Photo Credit: SeventyFour

ART adherence is crucial for sustained viral suppression in HIV, yet disparities exist among MSM. Understanding contributors is key to reducing these gaps.

“ART adherence is the first step toward achieving sustained viral suppression, which is vital to reducing HIV transmission,” Deesha Patel, MPH, notes. “Previous data have shown Black/African American and Hispanic/Latino MSM have lower prevalence of ART adherence and viral suppression compared with White MSM. It is critical to understand what contributes to these disparities so that appropriate actions can be taken to reduce them.”

For a study published in AIDS, Patel and colleagues “aimed to identify factors that may contribute to ongoing racial/ethnic disparities in ART adherence and sustained viral suppression among MSM.”

The researchers examined weighted data from the 2017-2021 cycles of the Medical Monitoring Project. Among MSM on ART, they determined prevalence differences (PDs) in ART adherence (100% ART adherence in the previous 30 days) and sustained viral suppression (all viral loads in the previous 12 months; <200 copies/mL or undetectable) for Black/African American and Hispanic/Latino MSM compared with White MSM. Patel and colleagues also examined whether controlling for certain variables decreased PDs.

“We examined various factors—ranging from social determinants of health (SDOH) to demographic, clinical, and behavioral factors—to ensure that we were getting the most complete picture possible when studying these disparities,” Patel says. “We felt that it was especially important to include SDOH, given that they are generally poorer among persons with HIV and may help explain some of the gaps in understanding persistent racial/ethnic disparities among MSM.”

SDOH “Must Be Addressed” to Reduce Disparities

The study included 9,047 Black/African American, Hispanic/Latino, and White MSM who reported current ART use.

Compared with White MSM, Black/African American and Hispanic/Latino MSM were more likely to be younger, live in households below the Federal Poverty Level, have hunger/food insecurity, have a high school diploma or less, experience homelessness, and have a history of violence by an intimate partner. Black/African American and Hispanic/Latino MSM were also more likely to be uninsured or be covered through the Ryan White HIV/AIDS Program only, have a gap in health coverage, have 9 years or less since the time of HIV diagnosis, and have any unmet need for ancillary services. Compared with White MSM, Black/African American MSM were more likely to have had one or more ED visits or have been incarcerated for more than 24 hours, and Hispanic/Latino MSM were less likely to report health literacy and had a higher prevalence of binge drinking.

Slightly more than 46% of MSM reported ART adherence, and 66.6% had sustained viral suppression. Patel and colleagues found that all covariates were associated with ART adherence (all P<0.001). All characteristics (P<0.05) except health literacy, history of violence by an intimate partner, and binge drinking were associated with sustained viral suppression.

“Our findings indicate that it is not just individual-level factors that contribute to racial/ethnic disparities in treatment outcomes,” Patel says. “SDOH must also be addressed if disparities are to be reduced.”

This requires considering a patient’s SDOH during clinic visits and connecting them to community resources as needed.

“We acknowledge that many clinicians have limited time and resources and that addressing SDOH requires structural change at all levels,” she continues. “However, there are still actions that clinicians can take, such as writing 90-day prescriptions if they know that a patient has difficulties obtaining monthly prescriptions—due to, for example, a lack of transportation—or promoting antistigma and anti-discrimination practices in their clinics.”

Incorporating SDOH into Clinic Visits & Interventions

Patel notes that research over many years has consistently shown differences in SDOH among persons with HIV by racial/ethnic groups, including MSM with HIV.

“A recent analysis also found that persons with HIV experience substantially poorer SDOH compared with the US population. In our study, it was promising to see that sustained viral suppression was not significantly different between Hispanic/Latino and White MSM. Our analysis provides evidence that it’s possible to reduce disparities among Black/African American MSM if SDOH are improved.”

Achieving this on a broader scale will require clinicians to “maximize innovations” and keep health equity at “the center of all we do,” she continues. “Clinics, for example, can implement programs that incentivize ART adherence or cover transportation costs to and from clinics and pharmacies. At the policy level, increasing investments in the Ryan White HIV/AIDS Program could improve access to HIV treatment and ancillary services.”

The current study also serves as a starting point for future research.

“Our analysis was unable to account for important factors such as stigma, discrimination, and racism, as well as differences in ART regimens,” Patel notes. “Assessing these factors could help explain the remaining disparities that our study noted, especially among Black/African American MSM. There is also more to be learned from the perspective of implementation science. Future studies can explore which specific strategies or interventions would make the greatest impact in reducing racial/ethnic disparities in HIV treatment outcomes.”

Key Takeaways

• Compared with White MSM, Black/African American and Hispanic/Latino MSM are more likely to live in poverty, have hunger/food insecurity, less education, and suboptimal insurance coverage
• These social determinants of health (SDOH) were all associated with ART adherence and sustained viral suppression
• SDOH must be addressed to reduce disparities in HIV
• Interventions that link patients to community services could increase ART adherence and sustained viral suppression