Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV

Experiences of racial discrimination in the medical setting and associations with medical mistrust and expectations of care among black patients seeking addiction treatment

INTRODUCTION

Experiences of racial discrimination in the medical setting are common among Black patients and may be linked to mistrust in medical recommendations and poorer clinical outcomes. However, little is known about the prevalence of experiences of racial mistreatment by healthcare workers among Black patients seeking addiction treatment, or how these experiences might influence Black patients' medical mistrust or expectations of care.

METHODS

Participants were 143 Black adults recruited consecutively from two university addiction treatment facilities in Columbus, Ohio. All participants completed validated surveys assessing perceptions of prior racial discrimination in the medical setting and group-based medical mistrust. Participants were also asked a series of questions about their expectations of care with regard to racial discrimination and addiction treatment. Descriptive analyses were used to characterize the sample with regard to demographics, perceived racial discrimination and medical mistrust. Kendall tau-b correlations assessed relationships between racial discrimination, mistrust and expectations of care.

RESULTS

Seventy-nine percent (n = 113) of participants reported prior experiences of racial discrimination during healthcare. Racial discrimination in the medical setting was associated with greater mistrust in the medical system and worse expectations regarding racial discrimination in addiction treatment including delays in care-seeking due to concern for discrimination, projected non-adherence and fears of discrimination-precipitated relapse.

CONCLUSIONS

Black patients seeking addiction treatment commonly report experiencing racial discrimination by healthcare workers which may be associated with mistrust in the medical system and expectations of care. Strategies to eliminate and mitigate experiences of racial discrimination may improve addiction treatment receptivity and engagement.

Coronavirus conspiracy beliefs and distrust of science predict risky public health behaviours through optimistically biased risk perceptions in Ukraine, Turkey, and Germany

The present paper examines the extent to which conspiracy beliefs about the COVID-19 outbreak and distrust of epidemiological science are likely to predict optimistically biased risk perceptions at the individual and group levels. We explored the factor structure of coronavirus conspiracy beliefs and their associations with trust in science in predicting risk perceptions using survey data collected in Ukraine ( N = 390), Turkey ( N = 290), and Germany ( N = 408). We further expected conspiracy beliefs and distrust of science to predict people’s willingness to attend public gatherings versus maintaining preventive physical distancing through optimistically biased risk perceptions. Metric noninvariance for key constructs across the samples was observed so the samples were analysed separately. In Ukraine, a two-factor structure of conspiracy beliefs was found wherein COVID-19 bioweapon (but not COVID-19 profit) beliefs were negatively associated with public gathering through optimistically biased individual risk perceptions. In Turkey and Germany, conspiracy beliefs showed a single-factor solution that was negatively associated with preventive distancing and positively related to public gathering through optimistically biased public risk metaperceptions. The hypothesis about the direct and indirect effects of trust in science on risky health behaviour was partially confirmed in all three samples. The observed discrepancies in our findings are discussed.

Feasibility and Acceptability of a Program to Promote Positive Affect, Well-Being and Gender Empowerment in Black Women Living with HIV

While programs and interventions intended to increase positive affect among people living with HIV (PLWH) and other chronic diseases have been associated with improved health outcomes, including decreased depression, programs have not been tailored specifically for Black women. We tailored a program designed to increase positive affect and to decrease depressive symptoms in PLWH to a group format for Black WLWH. We also added skills to increase gender empowerment. We then tested the acceptability and feasibility of this program with 8 Black WLWH. The program was acceptable and relatively feasible, as assessed by women’s participation and feedback about program clarity and helpfulness, which women rated above 9 on a 10-point scale. A few women suggested that optimal delivery point for some skills taught would be shortly after HIV diagnosis. A proof-of-concept program intended to bolster positive emotions and gender empowerment and decrease depression can be tailored for Black WLWH and is relatively feasible and acceptable. A randomized controlled trial is needed to assess the preliminary efficacy of this program on positive affect, depression, and other health outcomes for WLWH.

Are the current evaluation tools for advanced therapies biased?

PURPOSE OF REVIEW

Despite attention to racial disparities in outcomes for heart failure (HF) and other chronic diseases, progress against these inequities has been gradual at best. The disparities of COVID-19 and police brutality have highlighted the pervasiveness of systemic racism in health outcomes. Whether racial bias impacts patient access to advanced HF therapies is unclear.

RECENT FINDINGS

As documented in other settings, racial bias appears to operate in HF providers' consideration of patients for advanced therapy. Multiple medical and psychosocial elements of the evaluation process are particularly vulnerable to bias.

SUMMARY

Reducing gaps in access to advanced therapies will require commitments at multiple levels to reduce barriers to healthcare access, standardize clinical operations, research the determinants of patient success and increase diversity among providers and researchers. Progress is achievable but likely requires as disruptive and investment of immense resources as in the battle against COVID-19.

Black and Latino Persons Living with HIV Evidence Risk and Resilience in the Context of COVID-19: A Mixed-Methods Study of the Early Phase of the Pandemic

The COVID-19 pandemic has great potential to disrupt the lives of persons living with HIV (PLWH). The present convergent parallel design mixed-methods study explored the early effects of COVID-19 on African American/Black or Latino (AABL) long-term survivors of HIV in a pandemic epicenter, New York City. A total of 96 AABL PLWH were recruited from a larger study of PLWH with non-suppressed HIV viral load. They engaged in structured assessments focused on knowledge, testing, trust in information sources, and potential emotional, social, and behavioral impacts. Twenty-six of these participants were randomly selected for in-depth semi-structured interviews. Participants were mostly men (64%), African American/Black (75%), and had lived with HIV for 17 years, on average (SD=9 years). Quantitative results revealed high levels of concern about and the adoption of recommended COVID-19 prevention recommendations. HIV care visits were commonly canceled but, overall, engagement in HIV care and antiretroviral therapy use were not seriously disrupted. Trust in local sources of information was higher than trust in various federal sources. Qualitative findings complemented and enriched quantitative results and provided a multifaceted description of both risk factors (e.g., phones/internet access were inadequate for some forms of telehealth) and resilience (e.g., “hustling” for food supplies). Participants drew a direct line between structural racism and the disproportional adverse effects of COVID-19 on communities of color, and their knowledge gleaned from the HIV pandemic was applied to COVID-19. Implications for future crisis preparedness are provided, including how the National HIV/AIDS Strategy can serve as a model to prevent COVID-19 from becoming another pandemic of the poor.

Who Is Not Linking to HIV Care in Tennessee - the Benefits of an Intersectional Approach

Introduction

Guided by an intersectional approach, we assessed the association between social categories (individual and combined) on time to linkage to HIV care in Tennessee.

Methods

Tennessee residents diagnosed with HIV from 2012-2016 were included in the analysis (n=3750). Linkage was defined by the first CD4 or HIV RNA test date after HIV diagnosis. We used Cox proportional hazards models to assess the association of time to linkage with individual-level variables. We modeled interactions between race, age, gender, and HIV acquisition risk factor (RF), to understand how these variables jointly influence linkage to care.

Results

Age, race, and gender/RF weAima A. Ahonkhaire strong individual (p < 0.001 for each) and joint predictors of time to linkage to HIV care (p < 0.001 for interaction). Older individuals were more likely to link to care (aHR comparing 40 vs. 30 years, 1.20, 95%CI 1.11-1.29). Blacks were less likely to link to care than Whites (aHR= 0.73, 95% CI: 0.67-0.79). Men who have sex with men (MSM) (aHR = 1.18, 95%CI: 1.03-1.34) and heterosexually active females (females) (aHR = 1.32, 95%CI: 1.14-1.53) were more likely to link to care than heterosexually active males. The three-way interaction between age, race, and gender/RF showed that Black males overall and young, heterosexually active Black males in particular were least likely to establish care.

