Multifaceted Interventions Needed to Increase ART Adherence Among Black Men

Interventions that consider financial incentives, legal support, and housing assistance for Black sexual minority men who have sex with men and are living with HIV (BMSM+) are needed to increase both antiretroviral treatment (ART) adherence and viral suppression among these individuals, according to new study findings published in Journal of Acquired Immune Deficiency Syndromes.

In particular, ART adherence and HIV viral suppression both are lower among BMSM+ vs White men, the authors note.

“National surveillance data indicate that HIV care outcomes, such as viral suppression and linkage to care within a month of diagnosis, for racial/ethnic minority people have been improving,” they wrote. “Lower rates of engagement in care, ART adherence, and viral suppression persist, however, especially among Black people living with HIV compared with their White counterparts.”

Prior to their evaluation of 124 BMSM+ living in Los Angeles County (mean [SD] age, 35 [12.2] years), they conducted recruitment efforts via social networking apps and during the men’s clinic visits. The men who agreed to participate were then sent a cross-sectional survey that gathered demographic data and evaluated the men’s structural and psychosocial syndemics, or “2 or more afflictions that interact synergistically and contribute to the excess burden of disease in a population,” the authors wrote. Structural syndemics investigated were poverty, criminal justice involvement, and housing instability, and the psychosocial syndemics were depression, childhood sexual abuse, intimate partner violence, substance use, and alcohol-related problems. An additional survey sent via text gauged missed weekly ART doses.

The survey results from the LINX LA prospective, randomized comparison trial show that the cohort missed a mean (SD) 1.3 (2.09) weekly doses of their ART and reported high rates of the 3 structural syndemics evaluated: 56.1% reported poverty; 36.6%, criminal justice involvement; and 26.3%, housing instability. In addition, high rates of problem alcohol use, intimate partner violence, depression, and childhood sexual abuse were reported for psychosocial syndemics, at 15.5%, 16.9%, 39%, and 51.8%, respectively.

Overall, 79% of the study cohort was receiving ART at baseline. There was also a 63% greater risk (P < .05) of missing 1 ART dose with each 1-point increase in structural syndemic indicators, after accounting for the confounders of employment, age, education, and psychosocial syndemics.

Analyses also found:

• 56.1% reported annual incomes below the federal poverty line
• 41.9% reported any form of employment (full time, part time, self-employed)
• 95.9% had access to health insurance
• 88.8% had access to a primary care physician
• 31.7% reported 2 or more structural syndemic factors
• 43.3% reported 2 or more psychosocial syndemic factors

In addition, having an unstable housing situation was shown to have a statistically significant association with number of missed ART doses (internal rate of return, 1.68; 95% CI, 1.12-2.53; P = .012).

These findings add to existing research that shows Black gay men have higher rates of treatment nonadherence when they report depressive symptoms, substance use and drinking problems, trauma pertaining to several types of violence (physical/sexual assault, extreme violence), and homelessness and economic insecurity. Repeated incarcerations also are linked to lower ART adherence, even though significant gains in adherence are seen in newly released persons.

“Although previous research has focused largely on psychosocial factors as drivers of elevated rate of HIV among BMSM, this study uses syndemics theory,” the authors wrote, “which follows the tenet that disease clustering may be derived from structural conditions of inequity, poverty, and stigmatization and not just from psychosocial experiences.” This intersection, they continue, may also reduce how BMSM+ engage in HIV care through social support networks.

“The reality is that available benefits are often substandard because they fail to lift people out of poverty and into stable and habitable housing environments,” they conclude. “Taken together, this research supports the need for more broad-based HIV treatment interventions to support BMSM+, including those that tackle poverty, disproportionate rates in policing and criminalization, and housing instability.”

Reference

Holloway IW, Beltran R, Shah SV, et al. Structural syndemics and antiretroviral medication adherence among Black sexual minority men living with HIV. J Acquir Immune Defic Syndr. 2021;88(suppl 1):S12-S19. doi:10.1097/QAI.0000000000002806