HIV-Infected Individuals Who Delay, Decline, or Discontinue Antiretroviral Therapy: Comparing Clinic- and Peer-Recruited Cohorts

Medical mistrust of health systems as a moderator of resilience and self-reported HIV care engagement in Black and Latinx young adults living with HIV

OBJECTIVE

To study resilience and its association with HIV care engagement in a sample of young adult Black and Latinx people living with HIV (PLWH) in the United States and to test if a systems-level barrier, medical mistrust, would moderate the resilience-engagement association.

METHOD

Between April and August 2021, we recruited participants through social media and dating apps (N = 212) and verified age and HIV status through a review process of digital text-messaged and emailed photos. Participants completed a one-time online survey consisting of the Connor-Davidson Resilience Scale, The Index of Engagement in HIV Care, and the Medical Mistrust Index. We ran a regression-based moderation analysis using the Johnson-Neyman Technique to estimate regions of significance.

RESULTS

The sample (N = 212) was 80.5% Black and 19.5% Latinx with a mean age of 25.8 years (SD = 2.84). Higher resilience scores were associated with higher HIV care engagement scores (b = 0.72, p = .003), and medical mistrust moderated this relationship as evidenced by a mistrust by resilience interaction (b = -0.16, p = .01). Our regions of statistical significance showed that as mistrust increased, the size of the resilience-engagement association decreased.

CONCLUSION

Resilience may be a protective factor associated with greater participation and sense of connection to HIV care, but is diminished by mistrust of the medical system at large. This suggest that systems-level changes, in addition to individual-level interventions, are needed to address medical mistrust to fully harness the resilience of young PLWH. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Using the multiphase optimization strategy (MOST) framework to optimize an intervention to increase COVID-19 testing for Black and Latino/Hispanic frontline essential workers: A study protocol

Background

Among those at highest risk for COVID-19 exposure is the large population of frontline essential workers in occupations such food service, retail, personal care, and in-home health services, among whom Black and Latino/Hispanic persons are over-represented. For those not vaccinated and at risk for exposure to COVID-19, including frontline essential workers, regular (approximately weekly) COVID-19 testing is recommended. However, Black and Latino/Hispanic frontline essential workers in these occupations experience serious impediments to COVID-19 testing at individual/attitudinal- (e.g., lack of knowledge of guidelines), social- (e.g., social norms), and structural-levels of influence (e.g., poor access), and rates of testing for COVID-19 are insufficient.

Methods/design

The proposed community-engaged study uses the multiphase optimization strategy (MOST) framework and an efficient factorial design to test four candidate behavioral intervention components informed by an integrated conceptual model that combines critical race theory, harm reduction, and self-determination theory. They are A) motivational interview counseling, B) text messaging grounded in behavioral economics, C) peer education, and D) access to testing (via navigation to an appointment vs. a self-test kit). All participants receive health education on COVID-19. The specific aims are to: identify which components contribute meaningfully to improvement in the primary outcome, COVID-19 testing confirmed with documentary evidence, with the most effective combination of components comprising an “optimized” intervention that strategically balances effectiveness against affordability, scalability, and efficiency (Aim 1); identify mediators and moderators of the effects of components (Aim 2); and use a mixed-methods approach to explore relationships among COVID-19 testing and vaccination (Aim 3). Participants will be N = 448 Black and Latino/Hispanic frontline essential workers not tested for COVID-19 in the past six months and not fully vaccinated for COVID-19, randomly assigned to one of 16 intervention conditions, and assessed at 6- and 12-weeks post-baseline. Last, N = 50 participants will engage in qualitative in-depth interviews.

Discussion

This optimization trial is designed to yield an effective, affordable, and efficient behavioral intervention that can be rapidly scaled in community settings. Further, it will advance the literature on intervention approaches for social inequities such as those evident in the COVID-19 pandemic.

Trial registration

ClinicalTrials.gov: NCT05139927; Registered on 11/29/2021. Protocol version 1.0. May 2, 2022, Version 1.0

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13576-0.