Conclusions

Racial disparities persist in establishing HIV care in Tennessee, but data highlighting the combined influence of age, race, gender, and sexual orientation suggest that heterosexually active Black males should be an important focus of targeted interventions for linkage to HIV care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40615-021-01023-6.

The Effect of Various Supportive Housing Models on ART Adherence Among Persons Living With HIV in Supportive Housing

BACKGROUND

Providing permanent supportive housing to chronically homeless persons living with human immunodeficiency virus (PLH) contributes to improved human immunodeficiency virus (HIV) outcomes, including adherence to antiretroviral therapy (ART). This study seeks to understand whether certain components of housing, namely intensity of case management and specialized HIV housing programs, affects ART adherence for PLH in supportive housing.

METHODS

From 2015 to 2019 we conducted quantitative assessments with 157 PLH in supportive housing at baseline, 6-, 12-, and 18-month postbaseline to identify factors associated with ART adherence. General Estimating Equations for repeated measures were performed to assess bivariate and multivariate measures.

RESULTS

Two thirds of PLH in supportive housing reported 95% or greater adherence to ART. Multivariate analyses indicate that neither intensity of case management services nor specialized housing for PLH were associated with greater ART adherence. Greater time since diagnosis was positively associated with ART adherence. Greater depressive symptoms and African American race were negatively associated with ART adherence.

CONCLUSIONS

Study findings reveal that although prior research has established the importance of receipt of housing for homeless PLH, the type or intensity of case management services associated with that housing may not be as important as simply being housed. Our results highlight the importance of considering mental health and more recent HIV diagnosis when developing treatment and case management plans to enhance residents' ART adherence.

Conducting Virtual, Synchronous Focus Groups Among Black Sexual Minority Men: Qualitative Study

Background

Focus groups are useful to support HIV prevention research among US subpopulations, such as Black gay, Black bisexual, and other Black sexual minority men (BSMM). Virtual synchronous focus groups provide an electronic means to obtain qualitative data and are convenient to implement; however, the protocols and acceptability for conducting virtual synchronous focus groups in HIV prevention research among BSMM are lacking.

Objective

This paper describes the protocols and acceptability of conducting virtual synchronous focus groups in HIV prevention research among BSMM

Methods

Data for this study came from 8 virtual synchronous focus groups examined in 2 studies of HIV-negative BSMM in US cities, stratified by age (N=39): 2 groups of BSMM ages 18-24 years, 5 groups of BSMM ages 25-34 years, and 1 group of BSMM 35 years and older. Virtual synchronous focus groups were conducted via Zoom, and participants were asked to complete an electronic satisfaction survey distributed to their email via Qualtrics.

Results

The age of participants ranged from 18 to 44 years (mean 28.3, SD 6.0). All participants “strongly agreed” or “agreed” that they were satisfied participating in an online focus group. Only 17% (5/30) preferred providing written informed consent versus oral consent. Regarding privacy, most (30/30,100%) reported “strongly agree” or “agree” that their information was safe to share with other participants in the group. Additionally, 97% (29/30) reported being satisfied with the incentive.

Conclusions

Conducting virtual synchronous focus groups in HIV prevention research among BSMM is feasible. However, thorough oral informed consent with multiple opportunities for questions, culturally relevant facilitation procedures, and appropriate incentives are needed for optimal focus group participation.

What Do Adults With HIV Want? End-of-Life Care Goals, Values and Beliefs by Gender, Race, Sexual Orientation

OBJECTIVE

We examined factors influencing end-of-life care preferences among persons living with HIV (PLWH).

METHODS

223 PLWH were enrolled from 5 hospital-based clinics in Washington, DC. They completed an end-of-life care survey at baseline of the FACE™-HIV Advance Care Planning clinical trial.

FINDINGS

The average age of patients was 51 years. 56% were male, 66% heterosexual, and 86% African American. Two distinct groups of patients were identified with respect to end-of-life care preferences: (1) a Relational class (75%) who prioritized family and friends, comfort from church services, and comfort from persons at the end-of-life; and (2) a Transactional/Self-Determination class (25%) who prioritized honest answers from their doctors, and advance care plans over relationships. African Americans had 3x the odds of being in the Relational class versus the Transactional/Self-determination class, Odds ratio = 3.30 (95% CI, 1.09, 10.03), p = 0.035. Males were significantly less likely to be in the relational latent class, Odds ratio = 0.38 (CI, 0.15, 0.98), p = 0.045. Compared to non-African-Americans, African-American PLWH rated the following as important: only taking pain medicines when pain is severe, p = 0.0113; saving larger doses for worse pain, p = 0.0067; and dying in the hospital, p = 0.0285. PLWH who were sexual minorities were more afraid of dying alone, p = 0.0397, and less likely to only take pain medicines when pain is severe, p = 0.0091.

CONCLUSION

Integrating culturally-sensitive palliative care services as a component of the HIV care continuum may improve health equity and person-centered care.

A Community-Developed, Web-Based Mobile App Intervention Addressing Social Work and Legal Needs of Black Sexual Minority Men Living With HIV: Protocol for a Randomized Comparison Trial

Background

Black sexual minority men (BSMM) are disproportionately affected by HIV. Los Angeles County (LAC) carries a substantial burden of the HIV epidemic in California. Negative effects of both psychosocial and structural barriers highlight the timely need to increase HIV treatment among BSMM. Successful HIV interventions based on social media and mobile phone technology have been demonstrated. This protocol describes LINX LA, a study that tests LINX, a web-based mobile app that provides tailored social services, legal resources, and peer support for BSMM living with HIV (BSMM+) in LAC using a randomized comparison trial.

Objective

During phase 1, the LINX LA study aims to engage in an iterative design process to develop the LINX App using qualitative data to inform and tailor the mobile app technology and its functionality. In phase 2 of LINX LA, we will test the efficacy of the LINX App compared with the LINX App Plus to improve HIV treatment outcomes (ie, antiretroviral therapy adherence, viral suppression) among BSMM+ in LAC by addressing social work and legal needs and developing a forum for peer support.

Methods

In this study funded by the California HIV/AIDS Research Program, we will recruit and enroll BSMM+ participants (aged ≥18 years) in LAC (N=400) to participate in a 12-month study that includes access to the LINX App, which provides a forum for peer support and tailored content aimed at improving the use of social and legal resources. All participants will also receive survey-based interviews at 3 time points (at baseline and 6- and 12-month intervals) and weekly text message surveys that assess medication and treatment adherence. Treatment adherence and viral suppression will be extracted from medical record data. Half of the participants will also be randomly assigned to receive 3 individualized coaching sessions (at 1-, 3-, and 6-month intervals) and the ability to directly message their coach via the LINX App. Over the course of the study, LINX App participants will receive a minimum of US $130 in cash and LINX App Plus participants will receive a minimum of US $190. We hypothesize that participants enrolled in LINX App Plus will demonstrate greater improvement in HIV outcomes compared with LINX App participants.

Results

The LINX study will test the efficacy of a web-based mobile app intervention for BSMM+ in LAC (N=400). The LINX App seeks to increase participants’ knowledge of HIV; to facilitate access to necessary social and legal services, including information and referrals; and to increase social support across participants by providing a mediated forum for engagement.

Conclusions

The implementation of LINX LA aims to develop and test a culturally tailored approach to improve the HIV treatment outcomes of BSMM+.

