Background
Despite advances in the potency of antiretroviral (ARV) medications to treat and prevent transmission of human immunodeficiency virus (HIV), the most common regimens in the United States (U.S.) necessitate daily pill-taking. While there is consensus that social determinants of health (SDoH) hinder adherence, SDoH are typically measured and intervened upon at the individual level. Meanwhile, stark disparities in the geographic distribution of HIV morbidity and incidence suggest neighborhood-level factors may contribute to individual-level SDoH and inform interventions.
Methods
By linking U.S. National Neighborhood Data Archive’s neighborhood disadvantage index (NDI) to participant zip codes from a national cohort of partnered gay, bisexual and other men who have sex with men (GBMSM) living with HIV, we analyzed baseline relationships among neighborhood resources (NDI), SDoH (using a validated 10-point scale of adverse exposures), and low ARV adherence (below 90% by visual analog scale). Participants living in the U.S. were recruited and completed the parent study via remote electronic methods. Using multiple logistic regression, we quantified the independent associations of cumulative SDoH exposure and neighborhood disadvantage to low ARV adherence. Mediation analysis was used to test whether neighborhood disadvantage was associated with ARV adherence through SDoH.
Results
Among the 368 participants, higher NDI was significantly associated with low adherence (OR 19.30, CI 1.34-278.32) and an average 2.57 increase on the SDoH scale (CI 1.06-4.08). After controlling for age, race/ethnicity, problem substance use and other demographic variables, each additional SDoH exposure corresponded to a significant increase in the odds of low adherence (OR 1.46, CI 1.17-1.82), which mediated the relationship between neighborhood disadvantage and lower adherence (Sobel test statistic 3.18, p<0.01).
Conclusions
Consideration of residential neighborhood context together with the minimum adherence level required to achieve viral suppression may help inform clinical ARV regimen selection. Further research on the contribution of neighborhood conditions to SDoH is needed to strategically target interventions to low-resource areas where they may facilitate adherence among exposed residents.
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