Provider barriers to prescribing HAART to medically-eligible HIV-infected drug users

Awareness, knowledge, and attitudes related to HIV pre-exposure prophylaxis and other prevention strategies among physicians from Brazil and Mexico: cross-sectional web-based survey

Background

In order to end the HIV epidemic by 2030, combination HIV prevention including pre-exposure prophylaxis (PrEP) should be widely available, especially for the most vulnerable populations. In Latin America and the Caribbean (LAC), only 14 out of 46 countries have access to PrEP. In Brazil and Mexico, PrEP has been provided at no cost through the Public Health System since 2017 and 2021, respectively. Thus, HIV physicians’ perspectives about PrEP and other prevention strategies may differ. This study aimed to compare awareness, knowledge, and attitudes related to PrEP and other prevention strategies among HIV physicians from Brazil and Mexico.

Methods

Cross-sectional, web-based survey targeting physicians who prescribe antiretrovirals from both countries. Participants answered questions on socio-demographic, medical experience, awareness, knowledge, and attitudes towards PrEP and other HIV prevention strategies. We stratified all variables per country and compared frequencies using Chi-square, Fisher exact, and Wilcoxon-Mann-Whitney tests, as appropriate.

Results

From January–October 2020, 481 HIV physicians were included: 339(70.5%) from Brazil, 276(57.4%) male, and median age was 43 years (IQR = 36–53). Awareness of PrEP did not differ between Brazil and Mexico (84.6%), while awareness of other prevention strategies, including post-exposure prophylaxis and new PrEP technologies, was higher in Brazil. More Brazilians perceived U=U as completely accurate compared to Mexicans (74.0% vs. 62.0%, P < .001). Willingness to prescribe PrEP was 74.2%, higher among Brazilians (78.2%, P = .01). Overall, participants had concerns about consistent access to PrEP medication and the risk of antiretroviral resistance in case of acute HIV infection or seroconversion. The main barriers reported were assumptions that users could have low PrEP knowledge (62.0%) or limited capacity for adherence (59.0%). Compared to Brazilians, Mexicans reported more concerns and barriers to PrEP prescription (all; P ≤ .05), except for consistent access to PrEP medication and the lack of professionals to prescribe PrEP (both; P ≤ .01).

Conclusions

Although awareness of PrEP was similar in Brazil and Mexico, differences in knowledge and attitudes may reflect the availability and stage of PrEP implementation in these countries. Strengthening and increasing information on PrEP technologies and other HIV prevention strategies among HIV physicians could improve their comfort to prescribe these strategies and facilitate their scale-up in LAC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07900-y.

Initiation of Antiretroviral Therapy in the Hospital Is Associated With Linkage to Human Immunodeficiency Virus (HIV) Care for Persons Living With HIV and Substance Use Disorder

BACKGROUND

Studies have demonstrated benefits of antiretroviral therapy (ART) initiation on the day of human immunodeficiency virus (HIV) testing or at first clinical visit. The hospital setting is understudied for immediate ART initiation.

METHODS

CTN0049, a linkage-to-care randomized clinical trial, enrolled 801 persons living with HIV (PLWH) and substance use disorder (SUD) from 11 hospitals across the United States. This secondary analysis examined factors related to initiating (including reinitiating) ART in the hospital and its association with linkage to HIV care, frequency of outpatient care visits, retention, and viral suppression.

RESULTS

Of 801 participants, 124 (15%) initiated ART in the hospital, with more than two-thirds of these participants (80/124) initiating ART for the first time. Time to first HIV care visit among those who initiated ART in the hospital and those who did not was 29 and 54 days, respectively (P = .0145). Hospital initiation of ART was associated with increased frequency of HIV outpatient care visits at 6 and 12 months. There was no association with ART initiation in the hospital and retention and viral suppression over a 12-month period. Participants recruited in Southern hospitals were less likely to initiate ART in the hospital (P < .001).

CONCLUSIONS

Previous research demonstrated benefits of immediate ART initiation, yet this approach is not widely implemented. Research findings suggest that starting ART in the hospital is beneficial for increasing linkage to HIV care and frequency of visits for PLWH and SUD. Implementation research should address barriers to early ART initiation in the hospital.

