In Los Angeles County, race/ethnicity information for cases reported to the HIV/AIDS Reporting System (HARS) is most often obtained from reviewing patient medical records. However, race/ethnicity may be misclassified for some individuals due to health care staff not asking the patient for, or not recording their race/ethnicity, on the patientís chart. The problem with racial/ethnic misclassification may be especially pronounced for American Indians/Alaska Natives (AI/ANs). In Los Angeles County, AI/ANs constitute 0.33% of the total population and 0.29% of the cumulative AIDS cases reported. The latter proportion may be an underestimate due to racial/ethnic misclassification of AI/ANs with AIDS.
In 2002, Los Angeles County Department of Health Services HIV Epidemiology Program collaborated with the Centers for Disease Control and Prevention on a multi-site project to evaluate the accuracy of data on race/ethnicity for AIDS cases among American Indians and Alaska Natives. The objectives of the study were 1) to estimate the accuracy of race/ethnicity data for reported AIDS cases among AI/ANs in Los Angeles County and 2) to determine the factors associated with the misclassification.
All 44,013 persons reported with AIDS in Los Angeles County HARS through April 2002 were compared with 2.5 million records from the national Indian Health Services patient registry (IHS) from mid 1980s to January 2001. In all, 1,757 AI/ANs were also identified from the death certificate database in Los Angeles County Vital Records between 1980 and 1999 and 33 AI/ANs from Ryan White CARE Act-funded outpatient medical facilities in Los Angeles County since 1991.
Because of the requirement of tribal affiliation to utilize IHS, we consider IHS patient registry the most reliable of these three. However, not all AI/ANs utilize Indian Health services; this is especially true in urban areas, therefore, we also included the other two data sources for matching against the AIDS case registry
Exactly matched pairs were identified based on the name, birth date, gender, and social security number using the Integrity software. Partially matched pairs were reviewed and juried by three study investigators using a standardized protocol.
We identified substantial racial/ethnic misclassification among AI/AN AIDS cases reported in Los Angeles County, which has resulted in underestimation of AIDS rates in this racial/ethnic group. This study may be limited by low utilization of Indian Health Services in urban areas by American Indians/Alaska Natives, the underreporting of AI/AN in vital statistics, and insufficient information for persons with mixed races/ethnicities among the data sources. Institutions who rely solely on active and passive surveillance reporting should consider the effect of this underestimation when decision-making, program planning, and allocating resources for prevention and care services.
Virginia Hu, MPH, Epidemiologist
Mi Suk Yu-Harlan, MSPH, Epidemiologist
Douglas Frye, MD, MPH, Medical Epidemiologist