals were to (1) compare estimated rates of hospitalizations, among HIV positive individuals, for Native Hawaiians, Asian subgroups, and Whites, and (2) describe the demographic and clinical characteristics of hospitalized HIV positive individuals across these racial/ethnic groups to better understand any differences seen in estimated hospitalization rates. Due to the known disparities in access to care, socio-demographics, and clinical indicators among Native Hawaiians compared to other racial/ethnic groups in Hawai‘i we hypothesized that there would be higher rates of hospitalized HIV positive individuals in Native Hawaiians compared to other groups, and also that Native Hawaiians with HIV who were hospitalized would be younger and sicker compared to other racial/ethnic groups. ²¹

Methods

Study Setting

Hospital data in Hawai‘i has unique detail about AA/NHOPI, racial/ethnic groups not captured in state-level data in most other locations. Almost 40% of the state's population is Asian American.²² Hawai‘i is home to approximately 25% of the total US Native Hawaiian or Other Pacific Islander population.⁷

The Hawai‘i Health Information Corporation (HHIC) Data includes inpatient discharge data and all hospitalizations by all payers in Hawai‘i.²³ We used the inpatient hospitalization data from December 2006 to December 2010. HHIC inpatient data includes discharge data at the patient level on patient race/ethnicity, insurer, age, sex, and International Classification of Diseases—9th revision—Clinical Modification (ICD-9) primary diagnosis, secondary diagnosis, and procedure codes. Unique individuals can be identified across hospitals using a master patient identification variable. Because some individuals were hospitalized multiple times during the study period, we used this variable to identify these individuals. Our primary analyses focused on the individual patient, rather than the hospital visit as the unit of analysis.

Sample

All civilian hospitalizations of any individual aged >13 years were initially considered. However, because there were no hospitalizations including an HIV diagnosis among those 13–18 years, we considered hospitalization detail only among those 18 and older (N = 442,641). Hospitalizations were excluded if the payer was the Department of Defense (DOD), as the DOD hospital in Hawai‘i does not report detailed race/ethnicity (N = 49,233). As the number of individuals with HIV by race/ethnicity used as rate denominators is compiled for Hawai‘i residents specifically, individuals not living in Hawai‘i (N = 14,070) were also excluded. An additional 9,359 visits were excluded because the visit did not report valid race/ethnicity data, which was due to the following categories for race/ethnicity: “Unknown,” “Not Applicable,” or “Data not collected.” The total number of hospitalizations in the final sample was 369,979 among 210,770 unique individuals 18 years and older.

Hospitalized HIV positive individuals were identified using ICD-9 diagnosis codes. The ICD-9 codes of 042 and V08 on any the 20 available ICD-9 fields (1 primary and 19 secondary) were used to identify the hospitalizations of HIV positive individuals.

Estimated Rates

We used the number of HIV-infected individuals of each ethnicity living in Hawai‘i as the denominator for our estimated rates. Denominator values were obtained from the 2010 Hawai‘i AIDS surveillance data from the Hawai‘i Department of Health (HDOH) using the same age and Asian American and Native Hawaiian classification groups as in the HHIC data.²⁴ By statute, all laboratories and medical doctors in the state are required to report HIV care for all patients.²⁵ These are then de-duplicated with patients diagnosed in other states as only the original state of diagnosis can claim them for federal funding. In our analyses, to fully capture the number of individuals living with HIV in the state, we include people diagnosed elsewhere, but residing in Hawai‘i. (Our population numbers are thus similar, but distinct, from the data published by the HDOH in surveillance reports as the public reporting data is restricted to people diagnosed in Hawai‘i.) As the numerator and denominator for the “rate” of hospitalizations of HIV positive individuals is calculated from two distinct data sets and is not a true rate, we refer to it as an “estimated rate.”

Racial/Ethnic Categories

Estimated rates were calculated for the five primary racial/ethnic groups in Hawai‘i (Japanese, Chinese, Native Hawaiian, White, and Filipino). Additionally, we include an “Other” racial/ethnic category, which includes all racial/ethnic groups without sufficient sample sizes for individual analyses (eg, Samoan, Korean, Black, Hispanic). There is congruence between racial/ethnic categories from the HHIC data and the HDOH data as they are both self-reported as primary race/ethnicity.