A Bayesian natural cubic B-spline varying coefficient method for non-ignorable dropout

BACKGROUND

Dropout is a common problem in longitudinal clinical trials and cohort studies, and is of particular concern when dropout occurs for reasons that may be related to the outcome of interest. This paper reviews common parametric models to account for dropout and introduces a Bayesian semi-parametric varying coefficient model for exponential family longitudinal data with non-ignorable dropout.

METHODS

To demonstrate these methods, we present results from a simulation study and estimate the impact of drug use on longitudinal CD4 + T cell count and viral load suppression in the Women's Interagency HIV Study. Sensitivity analyses are performed to consider the impact of model assumptions on inference. We compare results between our semi-parametric method and parametric models to account for dropout, including the conditional linear model and a parametric frailty model. We also compare results to analyses that fail to account for dropout.

RESULTS

In simulation studies, we show that semi-parametric methods reduce bias and mean squared error when parametric model assumptions are violated. In analyses of the Women's Interagency HIV Study data, we find important differences in estimates of changes in CD4 + T cell count over time in untreated subjects that report drug use between different models used to account for dropout. We find steeper declines over time using our semi-parametric model, which makes fewer assumptions, compared to parametric models. Failing to account for dropout or to meet parametric assumptions of models to account for dropout could lead to underestimation of the impact of hard drug use on CD4 + cell count decline in untreated subjects. In analyses of subjects that initiated highly active anti-retroviral treatment, we find that the estimated probability of viral load suppression is lower in models that account for dropout.

CONCLUSIONS

Non-ignorable dropout is an important consideration when analyzing data from longitudinal clinical trials and cohort studies. While methods that account for non-ignorable dropout must make some unavoidable assumptions that cannot be verified from the observed data, many methods make additional parametric assumptions. If these assumptions are not met, inferences can be biased, making more flexible methods with minimal assumptions important.

A client-centered relational framework on barriers to the integration of HIV and substance use services: a systematic review

Background

Given the close connection between human immunodeficiency virus (HIV) infection and substance use disorder (SUD), access to integrated HIV and SUD services is critical for individuals experiencing both challenges and their biopsychosocial conditions.

Method

Adopting an integrative method, this systematic review included 23 empirical studies published between 2000 and 2018. Articles investigated providers’ and clients’ perspectives on barriers to accessing integrated HIV and SUD services in various service settings (e.g., HIV primary care, SUD treatment, pharmacy).

Results

Using a client-centered relational framework, we identified barriers in three relational domains with “the client” as the focus of each: client-provider, client-organization, and client-system. The review shows that (1) barriers to HIV and SUD services do not exist in isolation, but in the dynamics within and across three relational domains; (2) service providers and clients often have different perceptions about what constitutes a barrier and the origin of such barriers; and (3) interprofessional and interorganizational collaborations are crucial for integrating HIV and SUD services.

Conclusion

This review points out the limitations of the conventional paradigm grouping barriers to service integration into isolated domains (client, provider, organization, or system). Reforms in service arrangements and provider training are recommended to address barriers to integrated services.

Systemic Delays in the Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients in Houston, Texas: The Providers' Report Card

Background:

The current US HIV treatment guidelines support initiation of antiretroviral therapy (ART) for persons with HIV for personal health benefits and prevention of HIV transmission. However, high levels of adherence to ART are critical to maximize individual and public health benefits. We examined the nonclinical barriers to ART initiation for clinically eligible individuals and the provider- and patient-related factors associated with these barriers among HIV-infected patients in Houston/Harris County, Texas.

Methods:

We analyzed data obtained from a probability sample of HIV medical care providers (HMCPs) in 13 outpatient facilities in Houston/Harris County, Texas surveyed between June and September 2009. We used an inductive thematic approach to code HMCP responses to an open-ended question that asked the main reasons why providers may delay initiating ART for clinically eligible patients.

Results:

The reasons cited by providers for delaying ART for clinically eligible patients were adherence (42.5%; 95% confidence interval [CI]: 28.5-57.8), acceptance (30%; 95% CI: 18.1-45.4), and structural concerns (27.5%; 95% CI: 16.1-42.8), with significant variations (P < .0001) noted across patients’ race/ethnicity and transmission category. HIV medical care providers with 6 to 10 years’ experience in HIV care and those providing medical care for more than 100 patients monthly were about 4 times (adjusted odds ratio [aOR]: 3.80; 95% CI: 1.20-5.92; P = .039) and 10 times (aOR: 10.36; 95% CI: 1.42-22.70; P = .019) more likely to state adherence and acceptance concerns, respectively, as reasons for delaying ART for clinically eligible patients.

Conclusion:

Our findings highlight the fact that clinical guidelines are only a starting point for medical decision-making process and that patients themselves play an important role. HMCP access to referrals for other medical issues, support services, and treatment education may help improve adherence and patient readiness for ART, thereby avoiding systemic delays.

Immediate antiviral therapy for HIV-infected persons faces with various obstacles

Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) ranks eighth in the global burden of disease, making seriously threatens to global health. Given there is not yet a cure for HIV infection, antiretroviral therapy (ART) holds a key role not only in improving the prognosis of the patients, but also reducing the risk of HIV transmission. The immediate initiation of ART has been recommended in domestic and foreign policies and guidelines, yet the implementation of this strategy is not satisfactory. In developing countries and even in some developed countries, it still takes a long time for patients to go from the diagnosis of HIV infection to the acceptance of ART. Clarifying the obstacles to the implementation of immediate ART and finding strategies to cope with them have emerged as key problems in response to HIV/AIDS.

Improving HIV service delivery for people who inject drugs in Kazakhstan: study protocol for the Bridge stepped-wedge trial

BACKGROUND

People who inject drugs (PWID) in Kazakhstan face many barriers to HIV testing as well as to accessing HIV care, to retention in HIV care, and to initiating and adhering to anti-retroviral treatment (ART). Needle and syringe programs (NSPs) are an opportune setting for integrated interventions to link PWID to HIV care.

METHODS

This Hybrid Type II study employs a stepped-wedge design to evaluate both effectiveness and implementation outcomes of Bridge, an intervention to identify, test, and link HIV-positive PWID to HIV care. The study is conducted at 24 NSPs in three different regions of Kazakhstan, to assess outcomes on the individual, organizational, and policy levels.

DISCUSSION

This trial responds to an identified need for new models of HIV service delivery for PWID through harm reduction settings.

TRIAL REGISTRATION

NCT02796027 on June 10, 2016.

Evaluating the Impact of Housing Status on Gonorrhea and Chlamydia Screening in an HIV Primary Care Setting

INTRODUCTION

Gonorrhea and chlamydia (GC/CT) testing falls below recommended rates for people living with HIV (PLWH) in routine care. Despite evidence that homelessness and unstable housing (HUH) negatively impacts clinical outcomes for PLWH, little is known about GC/CT screening for HUH-PLWH in routine care.

METHODS

Using an observational cohort of PLWH establishing care at a large publicly funded HIV clinic in San Francisco between February 2013 and December 2014 and with at least 1 primary care visit (PCV) before February 2016, we assessed GC/CT testing for HUH (staying outdoors, in shelters, in vehicles, or in places not made for habitation in the last year) compared with stably housed patients. We calculated (1) the odds of having GC/CT screening at a PCV using logistic regression with random effects to handle intrasubject correlations and (2) the percent of time enrolled in clinical care in which patients had any GC/CT testing ("time in coverage") based on 180-day periods and using linear regression modeling.

RESULTS

Of 323 patients, mean age was 43 years, 92% were male, 52% were non-Latino white, and 46% were HUH. Homeless and unstably housed PLWH had 0.66 odds of GC/CT screening at a PCV than did stably housed patients (95% confidence interval, 0.44-0.99; P = 0.043). Time in coverage showed no difference by housing status (regression coefficient, -0.93; 95% confidence interval, -8.02 to 6.16; P = 0.80).

CONCLUSIONS

Homeless and unstably housed PLWH had 34% lower odds of GC/CT screening at a PCV, demonstrating a disparity in routine care provision, but similar time in coverage. More research is needed to effectively increase GC/CT screening among HUH-PLWH.