Perceived discrimination, adherence to antiretroviral therapy, and HIV care engagement among HIV-positive black adults: the mediating role of medical mistrust

Perceived discrimination and medical mistrust are contributors to HIV inequities. The current study examined whether medical mistrust mediated the associations between perceived discrimination and adherence to antiretroviral therapy (ART) as well as care engagement in a sample of 304 Black adults living with HIV. Perceived discrimination and medical mistrust were measured using validated scales; ART adherence was electronically monitored for a month; care engagement was determined by medical record data. Results support significant total indirect effects from perceived discrimination (due to HIV-serostatus, race, sexual orientation) to ART adherence through three types of medical mistrust (towards healthcare organizations, one's physician, and HIV-specific mistrust). The total indirect effects were also significant for care engagement and were largely driven by mistrust towards one's own physician. Findings suggest interventions at the provider or healthcare organization levels should address medical mistrust to improve the health and well-being of Black Americans living with HIV.

Interactive Mobile Phone HIV Adherence Support for Men Who Have Sex With Men in the Philippines Connect for Life Study: Mixed Methods Approach to Intervention Development and Pilot Testing

BACKGROUND

The HIV epidemic in the Philippines is one of the fastest growing epidemics globally, and infections among men who have sex with men are rising at an alarming rate. The World Health Organization recommends the use of mobile health (mHealth) technologies to engage patients in care and ensure high levels of adherence to antiretroviral therapy (ART). Existing mHealth interventions can be adapted and tailored to the context and population served.

OBJECTIVE

This study aims to create a locally tailored intervention using a mobile phone platform to support treatment adherence for HIV patients on ART in the Philippines.

METHODS

A mixed methods approach guided by the Behavior Change Wheel framework was used to adapt an existing mHealth adherence support platform for the local setting and target population. A literature review, retrospective clinical record review, and focus group discussions with patients were conducted to understand the drivers of ART adherence and tailor the intervention accordingly. The resulting intervention was pilot-tested for 8 weeks, followed by focus group discussions with patients who received the intervention to assess the acceptability of the design.

RESULTS

Key issues contributing to nonadherence included side effects, lack of behavioral skills for pill taking, social support, mental health, and substance use. Patients identified mHealth as an acceptable mode of intervention delivery and wanted mHealth services to be highly personalizable. The study team, clinicians, and software developers integrated these findings into the intervention, which included a menu of services as follows: pill reminders, health tips, adherence feedback, appointment reminders, and symptom reporting. During the pilot phase, technical issues in the interactive voice response system (IVRS) were identified and addressed. Patients who participated in the pilot phase expressed a preference for SMS text messaging over the IVRS. Patients responded positively to the appointment reminders and health tips, whereas patient feedback on daily and weekly pill reminders and adherence feedback was mixed.

CONCLUSIONS

The mobile phone-based SMS text messaging and IVRS intervention was acceptable to men who have sex with men in Manila, the Philippines, and qualitative analysis suggested that the intervention helped promote ART adherence and appointment attendance.

Initiation of Antiretroviral Therapy in the Hospital Is Associated With Linkage to Human Immunodeficiency Virus (HIV) Care for Persons Living With HIV and Substance Use Disorder

BACKGROUND

Studies have demonstrated benefits of antiretroviral therapy (ART) initiation on the day of human immunodeficiency virus (HIV) testing or at first clinical visit. The hospital setting is understudied for immediate ART initiation.

METHODS

CTN0049, a linkage-to-care randomized clinical trial, enrolled 801 persons living with HIV (PLWH) and substance use disorder (SUD) from 11 hospitals across the United States. This secondary analysis examined factors related to initiating (including reinitiating) ART in the hospital and its association with linkage to HIV care, frequency of outpatient care visits, retention, and viral suppression.

RESULTS

Of 801 participants, 124 (15%) initiated ART in the hospital, with more than two-thirds of these participants (80/124) initiating ART for the first time. Time to first HIV care visit among those who initiated ART in the hospital and those who did not was 29 and 54 days, respectively (P = .0145). Hospital initiation of ART was associated with increased frequency of HIV outpatient care visits at 6 and 12 months. There was no association with ART initiation in the hospital and retention and viral suppression over a 12-month period. Participants recruited in Southern hospitals were less likely to initiate ART in the hospital (P < .001).

CONCLUSIONS

Previous research demonstrated benefits of immediate ART initiation, yet this approach is not widely implemented. Research findings suggest that starting ART in the hospital is beneficial for increasing linkage to HIV care and frequency of visits for PLWH and SUD. Implementation research should address barriers to early ART initiation in the hospital.

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.

