Deconstructing Mistrust: The Unique Associations Between Physician Mistrust, Medical System Mistrust and Antiretroviral Therapy Adherence

Introduction: Medical mistrust is an important, potentially modifiable, risk factor for many health outcomes. For individuals with HIV, medical mistrust can contribute to non-adherence to treatment regimens, resulting in poorer health for the individual and increased transmission risk to the community. Medical mistrust is a complex construct that has been measured separately with respect to an individual’s physician and about the broader medical system. This study examined physician and system mistrust among a sample of hospitalized substance-using individuals with HIV to determine correlates of each type, and to test the unique association of physician and system mistrust with self-reported adherence to antiretrovirals.

 

Methods: This study was a secondary analysis of the Project HOPE baseline data. Project HOPE, a study from the National Drug Abuse Treatment Clinical Trials Network, was a repeated measures randomized controlled trial in which HIV-infected inpatients were recruited from 11 hospitals across the United States (Metsch, et al., 2016). Participants were 801 individuals with HIV who reported opioid, stimulant, and/or heavy alcohol use in the past year. The sample was predominantly minority (75% African American, 11% Hispanic), male (67%) and high school educated (60%). The health of this sample was severely compromised; 66% of the participants had a baseline CD4 count below 200 cells/µL. Independent variables included demographics, health status, experiences of discrimination, health literacy, perceived access to care, incarceration and drug treatment history. Structural equation modeling was used to (1) identify correlates of physician (measured by the Physician Patient Relationship scale) and medical mistrust (measured by the Group-Based Medical Mistrust Scale) and (2) assess the relationship between physician and medical mistrust with antiretroviral (ART) adherence.

 

Results: In multivariable analysis, medical system mistrust was significantly associated with older age, minority race/ethnicity, poorer access to health care, lower health literacy and any experience of racial or drug use discrimination. Physician mistrust was significantly associated with poorer access to health care and any experience of gender discrimination. Higher levels of physician mistrust, but not medical system mistrust, were significantly associated with lower odds of ART adherence.

 

Conclusions: This study furthers our understanding of medical mistrust by identifying unique correlates of system mistrust and physician mistrust, and articulating the importance of physician trust to medication adherence for a large, diverse sample of HIV-infected, substance-using individuals with severely compromised health.