Pneumoscystis carinii Pneumonia in Asians and Pacific Islanders

Methods. In an effort to assess the existence of such a racial/ethnic trend, the same type of data on frequency and proportion of confirmed PCP diagnoses as presenting opportunistic infection among adolescents and adults diagnosed with AIDS in the United States from 1984 through December of 1994 used by Hu and co-authors [1] were analyzed as produced directly from the Center for Disease Control and Prevention's Public Information Data Set (AIDSPIDS) [7] . Logistic regression analysis was conducted using SAS. Models were designed after Hu and co-authors [1] : the outcome was confirmed PCP diagnosis as the presenting opportunistic infection, race group was dummy coded as contrasts with each race group against "Asian and Pacific Islander", covariates were: year of diagnosis (entered as a continuous variable 84 through 94), transmission exposure group (using the AIDSPIDS exposure categories: injecting drug use, heterosexual contact with a person with or at increased risk for HIV infection, other exposures including hemophilia and blood transfusion, contrasted against men who have sex with men), age at diagnosis (using the AIDSPIDS age category entered as a continuous variable: 13 to 19 years, 20 to 24 years, 25 to 29 years, 30 to 34 years, 35 to 39 years, 40 to 44 years, 45 to 49 years, 50 to 54 years, 55 to 59 years, 60 to 64 years, 65 years or older), geographic region of residence in the United States (using the AIDSPIDS categories: Central, Western, Southern, Mid-Atlantic, and smaller msa (50,000 to 1,000,000), contrasted against North), gender (female, male), and birthplace (born in U.S, born outside U.S.).

Results. Inspection of these data show that compared to all other race groups, a higher proportion of Asians and Pacific Islanders with AIDS were diagnosed with PCP as presenting opportunistic infection each year from 1984 through 1994 in spite of the overall decrease in the incidence of PCP, as presenting opportunistic infection, diagnoses over that decade (beta for year of diagnosis controlling for race = -0.289, chi-square = 39224, p < 0.0001). For example, Asians and Pacific Islanders exhibited a high of 82.61% PCP diagnoses in presenting AIDS defining condition in 1984 when the average was 62.5%. Similarly, 23.51% of Asians and Pacific Islanders presenting AIDS defining conditions were attributed to PCP in 1994 when the average was 13.1%. Table 1 describes the results of a logistic regression was run to assess the strength and magnitude of the difference in risk for PCP diagnoses among Asians and Pacific Islanders for the 10 year period from 1984 to 1994, and adjusted odds ratios showed that Asians and Pacific Islanders were at increased risk for PCP compared to all other race group (p < 0.0001) controlling for year of diagnosis, transmission exposure group, geographic region of residence in the United States, gender, and birthplace.

Discussion. Asians and Pacific Islanders are at increased risk for PCP compared to each race group controlling for relevant temporal, demographic, and HIV transmission/exposure factors. The consistently high proportion of PCP diagnoses among Asians and Pacific Islanders with AIDS is thought to be, in part, the result of barriers to accessing adequate health care [2-4] . Hu et. al. [1] conclude that differences in AIDS-defining conditions by race/ethnicity are also likely due to differences in underlying exposure or reporting of conditions as well [5, 6] . Other researchers have elaborated the barriers to proper care as the result of the lack of culturally relevant and language appropriate educational materials, denial, distrust of institutions, fear of being identified as a person with AIDS, and poor knowledge of the disease and its sequelae [8, 9] . Before any firm conclusions can be made as to the nature of racial/ethnic differences in this disease process, readers should be cautioned that it may be necessary to acknowledge both methodologically, as well as statistically, that there exists a great deal of diversity and variance within each race/ethnic group [10] . It is crucial for researchers, clinicians, and policy makers to understand that Asians and Pacific Islanders, like other minority groups, may be experiencing barriers to receiving or maintaining prophylaxis for an easily preventable AIDS-defining condition.

Table 1. Adjusted odds ratios for AIDS - defining PCP diagnoses among Asians and Pacific Islanders in the United States versus other racial groups (controlling for year of AIDS diagnosis, transmission exposure risk group, gender, country of birth, region of residence, and age at diagnosis) [7].

*Race OR 95% Confidence Interval
A&PI >	Native American	1.367	(1.166, 1.605)
A&PI >	Latino	1.919	(1.783, 2.070)
A&PI >	African American	1.689	(1.567, 1.818)
A&PI >	White	1.533	(1.425, 1.650)
*each adjusted odds ratio was significant at p < .0001.