title: Environmental Influences on HIV Medication Adherence: The Role of Neighborhood Disorder.
abstract: OBJECTIVE
  We hypothesized that highly disordered neighborhoods would expose residents to environmental pressures, leading to reduced antiretroviral (ARV) medication adherence.
  
  
  METHODS
  Using targeted sampling, we enrolled 503 socioeconomically disadvantaged HIV-positive substance users in urban South Florida between 2010 and 2012. Participants completed a 1-time standardized interview that took approximately 1 hour. We tested a multiple mediation model to examine the direct and indirect effects of neighborhood disorder on diversion-related nonadherence to ARVs; risky social networks and housing instability were examined as mediators of the disordered neighborhood environment.
  
  
  RESULTS
  The total indirect effect in the model was statistically significant (P = .001), and the proportion of the total effect mediated was 53%. The model indicated substantial influence of neighborhood disorder on nonadherence to ARVs, operating through recent homelessness and diverter network size.
  
  
  CONCLUSIONS
  Long-term improvements in diversion-related ARV adherence will require initiatives to reduce demand for illicit ARV medications, as well as measures to reduce patient vulnerability to diversion, including increased resources for accessible housing, intensive treatment, and support services.
authors.affiliation: Hilary L. Surratt, Steven P. Kurtz, and Maria A. Levi-Minzi are with the Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, Fort Lauderdale, FL. Minxing Chen is with the Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston.
authors.forename: Hilary L
authors.initials: HL
authors.lastname: Surratt
authors.affiliation: Hilary L. Surratt, Steven P. Kurtz, and Maria A. Levi-Minzi are with the Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, Fort Lauderdale, FL. Minxing Chen is with the Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston.
authors.forename: Steven P
authors.initials: SP
authors.lastname: Kurtz
authors.affiliation: Hilary L. Surratt, Steven P. Kurtz, and Maria A. Levi-Minzi are with the Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, Fort Lauderdale, FL. Minxing Chen is with the Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston.
authors.forename: Maria A
authors.initials: MA
authors.lastname: Levi-Minzi
authors.affiliation: Hilary L. Surratt, Steven P. Kurtz, and Maria A. Levi-Minzi are with the Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, Fort Lauderdale, FL. Minxing Chen is with the Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston.
authors.forename: Minxing
authors.initials: M
authors.lastname: Chen
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D005260:Female; D005431:Florida / Q000453:epidemiology; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D008962:Models, Theoretical; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012931:Social Environment; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents