Drug Use and Receipt of Highly Active Antiretroviral Therapy among HIV-Infected Persons in Two U.S. Clinic Cohorts

Abstract

ObjectiveDrug use and receipt of highly active antiretroviral therapy (HAART) were assessed in HIV-infected persons from the Comprehensive Care Center (CCC; Nashville, TN) and Johns Hopkins University HIV Clinic (JHU; Baltimore, MD) between 1999 and 2005.MethodsParticipants with and without injection drug use (IDU) history in the CCC and JHU cohorts were evaluated. Additional analysis of persons with history of IDU, non-injection drug use (NIDU), and no drug use from CCC were performed. Activity of IDU and NIDU also was assessed for the CCC cohort. HAART use and time on HAART were analyzed according to drug use category and site of care.Results1745 persons were included from CCC: 268 (15%) with IDU history and 796 (46%) with NIDU history. 1977 persons were included from JHU: 731 (35%) with IDU history. Overall, the cohorts differed in IDU risk factor rates, age, race, sex, and time in follow-up. In multivariate analyses, IDU was associated with decreased HAART receipt overall (OR = 0.61, 95% CI: [0.45–0.84] and OR = 0.58, 95% CI: [0.46–0.73], respectively for CCC and JHU) and less time on HAART at JHU (0.70, [0.55–0.88]), but not statistically associated with time on HAART at CCC (0.78, [0.56–1.09]). NIDU was independently associated with decreased HAART receipt (0.62, [0.47–0.81]) and less time on HAART (0.66, [0.52–0.85]) at CCC. These associations were not altered significantly whether patients at CCC were categorized according to historical drug use or drug use during the study period.ConclusionsPersons with IDU history from both clinic populations were less likely to receive HAART and tended to have less cumulative time on HAART. Effects of NIDU were similar to IDU at CCC. NIDU without IDU is an important contributor to HAART utilization.

Substance Use: Impact on Adherence and HIV Medical Treatment

“…There is good recent evidence to suggest that substance use interferes with these treatment parameters. For example, among 3,722 patients with HIV/ AIDS, a history of drug use (injection drug use [IDU] and non-IDU) was significantly related to decreased receipt of ART and less time on ART [9]. Similarly, in a large sample (n=1038) of inpatients with HIV/AIDS, crack cocaine use and heavy drinking was associated with never having had a HIV-care provider and not receiving ART [32].…”

“…The use of heroin and other opioids, specifically via IDU, is associated with decreased ART receipt and adherence [9,62], poor virologic and immunologic responses to ART [63], and may place individuals at risk for transmitting HIV [64,65]. Opioid substitution therapy (OST), in particular methadone maintenance therapy (MMT) and buprenorphine-naloxone (BUP), has been shown to be effective in reducing opioid use, preventing relapse, and enhancing ART and HIV treatment adherence among people with HIV/AIDS [66][67][68].…”

“…These results underscore the clinical and public health significance of effective treatment as prevention through engagement/retention in care and ART adherence regarding the use of ART among people with HIV/AIDS. Substance use is highly prevalent among people living with HIV/AIDS, with 40-74% reporting comorbid substance use or related disorders [8][9][10][11][12]. This raises important public health concerns as substance use among people with HIV/AIDS has been consistently related to the presence of other psychiatric problems (eg, anxiety/ depression) [8,13], lower CD4 T-cell counts and poorer HIV viral suppression [14][15][16], and HIV medication nonadherence [17••, 18, 19••, 20].…”

Management of HCV and HIV infections among people who inject drugs

“…Overall, improvements in cART have increased the number of people eligible for therapy and the challenge is to provide treatment to those who need it. Whereas much of the global focus has been on the provision of cART to people living in resource-poor settings, there are serious discrepancies in access to cART between IDUs and other HIV-infected people in all countries [70,71 ]. In Baltimore, a study looking at trends in cART initiation among IDUs between 1996 and 2008 failed to show a substantial improvement in cART initiation despite the great strides in treatment during that period [72 ].…”

Stimulant Use and Progression to AIDS or Mortality After the Initiation of Highly Active Antiretroviral Therapy

“…5–10 There is evidence that substance users are less likely to access highly active anti-retroviral therapy (HAART), 11 , 12 and stimulant users initiate HAART at lower T-helper (CD4+) cell counts than their peers who do not use substances. 3 , 5 HIV-positive persons who engage in more regular stimulant use are also at greater risk for poorer adherence to HAART, which contributes to elevated viral load, 6–8 greater risk of onward HIV transmission, 13–15 and potentially faster HIV disease progression.…”