Demographic Characteristics

Hospitalizations of HIV positive individuals were considered by self-reported race/ethnicities of Japanese, Chinese, Native Hawaiian, Filipino, Other, or White; age group (18–30, 31–49, and 50+ years);⁴ sex (female and male); and payer (Public [Medicare and Medicaid], Private, and Other). Older age and sex are associated with increased hospitalization rates among those with HIV, but it is unknown if these disparities persist among AA/NHOPI populations.^{3, 26}

Clinical Characteristics

By race/ethnicity, we also considered key clinical indicators of hospitalized HIV positive individuals to better understand the patient populations by race/ethnicity. Clinical indicators were cardiometobolic illness, AIDS defining illness, other infections, and wasting/cachexia, all of which have been strongly associated with HIV.^27–28 These were defined by ICD-9 codes described in more detail in Table 1. We also considered overall co-morbidity, defined by the Charlson comorbidity index, and severity of illnesses.²⁹ Severity of illness was defined using 3M classification methods and is “the extent of physiological decomposition or organ system loss of function” within All Patient Refined Diagnosis Related Groups (APR-DRGs).³⁰ The 3M severity-of-illness classification method considers primary and secondary diagnoses and procedures from ICD-9 discharge codes, as well as age, sex, and discharge disposition, providing a four-point scale in which a higher score indicates greater severity.³⁰ We also considered the number of times HIV positive individuals were hospitalized during the time period.

Table 1.

Table of ICD-Codes for Clinical Classifications

Diagnosis	ICD-9 Codes
Cardio/Metabolic	Cardio/Metabolic Hypertension: 4011, 4010, 4019 Cardiovascular Disease: 41000, 41001, 41002, 41010, 41011, 41012, 41020, 41021, 41022, 41030, 41031, 41032, 41040, 41041, 41042, 41050, 41051, 41052, 41060, 41061, 41062, 41070, 41071, 41072, 41080, 41081, 41082, 41090, 41091, 41092, 4110, 4111, 41181, 41189, 4130, 4131, 4139, 41400, 41401, 41402, 41403, 41404, 41405, 41406, 41407, 4148, 4149, 4292, 43300, 43301, 43310, 43311, 43320, 43321, 43330, 43331, 43380, 43381, 43390, 43391, 43400, 43401, 43410, 43411, 43490, 43491, 4401, 44020, 44021, 44022, 44023, 44024, 44029, 44401, 44409, 4441, 44421, 44422, 44481, 44489, 4449, 44501, 44502, 44581, 44589 Hyperlipidemia: 2720, 2721,2722, 2723,2724, 2729 Obesity: 2780, 27800, 27801 Diabetes: 3572, 3620, 6480, 25000, 25001, 25002, 25003, 25010, 25011, 25012, 25013, 25020, 25021, 25022, 25023, 25030, 25031, 25032, 25033, 25040, 25041, 25042, 25043, 25050, 25051, 25052, 25053, 25060, 25061, 25062, 25063, 25070, 25071, 25072, 25073, 25080, 25081, 25082, 25083, 25090, 25091, 25092, 25093, 3572, 36201, 36202, 36203, 36204, 36205, 36206, 36207, 36641, 64800, 64801, 64802, 64803, 64804, 64880, 64881, 64882, 64883, 64884, 79021, 79022, 79029
AIDS defining	1124, 11289, 11284, 1141, 1143, 1175, 0074, 0785, 34830 34831, 34839, 0540, 05412, 05479, 11500, 11501, 11502, 11503 11504, 11509, 11510, 11511, 11512, 11513, 11514, 11519, 11590 11591, 11592, 11593, 11594, 11599, 0072, 1760, 1761 1762, 1763, 1764, 1765, 1768, 1769, 20020, 20021, 20022 20023, 20024, 20025, 20026, 20027, 20028, 20080, 20081, 20082 20083, 20084, 20085, 20086, 20087, 20088, 20011, 0311, 0312, 0318, 0319, 01300 – 01396, 01400 – 01486, 01500 – 01596 01600 – 01696, 01700 – 01796, 01800 – 01896, 1363, 0463, 0031 1300, 7994, 1800, 1801, 1808, 1809, 01000 – 01096, 01100 – 01196, 01200 – 01286
Other infections	0031, 0380, 03810, 03811, 03812, 03819, 0382, 0383, 03840, 03841, 03842, 03843, 03844, 03849, 0388, 0389, 99590, 99591, 99592, 99593, 99593, 99594, 99594
Wasting/cachexia	260, 261, 262, 2630, 2631, 2632, 2638, 2639, 64890, 64891, 64892, 64893, 64894, 76420, 76421, 76422, 76423, 76424, 76425, 76426, 76427, 76428, 76429, 99552, 99584

Statistical Analyses

Demographic data was first summarized by descriptive statistics. Unadjusted estimated rates and estimated rate ratios of hospitalized HIV positive individuals (compared to Whites) were calculated. Multivariable adjusted estimated rate ratios (aRR) were then calculated with negative binomial models, adjusting for age, sex, and payer type. Finally, we compared the clinical portrait of those hospitalized with HIV across racial ethnic groups and compared these using ANOVA for continuous variables and Chi-square tests for categorical variables. All data analyses were performed in SAS 9.3 (Cary, N.C., 2011) and a two-tailed P-value of less than 0.05 was regarded as statistically significant.