Stopping, starting, and sustaining HIV antiretroviral therapy: a mixed-methods exploration among African American/Black and Latino long-term survivors of HIV in an urban context

Background

Although periods of HIV antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained. Yet, little is known about factors that contribute to such ART non-persistence among long-term HIV survivors. The present study applied a convergent parallel mixed-methods design to explore the phenomena of stopping/starting and sustaining ART, focusing on low-socioeconomic status African American or Black and Latino persons living with HIV (PLWH) who face the greatest challenges.

Methods

Participants (N = 512) had poor engagement in HIV care and detectable HIV viral load. All received structured assessments and N = 48 were randomly selected for in-depth interviews. Quantitative analysis using negative binomial regression uncovered associations among multi-level factors and the number of times ART was stopped/started and the longest duration of sustained ART. Qualitative data were analyzed using a directed content analysis approach and results were integrated.

Results

Participants were diagnosed 18.2 years ago on average (SD = 8.6), started ART a median five times (Q1 = 3, Q3 = 10), and the median longest duration of sustained ART was 18 months (Q1 = 6, Q3 = 36). Factors associated with higher rates of stops/starts were male sex, transgender identity, cannabis use at moderate-to-high-risk levels, and ART- and care-related stigma. Factors associated with lower rates of stops/starts were older age, more years since diagnosis, motivation for care, and lifetime injection drug use (IDU). Factors associated with longer durations of sustained ART were Latino/Hispanic ethnicity, motivation for ART and care, and recent IDU. Factors associated with a shorter duration were African American/Black race, alcohol use at moderate-to-high-risk levels, and social support. Qualitative results uncovered a convergence of intersecting risk factors for stopping/starting ART and challenges inherent in managing HIV over decades in the context of poverty. These included unstable housing, which contributed to social isolation, mental health distress, and substance use concerns, the latter prompting selling (“diverting”) ART. Primarily complementary quantitative and qualitative findings described mechanisms by which risk/protective factors operated and ways PLWH successfully restart and/or sustain ART.

Conclusions

The field focuses substantially on ART adherence, but greater attention to reducing the frequency of ART non-persistence is needed, along with creating social/structural conditions favorable for sustained ART.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10464-x.

Medical Mistrust and the PrEP Cascade Among Latino Sexual Minority Men

Latino sexual minority men (SMM) have high HIV incidence rates but report low pre-exposure prophylaxis (PrEP) use. Medical mistrust predicts lower medical care use and could contribute to decreased PrEP engagement. This study examines how medical mistrust relates to the PrEP cascade among 151 Latino SMM aged 18-29. Logistic regressions were employed with medical mistrust predicting PrEP awareness, willingness, current use, and adherence. Greater medical mistrust was associated with decreased odds of all outcomes and may represent a barrier to PrEP engagement for Latino SMM. Further research should explore whether reducing medical mistrust among Latino SMM could increase PrEP engagement.

Early scale-up of antiretroviral therapy at diagnosis for reducing economic burden of cardiometabolic disease in HIV-infected population

OBJECTIVE

The current study aims to assess the effect of early scale-up of antiretroviral therapy (ART) at HIV diagnosis on the economic burden of cardiometabolic diseases (CMDs) in HIV-infected population.

DESIGN

Cohort study.

METHODS

The study cohort comprised 10 693 newly diagnosed HIV patients without CMDs before HIV diagnosis identified from a nationwide HIV cohort in Taiwan. The patients were stratified by ART use [medication possession ratio ≥0.8: (high) vs. <0.8: (low)] and AIDS-defining illnesses (ADI) status [present: (+) vs. absent: (-)] at the first year of HIV diagnosis into four groups: ART (low) and ADI (-), ART (low) and ADI (+), ART (high) and ADI (-), and ART (high) and ADI (+). The economic analysis of incident CMDs was from the perspective of Taiwan's single-payer healthcare system and estimated using generalized estimating equations.

RESULTS

CMDs significantly increased annual direct medical costs by 31% (hypertension) to 127% [cardiovascular diseases (CVDs)]. The annual cost burden of diabetes, dyslipidemia, and CVDs in the ART (high) and ADI (-) group significantly decreased by 42, 30, and 31%, respectively, compared with the ART (low) and ADI (+) group. Compared with the ART (low) and ADI (+) group, the annual cost burden of CVDs in the ART (high) and ADI (-) and ART (high) and ADI (+) groups decreased by 31 and 14%, respectively, suggesting increased cost-savings when ART is initiated at diagnosis before ADI occurrence.

