Journal of Behavioral Medicine

, Volume 39, Issue 6, pp 1056–1064 | Cite as

Race-based medical mistrust, medication beliefs and HIV treatment adherence: test of a mediation model in people living with HIV/AIDS

  • Seth C. KalichmanEmail author
  • Lisa Eaton
  • Moira O. Kalichman
  • Tama Grebler
  • Cynthia Merely
  • Brandi Welles


Race-based medical mistrust significantly predicts non-adherence to antiretroviral therapy (ART) in people living with HIV. The current study builds on previous research that shows beliefs about medication necessity (i.e., “My medicines protect me from becoming worse”) and concerns (i.e., “Having to take my medicines worries me”) mediate the association between race-based medical mistrust and medication adherence. Racial and ethnic minority men and women living with HIV and receiving ART (N = 178) in a southern US city completed computerized measures of demographic and health characteristics, telephone interviews of race-based medical mistrust and medication beliefs, and unannounced phone-based pill counts for ART adherence. Multiple mediation modeling showed that medical mistrust is related to medication necessity and concerns beliefs and ART adherence. Furthermore, medication necessity beliefs predicted ART adherence. The indirect effect of medical mistrust on adherence through medication necessity beliefs was also significant. Results confirm that medication necessity beliefs, although not concerns beliefs, mediate the association between medical mistrust and ART adherence. Medication necessity beliefs offer a viable target for interventions to improve ART adherence in the context of mistrust that patients may have for medical providers and health care systems.


Medication adherence Medical mistrust Medication beliefs HIV/AIDS 



This research was supported by National Institute of Nursing Research Grant R01-NR012962 National Institute of Alcohol Abuse and Alcoholism Grant R01-AA021471 and the National Institute on Drug Abuse Grant R01-DA033067.

Compliance with ethical standards

Conflict of interest

Seth C. Kalichman, Lisa Eaton, Moira O. Kalichman, Tama Grebler, Cynthia Merely and Brandi Welles declare that they have no conflict of interest.

Human and animal rights and Informed consent

All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients before being included in the study.