"It's Never Just About the HIV:" HIV Primary Care Providers' Perception of Substance Use in the Era of "Universal" Antiretroviral Medication Treatment

Antiretroviral therapy (ART) is recommended for all people living with HIV (PLWH), regardless of disease status. Substance use disorders (SUD) are common barriers to successful HIV treatment; however, few studies have comprehensively explored how HIV primary care providers take SUDs into account in the context of universal ART implementation. This study uses thematic analysis of qualitative interviews to explore providers' (N = 25) substance use assessment and factors associated with ART initiation. 64% of providers had 15 or more years of HIV treatment experience. Almost all providers agreed with the guidelines for universal ART initiation despite the presence of SUD. Still, identification and management of SUD is challenged by inconsistent assessment, providers' misperceptions about SUD and patients' willingness to discuss it, and lack of accessible treatment resources when SUD is identified. Greater guidance in systematic SUD assessment and management, combined with integrated addiction services, could enhance universal ART implementation among PLWH/SUD.

Patient profiles as organizing HIV clinicians' ART adherence management: a qualitative analysis

The effectiveness of antiretroviral therapy (ART) depends on optimal clinical management and patient adherence. Little is known about patient characteristics that clinicians consider in the management of ART adherence. Exploring this issue, five focus groups were conducted with 31 HIV-clinicians from across France. A qualitative typological analysis suggests that clinician management of patient adherence is based on characteristics that coalesce into seven patient profiles. For the "passive" patient, described as taking ART exactly as prescribed without questioning their doctor's expertise, a directive and simple management style was preferred. The "misleading" patient is characterized as concerned with social desirability and as reporting no adherence difficulties for fear of displeasing their doctor. If clinical outcomes are suboptimal, the clinicians' strategy is to remind them of the importance of open patient-clinician communication. The "stoic" patient is described as requesting and adequately taking the most potent ART available. Here, clinicians emphasize assessment of side effects, which the patient may minimize. The "hedonistic" patient's festive lifestyle and sexual risk-taking are seen as compromising adherence; with them, clinicians stress the patient's responsibility for their own health and that of their sexual partners. The "obsessive" patient is portrayed as having an irrational fear of ART failure and an inability to distinguish illusory from genuine adherence barriers. With this patient, clinicians seek to identify the latter. The "overburdened" patient is recognized as coping with life priorities that interfere with adherence and, with them, a forgiving ART is favored. The "underprivileged" patient is presented as having limited education, income and housing. In this case, clinicians seek to improve the patient's living conditions and access to care. These results shed light on HIV clinicians' ART adherence management. The value of these profiles for HIV care and patients should be investigated.

Primary Care Physicians' Willingness to Prescribe HIV Pre-exposure Prophylaxis for People who Inject Drugs

Pre-exposure prophylaxis for HIV (PrEP) is recommended for people who inject drugs (PWID). Despite their central role in disease prevention, willingness to prescribe PrEP to PWID among primary care physicians (PCPs) is largely understudied. We conducted an online survey (April-May 2015) of members of a society for academic general internists regarding PrEP. Among 250 respondents, 74% (n = 185) of PCPs reported high willingness to prescribe PrEP to PWID. PCPs were more likely to report high willingness to prescribe PrEP to all other HIV risk groups (p's < 0.03 for all pair comparisons). Compared with PCPs delivering care to more HIV-infected clinic patients, PCPs delivering care to fewer HIV-infected patients were more likely to report low willingness to prescribe PrEP to PWID (Odds Ratio [95% CI] = 6.38 [1.48-27.47]). PCP and practice characteristics were not otherwise associated with low willingness to prescribe PrEP to PWID. Interventions to improve PCPs' willingness to prescribe PrEP to PWID are needed.

Understanding HIV Care Provider Attitudes Regarding Intentions to Prescribe PrEP

INTRODUCTION

Preexposure prophylaxis (PrEP) is a promising approach to reducing HIV incidence. So, garnering the support of HIV providers, who are most familiar with antiretrovirals and likely to encounter patients in HIV serodiscordant relationships, to scale-up PrEP implementation is essential. We sought to determine whether certain subgroups of HIV providers were more likely to intend to prescribe PrEP.

METHODS

Surveys were administered to HIV providers in Miami, Florida and Washington, District of Columbia. Composite scores were developed to measure PrEP knowledge, experience, and likelihood of prescribing. Latent class analysis was used to stratify provider attitudes toward PrEP.