International Registered Report Identifier (IRRID)

PRR1-10.2196/19770

ART Adherence Among Men Who Have Sex with Men Living with HIV: Key Challenges and Opportunities

PURPOSE OF REVIEW

In the USA, gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV. High levels of adherence to antiretroviral therapy (ART) can dramatically improve outcomes for persons living with HIV and reduce the risk of HIV transmission to others. Yet, there are numerous individual, social, and structural barriers to optimal ART adherence. Many of these factors disproportionately impact Black MSM and may contribute to their poorer rates of ART adherence. This review synthesizes the key challenges and intervention opportunities to improve ART adherence among MSM in the USA.

RECENT FINDINGS

Key challenges to ART adherence include stigma, violence, depression, and substance use. Black MSM are significantly disadvantaged by several of these factors. There are several promising interventions to improve ART adherence among MSM, and there remains an opportunity to culturally tailor these to the needs of Black MSM populations to enhance adherence. Despite high rates of HIV among MSM, there continues to be a paucity of research on the various contributors to poor ART adherence among this population. Similarly, few interventions have been tested that lead to increased and sustained ART adherence among Black MSM.

Health care access, health care utilisation and sexual orientation disclosure among Black sexual minority men in the Deep South

Background Black gay, bisexual, and other sexual minority men (BSMM) account for 39.1% of new HIV infections among men who have sex with men and 78.9% of newly diagnosed cases among Black men. Health care access, health care utilisation and disclosing sexuality to providers are important factors in HIV prevention and treatment. This study explored the associations among sexual orientation disclosure, health care access and health care utilisation among BSMM in the Deep South.

METHODS

Secondary analysis of existing data of a population-based study in Jackson, Mississippi, and Atlanta, Georgia, was conducted among 386 BSMM. Poisson regression models were used to estimate prevalence ratios (PR) between sexual orientation disclosure to healthcare providers, health care access and health care utilisation.

RESULTS

The mean (±s.d.) age of participants was 30.5 ± 11.2 years; 35.3% were previously diagnosed with HIV and 3.7% were newly diagnosed with HIV. Two-thirds (67.2%) self-identified as homosexual or gay; 70.6% reported being very open about their sexual orientation with their healthcare providers. After adjustment, BSMM who were not open about their sexual orientation had a lower prevalence of visiting a healthcare provider in the previous 12 months than those who were very open with their healthcare provider (PR 0.42; 95% confidence interval 0.18-0.97).

CONCLUSION

Clinics, hospitals and other healthcare settings should promote affirming environments that support sexuality disclosure for BSMM.

Perceptions of network based recruitment for hepatitis C testing and treatment among persons who inject drugs: a qualitative exploration

BACKGROUND

Social network interventions that take advantage of existing individual and group relationships may help overcome the significant patient, provider, and system level barriers that contribute to low hepatitis C Virus (HCV) treatment uptake among people who inject drugs (PWID).

METHODS

We conducted semi-structured interviews with 20 HCV antibody positive PWID (15 male, 5 female) in Baltimore, Maryland, USA. We utilized thematic analysis and employed both inductive and deductive coding techniques to assess perceptions of barriers and facilitators of social network interventions for HCV testing, linkage to care, and treatment among PWID.

RESULTS

PWID perceived a high prevalence of HCV within their social networks, especially within injection drug use networks. Overwhelmingly, participants reported a willingness to discuss HCV and provide informational, instrumental, and emotional support to their network members. Support included sharing knowledge, such as where and how to access HCV care, as well as sharing lived experiences about HCV treatment that could help peers build trust within networks. Participants who were already linked into HCV care had an increased understanding of using social network interventions to provide peer navigation, by accompanying network members to HCV related appointments. Across interviews, drug use related stigma and feeling undeserving of HCV treatment due to previous negative experiences accessing the health care system emerged as a major barrier to linkage to HCV treatment and cure. Undeservingness was often internalized and projected onto network members. To overcome this, participants supported access to low-barrier HCV treatment in alternative locations such as community-based or mobile clinics and drug treatment centers.

CONCLUSION

Social network based interventions have potential to increase HCV treatment uptake among PWID. To be successful, these interventions will need to train peers to share accurate information and personal experiences with HCV testing and treatment and enhance their ability to provide support to network members who face significant stigma related to both HCV and drug use.

Mistrust and misinformation: A two-component, socio-epistemic model of belief in conspiracy theories

Although conspiracy theories are endorsed by about half the population and occasionally turn out to be true, they are more typically false beliefs that, by definition, have a paranoid theme. Consequently, psychological research to date has focused on determining whether there are traits that account for belief in conspiracy theories (BCT) within a deficit model. Alternatively, a two-component, socio-epistemic model of BCT is proposed that seeks to account for the ubiquity of conspiracy theories, their variance along a continuum, and the inconsistency of research findings likening them to psychopathology. Within this model, epistemic mistrust is the core component underlying conspiracist ideation that manifests as the rejection of authoritative information, focuses the specificity of conspiracy theory beliefs, and can sometimes be understood as a sociocultural response to breaches of trust, inequities of power, and existing racial prejudices. Once voices of authority are negated due to mistrust, the resulting epistemic vacuum can send individuals “down the rabbit hole” looking for answers where they are vulnerable to the biased processing of information and misinformation within an increasingly “post-truth” world. The two-component, socio-epistemic model of BCT argues for mitigation strategies that address both mistrust and misinformation processing, with interventions for individuals, institutions of authority, and society as a whole.

Community-Informed Development of a Campaign to Increase HIV Pre-exposure Prophylaxis (PrEP) Awareness Among African-American Young Adults

Pre-exposure prophylaxis (PrEP) for HIV prevention can help reduce racial/ethnic HIV disparities in the USA. However, the benefits of PrEP have not been equally distributed across races. Community-informed, culturally tailored media has the potential to increase PrEP awareness and acceptability among vulnerable African-American populations. More research is needed to identify media preferences around PrEP for these groups in order to optimize effectiveness of health messaging. This study details the development of a community-informed multimedia (print, digital, Internet radio, website, social media) campaign to increase PrEP awareness among African-American young adults (age 18-29 years). Eleven focus groups with African-American young adults and a community advisory board informed the intervention. Focus group participants expressed concerns with PrEP safety, efficacy, accessibility, the universality of HIV vulnerability, and representation. Campaign elements were then developed based on this feedback. Future studies should examine the effectiveness of culturally tailored multimedia PrEP campaigns.

The dual contingencies of ethnoraciality: Status-context disparities in health information sources among sexual minorities

Researchers often explore health (care) beliefs as a function of individual characteristics; yet, few consider the role of context in shaping both beliefs and the behaviors that are informed by them. As a sociopolitical construct, ethnoraciality provides a concerning source of bias in studies of health (care) beliefs because it inhabits both individual and contextual forms. This study examines whether the ethnoracial context of the residential area where sexual minorities live is associated with a particular health (care) belief - sources of trustworthy health information - and considers how ethnoracial group membership status differentiates these ecological associations drawing on mediation and moderation models. Using data from the 2010 Social Justice Sexuality Project, our analysis shows that sexual minorities who live with high concentrations of Latinos and Whites are less likely to rely exclusively on medical professionals for trustworthy health information than those who live with high concentrations of Blacks. Moreover, exclusive reliance on medical professionals for health information among Black and Latino sexual minorities is stronger in co-ethnic communities (predominately Black and Latino areas, respectively). The analysis also documents status and contextual differentials and status-context contingencies of reliance on the Internet, social networks, and multiple agents ("triangulation") as sources of health information. Findings suggest that place-based co-ethnic networks may facilitate disease prevention among Black and Latino sexual minorities by improving the quality of their relationships with sick role gatekeepers and breaking down the silos of the medical complex. The study concludes by considering the value of a place-based approach to alleviating health disparities among sexual minorities vis-à-vis the health care system.

