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Culturally tailored HIV interventions to increase ART adherence in young Black men who have sex with men should address social support and depression.

“Among MSM [men who have sex with men] living with HIV, Black MSM have the lowest percentage of viral suppression, an outcome that relies on antiretroviral therapy (ART) adherence,” researchers wrote in AIDS and Behavior. “In 2021, only 62% of Black/African American people living with HIV were virally suppressed compared to 72% of White [people with HIV] in the US. A recent systematic review among Black and Hispanic MSM living with HIV reported a ‘paucity of research on the various contributors to poor ART adherence.’”

Further, according to Mark S. Dworkin, MD, MPHTM, and colleagues, current literature has taken a “syndemic approach” to examining the structural and psychosocial factors that impact ART adherence, including substance/alcohol use, poverty, housing instability, and psychosocial distress. However, these studies have not enrolled younger patients with HIV.

Although the incidence of new HIV infections fell slightly among all MSM from 2010 to 2019, HIV incidence remained the same for Black men during this period. What’s more, 51% of all new HIV cases in 2019 among MSM younger than 25 years occurred in Black men, and Black men currently have the lowest rates of HIV suppression in any race or ethnic group of MSM.

Determinants of ART Adherence in Young Black MSM

Dr. Dworkin and colleagues gathered baseline data from patients enrolled in the My Personal Health Guide trial, which assessed the efficacy of a mobile app meant to improve HIV outcomes. All patients were Black men aged 18 to 34 years who were currently prescribed or initiating oral ART. Patients had either detectable viral loads within the past 4 weeks or a history of ART nonadherence.

A total of 315 participants from 23 states responded to questionnaires about their demographic and behavioral characteristics, as well as substance abuse and housing insecurity. Following the Information–Motivation–Behavioral Skills (IMB) model, interviewers spoke with patients about basic ART adherence information and knowledge, such as whether they should take their medicine with food; motivation for adherence; behavioral skills, in which interviewers rated patients’ confidence in their adherence; self-reported ART adherence; and depressive symptoms. They then used modeling to evaluate the direct and indirect effects of ART-related information, motivation, and behavioral skills on less-than-optimal ART adherence, defined as less than 80% on the Wilson’s adherence measure.

Factors Influencing Suboptimal ART Adherence

Overall, 28.3% of participants had non-optimal ART adherence, the researchers found.  There was a significant, direct association between low behavioral skills and non-optimal adherence in the full model (β=0.67; SE [standard error]=0.10; P<0.001). Furthermore, low behavioral skills were a significant mediating factor in the relationship between low motivation and non-optimal adherence (P<0.001).

In men who were not depressed or showed only mild symptoms of depression, low motivation had a larger impact on non-optimal adherence overall (β=0.30; SE=0.13; P<0.001), whereas there was no direct effect of low motivation on non-optimal adherence among patients with moderate or severe depression.

The study was limited by the fact that participants were recruited over social media and included patients who were not representative of the entire population of young Black MSM with HIV. However, the findings aligned with previous studies, and the study was the largest yet conducted in this cohort. It also included a preponderance of participants from the South, meaning it captured data from a region where ART adherence is often low.

“Using the IMB model, we found behavioral skills (treatment self-efficacy) to mediate the association between motivation and non-optimal ART adherence among young Black MSM living with HIV,” they wrote, reiterating that motivation was a greater factor in non-optimal adherence in patients without depression.

“Development of interventions to increase ART adherence among young Black MSM should assess and address both social support and depression to raise motivation,” Dr. Dworkin and colleagues noted.