Discrimination, Distrust, and Racial/Ethnic Disparities in Antiretroviral Therapy Adherence by HIV+ Patients

Background: Racial/ethnic minority status is inconsistently associated with antiretroviral therapy adherence. Discriminatory healthcare experiences and healthcare provider distrust are two patient-level factors hypothesized to contribute to racial/ethnic disparities. Little is known, however, about their effects on HIV treatment-related attitudes and adherence.

Methods: The sample was 1911 participants of the HIV Cost and Services Utilization Study who completed all three waves of data collection and were prescribed antiretroviral therapy (49% White, 33% Black, 15% Hispanic, 3% other racial/ethnic group). A mediation model, including covariates, was tested using structural equation modeling.

Results: Minority participants were less likely to report perfect adherence than white participants (40% vs. 50%, p ≤ .001). Almost half (41%) the participants reported ever experiencing discrimination in healthcare settings, while few participants reported distrust of their healthcare providers. The direct effect of minority status on adherence remained despite the presence of hypothesized mediators (b = -.21, p ≤ .05). The magnitude of indirect effects was negligible, and their sum was not statistically significant. Discrimination's effect on adherence was entirely indirect via greater distrust and weaker medication efficacy beliefs. Greater distrust was unexpectedly associated with better adherence (b = .06, p ≤ .05). Distrust indirectly affected adherence via greater psychological distress about taking antiretroviral therapy and weaker medication efficacy beliefs.

Conclusions: The relationship between racial/ethnic minority status and antiretroviral therapy adherence was not explained by patient-level sociodemographic, health, or psychosocial factors. These findings, however, generally support other research that has found subtle effects of patient-provider relationships on treatment adherence.