Alcohol Use and Ethnicity Independently Predict Antiretroviral Therapy Nonadherence Among Patients Living with HIV/HCV Coinfection

BACKGROUND

Adherence to antiretroviral therapy (ART) is important to counter synergistic effects of HIV and hepatitis C (HCV) in patients living with coinfection. Predictors of ART nonadherence among patients living with HIV/HCV coinfection are not well established. This knowledge would be advantageous for clinicians and behavioral health specialists who provide care to patients living with HIV/HCV coinfection.

OBJECTIVES

The purpose of this study was to assess prevalence and predictors of ART nonadherence in a sample of patients living with HIV/HCV coinfection who were actively in HIV clinical care.

METHOD

A sample of patients living with HIV/HCV coinfection who received care at a university-affiliated HIV clinic (n = 137) between January 2013 and July 2017 were included in the study. Computerized patient-reported data or outcomes (PROs) and electronic medical record data of these respective patients were collected and analyzed. Binomial logistic regression was used to examine predictors of ART nonadherence.

RESULTS

The prevalence of ART nonadherence was 31%. In multivariate analysis, African American ethnicity (OR = 3.28, CI 1.241-8.653, p = 0.017) and a higher number of alcoholic drinks per drinking day (OR = 1.31, CI 1.054-1.639, p = 0.015) were positively associated with ART nonadherence.

CONCLUSIONS

Behavioral health providers are encouraged to incorporate alcohol use reduce interventions in HIV clinical settings to reduce ART nonadherence among patients living with HIV/HCV coinfection. Additionally, public health professionals and researchers, and clinicians are encouraged to use inductive methods to discover why ART nonadherence disproportionately impacts African American patients living with HIV/HCV coinfection and to develop approaches that are sensitive to those respective barriers.

Association of Medical Mistrust and Poor Communication with HIV-Related Health Outcomes and Psychosocial Wellbeing Among Heterosexual Men Living with HIV

Studies have suggested that effective patient-provider relationships may reduce health disparities and foster engagement across the HIV care continuum among people living with HIV/AIDS. However, no studies have explored specific mechanisms between medical mistrust/poor communication and HIV-related/psychosocial health outcomes among HIV-positive men of color who have sex with women (MCSW) in the United States. From 2011 to 2012, the research team recruited 317 eligible participants in New York City. Using validated explanatory and predictive modeling strategies, we explored the associations between mistrust/poor communication and HIV-related/psychosocial health outcomes among this group. Subgroup analyses were further conducted to assess the different effects of non-Hispanic black and Hispanic men. A total of 313 males (204 black, 93 Hispanic, and 16 others) reported that valid responses were included in the current analysis. In the explanatory models, both mistrust and poor communication were negatively associated with various HIV-related and psychosocial outcomes among this group of HIV-positive MCSW. In the predictive models, predictors of mistrust for the overall sample and the black subsample were nearly the same. On the contrary, predictors of poor communication were substantially different when comparing black and Hispanic HIV-positive MCSW. Our findings confirm that patient-provider relationship quality is associated with poor HIV-related and psychosocial outcomes in black and Hispanic MCSW. A different set of multi-level predictors are associated with mistrust and poor communication comparing black and Hispanic MCSW. We call for interventions addressing patient-provider relationship quality that are tailored differently for black and Hispanic men.

Physician Mistrust, Medical System Mistrust, and Perceived Discrimination: Associations with HIV Care Engagement and Viral Load

Medical mistrust is an important risk factor for many health outcomes. For individuals with HIV and substance use co-morbidities, mistrust may influence engagement with health care, and affect overall health and transmission risk. Medical mistrust can be measured by an individual's mistrust of his/her physician, or mistrust of the medical system. This study examined both types of mistrust among 801 substance-using individuals with uncontrolled HIV infection. The aims were to determine how physician mistrust, medical system mistrust, and discrimination experiences were associated with engagement in HIV primary care. Findings indicated higher levels of physician mistrust, but not medical system mistrust, were associated with a longer time since the last visit to an HIV provider. Longer time since seeing an HIV care provider was associated with higher viral load. This study refines our understanding of the relationship between mistrust and HIV care engagement for a large, diverse sample of substance-using individuals.

Improving the HIV Prevention Landscape to Reduce Disparities for Black MSM in the South

Black men who have sex with men (MSM) in the South have the highest rates of HIV diagnosis in the country adding to the persistent racial disparities in HIV experienced by this population. The current HIV prevention and care landscape is heavily driven by individual-level clinical and biomedical approaches that have shown progress in reducing HIV diagnoses, but yield less than adequate results in reducing the HIV racial disparities for Black MSM in the South. In efforts to enhance focus on reducing the racial HIV disparities and more completely address the needs of Black MSM in the South, we offer insight on comprehensive approaches that can complement our current HIV prevention and care portfolio. There are five domains we discuss which include: (1) leveraging and integrating resources; (2) building upon existing program models designed to reduce disparities; (3) workforce development and cultural sensitivity; (4) social determinants of health data utilization; and 5) policy considerations. We urge public health practitioners and healthcare providers to consider and incorporate the outlined approaches to improve HIV outcomes along the continuum of care and ultimately reduce disparities in HIV affecting the quality of life of Black MSM living in the South.

Trajectories and Predictors of Longitudinal Preexposure Prophylaxis Adherence Among Men Who Have Sex With Men

Background

Adherence is necessary for efficacy of preexposure prophylaxis (PrEP), and text-messaging methods are promising tools for both adherence assessment and support. Although PrEP adherence is variable, little research has examined patterns of variability or factors associated with longitudinal use.

Methods

In the context of a randomized controlled trial of text-messaging versus standard of care for PrEP adherence, 181 men who have sex with men received once-daily tenofovir disoproxil fumarate/emtricitabine and daily adherence texts for 48 weeks. Growth mixture modeling (GMM) was used to identify subgroups of individuals with similar trajectories of text-reported adherence. Between-group differences in pharmacologic measures of adherence (ie, tenofovir diphosphate and emtricitabine triphosphate levels), as well as predictors and study-end attitudes associated with group membership, were examined.

Results

GMM identified 4 trajectories of text-reported adherence. Classes with higher text-reported adherence had higher drug concentrations. Younger age and minority race were associated with lower adherence, and individuals in classes with lower adherence had greater baseline levels of depression, substance use concerns, and sexual risk. Differences in study satisfaction were also associated with adherence.

Conclusions

This study supports the use of text-reported PrEP adherence. Identifying factors associated with less-than-optimal adherence may aid clinicians in anticipating at-risk patients requiring augmented intervention.

Clinical trials registration

NCT01761643.

Effects of individual and neighborhood socioeconomic status on antiretroviral therapy adherence: The role of adherence self-efficacy

This study aimed to examine the potential mediation effect of adherence self-efficacy on the associations between individual and neighborhood socioeconomic status and antiretroviral therapy adherence in a sample of 337 people living with HIV in South Carolina, United States. Results showed that there were no direct effects of individual or neighborhood socioeconomic status on antiretroviral therapy adherence, whereas both individual socioeconomic status and neighborhood socioeconomic status were associated with adherence self-efficacy, which in turn were related to antiretroviral therapy adherence. These findings suggest that interventions targeting adherence self-efficacy may improve antiretroviral therapy adherence among people living with HIV with low socioeconomic status or those living in socioeconomically disadvantaged neighborhoods.

