Adherence to Antiretroviral Therapy among Patients Attending an Inner-City HIV Primary Care Clinic: Non-obvious Factors are Most Important

Patient adherence is arguably the most important factor determining both individual and public health benefits of antiretroviral therapy (ART). Adherence issues also appear to be central in understanding the large disparities between African Americans and Whites in terms of lower rates of ART utilization and adherence. In an attempt to understand factors which constitute barriers or facilitators of adherence, particularly in African American populations, seven studies are reviewed which focus on the largely disadvantaged and African American patients receiving HIV care through the University of Maryland Medical System in Baltimore. Analysis of these studies reveals that ART adherence is better understood and predicted by “non-obvious,” complex, and often underlying factors, including the adverse circumstances which describe the HIV-infected individual who ends up receiving care in an emergency room and inpatient setting rather than from the same clinician in an outpatient clinic, patients’ subjective perceptions of their health care providers, mistrustful beliefs about HIV and its treatment, and dimensions of forgiveness and how these affect attitudes and behaviors about being HIV-infected and relating to others, medical systems, and God or spiritual being. More “obvious” factors such as knowledge of HIV and its treatment, “pill burden,” or providing external incentives or methods intended to help patients take their prescribed medicines do not play a significant role in adherence, and moreover, may have counter-intuitive effects, as discussed in two studies. We present a model of biodisparity, as the biological entrenchment of socioeconomic and healthcare access disparities, resulting from the conjoint influence of suboptimal adherence and the transmission of drug resistant virus within isolated social networks and disadvantaged sub-populations.