Barriers to Antiretroviral Therapy Adherence Among HIV-Positive Hispanic and Latino Men Who Have Sex with Men —United States, 2015–2019

During 2018, estimated incidence of human immunodeficiency virus (HIV) infection among Hispanic and Latino (Hispanic/Latino) persons in the United States was four times that of non-Hispanic White persons (1). Hispanic/Latino men who have sex with men (MSM) accounted for 24% (138,023) of U.S. MSM living with diagnosed HIV infection at the end of 2018 (1). Antiretroviral therapy (ART) adherence is crucial for viral suppression, which improves health outcomes and prevents HIV transmission (2). Barriers to ART adherence among Hispanic/Latino MSM have been explored in limited contexts (3); however, nationally representative analyses are lacking. The Medical Monitoring Project reports nationally representative estimates of behavioral and clinical experiences of U.S. adults with diagnosed HIV infection. This analysis used Medical Monitoring Project data collected during 2015–2019 to examine ART adherence and reasons for missing ART doses among HIV-positive Hispanic/Latino MSM (1,673). On a three-item ART adherence scale with 100 being perfect adherence, 77.3% had a score of ≥85. Younger age, poverty, recent drug use, depression, and unmet needs for ancillary services were predictors of lower ART adherence. The most common reason for missing an ART dose was forgetting; 63.9% of persons who missed ≥1 dose reported more than one reason. Interventions that support ART adherence and access to ancillary services among Hispanic/Latino MSM might help improve clinical outcomes and reduce transmission.

The Medical Monitoring Project used a two-stage sampling method. During the first stage, 16 states and one territory were sampled from all U.S. states, the District of Columbia, and Puerto Rico. During the second stage, simple random samples of adults with diagnosed HIV infection were selected for each participating jurisdiction from the National HIV Surveillance System, a census of persons with diagnosed HIV infection in the United States. In-person or telephone interviews were conducted during the 2015–2018 data cycles,* in which self-reported sociodemographic characteristics, ART adherence, drug and alcohol use, and symptoms of depression^† and anxiety^§ were ascertained.

ART adherence during the 30 days before the interview was assessed using a three-item scale; responses were aggregated and transformed into a previously validated composite score (range = 0–100), which has high internal reliability and is consistent with electronic drug monitoring measures (4,5). Ancillary services^¶ were defined as services that enable and support participants’ retention in HIV care (6). Sustained viral suppression was defined as all viral load measurements in the previous 12 months documented as undetectable or <200 viral RNA copies/mL.** Reasons for most recent missed ART dose consisted of predefined options that respondents could select and were limited to the 2018 data cycle because of skip-pattern changes that limited comparability with earlier data cycles.

This analysis was limited to men who self-identified as Hispanic/Latino, regardless of race, who were currently taking ART and self-identified as MSM (i.e., gay or bisexual or who reported having had sex with one or more men during the previous 12 months) (1,673). Among HIV-positive Hispanic/Latino MSM, the three components of the ART adherence scale and the ART adherence scale score (dichotomized as ≥85 versus <85 on the basis of the distribution of scores), by selected characteristics, were examined by using weighted percentages with corresponding 95% confidence intervals (CIs). Characteristics associated with high ART adherence (score ≥85) were assessed by using a multivariable logistic regression model to describe adjusted prevalence ratios (aPRs) with predicted marginal means (7). Characteristics with bivariate associations with ART adherence (p<0.1) were eligible for possible inclusion in the model. Backward selection was used to determine final model selection, where eligible covariates with significant associations (p<0.05) were retained in the final model. Among persons who reported ever missing ≥1 ART dose (348 during the 2018 data cycle), reasons for most recent missed dose were described; participants could report more than one reason. Sustained viral suppression status was assessed, comparing those with higher adherence (i.e., adherence score ≥85) with those with lower adherence (i.e., adherence score <85), using a univariate prevalence ratio (PR). All analyses were weighted to adjust for individual nonresponse and poststratified to known population totals by age, race/ethnicity, and sex from the National HIV Surveillance System. Analyses were conducted using survey procedures in SAS software (version 9.4; SAS Institute) and SAS-callable SUDAAN (version 11.0.3; RTI International).

During 2015–2019, 57.4% of Hispanic/Latino MSM reported taking all ART doses during the previous month, 52.9% reported doing an excellent job taking their medications, and 69.2% reported always taking their medications as recommended (Table 1). ART adherence was high for 77.3% (Table 2). Younger persons and those at or below the federal poverty threshold were less likely to report high ART adherence. Reported ART adherence was lower among persons who reported drug use in the previous year (67.2%) than among those who did not (81.9%), among persons who reported a recent history of depression (66.3%) than among those who did not (79.9%), and among persons who had unmet needs for ancillary services (71.6%) than among those without unmet needs (83.0%). Anxiety and history of homelessness were not associated with ART adherence after adjustment for other factors. Among persons who had ever missed ≥1 ART dose, the most commonly reported reasons for the most recent missed dose were forgetting to take medication (63.1%), a change in daily routine or travel (42.3%), and having fallen asleep early or overslept (33.6%) (Table 3). Approximately 64% of persons who missed ≥1 dose reported multiple reasons for missing ART. Sustained viral suppression was more common among persons with ART adherence scores ≥85 (75.3%) than among persons with lower scores (59.7%; PR = 0.61; 95% CI = 0.51–0.74).

Corresponding author: Stacy Crim, [email protected], 404-639-2257.

¹Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

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Abbreviations: CI = confidence interval; HIV = human immunodeficiency virus.
* Numbers might not sum to total because of missing data, and percentages might not sum to 100 because of rounding.
^† Percentages and corresponding CIs are weighted percentages.
^§ Time frame for all questions is the 30 days before the interview.
^¶ Value is excluded because coefficient of variation >0.30.

Abbreviations: CI = confidence interval; HIV = human immunodeficiency virus.
* Numbers are unweighted.
^† Adherence scale score is composite of three variables (number of missed days of ART, how often respondent took ART correctly, and how good of a job taking ART respondent reported) and ranges from 0 to 100, with 100 indicating perfect adherence.
^§ Percentages and corresponding CIs are weighted percentages.
^¶ Dash indicates that a value is not applicable.
** Poverty guidelines as defined by the U.S. Department of Health and Human Services.
^†† Living on the street, in a shelter, in a single-room–occupancy hotel, or in a car.
^§§ Binge drinking for men is defined as five or more alcoholic drinks in one sitting.
^¶¶ Depression was assessed by using the eight-item Patient Health Questionnaire algorithm.
*** Anxiety was assessed by using the Generalized Anxiety Disorder Scale.
^††† Retention in care was defined as documentation of two indications of outpatient HIV care, including a documented visit with an HIV provider, a documented CD4⁺ or viral load test, or a documented resistance test or tropism assay, ≥90 days apart during the previous 12 months.
^§§§ Ancillary services include HIV case management services, adherence counseling services, AIDS Drug Assistance Program services, patient navigation services, HIV peer group support, dental services, drug or alcohol counseling or treatment, mental health services, transportation assistance, shelter/housing services, Supplemental Security Income, Social Security Disability Insurance, food assistance, meals or food services, interpreter services, or legal services.

Abbreviation: CI = confidence interval.
* Respondents could select multiple reasons for missing a dose.
^† Data limited to 2018 cycle because of changes in skip-pattern preceding questions.
^§ Numbers might not sum to total because of missing data, and percentages might not sum to 100 because of rounding.
^¶ Percentages and corresponding CIs are weighted percentages.