RESULTS

Among 142 HIV providers, 73.2% had cared for more than 20 HIV-infected patients in the previous 3 months; 17% had ever prescribed PrEP. Latent class analysis identified 2 classes of providers (entropy, 0.904); class 1 (n = 95) found PrEP less effective and perceived barriers to prescribing it; class 2 (n = 47) perceived PrEP as moderately effective and perceived fewer barriers to prescribing it. Compared with class 2, class 1 had significantly less experience with PrEP delivery (t(22.7) = 2.88, P = 0.009) and was significantly less likely to intend to prescribe to patients with multiple sex partners (20% vs. 43%, P = 0.04) and those with a drug use history (7% vs. 24%, P = 0.001).

CONCLUSIONS

Although most HIV providers found PrEP to be effective, those considering it less effective had limited knowledge and experience with PrEP and had lesser intentions to prescribe. Provider training regarding whom should receive PrEP and addressing potential barriers to PrEP provision are needed if this HIV prevention method is to be optimized.

Retained in HIV Care But Not on Antiretroviral Treatment: A Qualitative Patient-Provider Dyadic Study

BACKGROUND

Patients retained in HIV care but not on antiretroviral therapy (ART) represent an important part of the HIV care cascade in the United States. Even in an era of more tolerable and efficacious ART, decision making in regards to ART offer and uptake remains complex and calls for exploration of both patient and provider perspectives. We sought to understand reasons for lack of ART usage in patients meeting the Health Resources Services Administration definition of retention as well as what motivated HIV primary care appointment attendance in the absence of ART.

METHODS AND FINDINGS

We conducted a qualitative study consisting of 70 in-depth interviews with ART-naïve and ART-experienced patients off ART and their primary care providers in two urban safety-net HIV clinics in San Francisco and New York. Twenty patients and their providers were interviewed separately at baseline, and 15 dyads were interviewed again after at least 3 mo and another clinic visit in order to understand any ART use in the interim. We applied dyadic analysis to our data. Nearly all patients were willing to consider ART, and 40% of the sample went on ART, citing education on newer antiretroviral drugs, acceptance of HIV diagnosis, social support, and increased confidence in their ability to adhere as facilitators. However, the strength of the provider recommendation of ART played an important role. Many patients had internalized messages from providers that their health was too good to warrant ART. In addition, providers, while demonstrating patient-centered care through sensitivity to patients experiencing psychosocial instability, frequently muted the offer of ART, at times unintentionally. In the absence of ART, lab monitoring, provider relationships, access to social services, opiate pain medications, and acute symptoms motivated care. The main limitations of this study were that treatment as prevention was not explored in depth and that participants were recruited from academic HIV clinics in the US, making the findings most generalizable to this setting.

CONCLUSIONS

Provider communication with regard to ART is a key focus for further exploration and intervention in order to increase ART uptake for those retained in HIV care.

Clinician Perspectives on Delaying Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients

Objectives:

Guidelines for antiretroviral therapy (ART) initiation have evolved, but consistently note that adherence problems should be considered and addressed. Little is known regarding the reasons providers delay ART initiation in clinically eligible patients.

Methods:

In 2009, we surveyed a probability sample of HIV care providers in 582 outpatient facilities in the United States and Puerto Rico with an open-ended question about nonclinical reasons for delaying ART initiation in otherwise clinically eligible patients.

Results:

Very few providers (2%) reported never delaying ART. Reasons for delaying ART were concerns about patient adherence (68%), patient acceptance (60%), and structural barriers (33%). Provider and practice characteristics were associated with reasons for delaying ART.

Conclusion:

Reasons for delaying ART were consistent with clinical guidelines and were both patient level and structural. Providers may benefit from training and access to referrals for ancillary services to enhance their ability to monitor and address these issues with their patients.

Discontinuation of antiretroviral therapy among adults receiving HIV care in the United States

BACKGROUND

Continuous antiretroviral therapy (ART) is important for maintaining viral suppression. This analysis estimates prevalence of and reason for ART discontinuation.

METHODS

Three-stage sampling was used to obtain a nationally representative, cross-sectional sample of HIV-infected adults receiving HIV care. Face-to-face interviews and medical record abstractions were collected from June 2009 to May 2010. Data were weighted based on known probabilities of selection and adjusted for nonresponse. Patient characteristics of ART discontinuation, defined as not currently taking ART, stratified by provider-initiated versus non-provider-initiated discontinuation, were examined. Weighted logistic regression models predicted factors associated with ART discontinuation.

