US barriers to ARV therapy

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Up to 60% of persons living with HIV (PLHA) in the US are neither taking antiretroviral therapy (ART) nor well engaged in HIV primary care, with racial/ethnic minorities more likely to experience barriers to engagement along this HIV continuum of care than their white counterparts. In fact, only 30% of persons living with HIV/Aids (PLHA) in the US have achieved “viral suppression,” the ultimate goal of HIV treatment.

Indeed, PLHA poorly engaged in HIV primary care and/or those who are not on ART are at elevated risk for a host of poor outcomes, including more frequent hospitalisations, lower quality of life, and even earlier mortality, and also run a greater risk of transmitting HIV to their partners. Further, poor engagement in HIV care and lack of ART initiation with good adherence are major drivers of high health care costs among PLHA.

However, for a substantial proportion of the population of PLHA in the US, barriers to ART initiation with good adherence and HIV care are complex and serious. Among African American/Black and Latino PLHA, these barriers include fear of side effects from ART, medical mistrust, difficulties managing the emotional aspects of HIV/Aids treatment, low self efficacy regarding the ability to manage adherence, “competing priorities” arising from substance use problems and mental health distress, and fear of social stigma – all complicated by low socio-economic status. There is an urgent need, therefore, for potent and sustainable behavioural interventions to improve outcomes along the HIV continuum of care for the nation’s most vulnerable PLHA.

To this end, researchers from the Centre for Drug Use and HIV Research (CDUHR) at New York University College of Nursing (NYUCN) explored a novel behavioural intervention targeted to PLHA from African American/Black and Latino racial/ethnic backgrounds who were not taking ART and often not well engaged in HIV care, recruited mainly though peers, as this group is not found in substantial numbers in hospital-based HIV clinics.

The study explored the feasibility, acceptability, and evidence of efficacy of a new multi-component intervention for these groups. Through the framework of the Theory of Triadic Influence, a multi-level social-cognitive theory focused on three “streams of influence” (individual-, social-, and structural-levels of influence), researchers developed a set of components to ameliorate the barriers to HIV care and ART use most commonly experienced by these groups. The intervention’s main counselling approach was motivational interviewing (MI), a flexible, collaborative counselling method that actively engages, focuses, and guides participants in order to elicit and strengthen intrinsic motivation for behaviour change. The intervention, called “Heart to Heart,” was culturally targeted to this population, and intervention components were also individually tailored to the needs of each participant. The study was conducted by the New York University College of Nursing (NYUCN), Mount Sinai Beth Israel Medical Centre, and Mount Sinai St Luke’s-Roosevelt Hospital Centre.

“This is a novel ‘pre-adherence’ intervention designed for those who are not appropriate for most adherence programmes and services, because they have refused or do not believe they are ready for ART. Heart to Heart is unique in its focus on the underlying emotional, social, and attitudinal barriers to ART and HIV care, including fear and mistrust, which act simultaneously to reduce initiation and adherence to ART and engagement in HIV care,” said Dr Marya Gwadz, senior research scientist at NYUCN and the study’s principal investigator. “These individuals are generally opposed to the idea of going on ART, and even afraid to do so, and as a result they avoid HIV care because they don’t want to discuss ART with their health care providers, or have to explain, once again, why they are not on these life-preserving regimens.”

“The challenge for us as interventionists was to develop an approach to engage participants in an examination of this important decision they were making, and to have them on the one hand unpack the barriers and fears they experience, and on the other hand, the fact that for most people ART is their best chance for a long and healthy life,” said Liz Applegate, the project’s coordinator. “The MI approach was a vital part of engaging participants in this challenging personal evaluation. The overall goal of the intervention was to develop durable, high quality intrinsic motivation for behaviour change. In keeping with that approach, the project’s tagline was ‘No pressure, no judgments,’ which set a positive tone for wary participants.”

The intervention was comprised of three individual sessions; up to five focused support groups with other participants, co-led by a trained facilitator and a “successful” peer who was taking ART with good adherence and well engaged in HIV care; and individualized patient navigation for 12-24 weeks depending on the participant’s need. “Participants wanted to hear about these issues from their peers who had been there, who had struggled with this decision themselves, gone through the same apprehensions, and who had gotten over the mountain and were doing well on ART and making their HIV care appointments regularly,” said Dr Noelle R Leonard, a study co-investigator. “This was one of the most successful aspects of the intervention.”

The study’s primary aim was to examine the acceptability and feasibility of procedures and the intervention components, and explore evidence of intervention efficacy on two primary endpoints: ART adherence, evaluated via ART concentrations in hair samples, and viral load suppression from medical records. “The assessment of adherence based on ART concentrations in hair samples is an innovative and feasible way of taking a look at patterns of medication-taking over a period of time, lending a greater deal of precision and detail to behavioural studies such as this,” said Dr Monica Gandhi, a study collaborator.

This was a small study designed to explore intervention components and refine procedures. The study’s participants (N=95) were African American/Black and Latino adult PLHA with CD4 <= 500 cells/mm3 not taking ART, randomized 1:1 to intervention or control arms, the latter receiving treatment as usual. The intervention was found to be feasible and acceptable. Eight months post-baseline, intervention participants tended to be more likely to evidence “good” (that is, 7 day a week) adherence assessed via hair sample analysis (60% among intervention arm participants vs. 26.7% among controls), and also had lower HIV viral load levels based on the medical record than controls, at a statistically significant level (a difference of 0.88 log10 viral load), both large effect sizes. Thus the intervention components were highly promising, and merit further study with this vulnerable population.

“Interventions to support ART initiation and continuation are vital, for individual PLHA, their loved ones, and the public health,” notes Dr Charles Cleland, a study co-investigator. “Although this was a small study, the intervention demonstrated efficacy with a large effect size on the most critical HIV endpoint, viral load suppression, assessed with objective bio-marker data. We believe this study sheds light on new approaches to addressing ART adherence – the ‘Achilles’ heel’ of HIV treatment.”

New York University material
AIDS and Behaviour abstract


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