  1. Altice, F. L., Mostashari, F., & Friedland, G. H. (2001). Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 28, 47–58.CrossRefPubMedGoogle Scholar
  2. Bangsberg, D., & Deeks, S. G. (2002). Is average adherence to HIV antiretroviral therapy enough? Jounal of General Internal Medicine, 17, 812–813.CrossRefGoogle Scholar
  3. Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182.CrossRefPubMedGoogle Scholar
  4. Bogart, L. M., Wagner, G., Galvan, F. H., & Banks, D. (2010). Conspiracy beliefs about HIV are related to antiretroviral treatment nonadherence among african american men with HIV. Journal of Acquired Immune Deficiency Syndromes, 53, 648–655.PubMedPubMedCentralGoogle Scholar
  5. Carrieri, M. P., Villes, V., et al. (2007). Self-reported side-effects of anti-retroviral treatment among IDUs: A 7-year longitudinal study (APROCO-COPILOTE COHORT ANRS CO-8). International Journal of Drug Policy, 18, 288–295.CrossRefPubMedGoogle Scholar
  6. Casagrande, S. S., Gary, T. L., LaVeist, T. A., Gaskin, D. J., & Cooper, L. A. (2007). Perceived discrimination and adherence to medical care in a racially integrated community. Journal of General Internal Medicine, 22, 389–395.CrossRefPubMedPubMedCentralGoogle Scholar
  7. Dale, S. K., Bogart, L. M., Wagner, G. J., Galvan, F. H., & Klein, D. J. (2014). Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV. Journal of Health Psychology, 21, 1311–1321.CrossRefPubMedGoogle Scholar
  8. Earl, T. R., Beach, M. C., Lombe, M., Korthuis, P. T., Sharp, V. L., Cohn, J. A., & Saha, S. (2013). Race, relationships and trust in providers among black patients with HIV/AIDS. Social Work Research, 37, 219–226.CrossRefPubMedPubMedCentralGoogle Scholar
  9. Fredericksen, R., Feldman, B. J., Brown, T., Schmidt, S., Crane, P. K., Harrington, R. D., & Crane, H. M. (2014). Unannounced telephone-based pill counts: A valid and feasible method for monitoring adherence. AIDS and Behavior, 18, 2265–2273.CrossRefPubMedPubMedCentralGoogle Scholar
  10. Gaston, G. B., & Alleyne-Green, B. (2013). The impact of African Americans’ beliefs about HIV medical care on treatment adherence: A systematic review and recommendations for interventions. AIDS and Behavior, 17, 31–40.CrossRefPubMedGoogle Scholar
  11. Gonzalez, J. S., Penedo, F. J., Llabre, M. M., Duran, R. E., Antoni, M. H., Schneiderman, N., & Horne, R. (2007). Physical symptoms, beliefs about medications, negative mood, and long-term HIV medication adherence. Annals of Behavioral Medicine, 34, 46–55.CrossRefPubMedGoogle Scholar
  12. Haberer, J. E., Robbins, G. K., Ybarra, M., Monk, A., Ragland, K., Weiser, S. D., & Bangsberg, D. R. (2011). Real-time electronic adherence monitoring is feasible, comparable to unannounced pill counts, and acceptable. AIDS and Behavior, 16, 375–382.CrossRefGoogle Scholar
  13. Horne, R. (1999). Patients’ beliefs about treatment: The hidden determinant of treatment outcome? Joural of Psychosomatic Research, 47, 491–495.CrossRefGoogle Scholar
  14. Horne, R., Chapman, S. C., Parham, R., Freemantle, N., Forbes, A., & Cooper, V. (2013). Understanding patients’ adherence-related beliefs about medicines prescribed for long-term conditions: A meta-analytic review of the necessity-concerns framework. PLoS One, 8, e80633. doi: 10.1371/journal.pone.0080633 CrossRefPubMedPubMedCentralGoogle Scholar
  15. Horne, R., Cooper, V., Gellaitry, G., Date, H. L., & Fisher, M. (2007). Patients’ perceptions of highly active antiretroviral therapy in relation to treatment uptake and adherence: The utility of the necessity-concerns framework. Journal of Acquired Immune Deficiency Syndromes, 45, 334–341.PubMedGoogle Scholar
  16. Jonsdottir, H., Friis, S., Horne, R., Pettersen, K. I., Reikvam, A., & Andreassen, O. A. (2009). Beliefs about medications: Measurement and relationship to adherence in patients with severe mental disorders. Acta Psychiatrica Scandavia, 119, 78–84.CrossRefGoogle Scholar
  17. Kalichman, S., Amaral, C. M., Cherry, C., Flanagan, J. A., Pope, H., Eaton, L., & Schinazi, R. (2008). Monitoring Antiretroviral adherence by unannounced pill counts conducted by telephone: Reliability and criterion-related validity. HIV Clinical Trials, 9, 298–308.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Kalichman, S. C., Amaral, C., Swetsze, C., Eaton, L., Kalichman, M. O., Cherry, C., & Schinazi, R. F. (2010). Monthly unannounced pill counts for monitoring HIV treatment adherence: Tests for self-monitoring and reactivity effects. HIV Clinical Trials, 11, 325–331.CrossRefPubMedGoogle Scholar
  19. Kalichman, S., Eaton, L., Kalichman, M., & Cherry, C. (2015). Medication beliefs mediate the association between medical mistrst and antiretroviral adherence among African-Americans living with HIV. Journal of Health Psychology. doi: 10.1177/1359105315600239.
