The Impact of HIV On Behavioral Health Service Utilization: Propensity Score Analysis of Nationally Representative Household Survey Data
Studies that have examined access to services have yielded mixed results as to whether access to behavioral health services among people with co-occurring substance use and mental health disorders (COD) is affected negatively or positively by HIV status. Moreover, most of that research has been conducted among clinical samples (either people in medical settings or outpatient treatment). This study uses a nationally representative household survey and advanced statistical method to contribute to a better understanding of access to care.
Data are from the 2008-2011 National Survey on Drug Use and Health (NSDUH), which is a nationally representative household survey conducted in the 50 states and the District of Columbia. The NSDUH relies on computer-assisted face-to face interviews to gather information from household residents across the United States. Only people age 18 years or older with both a mental illness and a substance use disorder (drug or alcohol abuse or dependence) were selected for this study. Two questions about participation in mental health treatment and substance use treatment in the past year were used to create the dependent variable. Conditioning variables included gender, age, educational level, race, criminal history, ever injected drugs, insurance resources, income level, perceived need for treatment, and severity of behavioral disorders. R was used to conduct propensity score matching analysis. After one-to-many propensity score matching adjusting for the conditioning variables, two groups were formed: 29 “cases” (people with COD and HIV) and 451 “controls” (people with COD but not HIV)”. The impact of HIV on behavioral health utilization was assessed through logistic regression. All significance tests were two-tailed, P<.05.
Approximately two thirds (69%) of people with COD and HIV accessed behavioral health services in the past year, but slightly less than one half (45.7%) of people with only COD accessed behavioral health care. HIV status is significantly associated with behavioral health service utilization; among people with comorbid substance use and mental health disorders, the odds of behavioral health service use are 2.64 times higher for people living with HIV than without HIV.
Conclusion and Implications
Among people with COD, those who also have HIV are more likely to participate in behavioral health services. This finding may be partially explained by federal initiatives to increase access to care for persons with HIV. The results also suggest there may be unmet need and unequal access to care among people with only COD, highlighting policy-relevant questions for implementing the Affordable Care Act to equalize access overall.