RESULTS

Of adults receiving HIV care in the United States who reported ever initiating ART, 5.6% discontinued treatment. Half of those who discontinued treatment reported provider-initiated discontinuation. Provider-initiated ART discontinuation patients were more likely to have a nadir CD4 ≥ 200 cells per cubic millimeter. Non-provider-initiated ART discontinuation patients were more likely to have unmet need for supportive services and to have not received HIV care in the past 3 months. Among all patients who discontinued, younger age, female gender, not having continuous health insurance, incarceration, injection drug use, nadir CD4 count ≥ 2 00 cells per cubic millimeter, unmet need for supportive services, no care in the past 3 months and HIV diagnosis ≥ 5 years before interview were independently associated with ART discontinuation.

CONCLUSIONS

These findings inform development of interventions to increase ART persistence by identifying groups at increased risk of ART discontinuation. Evidence-based interventions targeting vulnerable populations are needed and are increasingly important as recent HIV treatment guidelines have recommended universal ART.

Impact of supervised drug consumption services on access to and engagement with care at a palliative and supportive care facility for people living with HIV/AIDS: a qualitative study

Introduction

Improvements in the availability and effectiveness of highly active antiretroviral therapy (HAART) have prolonged the lives of people living with HIV/AIDS. However, mortality rates have remained high among populations that encounter barriers to accessing and adhering to HAART, notably people who use drugs. This population consequently has a high burden of illness and complex palliative and supportive care needs, but is often unable to access these services due to anti-drug policies and discrimination. In Vancouver, Canada, the Dr. Peter Centre (DPC), which operates a 24-bed residential HIV/AIDS care facility, has sought to improve access to palliative and supportive care services by adopting a comprehensive harm reduction strategy, including supervised injection services. We undertook this study to explore how the integration of comprehensive harm reduction services into this setting shapes access to and engagement with care.

Methods

Qualitative interviews were conducted with 13 DPC residents between November 2010 and August 2011. Interviews made use of a semistructured interview guide which facilitated discussion regarding how the DPC Residence's model of care (a) shaped healthcare access, (b) influenced healthcare interactions and (c) impacted drug use practices and overall health. Interview transcripts were analysed thematically.

Results

Participant accounts highlight how the harm reduction policy altered the structural-environmental context of healthcare services and thus mediated access to palliative and supportive care services. Furthermore, this approach fostered an atmosphere in which drug use could be discussed without the risk of punitive action, and thus increased openness between residents and staff. Finally, participants reported that the environmental supports provided by the DPC Residence decreased drug-related risks and improved health outcomes, including HAART adherence and survival.

Conclusions

This study highlights how adopting comprehensive harm reduction services can serve to improve access and equity in palliative and supportive care for drug-using populations.

Disparities in HIV transmission risk among HIV-infected black and white men who have sex with men, United States, 2009

OBJECTIVE

To better understand why HIV incidence is substantially higher among black than white men who have sex with men (MSM), we present the first nationally representative estimates of factors that contribute to transmission - sexual behavior, antiretroviral therapy (ART) use, and viral suppression - among HIV-infected black and white MSM in the United States.

DESIGN

The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States.

METHODS

We used weighted interview and medical record data collected during June 2009 to May 2010 to estimate the prevalence of sexual behaviors, ART use, and viral suppression among sexually active HIV-infected black and white MSM. We used χ tests to assess significant differences between races and logistic regression models to identify factors that mediated the racial differences.

RESULTS

Sexual risk behaviors among black and white MSM were similar. Black MSM were significantly less likely than white MSM to take ART (80 vs. 91%) and be durably virally suppressed (48 vs. 69%). Accounting for mediators (e.g. age, insurance, poverty, education, time since diagnosis, and disease stage) reduced, but did not eliminate, disparities in ART use and rendered differences in viral suppression among those on ART insignificant.

CONCLUSION

Lower levels of ART use and viral suppression among HIV-infected black MSM may increase the likelihood of HIV transmission. Addressing the patient-level factors and structural inequalities that contribute to lower levels of ART use and viral suppression among this group will improve clinical outcomes and might reduce racial disparities in HIV incidence.

