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.

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 selfreported sociodemographic characteristics, ART adherence, drug and alcohol use, and symptoms of depression † and anxiety § were ascertained. * Interviews are conducted during June-May for each annual cycle; this analysis combined 2015-2018 cycles. Response rates for participants ranged from 40% to 46% by cycle year. † Symptoms of depression during the previous 2 weeks were assessed using the eight-item Patient Health Questionnaire. § Symptoms of anxiety during the previous 2 weeks were assessed using the Generalized Anxiety Disorder Scale.
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 ¶ Ancillary services include HIV case management services, ART 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. ** Persons with unknown viral load measurements were analyzed with those with detectable viral loads.
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%

Summary
What is already known about this topic? Antiretroviral therapy (ART) adherence is crucial for viral suppression, a critical outcome for maintaining health in persons with HIV infection. Hispanic/Latino men who have sex with men (MSM) have disproportionately high HIV infection rates; their barriers to ART adherence have not been extensively explored.
What is added by this report?
ART adherence was lower among younger Hispanic/Latino MSM and those who experienced poverty or reported drug use, depression, or unmet ancillary service needs. The most common reason for missing ART doses was forgetting (63.1%); 63.9% who missed doses reported multiple reasons.
What are the implications for public health practice?
Expanding access to ancillary services among Hispanic/Latino MSM, particularly those experiencing barriers to ART adherence, might improve clinical outcomes.
( 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).

Discussion
Although high overall, self-reported ART adherence among HIV-positive Hispanic/Latino MSM was lower among younger persons, those living at or below poverty, and those who reported drug use, depression, and unmet needs for ancillary services. The most commonly reported reason for last missed ART dose was forgetting to take it; three in five persons reported multiple reasons. These results indicate possible avenues for interventions to help Hispanic/Latino MSM engage in care and remain ART-adherent. Ancillary services (e.g., counseling for mental health and substance use disorders, financial support, and assistance with food and housing) might reduce barriers to ART adherence. Colocating these services with outpatient care (e.g., HIV patient-centered medical home model of the Ryan White HIV/AIDS Program)(8) can encourage engagement and retention in HIV care. In a study of ART adherence among African American and Hispanic/Latino MSM, younger participants reported better adherence when their care location also offered ancillary services to help them address other needs (3). Making these services more broadly available and easily accessible might remove barriers to ART adherence and improve health outcomes.
Approximately two thirds of persons who had missed ≥1 ART dose reported having forgotten to take it. Interventions that include reminders might help prevent these lapses. An analysis of systematic reviews of ART adherence interventions found that text messaging interventions were among the most successful for improving both self-reported adherence and viral load (9). Other interventions that have increased ART adherence include peer support and cognitive behavioral therapy. Interventions that include multiple strategies were more likely to increase ART adherence, although effects were often short-lived (10).