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Clinical outcomes of young black men receiving HIV medical care in the United States, 2009-2014
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JAIDS Feb 13 2019 - Chowdhury, Pranesh, MD, MPH1; Beer, Linda, PhD1; Shouse, R. Luke, MD, MPH1; Bradley, Heather, PhD1 for the Medical Monitoring Project
Background: More than one-quarter of 2016 HIV diagnoses among blacks in the U.S. occurred among persons aged 15-24 years, and three-quarters were among men. Although the prevalence of viral suppression at all tests in the past 12 months (durable viral suppression) among persons receiving HIV care increased from 58% to 68% during 2009-2013, we do not know whether this same improvement was seen among young black men receiving care.
Methods: We analyzed 2009-2014 Medical Monitoring Project (MMP) data collected from 336 black men aged 18-24 years. We estimated the proportion of young black men receiving HIV care who were prescribed antiretroviral therapy (ART), adherent to ART, and durably virally suppressed. We assessed changes in clinical outcomes over time and their association with patient characteristics, health behaviors, and depression.
Results: During 2009-2014, 80% of young black men receiving HIV care were prescribed ART, 73% were adherent to ART, and 36% had durable viral suppression. There was no significant change in viral suppression over this period. ART prescription and durable viral suppression were significantly higher among those receiving Ryan White HIV/AIDS Program assistance compared with those did not. Durable viral suppression was significantly lower among those who used drugs compared with those who did not.
Conclusions: Viral suppression among young black men during 2009-2014 was lower than among the overall population receiving HIV care in 2013 (36% vs. 68%). Increasing viral suppression is essential to improve health and reduce HIV transmissions in this key population.
Among young black men receiving HIV care during 2009-2014, 72.3% reported MSM sexual behavior, 14.7% had less than high school education, 54.2% lived at or below federal poverty guidelines, and 11.9% were homeless at any time in the past 12 months (Table 1). These characteristics did not change from 2009 to 2014. More than half (52.7%) received RWHAP assistance to pay for medical care or ART medications. Overall, 36.3% were current cigarette smokers, 44.5% used injection or non-injection drugs and 20.4% had current depression. During 2009-2014, 80.1% of young black men were prescribed ART, 72.6% were adherent to ART, and 35.7% had durable viral suppression. ART prescription increased from 60.5% in 2009-2010 to 88.2% in 2013-2014 (β=0.13, P for trend <0.05), but there was no significant change in ART adherence or viral suppression over time.
Bivariate analyses indicated that there were no significant associations between clinical outcomes and MSM sexual behavior, education level, household income, homelessness, cigarette smoking and binge drinking (Table 2). However, ART prescription was higher among young black men who had any RWHAP assistance compared to those who did not (93.2% vs. 66.8%, P <0.05). ART adherence was lower among those who had current depression compared to others (53.1% vs. 77.6%, P <0.05). Durable HIV viral suppression was higher among young black men who received RWHAP assistance compared with those who did not (46.0% vs. 25.4%, P <0.05); but was lower among those who used injection or non-injection drugs compared with those who did not (28.0% vs. 42.0%, P <0.05).
Discussion
Among young black men who received HIV medical care in the United States, ART prescription increased by 46% from 2009 to 2014 but there were no accompanying significant increases in ART adherence or viral suppression. Moreover, viral suppression was lower among young black men during 2009-2014 (34.2%) than among all adults (68%) and young adults aged 18-29 years (51%) who were in HIV clinical care during 2013. The increase in ART prescription may be attributable to changes in ART prescription guidelines recommending early initiation of ART [11]. Although simpler and more tolerable ART regimens also became available for the treatment of HIV infection during the years included in this study [12], these developments may not have yielded increased medication adherence for this population. Low prevalence of ART adherence and viral suppression were observed overall and lowest among young black men who were depressed or used drugs.
Poor HIV clinical outcomes are related to individual behaviors but also to the social, contextual, and environmental factors in which these behaviors occur [13]. Our study indicates that a high proportion of young black men were living at or below the poverty level, nearly 12% were homeless, and sociodemographics factors did not change during the study period. Interventions to increase viral suppression that take social determinants of health into account and address particular challenges that young black men may experience are needed.
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