Positive religious coping predicts self-reported HIV medication adherence at baseline and twelve-month follow-up among Black Americans living with HIV in the Southeastern United States

This paper presents the results of secondary data analyses investigating the influence of religious coping on HIV medication adherence across time among 167 Black Americans living with HIV (BALWH) in the Southeastern United States. Participants were recruited from a large urban clinic in Atlanta, GA and completed questionnaires about their religious coping at baseline assessment and about their medication adherence at baseline and 12-month follow-up assessment. Descriptive analyses and multiple linear regression were used to determine the association between religious coping and HIV medication adherence. Findings indicated that after controlling for age and depressive symptoms at baseline, positive religious coping significantly predicted medication adherence at baseline and 12-month follow-up. Negative religious coping was inversely associated with medication adherence at baseline after controlling for age and depressive symptoms but not at 12-month follow-up. The implications of these findings for future research and intervention work related to medication adherence among BALWH are discussed.

Antiretroviral Adherence Trajectories Among Black Americans Living with HIV

Black people living with HIV (BPLWH) are less likely to adhere to antiretroviral treatment than are members of other racial/ethnic groups. Data were combined from two studies of BPLWH (n = 239) to estimate adherence trajectories using a semiparametric, group-based modeling strategy over three time-points (spanning 6 months). Analyses identified three groups of individuals (high-stable, moderately low-stable, low-decreasing). Multinomial logistic regressions were used to predict trajectory membership with multiple levels of socio-ecological factors (structural, institutional/health system, community, interpersonal/network, individual). Older age was associated with being in the high-stable group, whereas substance use, lower perceived treatment effectiveness, and lower quality healthcare ratings were related to being in the moderately low-stable group. In sum, multiple socio-ecological factors contribute to adherence among BPLWH and thus could be targeted in future intervention efforts.

Differences in Medical Mistrust Between Black and White Women: Implications for Patient-Provider Communication About PrEP

Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention method. PrEP uptake has been persistently low among US women, particularly Black women, who account for 61% of new HIV diagnoses among women. Further understanding of barriers to Black women accessing PrEP is needed. This 2017 cross-sectional survey study explored race-based differences in PrEP interest and intention among women and the indirect association between race and comfort discussing PrEP with a healthcare provider through medical mistrust. The sample consisted of 501 adult women (241 Black; 260 White) who were HIV-negative, PrEP-inexperienced, and heterosexually active. Black women reported greater PrEP interest and intention than White women. However, Black women expressed higher levels of medical mistrust, which, in turn, was associated with lower comfort discussing PrEP with a provider. Medical mistrust may operate as a unique barrier to PrEP access among Black women who are interested in and could benefit from PrEP.

"A Gay Man and a Doctor are Just like, a Recipe for Destruction": How Racism and Homonegativity in Healthcare Settings Influence PrEP Uptake Among Young Black MSM

Young, Black, gay bisexual or other MSM are significantly less likely to use PrEP than their White counterparts. These disparities may be due, in part, to medical mistrust and mistreatment within the healthcare system. This study aimed to uncover how young Black MSM's perceptions of, and experiences with, health care contribute to low engagement in the healthcare system and low PrEP utilization. In late 2017 and early 2018, we conducted six focus groups with 44 Black MSM ages 16-25 in Milwaukee. Focus group topics included participants' knowledge and perceptions of PrEP, perceptions and stereotypes about PrEP users, and general healthcare utilization patterns and behaviors. Focus group transcripts were transcribed verbatim and coded using MAXQDA qualitative analysis software. We used a team-based approach to thematic content analysis to understand how racism and homonegativity affected healthcare access and experiences. Results from this study help to characterize what contributes to mistrust of the healthcare system and healthcare providers to negatively affect PrEP use among young Black MSM. Focus group discussions revealed how previous and anticipated negative interactions with physicians and skepticism about the healthcare system have alienated young Black MSM from the health care system and created significant barriers to PrEP. Efforts to increase PrEP uptake and must address negative and discriminatory interactions with providers and the healthcare system.

Age matters: differences in correlates of self-reported HIV antiretroviral treatment adherence between older and younger Black men who have sex with men living with HIV

Black men who have sex with men (BMSM) show lower levels of adherence to antiretroviral therapy (ART) for HIV medications than other racial/ethnic groups in the U.S. Yet, little is known about age differences in factors that predict ART adherence among BMSM. We combined data from two surveys of HIV-positive BMSM, resulting in 209 participants (130 aged 18-50 years; 79 aged 50 years or older). Multivariate linear regressions examined associations between baseline characteristics and adherence to HIV medications as well as interactions of baseline characteristics with age. The associations between trust in healthcare and doctor satisfaction ratings with higher adherence were stronger for older vs younger men (p < .05); the association between problem drinking and lower adherence was stronger among younger men (p < .05). Future research should examine how interventions may address these age-specific factors to improve ART adherence among BMSM living with HIV.

Brief Report: Clinical Outcomes of Young Black Men Receiving HIV Medical Care in the United States, 2009-2014

BACKGROUND

More than one-quarter of 2016 HIV diagnoses among blacks in the United States occurred among persons aged 15-24 years, and three-quarters were among men. Although the prevalence of viral suppression in all tests in the past 12 months (durable viral suppression) among persons receiving HIV care increased from 58% to 68% during 2009-2013, we do not know whether this same improvement was observed among young black men receiving care.

METHODS

We analyzed the 2009-2014 Medical Monitoring Project data collected from 336 black men aged 18-24 years. We estimated the proportion of young black men receiving HIV care who were prescribed antiretroviral therapy (ART), adherent to ART, and durably virally suppressed. We assessed changes in clinical outcomes over time and their association with patient characteristics, health behaviors, and depression.

RESULTS

During 2009-2014, 80% of young black men receiving HIV care were prescribed ART, 73% were adherent to ART, and 36% had durable viral suppression. There was no significant change in viral suppression over this period. ART prescription and durable viral suppression were significantly higher among those receiving the Ryan White HIV/AIDS Program assistance compared with those who did not. Durable viral suppression was significantly lower among those who used drugs compared with those who did not.

CONCLUSIONS

Viral suppression among young black men during 2009-2014 was lower than that among the overall population receiving HIV care in 2013 (36% vs. 68%). Increasing viral suppression is essential to improve health and reduce HIV transmissions in this key population.

Ubiquitous Yet Unclear: A Systematic Review of Medical Mistrust

Peer-reviewed articles (n = 124) examining associations between medical mistrust (MM) and health outcomes from four databases, between January 1998 and May 2018, were reviewed; 36 qualitative and 88 quantitative studies met the inclusion criteria. The Williams and Mohammed framework guided our narrative synthesis of the studies; it argues that basic causes (e.g., biased institutions) affect the social status of marginalized groups which in turn effects multiple proximal pathways leading to responses and poor health. Most studies were cross-sectional with US-based samples. The MM in qualitative studies were categorized as interpersonal (n = 30), systemic (n = 22), and/or vicarious (n = 18); 25% did not explicitly note the basic causes of MM and race/ethnicity was often confounded with socioeconomic status (SES). All but three studies discussed an association between MM and a behavior response; no study focused on an actual health outcome. Most quantitative studies used multivariate regression analyses; only 15 of the 88 utilized advanced modeling techniques (e.g., mediation). Most (75%) studies did not describe basic causes for MM and 43% utilized low income samples. MM was conceptualized as a predictor/proximal pathway (in 73 studies) associated with a variety of responses, most commonly behavioral (e.g., diminished adherence); 14 studies found an association between MM and a specific health measure. This review underscores the need for future qualitative studies to place MM central to their research questions as in-depth descriptions of MM were limited. Future quantitative studies should replicate findings using more advanced analytical strategies that examine the relationship between MM and health outcomes.