  20. Kalichman, S. C., Kalichman, M. O., Cherry, C., Swetzes, C., Amaral, C. M., White, D., & Eaton, L. (2011). Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: An initial test of concept trial. AIDS Patient Care STDs, 25, 303–310.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Kalichman, S., Rompa, D., & Cage, M. (2000). Distinguishing between overlapping somatic symptoms of depression and HIV disease in people living with HIV–AIDS. Journal of Nervous and Mental Disicions, 188, 662–670.CrossRefGoogle Scholar
  22. Lima, V. D., Bangsberg, D. R., Harrigan, P. R., Deeks, S. G., Yip, B., Hogg, R. S., & Montaner, J. S. (2010). Risk of viral failure declines with duration of suppression on highly active antiretroviral therapy irrespective of adherence level. Journal of Acquired Immune Deficiency Syndromes, 55, 460–465.CrossRefPubMedPubMedCentralGoogle Scholar
  23. Maulsby, C., Millett, G., Lindsey, K., Kelley, R., Johnson, K., Montoya, D., & Holtgrave, D. (2014). HIV among Black men who have sex with men (MSM) in the United States: A review of the literature. AIDS and Behavior, 18, 10–25.CrossRefPubMedGoogle Scholar
  24. McFall, A. M., Dowdy, D. W., Zelaya, C. E., Murphy, K., Wilson, T. E., Young, M. A., & Althoff, K. N. (2013). Understanding the disparity: Predictors of virologic failure in women using highly active antiretroviral therapy vary by race and/or ethnicity. Journal of Acquired Immune Deficiency Syndromes, 64, 289–298.CrossRefPubMedGoogle Scholar
  25. Morrison-Beedy, D., Carey, M. P., & Tu, X. (2006). Accuracy of audio computer-assisted self-interviewing (ACASI) and self-administered questionnaires for the assessment of sexual behavior. AIDS and Behavior, 10, 541–552.CrossRefPubMedPubMedCentralGoogle Scholar
  26. Nozaki, I., Kuriyama, M., Manyepa, P., Zyambo, M. K., Kakimoto, K., & Barnighausen, T. (2013). False beliefs about ART effectiveness, side effects and the consequences of non-retention and non-adherence among ART patients in Livingstone, Zambia. AIDS and Behavior, 17, 122–126.CrossRefPubMedGoogle Scholar
  27. Parienti, J. J., Barrail-Tran, A., Duval, X., Nembot, G., Descamps, D., Vigan, M., & Goujard, C. (2013). Adherence profiles and therapeutic responses of treatment-naive HIV-infected patients starting boosted atazanavir-based therapy in the ANRS 134-COPHAR 3 trial. Antimicrobial Agents and Chemotherapy, 57, 2265–2271.CrossRefPubMedPubMedCentralGoogle Scholar
  28. Pellowski, J. A., Kalichman, S. C., & Finitsis, D. J. (2015). Reliability and validity of a single-item rating scale to monitor medication adherence for people living with HIV and lower health literacy. HIV Clinical Trials, 16, 1–9.CrossRefPubMedGoogle Scholar
  29. Pellowski, J. A., Kalichman, S. C., Matthews, K. A., & Adler, N. (2013). A pandemic of the poor: Social disadvantage and the U.S. HIV epidemic. American Psychologist, 68, 197–209.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. [Research Support, N.I.H., Extramural]. Behavior Research Methods, 40, 879–891.CrossRefPubMedGoogle Scholar
  31. Reynolds, N. R., Testa, M. A., Su, M., Chesney, M. A., Neidig, J. L., Frank, I., & Robbins, G. K. (2008). Telephone support to improve antiretroviral medication adherence: A multisite, randomized controlled trial. Journal of Acquired Immune Deficiency Syndromes, 47, 62–68.CrossRefPubMedGoogle Scholar
  32. Saha, S., Jacobs, E. A., Moore, R. D., & Beach, M. C. (2010). Trust in physicians and racial disparities in HIV care. AIDS Patient Care STDs, 24, 415–420.CrossRefPubMedPubMedCentralGoogle Scholar
  33. Shelton, R. C., Winkel, G., Davis, S. N., Roberts, N., Valdimarsdottir, H., Hall, S. J., & Thompson, H. S. (2010). Validation of the group-based medical mistrust scale among urban black men. Journal of General Internal Medicine, 25, 549–555.CrossRefPubMedPubMedCentralGoogle Scholar
  34. Siddiqi, A. E., Hu, X., & Hall, H. I. (2015). Mortality among blacks or African Americans with HIV infection: United States, 2008–2012. Morbidity and Mortality Weekly Report, 64, 81–86.PubMedGoogle Scholar
  35. Simoni, J. M., Huh, D., Wilson, I. B., Shen, J., Goggin, K., Reynolds, N. R., & Liu, H. (2012). Racial/ethnic disparities in ART adherence in the United States: Findings from the MACH14 study. Journal of Acquired Immune Deficiency Syndromes, 60, 466–472.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Seth C. Kalichman
    • 1
    Email author
  • Lisa Eaton
    • 1
  • Moira O. Kalichman
    • 1
  • Tama Grebler
    • 1
  • Cynthia Merely
    • 1
  • Brandi Welles
    • 1
  1. 1.Department of PsychologyUniversity of ConnecticutStorrsUSA

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