Sensitivity Analyses

Because our denominators and numerators did not come from the same data set and are subject to uncertainty in their racial/ethnic categorization concordance, we performed a sensitivity analysis. We evaluated the impact on significance of our findings if the denominator for each Asian American and Native Hawaiian group was underestimated. We reanalyzed the data by increasing the denominators of the groups by 25% and 50%, as this would make finding disparities compared to Whites among these groups less likely.

Results

Of the 210,770 individuals who were hospitalized, 613 were hospitalized HIV positive individuals. Table 2 describes the demographic portrait of these hospitalized HIV positive individuals across race/ethnicity. Groups differed significantly across sex, payer, and age. Of note, the average age of hospitalized HIV positive individuals varied significantly across groups (P-value <.001), with Native Hawaiians being the youngest (45 years), followed by Filipinos (47 years), Whites (49 years), Chinese (50 years) and Japanese (54 years). While all groups were predominately male, Native Hawaiians had higher numbers of females (28%), followed by Filipinos (23%) and Others (22%). By comparison, only 10% of Chinese, 12% of Whites and 12% of Japanese were female. Seventy-seven percent of Native Hawaiian hospitalized HIV positive individuals were covered by public payers compared to 62% of Whites, 51% of Filipinos, 49% of Japanese, and 30% of Chinese (P = .002).

Table 2.

Demographics of HIV Positive Individuals Hospitalized in Hawai‘i (December 2006–December 2010; 13+ years) by Race/Ethnic Group

	Chinese	Filipino	Native Hawaiian	Japanese	White	Other	Total	P-value
n	10	35	96	33	297	142	613
	%	%	%	%	%	%	%
Female	10.0	22.9	28.1	12.1	10.8	21.8	16.8	.001
Public Payer	30.0	51.4	77.1	48.5	62	66.9	63.6	.002
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Age	49.5 (13.4)	46.8 (9.2)	45.3 (9.9)	53.5 (14.0)	49.4 (9.0)	44.4 (11.6)	47.6 (10.5)	< .001

Table 3 shows the estimated rates, estimated rate ratios, and adjusted estimated rate ratios for those hospitalized with HIV. In unadjusted analyses, it appears that more than half of the Native Hawaiians living with HIV were hospitalized during the study period. In adjusted analyses, Native Hawaiians (aRR: 3.21; 95% CI: 2.11–4.88), Japanese (aRR: 2.27; 95% CI: 1.38–3.72), and Filipinos (aRR: 1.62; 95% CI: 1.01–2.59) living with HIV all had higher likelihood of being hospitalized compared to Whites, even when controlling for age, sex, and payer. Chinese did not vary significantly from Whites.

Table 3.

Estimated Rates, Rate Ratios (compared to Whites), and Adjusted Estimated Rate Ratios of Hospitalizations among HIV Positive Individuals from HHIC Data (December 2006–December 2010; 13+ years) by Race/Ethnic Group

	Chinese	Filipino	Native Hawaiian	Japanese	White	Other
Number of patients with HIV hospitalizations	10	35	96	33	297	142
Number with HIVa	36	131	170	89	1509	665
Rate (×100)	27.8	26.7	56.5	37.1	19.7	21.4
Estimated Rate Ratios [with 95% Confidence Interval]	1.41 [0.75, 2.65]	1.36 [0.96, 1.93]	2.87 [2.28, 3.61]	1.88 [1.31, 2.70]	1.0	1.09 [0.89, 1.33]
Adjusted Estimated Rate Ratios [with 95% Confidence Interval]b	1.66 [0.85, 3.22]	1.62 [1.01, 2.59]	3.21 [2.11, 4.88]C	2.27 [1.38, 3.72]c	1.0	1.26 [0.84, 1.90]c

^aFrom Hawai‘i Department of Health.

^bAdjusted for sex, age, and payer.

^cSignificantly different from Whites at P-value < .001.

In our sensitivity analyses (Appendix), we tested the significance of our findings if the Asian American and Native Hawaiian group denominators were underestimated. With a 25% increase, Japanese and Native Hawaiians still had significantly higher estimated rates of hospitalizations among HIV positive individuals compared to Whites. Even with a 50% increase, Native Hawaiians had significantly higher estimated rates of hospitalizations among HIV positive individuals compared to Whites.