CONCLUSION

The early scale-up of ART at diagnosis before ADI occurrence is important for minimizing the economic burden of incident CMDs among HIV-infected patients.

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.

Systemic Delays in the Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients in Houston, Texas: The Providers' Report Card

Background:

The current US HIV treatment guidelines support initiation of antiretroviral therapy (ART) for persons with HIV for personal health benefits and prevention of HIV transmission. However, high levels of adherence to ART are critical to maximize individual and public health benefits. We examined the nonclinical barriers to ART initiation for clinically eligible individuals and the provider- and patient-related factors associated with these barriers among HIV-infected patients in Houston/Harris County, Texas.

Methods:

We analyzed data obtained from a probability sample of HIV medical care providers (HMCPs) in 13 outpatient facilities in Houston/Harris County, Texas surveyed between June and September 2009. We used an inductive thematic approach to code HMCP responses to an open-ended question that asked the main reasons why providers may delay initiating ART for clinically eligible patients.

Results:

The reasons cited by providers for delaying ART for clinically eligible patients were adherence (42.5%; 95% confidence interval [CI]: 28.5-57.8), acceptance (30%; 95% CI: 18.1-45.4), and structural concerns (27.5%; 95% CI: 16.1-42.8), with significant variations (P < .0001) noted across patients’ race/ethnicity and transmission category. HIV medical care providers with 6 to 10 years’ experience in HIV care and those providing medical care for more than 100 patients monthly were about 4 times (adjusted odds ratio [aOR]: 3.80; 95% CI: 1.20-5.92; P = .039) and 10 times (aOR: 10.36; 95% CI: 1.42-22.70; P = .019) more likely to state adherence and acceptance concerns, respectively, as reasons for delaying ART for clinically eligible patients.

Conclusion:

Our findings highlight the fact that clinical guidelines are only a starting point for medical decision-making process and that patients themselves play an important role. HMCP access to referrals for other medical issues, support services, and treatment education may help improve adherence and patient readiness for ART, thereby avoiding systemic delays.

Shifting the Paradigm in HIV Prevention and Treatment Service Delivery Toward Differentiated Care for Youth

Despite significant progress in the fight against HIV/AIDS in the United States, HIV prevention and treatment disparities among key populations remain a national public health concern. While new HIV diagnoses are increasing among people under age 30—in particular among racial, ethnic, and sexual minority adolescents and young adults (AYA)—dominant prevention and treatment paradigms too often inadequately consider the unique HIV service needs of AYA. To address this gap, we characterize persistent and largely overlooked AYA disparities across the HIV prevention and treatment continuum, identify AYA-specific limitations in extant resources for improving HIV service delivery in the United States, and propose a novel AYA-centered differentiated care framework adapted to the unique ecological and developmental factors shaping engagement, adherence, and retention in HIV services among AYA. Shifting the paradigm for AYA to differentiated HIV care is a promising approach that warrants implementation and evaluation as part of reinforced national efforts to end the HIV epidemic in the United States by 2030.

"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.

Using the multiphase optimization strategy (MOST) to optimize an HIV care continuum intervention for vulnerable populations: a study protocol

BACKGROUND

More than half of persons living with HIV (PLWH) in the United States are insufficiently engaged in HIV primary care and not taking antiretroviral therapy (ART), mainly African Americans/Blacks and Hispanics. In the proposed project, a potent and innovative research methodology, the multiphase optimization strategy (MOST), will be employed to develop a highly efficacious, efficient, scalable, and cost-effective intervention to increase engagement along the HIV care continuum. Whereas randomized controlled trials are valuable for evaluating the efficacy of multi-component interventions as a package, they are not designed to evaluate which specific components contribute to efficacy. MOST, a pioneering, engineering-inspired framework, addresses this problem through highly efficient randomized experimentation to assess the performance of individual intervention components and their interactions. We propose to use MOST to engineer an intervention to increase engagement along the HIV care continuum for African American/Black and Hispanic PLWH not well engaged in care and not taking ART. Further, the intervention will be optimized for cost-effectiveness. A similar set of multi-level factors impede both HIV care and ART initiation for African American/Black and Hispanic PLWH, primary among them individual- (e.g., substance use, distrust, fear), social- (e.g., stigma), and structural-level barriers (e.g., difficulties accessing ancillary services). Guided by a multi-level social cognitive theory, and using the motivational interviewing approach, the study will evaluate five distinct culturally based intervention components (i.e., counseling sessions, pre-adherence preparation, support groups, peer mentorship, and patient navigation), each designed to address a specific barrier to HIV care and ART initiation. These components are well-grounded in the empirical literature and were found acceptable, feasible, and promising with respect to efficacy in a preliminary study.

