Abstract
BackgroundAlthough periods of HIV antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained. Yet, little is known about factors that contribute to such ART non-persistence among long-term HIV survivors. The present study applied a convergent parallel mixed-methods design to explore the phenomena of stopping/starting and sustaining ART, focusing on low-socioeconomic status African American or Black and Latino persons living with HIV (PLWH) who face the greatest challenges.MethodsParticipants (N = 512) had poor engagement in HIV care and detectable HIV viral load. All received structured assessments and N = 48 were randomly selected for in-depth interviews. Quantitative analysis using negative binomial regression uncovered associations among multi-level factors and the number of times ART was stopped/started and the longest duration of sustained ART. Qualitative data were analyzed using a directed content analysis approach and results were integrated.ResultsParticipants were diagnosed 18.2 years ago on average (SD = 8.6), started ART a median five times (Q1 = 3, Q3 = 10), and the median longest duration of sustained ART was 18 months (Q1 = 6, Q3 = 36). Factors associated with higher rates of stops/starts were male sex, transgender identity, cannabis use at moderate-to-high-risk levels, and ART- and care-related stigma. Factors associated with lower rates of stops/starts were older age, more years since diagnosis, motivation for care, and lifetime injection drug use (IDU). Factors associated with longer durations of sustained ART were Latino/Hispanic ethnicity, motivation for ART and care, and recent IDU. Factors associated with a shorter duration were African American/Black race, alcohol use at moderate-to-high-risk levels, and social support. Qualitative results uncovered a convergence of intersecting risk factors for stopping/starting ART and challenges inherent in managing HIV over decades in the context of poverty. These included unstable housing, which contributed to social isolation, mental health distress, and substance use concerns, the latter prompting selling (“diverting”) ART. Primarily complementary quantitative and qualitative findings described mechanisms by which risk/protective factors operated and ways PLWH successfully restart and/or sustain ART.ConclusionsThe field focuses substantially on ART adherence, but greater attention to reducing the frequency of ART non-persistence is needed, along with creating social/structural conditions favorable for sustained ART.
Highlights
Periods of Human immunodeficiency virus (HIV) antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained
Factors associated with lower rates of stops/starts were older age, more years since diagnosis, motivation for care, and lifetime injection drug use (IDU)
Factors associated with a shorter duration were African American/Black race, alcohol use at moderate-to-high-risk levels, and social support
Summary
Periods of HIV antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained. In the third decade of the HIV epidemic, there is growing optimism, in higher-resource settings such as the United States, about the possibility of reaching the 90–90-90 goals set by the World Health Organization, in which 90% of those with HIV infection will be diagnosed, 90% of these will receive HIV antiretroviral therapy (ART), and 90% of these will achieve HIV viral suppression [1]. Reaching these 90–9090 targets is critical to achieving the larger public health objective of ending HIV transmission, referred to as “ending the HIV epidemic” [2]. In contrast to the large literature on ART non-adherence [11], substantially less is known about ART non-persistence
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