Behavioral Intervention Improves Treatment Outcomes Among HIV-Infected Individuals Who Have Delayed, Declined, or Discontinued Antiretroviral Therapy: A Randomized Controlled Trial of a Novel Intervention

Abstract

Nationally up to 60 % of persons living with HIV are neither taking antiretroviral therapy (ART) nor well engaged in HIV care, mainly racial/ethnic minorities. This study examined a new culturally targeted multi-component intervention to address emotional, attitudinal, and social/structural barriers to ART initiation and HIV care. Participants (N = 95) were African American/Black and Latino adults with CD4<500 cells/mm3 not taking ART, randomized 1:1 to intervention or control arms, the latter receiving treatment as usual. Primary endpoints were adherence, evaluated via ART concentrations in hair samples, and HIV viral load suppression. The intervention was feasible and acceptable. Eight months post-baseline, intervention participants tended to be more likely to evidence “good” (that is, 7 days/week) adherence (60 vs. 26.7 %; p = 0.087; OR = 3.95), and had lower viral load levels than controls (t(22) = 2.29, p = 0.032; OR = 5.20), both large effect sizes. This highly promising intervention merits further study.

Cascade of Refusal—What Does It Mean for the Future of Treatment as Prevention in Sub-Saharan Africa?

“…This is largely due to losses of PLWH whose CD4+ counts are too high to render them able to start treatment [9–13] and failure to initiate treatment promptly among those who are already ART eligible at HIV diagnosis [7, 14]. There is a growing body of literature focused on pre-ART losses and the need to understand both structural and socio-behavioral barriers to ART initiation, in order to inform effective combination interventions [15•, 16–18]. …”

Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration

“…Self-Determination Theory is the accepted theoretical underpinning of Motivational Interviewing [68, 69], an approach considered culturally appropriate and highly efficacious for populations of color [70]. Our own intervention research with AABH-PLWH to address health inequity integrates Motivational Interviewing with CRT, and takes the approach of directly uncovering and exploring counter-narratives, medical distrust, and fear in intervention components, while not necessarily seeking to change or influence these understandings, and also acknowledging and fostering autonomy, relatedness, and competence, the core self-determination needs [17, 71, 72]. Similarly, Wagner and Bogart and colleagues [73] have developed a promising culturally appropriate ART adherence intervention for African American PLWH, one which foregrounds counter-narratives [73].…”

“…Further, health care and social service providers have the opportunity to assist AABH-PLWH in achieving optimal HIV outcomes by providing a forum for patients to openly address fears and concerns rooted in racial/ethnic and class-based inequality; recognizing that delayed initiation of ART is a valid option for AABH-PLWH with serious barriers to ART; attending to the need of AABH-PLWH to be seen as a whole person; and providing a space within which individuals feel comfortable discussing distrust of HIV care and ART with peers. Further, culturally appropriate social/behavioral interventions in the clinic and community-based settings have an important role to play in reducing these racial/ethnic disparities [17, 44, 75, 76]. …”

“…Procedures were approved by the Institutional Review Boards at New York University and two collaborating hospital sites. The larger study is described in more detail elsewhere [17, 44]. …”

“…This literature to date has focused primarily on barriers at the individual level of influence, such as unsupportive health beliefs, including negative outcome expectancies regarding ART, low self-efficacy to manage ART, and negative emotions, including fear [13, 14], as well as substance use [15], and mental health concerns, primarily depression [16, 17]. Further, lack of knowledge about HIV care/ART guidelines may impede care and ART uptake [18], and AABH-PLWH often decline ART because they believe they lack skills to adhere to ART regimens [19, 20].…”