Race, Relationships, and Trust in Providers among Black Patients with HIV/AIDS

HIV/AIDS prevalence and mortality rates within the black community are of great concern. Although black Americans make up only 13% of the population, they account for half of all new HIV infections in the United States (Centers for Disease Control and Prevention, 2009; I. Hall et al., 2008). Moreover, access to HIV care and treatment adherence are poorer for black people than for any other racial or ethnic group (Halkitis, Palamar, & Mukherjee, 2008; Heslin, Andersen, Ettner, & Cunningham, 2005; Korthuis et al., 2008; Pence et al., 2008). Although these disparities are likely to be multifactorial in origin, mistrust of medical professionals is believed to play an important role (Thrasher, Earp, Golin, & Zimmer, 2008). For black patients, mistrust of the medical community is well established and particularly prevalent for HIV treatment (Bogart & Thorburn, 2005; Cunningham, Sohler, Korin, Gao, & Anastos, 2007; Gamble, 1997; Halbert, Armstrong, Gandy, & Shaker, 2006; Herek & Capitanio, 1994; Stepanikova, Mollborn, Cook, Thom, & Kramer, 2006). A growing body of literature on race concordance between patients and providers lends support to the idea that trust may play a role in HIV-related health care disparities. For black patients in particular, race concordance represents a connection based on shared cultural beliefs and values that are associated with patients feeling more trustful and positive about their care (Saha, Arbelaez, & Cooper, 2003; Street, O'Malley, Cooper, & Haidet, 2008). A close and trusting patient–provider relationship has in turn been identified as a strong predictor of HIV treatment adherence (Altice, Mostashari, & Friedland, 2001; Beach, Keruly, & Moore, 2006; Mostashari, Riley, Selwyn, & Altice, 1998). Prior studies have demonstrated benefits of race concordance for black patients with HIV/AIDS (King, Wong, Shapiro, Landon, & Cunningham, 2004), but the majority of black patients in the United States do not see a race-concordant provider (Saha, 2009). It can be difficult for providers to discern what is or is not working for the patient. This may be especially challenging when providing treatment for black patients who may exercise a level of caution, skepticism, or self-preservation concerning how they are treated (referred to as health cultural paranoia) as a result of previous perceptions of negative, discriminatory, or racist interactions within racially discordant clinical encounters (Ridley, 1984). Within mental health settings, healthy cultural paranoia (sometimes interchangeable with the term cultural mistrust) continues to be noted in studies that seek to explain observations of skepticism or reservation for black patients (Terrell & Terrell, 1981; Whaley, 2001). Given the disproportionate burden experienced by black patients in HIV/AIDS settings, it is imperative that the factors that are associated with black patients’ trust in HIV care providers of all racial and ethnic backgrounds are identified. Poor patient–provider communication undoubtedly contributes to poor patient outcomes. Patients who are not comfortable with their provider may not disclose important information and, in turn, providers may not communicate or present information in a way that is clear to the patients. Ultimately, these issues can have severe health consequences for patients affected with HIV/AIDS. In addition, patients who do not trust their physician or feel that the physician does not care about their unique needs may not engage in or adhere to the prescribed treatment plan. In this study, we specifically examined black patients’ trust in their HIV care providers, focusing on characteristics that might serve as targets for interventions to improve patient–provider relationships.