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Racial/Ethnic Disparities in ART Adherence in the United States: Findings From the MACH14 Study

Simoni, Jane M. PhD*; Huh, David MS*; Wilson, Ira B. MD, MSc; Shen, Jie PhD; Goggin, Kathy PhD§; Reynolds, Nancy R. PhD; Remien, Robert H. PhD; Rosen, Marc I. MD#; Bangsberg, David R. MD, MPH**; Liu, Honghu PhD††

JAIDS Journal of Acquired Immune Deficiency Syndromes: August 15th, 2012 - Volume 60 - Issue 5 - p 466–472
doi: 10.1097/QAI.0b013e31825db0bd
Clinical Science

Background: Minority race/ethnicity is generally associated with antiretroviral therapy nonadherence in US-based studies. Limitations of the existing literature include small samples, subjective adherence measures, and inadequate control for potential confounders such as mental health and substance use, which have been consistently associated with poorer adherence.

Methods: Individual-level data were pooled from 13 US-based studies employing electronic drug monitoring to assess adherence. Adherence was operationalized as percent of prescribed doses taken from the first 12 (monthly) waves of data in each study. Depression symptoms were aggregated from several widely used assessments, and substance use was operationalized as any use of cocaine/stimulants, heroin/opiates, ecstasy, hallucinogens, or sedatives in the 30–365 days preceding baseline.

Results: The final analytic sample of 1809 participants ranged in age from 18 to 72 years and was 67% male. Participants were 53% African American, 14% Latino, and 34% White. In a logistic regression adjusting for age, gender, income, education, and site, race/ethnicity was significantly associated with adherence (P < 0.001) and persisted in a model that also controlled for depression and substance use (P < 0.001), with African Americans having significantly lower adherence than Latinos [odds ratio (OR) = 0.72, P = 0.04] and whites (OR = 0.60, P < 0.001). Adherence did not differ between whites and Latinos (OR = 0.84, P = 0.27).

Conclusions: Racial/ethnic differences in demographics, depression, and substance abuse do not explain the lower level of antiretroviral therapy adherence in African Americans observed in our sample. Further research is needed to explain the persistent disparity and might examine factors such as mistrust of providers, health literacy, and inequities in the health care system.

*Department of Psychology, University of Washington, Seattle, WA

Department of Health Services, Policy & Practice, Alpert Medical School, Brown University, Providence, RI

Division of Public Health and Community Dentistry, School of Dentistry, University of California Los Angeles (UCLA), Los Angeles, CA

§Department of Psychology, University of Missouri-Kansas City, Kansas City, MO

School of Nursing, Yale University, New Haven, CT

College of Physicians and Surgeons, Columbia University

#Yale University School of Medicine, West Haven, CT

**Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Cambridge, MA

††Division of Public Health and Community Dentistry, Department of Medicine and Department of Biostatistics, University of California Los Angeles (UCLA), Los Angeles, CA

Correspondence to: Jane M. Simoni, PhD, Department of Psychology, University of Washington, Box 351525, Seattle, WA 98195 (e-mail:

Supported by the multisite adherence collaboration in HIV (MACH14) grant R01MH078773 from the National Institute of Mental Health (NIMH), Office on AIDS. The original grants of individual participating studies are: R01DA11869, R01MH54907, R01NR04749, R01NR04749, R01MH68197, R01DA13826, K23MH01862, R01MH01584, R01AI41413, R01 MH61173, NIH/NIAID AI38858, AI069419, K02DA017277, R01DA15215, NIMH P01MH49548, R01MH58986, R01MH61695, CC99-SD003, CC02-SD-003, and R01DA015679.

The authors have no conflicts of interest to disclose.

Parts of the data were presented at 6th NIMH/IAPAC International Conference on HIV Treatment Adherence; May 2011; Miami, FL.

The content of the article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Received December 23, 2011

Accepted May 3, 2012

© 2012 Lippincott Williams & Wilkins, Inc.