Experiences with stigma and discrimination in healthcare settings are associated with negative health outcome for persons with HIV (PWH). PWH may experience discrimination due to the intersection of multiple marginalized social identities. Describing these experiences is important for informing interventions and strategies to reduce stigma and discrimination. We report experiences with discrimination in HIV healthcare settings attributed to multiple characteristics, e.g., sexual orientation, race/ethnicity, income, or social class, and/or injection drug use, among a nationally representative sample of persons with diagnosed HIV in the United States using data from the Medical Monitoring Project (MMP). We calculated weighted prevalences and associated 95% confidence intervals for any discrimination and discrimination attributed to multiple characteristics (intersectional discrimination). Among those experiencing discrimination, nearly 1 in 4 persons reported intersectional discrimination, with a higher burden among key populations of focus for HIV prevention and treatment. Discrimination was attributed to HIV status (62.5%), sexual orientation (60.4%), and race/ethnicity (54.3%). Persons who experienced intersectional discrimination were less likely to have a regular HIV care provider, have trust in HIV care or treatment information from healthcare providers, and be antiretroviral treatment or HIV care visit adherent. Future studies should explore methods to operationalize and assess experiences with intersectional stigma and discrimination and use the outcomes to inform qualitative research that provides more context and a deeper understanding of experiences with intersectional discrimination among PWH.

In the United States, one in four adults is living with a disability. Age-related changes, disease-related pathology and treatments can place a person with HIV at risk for a disability. We analyzed nationally representative data to describe disability status among adults ≥18 years with diagnosed HIV in the United States and Puerto Rico by demographic characteristics, health behaviors, quality of care, clinical outcomes and mental health status. We reported weighted percentages and prevalence ratios with predicted marginal means to evaluate significant differences between groups (P < .05). Overall, 44.5% reported any disability; the most frequently reported disabilities were related to mobility (24.8%) and cognition (23.9%). Persons who lived in households at or below the poverty level or who experienced homelessness in the last 12 months reported a higher prevalence of any disability than persons who were not poor or not homeless (60.2% vs. 33.4% and 61.8% vs. 42.8%, respectively). Prevalence of depression and anxiety was higher among persons with any disability compared with those with no disability (32.8% and 26.6% versus 10.1% and 7.0%, respectively). Enhancing support from clinicians and ancillary providers may help optimize long-term health outcomes among HIV-positive persons with disabilities.

Research suggests that language barriers in health care settings may adversely affect clinical outcomes and patient satisfaction. We describe the characteristics of adults with limited English proficiency (LEP) and diagnosed HIV in the United States. The Medical Monitoring Project is a complex sample survey of adults with diagnosed HIV in the United States that uses two-stage, probability-proportional-to-size sampling. We analyzed weighted interview and medical record data collected from June 2015-May 2018. The prevalence of LEP among adults with HIV was 10%. Higher percentages of adults with LEP, compared with adults with English proficiency (EP), were female, Hispanic/Latino, less educated and poor, only had Ryan White HIV/AIDS Program (RWHAP) health care coverage, attended RWHAP-funded facilities, were satisfied with their HIV medical care, were prescribed antiretroviral therapy (ART), were virally suppressed and received testing for sexually transmitted diseases. We found no statistical difference in ART adherence among adults with LEP and EP. Despite the association between LEP and the risk for health disparities, more persons with LEP were virally suppressed compared with persons with EP. One possible explanation is attendance at RWHAP-funded facilities by adults with LEP; however, future studies are needed to explore other possible explanations.

Homelessness is a challenge to retention in HIV care and adherence to antiretroviral therapy. We describe the sociodemographic and behavioral characteristics of HIV-positive adults who reported recent homelessness. The Medical Monitoring Project is a complex sample survey of HIV-positive adults receiving medical care in the United States. We used weighted interview and medical record data collected from June 2009 to May 2015 to estimate the prevalence of depression, substance use, and HIV risk behaviors among adults experiencing recent homelessness. From 2009 to 2015, 8.3% of HIV-positive adults experienced recent homelessness. Homeless adults were more likely than housed adults to have major depression, to binge drink, use non-injection drugs, use injection drugs, and smoke. Over 60% of homeless adults were sexually active during the past year, with homeless adults reporting more condomless sex with an HIV-negative or unknown status sex partner than housed adults. Programs attempting to improve the health outcomes of HIV-positive homeless persons and reduce ongoing HIV transmission can focus on providing basic needs, such as housing, and ancillary services, such as mental health counseling or substance abuse treatment and counseling.