Methodological considerations for conducting focus groups in HIV prevention research among Black men who have sex with men

INTRODUCTION

Focus groups are an important learning tool in HIV prevention research among U.S. Black men who have sex with men (BMSM), for whom incidence persists. Focus groups are useful in designing interventions, but many have struggled to engage BMSM in research. To optimize the utility of focus group methodology on HIV prevention among BMSM, this paper offers methodological considerations for conducting and managing focus groups with BMSM.

METHODS

Perspectives come from the process of conducting nine focus groups (N = 52) to explore the role of religion and spirituality in the lives of BMSM in Baltimore City and how these concepts could be used to inform local HIV prevention interventions.

RESULTS

Themes from field notes captured important concepts to consider regarding the following: recruitment and retention, recruiting from within the social network, screening for HIV status, focus group stratification, and focus group facilitation.

DISCUSSION

Considerations and recommendations for mitigating the challenges in focus group research and enriching data collection with BMSM are outlined.

"Like I Have No Choice": A Qualitative Exploration of HIV Diagnosis and Medical Care Experiences While Incarcerated and Their Effects

It is estimated that one in six Black and Latino adult persons living with HIV (PLWH) spend time in correctional institutions each year. Yet after release, PLWH of color evidence poor HIV health outcomes across the HIV care continuum. This study, guided by an ecological approach and Critical Race Theory, sought to understand the lived experiences of socioeconomically disadvantaged PLWH of color who received an HIV diagnosis and/or medical care while incarcerated, and the ways in which those experiences influenced engagement in medical care after release. Drawn from a larger study in Brooklyn, NY, in 2013-2016, a subset of 28 participants who received in-depth qualitative interviews were purposively sampled for a secondary analysis of participants who received an HIV diagnosis and/or medical care while incarcerated. Using an Interpretive Phenomenological Analysis, we found participant's experiences were shaped by longstanding mistrust of the medical establishment. While incarcerated, lack of autonomy, substandard medical care, and poor social support exacerbated medical mistrust and avoidance of HIV medical care long after release. Engagement in HIV medical care and treatment were also impacted by a dynamic interplay of factors including substance use, prolonged periods of denial, poverty, and repeated bouts of incarceration. Given that experiences of HIV diagnosis and medical care while incarcerated have long-ranging, adverse effects, we argue that a better understanding of the ways in which PLWH of color experience HIV diagnosis and medical care while incarcerated may serve to inform intervention efforts within correctional institutions to improve HIV health outcomes.

Whose Responsibility Is It to Dismantle Medical Mistrust? Future Directions for Researchers and Health Care Providers

Medical mistrust persists and appears to be growing. The public health literature on medical mistrust has largely focused on mistrust among Black and African American populations due to legacies of abuse and mistreatment, such as the infamous Tuskegee Syphilis Study. However, research is now emerging that explores mistrust among various populations and in varying contexts, and the literature now largely emphasizes the role of ongoing, present-day social and economic inequalities in shaping and sustaining mistrust, particularly among populations who experience staggering health disparities. This special issue showcased nine articles exploring medical mistrust among diverse populations, exploring a wide array of topics and spanning myriad methodologies. In addition to a rigorous systematic review of the literature, this issue covers several critical subareas of the health disparities literature, including preventative health screenings among Black men, discrimination and cultural factors among rural Latinx communities, health care satisfaction among Latina immigrant women, the complex relationship between HIV testing and "conspiracy beliefs" among Black populations, pre-exposure prophylaxis use among transgender women, the impacts of mass incarceration on HIV care, eHealth interventions to address chronic diseases among sexual minority men of color, and participatory research to engage underserved populations as co-researchers. The purpose of this article is to provide a brief summary of the nine manuscripts in this special issue and to outline some recommendations and future directions for research on medical mistrust.

Medical Mistrust, Racism, and Delays in Preventive Health Screening Among African-American Men

The contribution of medical mistrust to healthcare utilization delays has gained increased public health attention. However, few studies examine these associations among African-American men, who delay preventive healthcare more often and report higher levels of medical mistrust than non-Hispanic White men. Additionally, studies rarely account for other factors reportedly working in tandem with medical mistrust to increase African-American men's preventive health screening delays (i.e., everyday racism and perceived racism in healthcare). We examined associations between medical mistrust, perceived racism in healthcare, everyday racism, and preventive health screening delays. Analyses were conducted using cross-sectional data from 610 African-American men aged 20 years and older recruited primarily from barbershops in four US regions (2003-2009). Independent variables were medical mistrust (MM), everyday racism (ER), and perceived racism in healthcare (PRH). Dependent variables were self-reported routine checkup, blood pressure screening, and cholesterol screening delays. Using multiple logistic regression and tests for mediation, we calculated odds ratios and 95% confidence intervals to assess associations between the independent and dependent variables. After final adjustment, African-American men with higher MM were significantly more likely to delay blood pressure screenings. Men with more frequent ER exposure were significantly more likely to delay routine checkups and blood pressure screenings. Higher levels of PRH were associated with a significant increased likelihood of delaying cholesterol screening. MM did not mediate associations between ER and screening delays. Increasing preventive health screening among African-American men requires addressing medical mistrust and racism in and outside healthcare institutions.

HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015: A Cohort Study

BACKGROUND

Because HIV viral suppression is essential for optimal outcomes and prevention efforts, understanding trends and predictors is imperative to inform public health policy.

OBJECTIVE

To evaluate viral suppression trends in people living with HIV (PLWH), including the relationship of associated factors, such as demographic characteristics and integrase strand transfer inhibitor (ISTI) use.

DESIGN

Longitudinal observational cohort study.

SETTING

8 HIV clinics across the United States.

PARTICIPANTS

PLWH receiving clinical care.

MEASUREMENTS

To understand trends in viral suppression (≤400 copies/mL), annual viral suppression rates from 1997 to 2015 were determined. Analyses were repeated with tests limited to 1 random test per person per year and using inverse probability of censoring weights to address loss to follow-up. Joint longitudinal and survival models and linear mixed models of PLWH receiving antiretroviral therapy (ART) were used to examine associations between viral suppression or continuous viral load (VL) levels and demographic factors, substance use, adherence, and ISTI use.

RESULTS

Viral suppression increased from 32% in 1997 to 86% in 2015 on the basis of all tests among 31 930 PLWH. In adjusted analyses, being older (odds ratio [OR], 0.76 per decade [95% CI, 0.74 to 0.78]) and using an ISTI-based regimen (OR, 0.54 [CI, 0.51 to 0.57]) were associated with lower odds of having a detectable VL, and black race was associated with higher odds (OR, 1.68 [CI, 1.57 to 1.80]) (P < 0.001 for each). Similar patterns were seen with continuous VL levels; when analyses were limited to 2010 to 2015; and with adjustment for adherence, substance use, or depression.

LIMITATION

Results are limited to PLWH receiving clinical care.

CONCLUSION

HIV viral suppression rates have improved dramatically across the United States, which is likely partially attributable to improved ART, including ISTI-based regimens. However, disparities among younger and black PLWH merit attention.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Treatment perceptions in patients with asthma: Synthesis of factors influencing adherence

BACKGROUND

Non-adherence to asthma treatment is a contributing factor for poorly controlled asthma.

