Linda Beer, PhD and Jacek Skarbinski, MD for the Medical Monitoring Project
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1 Adherence to Antiretroviral Therapy and Disparities in Viral Suppression among U.S. Black and White Men Who Have Sex With Men Medical Monitoring Project, 2009 Linda Beer, PhD and Jacek Skarbinski, MD for the Medical Monitoring Project 8th International Conference on HIV Treatment and Prevention Adherence June 2013 The findings and conclusions presented are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. The authors declare no conflicts of interest. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
2 Background In the United States, black men who have sex with men (MSM) are disproportionately affected by HIV Higher rates of HIV incidence and prevalence Less likely to be virally suppressed Viral suppression associated with decreased morbidity, mortality, and risk of HIV transmission Adherence to antiretroviral therapy (ART) key to suppressing viral replication Differences in medication adherence may contribute to racial disparity in viral suppression among MSM, but prior studies have been limited
3 Objectives Present nationally representative estimates of adherence and viral suppression among black and white MSM receiving care in the United States Assess whether differences in adherence were associated with differences in viral suppression Assess whether factors associated with adherence differed among black and white MSM
4 Methods Analysis of Medical Monitoring Project (MMP) data collected June May 2010 Ongoing supplemental HIV surveillance system Interview and medical record data from HIV-infected adults receiving care 16 U.S. states (including 6 separately funded areas) and one territory Three-stage sample design States HIV care-providing facilities HIV-infected adults receiving care Response rates for matched data States = 100% Facilities = 76% Patients = 51% Overall = 39%
5 Methods Persons included: black or white non-hispanic male MMP participants Oral or anal sex with a man during the past year If abstinent, reported homosexual/gay/bisexual identity Compared prevalence among HIV-infected BMSM and WMSM of ART use: Self-reported current use of ART Adherence: Self-reported 100% adherence to ART doses in the past 72 hours (ACTG) Viral suppression: Most recent viral load documented undetectable or < 200 copies/ml
6 Methods Modified Rao-Scott chi-square tests to identify significant bivariate differences in factors associated with adherence by race Sociodemographics, alcohol and substance use, dosing, side effects, medication beliefs Analyses accounted for clustering, unequal selection probabilities, and non-response
7 RESULTS: CHARACTERISTICS OF HIV-INFECTED BLACK AND WHITE MSM
8 Characteristics of HIV-infected Black and White MSM, MMP 2009: Sociodemographic Factors Black MSM (n=445) White MSM (n=1,004) p value % % Age at interview (years) < Educational attainment < High school 11 5 <.01 High school or equiv > High school At or below poverty <.01 Homeless (past 12 mths) 9 4 <.01
9 Characteristics of HIV-infected Black and White MSM, MMP 2009: Health Care Access and Clinical Factors Any lapse in health care coverage (past 12 months) Black MSM (n=445) White MSM (n=1,004) % % p value <.01 HIV disease stage Clinical or immunologic AIDS No AIDS and nadir CD No AIDS and nadir CD4 > Time since HIV diagnosis (years) < <.01 >
10 RESULTS: ART USE, ADHERENCE, AND VIRAL SUPPRESSION
11 Use Of and Adherence to Antiretroviral Therapy (ART) Among HIV-infected Black and White Men Who Have Sex With Men (MSM) Medical Monitoring Project (MMP) United States, % HIV-infected Black MSM HIV-infected White MSM 80% P <.01 P =.02 60% 40% 82% (78-86)* 93% (92-95) 79% (74-84) 88% (84-92) 20% 0% *95% confidence limits Take ART 100% Adherent (among those on ART)
12 Recent Viral Suppression Among Black and White Men Who Have Sex With Men (MSM) by ART Use and Viral Suppression Medical Monitoring Project (MMP) United States, % 80% HIV-infected Black MSM p <.01 HIV-infected White MSM p =.02 p =.07 60% 40% 20% 65% (58-71)* 81% (78-85) 77% (71-83) 86% (82-90) 64% suppressed among nonadherent p = <.01 81% (76-86) 87% (83-91) 80% suppressed among nonadheren p =.08 0% Viral suppresstion Viral suppresstion (among those taking ART) Viral suppresstion (among those taking ART and adherent) *95% confidence limits, viral suppression: most recent viral load documented <200 or undetectable; ART=antiretroviral therapy
13 RESULTS: RACIAL DIFFERENCES IN FACTORS ASSOCIATED WITH ADHERENCE
14 Variables Examined for Association with Adherence Age Education Poverty Homelessness Incarceration Depression Drug use Stimulant use Binge drinking Health coverage/insurance Years since HIV diagnosis One daily dose Side effects Being sure can take medicine Being sure medication has positive effect Being sure of resistance if nonadherent Social support
15 Variables Not Significantly Associated With Adherence Among Black and White MSM Age Poverty Homelessness Incarceration Health coverage/insurance Years since HIV diagnosis One daily dose Social support
16 Factors Significantly Associated with 100% Adherence Among Black and White MSM MMP 2009 Black MSM White MSM Adherent Adherent PR % % PR Sure of ability to take Not at all/somewhat 40 Ref. 44 Ref. medications as directed Very/extremely Binge drinking No Yes 66 Ref. 79 Ref. Drug use No Yes 65 Ref. 83 Ref. Stimulant use No Yes 57 Ref. 74 Ref. All percentages weighted; PR= prevalence ratio; all differences significant at p <.05.
17 Factors Significantly Associated with 100% Adherence Among Black and White MSM MMP 2009 Black MSM White MSM Adherent Adherent PR % % PR Education < High School 69 Ref. 81 Ref. High School > High School Sure of resistance if do not Not at all/somewhat 78 Ref. 81 Ref. take medications as Very/extremely instructed Sure medications will have a positive effect on health Not at all/somewhat Very/extremely Ref Ref Troubled by side effects Never/rarely About half or more 67 Ref. 84 Ref. Depression No Yes 69 Ref. 87 Ref. All percentages weighted; PR= prevalence ratio; yellow indicates significant at p <.05.
18 IMPLICATIONS, LIMITATIONS, AND CONCLUSIONS
19 Areas to Target for Interventions to Improve Adherence Among MSM For Black and White MSM Increase self-efficacy around taking medications as directed Screen for and treat alcohol and substance abuse For White MSM Address factors associated with low educational attainment that affect adherence (literacy/numeracy?) Increase knowledge about adherence and resistance relationship For Black MSM Increase ART use Screen for and treat depression Reduce side effects Increase beliefs about positive effects of medications on health
20 Limitations Adherence measure likely overestimates actual adherence Measurement of adherence and viral load were not necessarily contemporaneous Lower than optimal response rates, but estimates were adjusted for nonresponse
21 Conclusions Although differences remained, use of and adherence to ART reduced disparities in viral suppression among BMSM and WMSM Increasing ART use and adherence among BMSM are key steps towards decreasing racial disparities in treatment outcomes among MSM The development and implementation of ART use and adherence interventions that specifically address the needs of BMSM should be prioritized
22 Acknowledgments MMP facility staff and patients MMP Principal Investigators and Project Coordinators MMP Provider Advisory Board and Community Advisory Board members CDC Clinical Outcomes Team
23 Thank you! Linda Beer National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
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