Who is not benefitting from contemporary antiretroviral therapy? Correlates of virological non suppression among people with HIV accessing care in a Boston community health center

Despite significant resources invested to control and ultimately eradicate HIV, a subset of people living with HIV (PLWH) have not fully benefitted from treatment advances, even in resource-rich settings. This study aimed to better understand the factors impeding HIV viral suppression in high resource settings with nearly universal access to health insurance and affirmative and culturally tailored care for sexual and gender minority (SGM) PLWH. We used electronic medical record data from 2,843 PLWH at a federally qualified community health center in Boston, Massachusetts focused on SGM clients and PLWH to conduct bivariate comparisons and multivariable regression models assessing sociodemographic, clinical, and mental health characteristics associated with virological suppression. Within the bivariate comparisons, we used the Wilcoxson Rank-Sum Test and chi-square tests. The majority (96.2%) were virally suppressed at their last assessment. Those who were unsuppressed were younger ( p <.001), in care less time ( p <.001), more likely to live in poverty ( p =.03), be Black or multi-racial ( p =.002) and have a psychotic disorder ( p =.008) but were less likely to have an alcohol use disorder ( p =.02). In multivariable logistic models, risk of alcohol use disorder and having a recorded psychotic disorder documented were associated with higher odds of virally unsuppression (aOR = 0.4, 95% CI = 0.2–0.8 and aOR = 5.8, 95% CI = 2.5–13.8; respectively). Neither the GAD-7, PHQ-9, nor the DAST were associated with viral suppression in similar models. Over 40 years into the HIV epidemic, in high resource settings with SGM expertise, PLWH in poverty, who are Black and multi-racial, and those with serious mental illness still need additional interventions to achieve viral suppression. To eradicate HIV in high resource settings, investment in efforts to eliminate poverty and racial inequities and increase access to quality mental healthcare are needed.