Table 4 shows the clinical portrait of HIV positive individuals, who were hospitalized, by race/ethnicity to add insight into the possible reasons for these disparities. Although percentages differed among racial/ethnic groups, the only significant (P-value < .05) variation across groups was in wasting/cachexia, which was highest in Native Hawaiians (14%). The average number of times HIV positive individuals were hospitalized during the study period was approximately two across all racial/ethnic groups.

Table 4.

Clinical Characteristics of HIV Positive Individuals Hospitalized in Hawai‘i in HHIC data (December 2006–December 2010; 13+ years) by Race/Ethnic Group

	Chinese	Filipino	Native Hawaiian	Japanese	White	Other	P-value
	%	%	%	%	%	%
Cardio/Metabolic	60.0	37.1	29.9	33.3	36.7	33.3	0.49
AIDS defining	20.0	22.9	20.6	15.1	12.0	14.5	0.21
Other infections	20.0	11.4	11.3	3.0	5.7	8.0	0.14
Wasting/cachexia	10.0	8.6	14.4	9.1	5.0	10.9	0.04
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Comorbidity (Charlson)	2.9 (2.5)	1.2 (1.9)	1.5 (2.1)	1.7 (2.6)	1.6 (2.3)	1.4 (2.3)	0.43
Severity of Illness	2.7 (1.1)	2.6 (0.9)	2.4 (1.0)	2.4 (0.7)	2.4 (0.8)	2.4 (0.9)	0.80
# HIV-related hospitalizations	2.1 (1.6)	2.4 (4.0)	2.3 (2.2)	1.9 (1.4)	2.1 (2.2)	2.1 (2.4)	0.95

Discussion

This study has several key findings. First, as expected, HIV positive individuals who are Native Hawaiian appear to be hospitalized at much higher rates than HIV positive individuals who are White. We also found that some Asian subgroups, specifically Japanese and Filipino populations, appear to have higher rates of hospitalizations among HIV positive individuals compared to Whites. While Japanese groups have strong health profiles in Hawai‘i,²¹ HIV may still have a stigma within the community, contributing to health disparities among a group that otherwise shows few health disparities in Hawai‘i.

Our analysis of the clinical characteristics provides further insight into this issue, allowing us to consider if rate differences are due to delayed entry into care by some groups, which might result in more opportunistic infections among Native Hawaiians and other groups. Alternatively, the rate differences could simply be a manifestation of high rates of other comorbid conditions (eg, cardiovascular disease/diabetes) leading to higher hospitalization rates in some AA/NHOPI populations. We had hypothesized that Native Hawaiian individuals who are HIV positive would be hospitalized sicker compared to other racial/ethnic groups. Although there was variation in clinical characteristics across racial/ethnic groups, we found that, unexpectedly, the clinical portrait was not consistently worse for Native Hawaiians compared to Whites nor was it worse for Asian groups. The one exception was in wasting/cachexia, which did vary significantly across groups, and was highest in Native Hawaiians. Wasting, even in the era of HAART is associated with the diagnosis of AIDS and poorer immune function as assessed by CD4 count,³¹ and this association may reflect delayed entry, poorer access or unwillingness to access medical care in the Native Hawaiian population.

Unlike some other states with waiting lists for the AIDS Drug Assistance Program (ADAP), everyone who applies in Hawai‘i has access to HAART and HIV care. Thus, access to care should not be a major constraint once a diagnosis is obtained.³² The differences in rates by race/ethnicity may instead be due to factors such as a diagnosis further along in the course of illness, issues with retention in care, adherence, choice of alternative treatments, or non-monetary access to care issues like time, transportation, or stigma. The disparities in hospitalizations among those with HIV for Native Hawaiians and other racial/ethnic groups may also reflect the underlying disparities in many different areas of health, and not necessarily be related to HIV status. These issues deserve further study.

We also expected to find age disparities for Native Hawaiians compared to other racial/ethnic groups. Indeed, Native Hawaiian individuals with HIV who were hospitalized had the lowest average age (45 years) among all groups studied, four years less than the average for Whites and nine years less than the average for Japanese. Native Hawaiians were also more likely to be on Medicaid with 77% under a public payer compared to 49% of Japanese and 30% of Chinese (the lowest groups).