METHODS/DESIGN

Study aims are: 1) using a highly efficient fractional factorial experimental design, identify which of five intervention components contribute meaningfully to improvement in HIV viral suppression, and secondary outcomes of ART adherence and engagement in HIV primary care; 2) identify mediators and moderators of intervention component efficacy; and 3) using a mathematical modeling approach, build the most cost-effective and efficient intervention package from the efficacious components. A heterogeneous sample of African American/Black and Hispanic PLWH (with respect to age, substance use, and sexual minority status) will be recruited with a proven hybrid sampling method using targeted sampling in community settings and peer recruitment (N = 512).

DISCUSSION

This is the first study to apply the MOST framework in the field of HIV prevention and treatment. This innovative study will produce a culturally based HIV care continuum intervention for the nation's most vulnerable PLWH, optimized for cost-effectiveness, and with exceptional levels of efficacy, efficiency, and scalability.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02801747 , Registered June 8, 2016.

Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration

Background

African American/Black and Hispanic persons living with HIV (AABH-PLWH) in the U.S. evidence insufficient engagement in HIV care and low uptake of HIV antiretroviral therapy, leading to suboptimal clinical outcomes. The present qualitative study used critical race theory, and incorporated intersectionality theory, to understand AABH-PLWH’s perspectives on the mechanisms by which structural racism; that is, the macro-level systems that reinforce inequities among racial/ethnic groups, influence health decisions and behaviors.

Methods

Participants were adult AABH-PLWH in New York City who were not taking antiretroviral therapy nor well engaged in HIV care (N = 37). Participants were purposively sampled for maximum variation from a larger study, and engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach.

Results

We found AABH-PLWH experienced HIV care and medication decisions through a historical and cultural lens incorporating knowledge of past and present structural racism. This contextual knowledge included awareness of past maltreatment of people of color in medical research. Further, these understandings were linked to the history of HIV antiretroviral therapy itself, including awareness of the first HIV antiretroviral regimen; namely, AZT (zidovudine) mono-therapy, which was initially prescribed in unacceptably high doses, causing serious side effects, but with only modest efficacy. In this historical/cultural context, aspects of structural racism negatively influenced health care decisions and behavior in four main ways: 1) via the extent to which healthcare settings were experienced as overly institutionalized and, therefore, dehumanizing; 2) distrust of medical institutions and healthcare providers, which led AABH-PLWH to feel pressured to take HIV antiretroviral therapy when it was offered; 3) perceptions that patients are excluded from the health decision-making process; and 4) an over-emphasis on antiretroviral therapy compared to other non-HIV related priorities. We found that although participants were located at the intersection of multiple social categories (e.g., gender, social class, AABH race/ethnicity), race/ethnicity and social class were described as primary factors.

Conclusions

Critical race theory proved useful in uncovering how macro-level structural racism affects individual-level health decisions and behaviors. HIV clinical settings can counter-balance the effects of structural racism by building “structural competency,” and interventions fostering core self-determination needs including autonomy may prove culturally appropriate and beneficial for AABH-PLWH.

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.

Population-Based Estimates of Life Expectancy After HIV Diagnosis: United States 2008-2011

INTRODUCTION

Using National HIV surveillance system data, we estimated life expectancy and average years of life lost (AYLL) among persons diagnosed with HIV infection during 2008-2011.

METHODS

Population-based surveillance data, restricted to persons with diagnosed HIV infection aged 13 years or older, from all 50 states and Washington, D.C. were used to estimate life expectancy after HIV diagnosis using the life table method. Generated estimates were compared with life expectancy in the general population in the same calendar year to calculate AYLL. Life expectancy and AYLL were also estimated for subgroups by age, sex, and race/ethnicity.