Since 2012, U.S. clinical guidelines for antiretroviral therapy (ART) initiation have recommended universal ART prescription barring patient contraindications. Although ART prescription has significantly increased among U.S. HIV patients in recent years, the reasons for this increase, and why some patients are still not taking ART, are not well characterized. To fill these gaps, we analyzed data from the Medical Monitoring Project (MMP), to assess the proportion of persons who reported provider-advised ART deferral during 2009-2014, and used bivariate linear regression to estimate linear trends in provider-advised ART deferral over time by patient characteristics and clinical setting. During this period, the proportion of patients reporting provider-advised ART deferral decreased from 67% to 40%. Significant decreases were observed in all patient subgroups and clinical settings. Patients recently reporting non-provider-advised reasons for ART deferral were significantly less likely to be virally suppressed and more likely to have inconsistent care, be depressed, binge drink, and use illicit drugs. This work suggests that U.S. providers are recommending ART deferral for fewer patients, consistent with increasing adoption of 2012 universal prescribing guidelines. Addressing patients' financial, mental health, and substance use barriers may be needed to achieve universal ART prescription in the United States.

The prevalence of discrimination in healthcare settings among HIV patients in the United States is unknown. The Medical Monitoring Project (MMP) is a complex sample survey of adults receiving HIV medical care in the United States. We analyzed nationally representative MMP data collected 2011-2015. We assessed the prevalence of self-reported healthcare discrimination, perceived reasons for discrimination, and factors associated with discrimination among persons with HIV diagnoses </=5 years before interview (n = 3,770). Overall, 14.1% of patients living with HIV (PLWH) experienced discrimination, of whom 82.2% attributed the discrimination to HIV. PLWH reporting poverty, homelessness, or attending a non-Ryan White HIV/AIDS Program (RWHAP) facility were more likely to report discrimination compared with other groups. Of patients attending non-RWHAP facilities, discrimination was higher among those in poverty (27.5%) vs. not in poverty (15.1%). Discrimination was associated with homelessness regardless of facility type, and was highest among homeless persons attending non-RWHAP facilities. Healthcare discrimination was commonly reported among PLWH, and was most often attributed to HIV status. Discrimination was higher among those reporting poverty or homelessness, particularly those attending non-RWHAP facilities. Incorporating practices, such as anti-discrimination training, in facilities may reduce healthcare discrimination.

Smoking increases HIV-related and non-HIV-related morbidity and mortality for persons with HIV infection. We estimated changes in cigarette smoking among adults with HIV and adults in the general U.S. population from 2009 to 2014 to inform HIV smoking cessation programs. Among HIV-positive adults, rates of current smoking declined from 37.6% (confidence interval [CI]: 34.7-40.6) in 2009 to 33.6% (CI: 29.8-37.8) in 2014. Current smoking among U.S. adults declined from 20.6% (CI: 19.9-21.3) in 2009 to 16.8% (CI: 16.2-17.4) in 2014. HIV-positive adults in care were significantly more likely to be current smokers compared with the general U.S. population; they were also less likely to quit smoking. For both HIV-positive adults in care and the general population, disparities were noted by racial/ethnic, educational level, and poverty-level subgroups. For most years, non-Hispanic blacks, those with less than high school education, and those living below poverty level were more likely to be current smokers and less likely to quit smoking compared with non-Hispanic whites, those with greater than high school education, and those living above poverty level, respectively. To decrease smoking-related causes of illness and death and to decrease HIV-related disparities, smoking cessation interventions are vital as part of routine care with HIV-positive persons. Clinicians who care for HIV-positive persons who smoke should utilize opportunities to discuss and implement smoking cessation strategies during routine clinical visits.