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The Influence of Psychosocial Characteristics and Race/Ethnicity on the Use, Duration, and Success of Antiretroviral Therapy

Pence, Brian Wells PhD, MPH*†; Ostermann, Jan PhD*†‡; Kumar, Virender PhD§; Whetten, Kathryn PhD, MPH*†‡; Thielman, Nathan MD, MPH*∥; Mugavero, Michael J MD, MHSc

JAIDS Journal of Acquired Immune Deficiency Syndromes: February 1st, 2008 - Volume 47 - Issue 2 - p 194-201
doi: 10.1097/QAI.0b013e31815ace7e
Clinical Science

Background: Expanded access to antiretroviral therapy (ART) has produced dramatic reductions in HIV-associated morbidity and mortality. Disparities in access to and benefit from ART have been observed by race, gender, and mental health status, however.

Methods: From 2001 to 2002, 611 HIV-positive patients were consecutively recruited from 5 southeastern US states and followed for 3 years. We evaluated demographic and psychosocial predictors of probability of receiving ART among all those eligible for ART (on ART, CD4 <350 cells/mm3 or viral load [VL] >55,000 copies/mL in the year preceding enrollment), time to first ART discontinuation among those on ART, and time to VL >400 copies/mL among those on ART with VL <400 copies/mL at enrollment.

Results: Of 611 participants, 474 consented to medical record abstraction and had known ART status at enrollment; 81% (385 of 474) of all participants and 89% (385 of 435) of ART-eligible participants were receiving ART at enrollment. In multivariable analyses, ART receipt was associated with greater age (adjusted odds ratio = 1.92 per 10 years, 95% confidence interval: 1.23 to 3.01), fewer recent stressful life events (odds ratio = 0.68, 95% confidence interval: 0.51 to 0.92), less alcohol use (odds ratio = 0.64, 95% confidence interval: 0.46 to 0.90), and greater perceived self-efficacy (OR = 2.82, 95% confidence interval: 1.41 to 5.62). No psychosocial characteristics were associated with ART discontinuation or virologic failure. No racial/ethnic or gender disparities were observed in ART receipt; however, minority racial/ethnic groups were faster to discontinue ART (adjusted hazard ratio = 2.44, 95% confidence interval: 1.33 to 4.49) and experience virologic failure (adjusted hazard ratio = 2.01, 95% confidence interval: 1.09 to 3.71).

Conclusions: Patients with unfavorable psychosocial profiles were less likely to be on ART, perhaps attributable to providers' or patients' expectations of readiness. Psychosocial characteristics were not associated with ART discontinuation or virologic failure, however, possibly reflecting the selection process involved in who initiates ART. Racial disparities in ART discontinuation and virologic failure merit further attention.

From the *Health Inequalities Program, Center for Health Policy, Duke University, Durham, NC; †Terry Sanford Institute of Public Policy, Duke University, Durham, NC; ‡Department of Community and Family Medicine, Duke University, Durham, NC; §Westat, Rockville, MD; ∥Division of Infectious Diseases and International Health, Department of Medicine, Duke University, Durham, NC; and the ¶Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL.

Received for publication March 28, 2007; accepted September 10, 2007.

Supported in part by the National Institute of Mental Health (NIMH), the National Institute of Drug Abuse (NIDA), and the National Institute of Nursing Research (NINR); grant 5R01MH061687-05 of the National Institutes of Health, and grant 1R21 AA015052-01 A1 from the National Institute of Alcoholism and Alcohol Abuse. N. Thielman receives support from the AIDS Clinical Trial Group (V01-39156).

Correspondence to: Brian Wells Pence, PhD, Center for Health Policy, Box 90253, Duke University, Durham NC 27708 (e-mail: bpence@aya.yale.edu).

© 2008 Lippincott Williams & Wilkins, Inc.