Overall, 83% of those with HIV who were hospitalized were male, reflecting underlying HIV prevalence differences by sex. Native Hawaiians had the highest percentage of hospitalizations among HIV positive individuals by females (28%), followed by Filipinos (23%). This is consistent with the higher proportion of females among people living with HIV in these ethnic groups and reflective of increased heterosexual risk for HIV infection in these populations.²⁴

In addition to the specific health disparities identified in this study, the results underscore the critical importance of disaggregating AA/NHOPI groups in health-related research generally and HIV research specifically. ^15–17 Doing so revealed very different rates of hospitalizations among HIV positive individuals and distinct demographic profiles for Asian American subgroups and Native Hawaiians. Future work should consider other disaggregated Pacific Islander subgroups (eg, Samoan, Micronesian, Tongan) as well.

Limitations

Our study has a number of important strengths, including the state-level all-payer inpatient hospitalization database with detail regarding Native Hawaiians and Asian subgroups. Also, unlike some previous studies on this topic, our study was able to consider multiple visits by unique individuals,⁵ removing any bias from differential re-hospitalization rates by racial/ethnic group. However, we do have some limitations.

One limitation is the compatibility between the way in which race/ethnicity data is collected by the hospitals and by HDOH surveillance systems. Another limitation is that the HDOH surveillance data used as our rate denominators reflects all diagnosed cases of HIV, which are required by law to be reported by all physicians and laboratories. However, people who are infected with HIV, but have not been tested and diagnosed are not included in the denominator. If certain ethnic groups were less likely to be tested, then the hospitalization rates for these groups relative to other groups would be exaggerated.

Because of these concerns, we performed a sensitivity analysis of our findings assuming higher denominators for Asian American subgroups and Native Hawaiians. (This is the more conservative direction, which assumes errors in the direction of less disparities.) The sensitivity analyses support our findings of important disparities in hospitalizations among those with HIV in some AA/NHOPI groups. After a 25% increase in the denominator, Japanese and Native Hawaiians still had significantly greater estimated rates of hospitalizations for those with HIV compared to Whites. Even after a 50% increase in the denominators, Native Hawaiians still showed significantly higher estimated rates of hospitalizations among HIV positive individuals compared to Whites. Our findings of disparities in hospitalizations among HIV positive individuals by race/ethnicity appear robust.

This study uses administrative data and does not include additional sociodemographic (eg, education) or cultural characteristics that might be useful for understanding study results. Further research might consider how these additional factors impact findings, and consider in more detail the pathways and barriers to HIV-related care. Additionally, while we consider some clinical options that may explain these differences, these did not appear likely to explain differences, as the clinical portraits were very similar. Other clinical details (such as substance use and immunologic or virologic status) may be useful. Other information, such as delayed entry into care, would also be important to consider in future research.

This study provides important, novel descriptive information about disparities in hospitalizations among people with HIV in Hawai‘i by race/ethnicity that can support and direct future work in this area. Future studies should address study limitations. For instance, we were not able to follow a cohort of HIV positive individuals to see how often they were hospitalized each year. Instead, we use two distinct databases over multiple years to determine our rates. (Thus, we used the term “estimated rates.”) Additionally, we are not able to compare if the estimated rates of hospitalizations among HIV positive individuals (overall) was different from the rate of hospitalizations in the state in general and could not test whether HIV contributes any additional burden to the hospitalizations in Hawai‘i, and if so to what extent. These will be fruitful areas for additional research.

Conclusions

Disparities appear to exist in rates of hospitalizations among HIV positive individuals for Native Hawaiians and Asians, as well as in the demographic and, to some degree, the clinical characteristics of those hospitalized. Native Hawaiians who are HIV positive appear to be particularly vulnerable to risk of hospitalizations and at younger ages. This information can be useful for targeted research, policy, and clinical practice to address these disparities among HIV-infected patients in Hawai‘i and elsewhere. Further research is warranted to investigate the reasons for these health disparities.

Appendix

Sensitivity Analysis of Estimated Rate Ratios (compared to Whites) with a 25% and 50% Increase in the Denominators

	Original				25% increase				50% increase
	RR Estimate	95% CI		P-value	RR Estimate	95% CI		P-value	RR Estimate	95% CI		P-value
Chinese vs. White	1.66	0.85	3.22	.1367	1.33	0.68	2.58	.4063	1.24	0.64	2.42	.5221
Filipino vs. White	1.62	1.01	2.59	.0472	1.29	0.80	2.07	.2918	1.07	0.67	1.72	.7677
Native Hawaiian vs. White	3.21	2.11	4.88	< .0001	2.56	1.68	3.89	< .0001	2.14	1.40	3.25	.0004
Japanese vs. White	2.27	1.38	3.72	.0012	1.82	1.11	2.98	.0179	1.51	0.92	2.47	.1047
Others vs. White	1.26	0.84	1.90	.2578	1.26	0.84	1.90	.2578	1.26	0.84	1.90	.2578

Conflict of Interest

None of the authors identify a conflict of interest.