RESULTS

The overall life expectancy after HIV diagnosis in the United States increased by 3.43 years from 25.43 (95% CI: 25.37 to 25.49) in 2008 to 28.86 (95% CI: 28.80 to 28.92) in 2011. Improvements were observed irrespective of sex, race/ethnicity, transmission category, and stage of disease at diagnosis, though the extent of improvement varied by different characteristics. Based on the life expectancy in the general population, in 2010, the AYLL were 12.8 years for males and 16.5 years for females. By race/ethnicity, on average, blacks (13.3 years) and whites (13.4 years) had fewer AYLL than Hispanics/Latinos (14.7).

CONCLUSIONS

Despite improvements in life expectancy among people diagnosed with an HIV infection during 2008-2011, disparities by sex and by race/ethnicity persist. Targeted efforts should continue to further reduce disparities and improve life expectancy after HIV diagnosis.

The Influence of Medication Attitudes on Utilization of Antiretroviral Therapy (ART) in Indonesian Prisons

Negative attitudes toward HIV medications may restrict utilization of antiretroviral therapy (ART) in Indonesian prisons where many people living with HIV (PLH) are diagnosed and first offered ART. This mixed-method study examines the influence of medication attitudes on ART utilization among HIV-infected Indonesian prisoners. Randomly-selected HIV-infected male prisoners (n = 102) completed face-to-face in-depth interviews and structured surveys assessing ART attitudes. Results show that although half of participants utilized ART, a quarter of those meeting ART eligibility guidelines did not. Participants not utilizing ART endorsed greater concerns about ART efficacy, safety, and adverse effects, and more certainty that ART should be deferred in PLH who feel healthy. In multivariate analyses, ART utilization was independently associated with more positive ART attitudes (AOR = 1.09, 95 % CI 1.03-1.16, p = 0.002) and higher internalized HIV stigma (AOR = 1.03, 95 % CI 1.00-1.07, p = 0.016). Social marketing of ART is needed to counteract negative ART attitudes that limit ART utilization among Indonesian prisoners.

Exploring How Substance Use Impedes Engagement along the HIV Care Continuum: A Qualitative Study

Drug use is associated with low uptake of HIV antiretroviral therapy (ART), an under-studied step in the HIV care continuum, and insufficient engagement in HIV primary care. However, the specific underlying mechanisms by which drug use impedes these HIV health outcomes are poorly understood. The present qualitative study addresses this gap in the literature, focusing on African-American/Black and Hispanic persons living with HIV (PLWH) who had delayed, declined, or discontinued ART and who also were generally poorly engaged in health care. Participants (N = 37) were purposively sampled from a larger study for maximum variation on HIV indices. They engaged in 1-2 h audio-recorded in-depth semi-structured interviews on HIV histories guided by a multilevel social-cognitive theory. Transcripts were analyzed using a systematic content analysis approach. Consistent with the existing literature, heavy substance use, but not casual or social use, impeded ART uptake, mainly by undermining confidence in medication management abilities and triggering depression. The confluence of African-American/Black or Hispanic race/ethnicity, poverty, and drug use was associated with high levels of perceived stigma and inferior treatment in health-care settings compared to their peers. Furthermore, providers were described as frequently assuming participants were selling their medications to buy drugs, which strained provider-patient relationships. High levels of medical distrust, common in this population, created fears of ART and of negative interactions between street drugs and ART, but participants could not easily discuss this concern with health-care providers. Barriers to ART initiation and HIV care were embedded in other structural- and social-level challenges, which disproportionately affect low-income African-American/Black and Hispanic PLWH (e.g., homelessness, violence). Yet, HIV management was cyclical. In collaboration with trusted providers and ancillary staff, participants commonly reduced substance use and initiated or reinitiated ART. The present study highlights a number of addressable barriers to ART initiation and engagement in HIV care for this vulnerable population, as well as gaps in current practice and potential junctures for intervention efforts.