AIM

The aim of this systematic review is to explore patients' perceptions of their inhaled asthma treatment, and how these relate to adherence, using both qualitative and quantitative data.

METHODS

Pre-determined search terms and inclusion criteria were used to search electronic databases (The Cochrane Library, MEDLINE, EMBASE and PsycINFO). Two researchers screened titles and abstracts using the Rayyan web app and data were extracted in relation to psychological components (beliefs about, and attitudes towards, medicines) and adherence.

RESULTS

Of 1638 papers, 36 met the inclusion criteria. Key themes were: Perceived need for treatment - all 12 studies using the BMQ to measure patients' perceived need for treatment found that patients' beliefs about their necessity for treatment were associated with adherence-; Concerns about treatment - immediate and long-term side effects (58%), worries about safety (19%), and potential addiction to asthma medication (31%)-; and Perceived social stigma - 22% of studies reported that embarrassment contributed to poor adherence.

CONCLUSIONS

Acknowledging and addressing patient treatment beliefs and perceptual barriers to adherence is integral to designing adherence interventions for asthma patients. Further research is needed to better our understanding of the relationship between treatment perceptions and adherence.

Factors Associated with Immunization Opinion Leadership among Men Who Have Sex with Men in Los Angeles, California

We sought to identify the characteristics of men who have sex with men (MSM) who are opinion leaders on immunization issues and to identify potential opportunities to leverage their influence for vaccine promotion within MSM communities. Using venue-based sampling, we recruited and enrolled MSM living in Los Angeles (N = 520) from December 2016 to February 2017 and evaluated characteristic differences in sociodemographic characteristics, health behaviors, and technology use among those classified as opinion leaders versus those who were not. We also asked respondents about their past receipt of meningococcal serogroups A, C, W, and Y (MenACWY) and meningococcal B (MenB) vaccines, as well as their opinions on the importance of 13 additional vaccines. Multivariable results revealed that non-Hispanic black (aOR = 2.64; 95% CI: 1.17⁻5.95) and other race/ethnicity (aOR = 2.98; 95% CI: 1.41⁻6.29) respondents, as well as those with a history of an STI other than HIV (aOR = 1.95; 95% CI: 1.10⁻3.48), were more likely to be opinion leaders. MenACWY (aOR = 1.92; 95% CI: 1.13⁻3.25) and MenB (aOR = 3.09; 95% CI: 1.77⁻5.41) vaccine uptake, and perceived importance for these and seven additional vaccines, were also associated with being an opinion leader. The results suggest that the co-promotion of vaccination and other health promotion initiatives via opinion leaders could be a useful strategy for increasing vaccination among MSM.

The Impact of Psychosocial Factors on Health and Retention Outcomes for People Living With HIV: Implications for Rehabilitation Counselors and Educators

Despite medical advancements that have significantly improved the health outcomes of people living with HIV (PLWH), many do not achieve optimal health outcomes due to psychosocial barriers. This 5-year retrospective longitudinal study draws upon the International Classification of Functioning, Disability, and Health (ICF) framework to conceptualize the relationships between personal and environmental factors and health and retention outcomes among a sample of 704 PLWH in Pennsylvania. A generalized estimated equations (GEE) model was used to model retention in care outcomes (at least one medical visit every 6 months) and a general linear mixed (GLM) model was used to analyze immune system health outcomes (CD4%). This exploratory study reveals that gender, age, race, use of antiretroviral (ARV) medications, use of case management service, mental health diagnosis, and alcohol use were significantly associated with retention in care, whereas race, ethnicity, gender, mental health treatment, use of ARV medications, use of case management services, and retention in care status were significantly associated with the immune system health outcome of CD4%. The results suggest a need for rehabilitation interventions to address key psychosocial issues, as rehabilitation counselors have a unique skill set to address the medical case management needs of individuals with HIV. Implications for rehabilitation counselors and educators are discussed.

Cultural Issues in Medication Adherence: Disparities and Directions

Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, the patient's family and culture, interactions with healthcare providers, and the healthcare system itself. Because of its association with worse outcomes, poor medication adherence is considered a potential contributor to disparities in health outcomes observed for various conditions across racial and ethnic groups. While there are no simple answers, it is clear that patient, provider, cultural, historical, and healthcare system factors all play a role in patterns of medication use. Here, we provide an overview of the interface between culture and medication adherence for chronic conditions; discuss medication adherence in the context of observed health disparities; provide examples of cultural issues in medication adherence at the individual, family, and healthcare system/provider level; review potential interventions to address cultural issues in medication use; and provide recommendations for future work.

Cultural Issues in Medication Adherence: Disparities and Directions

Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, the patient's family and culture, interactions with healthcare providers, and the healthcare system itself. Because of its association with worse outcomes, poor medication adherence is considered a potential contributor to disparities in health outcomes observed for various conditions across racial and ethnic groups. While there are no simple answers, it is clear that patient, provider, cultural, historical, and healthcare system factors all play a role in patterns of medication use. Here, we provide an overview of the interface between culture and medication adherence for chronic conditions; discuss medication adherence in the context of observed health disparities; provide examples of cultural issues in medication adherence at the individual, family, and healthcare system/provider level; review potential interventions to address cultural issues in medication use; and provide recommendations for future work.

Impact of Depression and Demoralization on Blood Pressure Control in African Americans with Hypertension: Findings from the TRIUMPH Trial

BACKGROUND

African Americans develop hypertension earlier and have worse cardiovascular outcomes than Caucasians. Accumulating evidence suggests that psychological distress may play a role in the observed racial differences in hypertension. Several studies have investigated the relationship between depression and hypertension while little is still known about the role of demoralization.

METHODS

Using data from the Trial Using Motivational Interviewing, Positive Affect, and Self-affirmation in African Americans with Hypertension (TRIUMPH), logistic regression models were used to estimate differences in blood pressure control at 12 months among participants with demoralization, depression, and both conditions.

RESULTS

Our logistic models showed that reported psychosocial symptoms significantly differed in predicting success in blood pressure control at 12 months. Contrast analyses showed that, after adjusting for sociodemographic, clinical, and psychosocial variables, demoralized patients were less likely to achieve blood pressure control than participants without affective conditions (p = 0.020). Similar results emerged for patients with depression (p = 0.042) and both conditions (p = 0.022).

CONCLUSIONS

Depression can be extremely debilitating and has serious health consequence. Our findings confirm this result and show that, even though depression and demoralization share common features, they are two distinct clinical phenomena with similar negative impact on blood pressure control in African Americans.

Direct-Acting Antivirals Improve Access to Care and Cure for Patients With HIV and Chronic HCV Infection

Background

Direct-acting antivirals (DAA) as curative therapy for hepatitis C virus (HCV) infection offer >95% sustained virologic response (SVR), including in patients with human immunodeficiency virus (HIV) infection. Despite improved safety and efficacy of HCV treatment, challenges remain, including drug-drug interactions between DAA and antiretroviral therapy (ART) and restrictions on access by payers.

Methods

We performed a retrospective cohort study of all HIV/HCV co-infected and HCV mono-infected patients captured in care at our institution from 2011-2015, reflecting the DAA era, to determine treatment uptake and SVR, and to elucidate barriers to accessing DAA for co-infected patients.

Results

We identified 9290 patients with HCV mono-infection and 507 with HIV/HCV co-infection. Compared to mono-infected patients, co-infected patients were younger and more likely to be male and African-American. For both groups, treatment uptake improved from the DAA/pegylated interferon (PEGIFN)-ribavirin to IFN-free DAA era. One-third of co-infected patients in the IFN-free DAA era required ART switch and nearly all remained virologically suppressed after 6 months. We observed SVR >95% for most patient subgroups including those with co-infection, prior treatment-experience, and cirrhosis. Predictors of access to DAA for co-infected patients included Caucasian race, CD4 count ≥200 cells/mm³, HIV virologic suppression and cirrhosis. Time to approval of DAA was longest for patients insured by Medicaid, followed by private insurance and Medicare.

