Barriers to Use of Free Antiretroviral Therapy in Injection Drug Users

Abstract

Context.-In British Columbia, human immunodeficiency virus (HIV)-infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown. Objective.-To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users. Design.-Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program. Setting.-British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50ϫ10 9 /L (500/µL) and/or HIV-1 RNA levels higher than 5000 copies/mL. Subjects.-A total of 177 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May 1996. Main Outcome Measures.-Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection. Results.-After a median of 11 months after first eligibility, only 71 (40%) of 177 patients had received any antiretroviral drugs, primarily double combinations (47/ 71 [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1 RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/ 10-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-12.37). Conclusions.-Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.

Alcohol Use and Incarceration Adversely Affect HIV-1 RNA Suppression Among Injection Drug Users Starting Antiretroviral Therapy

“…Second, the participants in our study likely included drug users whom their physicians may have considered potentially more adherent to antiretroviral therapy relative to the larger pool of eligible HIV-infected injection drug users who are not receiving any treatment. 7 Third, since our observation period included 1996-1997, 101 (43%) of the injection drug users were started on dual nucleoside therapy rather than HAART that, as expected, portended a lower likelihood of viral suppression. Fourth, the alcohol exposure variable used in this analysis is not refined enough to define alcohol dependence or abuse, and we have no information on quantity or frequency.…”

“…Other specific independent variables assessed included: incarceration in the previous 6 months; age; gender; enrollment in a methadone maintenance program at the time of initiating antiretroviral therapy; baseline CD4 cell count; baseline log 10 HIV-1 RNA; initial antiretroviral therapy regimen with highly active antiretroviral therapy comprising three or more antiretroviral medications; months on therapy; and adherence to antiretroviral therapy, which was measured using pharmacy refill compliance data. 7,[9][10][11] In brief, we calculated adherence as the ratio of number of months the patients received antiretroviral therapy refills relative to total number of months of follow-up in year 1. The Providence Health Care Ethics Committee for Human Experimentation approved the data collection for this study.…”

Interaction between buprenorphine and atazanavir or atazanavir/ritonavir

“…Adherence to medical regimens among IDUs is often poor Metha at al., 1997). As a result, highly active antiretroviral therapy (HAART) is frequently underutilized in this population because of concerns regarding effective viral suppression (Celentano et al, 2001;Lucas et al, 2001;Strathdee at al., 1998). Treatment for opioid dependence that includes opioidassisted therapy can promote adherence to HIV disease treatment regimens by stabilizing the chaotic lifestyle of the opioid-addicted individual.…”

The prevalence of homelessness among injection drug users with and without HIV infection

“…2-4 Conversely, drug users report a high prevalence of homelessness. [5][6][7][8][9] The prevalence of HIV infection among homeless populations has been estimated as 3% in a national survey 1~ to local samples that have reported proportions from 9% to 62~ ~- 13 The proportion of homelessness among people living with HIV/ AIDS ranges anywhere from 8% to 64%. 5' 8A4-16 There are significant methodological difficulties in examining the relationship between homelessness and injection drug use or HIV/AIDS given the general instability and inaccessibility of these populations.…”