Understanding Cross-Sectional Racial, Ethnic, and Gender Disparities in Antiretroviral Use and Viral Suppression Among HIV Patients in the United States

To examine racial/ethnic and gender disparities in antiretroviral (ART) use and viral suppression among HIV-infected persons in care and identify factors that might account for observed disparities. The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States. We used weighted interview and medical record data collected 06/2009 to 05/2012 to estimate the prevalence of ART use and viral suppression among gender-stratified racial/ethnic groups. We used χ² tests to identify significant differences in outcomes between white men versus other groups, and logistic regression models to identify the most parsimonious set of factors that could account for each observed difference. We found no significant disparity in ART use between white and Hispanic men, and no disparities between white men and white and Hispanic women after adjustment for disease stage, age, and poverty. Disparities in ART use between white men and black persons persisted after adjusting for other factors, but the observed differences were relatively small. Differences in ART use and adherence, demographic characteristics, and social determinants of health such as poverty, education, and insurance accounted for the observed disparities in viral suppression between white men and all groups except black men. In our model, accounting for these factors reduced the prevalence difference in viral suppression between white and black men by almost half. We found that factors associated with disparities differed among men and women of the same race/ethnicity, lending support to the assertion that gender affects access to care and health status among HIV-infected patients. In addition to supporting efforts to increase ART use and adherence among persons living with HIV, our analysis provides evidence for the importance of social determinants of health in understanding racial/ethnic and gender differences in ART use and viral suppression.

On the Margins of Pharmaceutical Citizenship: Not Taking HIV Medication in the "Treatment Revolution" Era

With the expanding pharmaceuticalization of public health, anthropologists have begun to examine how biomedicine's promissory discourses of normalization and demarginalization give rise to new practices of and criteria for citizenship. Much of this work focuses on the biomedicine-citizenship nexus in less-developed, resource-poor contexts. But how do we understand this relationship in resource-rich settings where medicines are readily available, often affordable, and a highly commonplace response to illness? In particular, what does it mean to not use pharmaceuticals for a treatable infectious disease in this context? We are interested in these questions in relation to the recent push for early and universal treatment for HIV infection in Australia for the twin purposes of individual and community health. Drawing on Ecks's concept of pharmaceutical citizenship, we examine the implications for citizenship among people with HIV who refuse or delay recommended medication. We find that moral and normative expectations emerging in the new HIV "treatment revolution" have the capacity to both demarginalize and marginalize people with HIV.

Behavioral intervention improves treatment outcomes among HIV-infected individuals who have delayed, declined, or discontinued antiretroviral therapy: a randomized controlled trial of a novel intervention

Nationally up to 60 % of persons living with HIV are neither taking antiretroviral therapy (ART) nor well engaged in HIV care, mainly racial/ethnic minorities. This study examined a new culturally targeted multi-component intervention to address emotional, attitudinal, and social/structural barriers to ART initiation and HIV care. Participants (N = 95) were African American/Black and Latino adults with CD4 < 500 cells/mm(3) not taking ART, randomized 1:1 to intervention or control arms, the latter receiving treatment as usual. Primary endpoints were adherence, evaluated via ART concentrations in hair samples, and HIV viral load suppression. The intervention was feasible and acceptable. Eight months post-baseline, intervention participants tended to be more likely to evidence "good" (that is, 7 days/week) adherence (60 vs. 26.7 %; p = 0.087; OR = 3.95), and had lower viral load levels than controls (t(22) = 2.29, p = 0.032; OR = 5.20), both large effect sizes. This highly promising intervention merits further study.

Integrating Antiretroviral Strategies for Human Immunodeficiency Virus Prevention: Post- and Pre-Exposure Prophylaxis and Early Treatment

Best practices for integrating HIV testing and antiretroviral interventions for prevention and treatment are suggested based on research evidence and existing normative guidance. The goal is to provide high impact prevention services during periods of substantial risk.

Best practices for integrating human immunodeficiency virus (HIV) testing and antiretroviral interventions for prevention and treatment are suggested based on research evidence and existing normative guidance. The goal is to provide high-impact prevention services during periods of substantial risk. Antiretroviral medications are recommended for postexposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), and treatment of HIV infection. We reviewed research evidence and current normative guidelines to identify best practices for integrating these high-impact prevention strategies. More sensitive HIV tests used for screening enable earlier diagnosis and treatment of HIV infection, more appropriate counseling, and help limit drug resistance. A fully suppressive PEP regimen should be initiated based on exposure history or physical findings when sensitive diagnostic testing is delayed or not available and antibody tests are negative. Transitions from PEP to PrEP are often warranted because HIV exposure events may continue to occur. This algorithmic approach to integrating PEP, PrEP, and early treatment decisions may increase the uptake of these interventions by a greater number and diversity of knowledgeable healthcare providers.