Conclusions

DAA therapy has significantly improved access to HCV treatment and high SVR is independent of HIV status. However, in order to realize cure for all, barriers and disparities in access need to be urgently addressed.

Do Persons Living with HIV Continue to Fill Prescriptions for Antiretroviral Drugs during a Gap in Care? Analysis of a Large Commercial Claims Database

The significance of a gap in HIV care depends, at least partially, on whether patients continue to fill prescriptions for antiretroviral (ARV) drugs during the gap in care. We used a billing claims database to determine the proportion of persons who filled ≥1 prescription for ARV drugs during a gap in care (no clinic visit in >6 months). Persons were stratified into 3 groups: "never" (prescriptions never filled), "sometimes" (prescriptions filled >0%-<100% of months), and "always" (prescriptions filled monthly). Logistic regression analyses were conducted to determine factors associated with "never" filling ARV drugs. Of 14 308 persons, 69% (n = 9817), 13% (n = 1928), and 18% (n = 2563) "never," "sometimes," and "always" filled ARV drugs during the gap in care. Persons aged 18 to 29 years (odds ratio [OR] = 1.56, 95% confidence interval [CI] 1.39-1.74), women (OR = 1.67, CI 1.52-1.83), and persons from the Northeast region of the United States (OR = 1.86, CI 1.69-2.03) were more likely to never fill ARV drugs than persons aged ≥30 years, men, and persons outside the Northeast, respectively. Efforts should be made to minimize gaps in care, emphasize importance of therapy, and provide adherence support.

Racial centrality may be linked to mistrust in healthcare institutions for African Americans

Evidence suggests that racial identity is an important component to African Americans' self-concepts and therefore may be relevant to patients' trust in healthcare, yet little is known as to how racial identity may influence trust or mistrust. African American adults (N = 220) in the greater Portland, Oregon, area provided survey reports of healthcare-related attitudes and experiences. Those who reported higher racial centrality had lower trust in healthcare institutions. Based on these findings, clinicians employing patient-centered care approaches should recognize racial identity as an important component to patients' experiences when they seek to deliver equitable care to African American patients.

Pre-exposure prophylaxis for HIV prevention in women: current perspectives

There are ~900,000 new HIV infections among women every year, representing nearly half of all new HIV infections globally. In the US, nearly one-fifth of all new HIV infections occur among women, and women from racial and ethnic minority communities experience disproportionately high rates of new HIV infections. Thus, there is a need to develop and implement effective HIV prevention strategies for women in the US and internationally, with a specific need to advance strategies in minority communities. Previous studies have demonstrated that oral HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral medications by HIV-uninfected persons to prevent HIV acquisition, can reduce HIV incidence among women who are adherent to PrEP. However, to date, awareness and uptake of PrEP among women have been very limited, suggesting a need for innovative strategies to increase the knowledge of and access to PrEP among women in diverse settings. This narrative review summarizes the efficacy and safety data of PrEP in women, discusses considerations related to medication adherence for women who use PrEP, and highlights behavioral, social, and structural barriers to maximize the effectiveness of PrEP in women. It also reviews novel modalities for PrEP in women which are being developed and tested, including topical formulations and long-acting injectable agents that may offer advantages as compared to oral PrEP and proposes a community-oriented, social networking framework to increase awareness of PrEP among women. If women are provided with access to PrEP and support to overcome social and structural barriers to adhere to PrEP, this prevention strategy holds great promise to impact the HIV epidemic among women in the US and globally.

The differences between medical trust and mistrust and their respective influences on medication beliefs and ART adherence among African-Americans living with HIV

OBJECTIVE

The purpose of this study was to examine the relationships between medical mistrust and trust and to determine if these measures differentially predict antiretroviral therapy (ART) medication adherence for African-American adults living with HIV.

DESIGN

A total of 458 HIV positive African-Americans completed a cross-sectional survey.

MAIN OUTCOME MEASURES

Self-reported ART adherence was collected using the visual-analog scale. The Beliefs About Medicines Questionnaire was used to assess medication necessity and concern beliefs.

RESULTS

All measures of medical mistrust and trust were significantly negatively correlated, ranging from r = -.339 to -.504. Race-based medical mistrust significantly predicted medication necessity and concern beliefs, whereas general medical mistrust only significantly predicted medication concerns. Both measures of trust significantly predicted medication necessity beliefs and medication concerns. Higher levels of race-based medical mistrust predicted lower medication adherence, whereas, neither trust in own physician nor trust in health care provider significantly predicted medication adherence. However, trust in own physician significantly predicted medication necessity beliefs, which predicted medication adherence.

CONCLUSION

Trust and mistrust are not simply opposites of one another. These findings provide evidence for the complexity of understanding the relationship between health care trust, mistrust and patient-related health beliefs and behaviours.

Medical mistrust as a key mediator in the association between perceived discrimination and adherence to antiretroviral therapy among HIV-positive Latino men

Discrimination has been found to have deleterious effects on physical health. The goal of the present study was to examine the association between perceived discrimination and adherence to antiretroviral therapy (ART) among HIV-positive Latino men and the extent to which medical mistrust serves as a mediator of that association. A series of linear and logistic regression models was used to test for mediation for three types of perceived discrimination (related to being Latino, being perceived as gay and being HIV-positive). Medical mistrust was found to be significantly associated with perceived discrimination based on Latino ethnicity and HIV serostatus. Medical mistrust was found to mediate the associations between two types of perceived discrimination (related to being Latino and being HIV-positive) and ART adherence. Given these findings, interventions should be developed that increase the skills of HIV-positive Latino men to address both perceived discrimination and medical mistrust.

Barriers to Hepatitis C Virus (HCV) Treatment Initiation in Patients With Human Immunodeficiency Virus/HCV Coinfection: Lessons From the Interferon Era

BACKGROUND

Hepatitis C is a major cause of mortality among human immunodeficiency virus (HIV)-infected patients, yet hepatitis C virus (HCV) treatment uptake has historically been low. Although the removal of interferon removes a major barrier to HCV treatment uptake, oral therapies alone may not fully eliminate barriers in this population.

METHODS

Within the Johns Hopkins Hospital HIV cohort, a nested case-control study was conducted to identify cases, defined as patients initiating HCV treatment between January 1996 and 2013, and controls, which were selected using incidence density sampling (3:1 ratio). Controls were matched to cases on date of enrollment. Conditional logistic regression was used to evaluate factors associated with HCV treatment initiation.

RESULTS

Among 208 treated cases and 624 untreated controls, the presence of advanced fibrosis (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.26-3.95), recent active drug use (OR, 0.36; 95% CI, 0.19-0.69), and non-black race (OR, 2.01; 95% CI, 1.26-3.20) were independently associated with initiation of HCV therapy. An increasing proportion of missed visits was also independently associated with lower odds of HCV treatment (25%-49% missed visits [OR, 0.49; 95% CI, 0.27-0.91] and ≥50% missed visits [OR, 0.24; 95% CI, 0.12-0.48]).

CONCLUSIONS

Interferon-free treatments may not be sufficient to fully overcome barriers to HCV care in HIV-infected patients. Interventions to increase engagement in care for HIV and substance use are needed to expand HCV treatment uptake.