Drinking motives as prospective predictors of outcome in an intervention trial with heavily drinking HIV patients

BACKGROUND

Heavy alcohol consumption in HIV patients is an increasing health concern. Applying the drinking motivational model to HIV primary care patients, drinking motives (drinking to cope with negative affect, for social facilitation, and in response to social pressure) were associated with alcohol consumption at a baseline interview. However, whether these motives predict continued heavy drinking or alcohol dependence in this population is unknown.

METHODS

Participants were 254 heavy-drinking urban HIV primary care patients (78.0% male; 94.5% African American or Hispanic) participating in a randomized trial of brief drinking-reduction interventions. Drinking motive scales, as well as measures of alcohol consumption and alcohol dependence, were administered at baseline. Consumption and dependence measures were re-administered at the end of treatment two months later. Regression analyses tested whether baseline drinking motive scale scores predicted continued heavy drinking and alcohol dependence status at the end of treatment, and whether motives interacted with treatment condition.

RESULTS

Baseline drinking to cope with negative affect predicted continued heavy drinking (p<0.05) and alcohol dependence, the latter in both in the full sample (adjusted odds ratio [AOR]=2.14) and among those with baseline dependence (AOR=2.52). Motives did not interact with treatment condition in predicting alcohol outcomes.

CONCLUSIONS

Drinking to cope with negative affect may identify HIV patients needing targeted intervention to reduce drinking, and may inform development of more effective interventions addressing ways other than heavy drinking to cope with negative affect.

Drug treatment and the conditionality of HIV treatment access: a qualitative study in a Russian city

AIMS

We explored social factors affecting access to antiretroviral HIV treatment (ART) among people who inject drugs (PWID) in a Russian city with a large HIV burden.

DESIGN

Qualitative interview study.

SETTING

Community settings in Ekaterinburg, Russian Federation.

PARTICIPANTS

42 PWID living with HIV and 11 health practitioners.

MEASUREMENTS

Thematic analyses of in-depth qualitative interviews.

FINDINGS

Access to ART was felt by participants to be contingent upon their capacity to demonstrate a commitment to becoming 'drug free'. We identify, across interview accounts, a treatment access narrative of 'treat drugs before HIV'. This narrative is upheld by ART providers' concerns to maximize clinical outcome in the face of adherence doubts, as well as by would-be patients' perceptions of expectations placed upon them by the treatment system and their own doubts regarding treatment engagement. This has the effect of reproducing a habit of ART delay and disengaging people from the treatment system. Difficulties accessing ART, and the perceived rationing of treatment on account of untreated drug use, were experienced as 'moral discipline' for falling short of treatment 'deservedness'. Participants describe a 'Catch 22' system, where they are invited to treat their drug use in a setting where effective drug treatment was perceived as unavailable.

CONCLUSIONS

Inadequate drug treatment practices act as structural obstacles to realizing HIV treatment. Evidence internationally suggests that effective drug treatment, including opioid substitution therapy, improves access and adherence to antiretroviral treatment among people who inject drugs. Policy shifts are urgently needed in this setting to enable systemic improvements to drug treatment, especially given large HIV treatment demand.

Patterns of heroin and cocaine injection and plasma HIV-1 RNA suppression among a long-term cohort of injection drug users

BACKGROUND

Previous studies suggest that active drug use may compromise HIV treatment among HIV-positive injection drug users (IDU). However, little is known about the differential impacts of cocaine injection, heroin injection, and combined cocaine and heroin injection on plasma HIV-1 RNA suppression.

METHODS

Data were derived from a longstanding open prospective cohort of HIV-positive IDU in Vancouver, Canada. Kaplan-Meier methods and Cox proportional hazards regression were used to examine the impacts of different drug use patterns on rates of plasma HIV-1 RNA suppression.

RESULTS

Between May 1996 and April 2008, 267 antiretroviral (ART) naïve participants were seen for a median follow-up duration of 50.6 months after initiating ART. The incidence density of HIV-1 RNA suppression was 65.2 (95%CI: 57.0-74.2) per 100 person-years. In Kaplan-Meier analyses, compared to those who abstained from injecting, individuals injecting heroin, cocaine, or combined heroin/cocaine at baseline were significantly less likely to achieve viral suppression (all p<0.01). However, none of the drug use categories remained associated with a reduced rate of viral suppression when considered as time-updated variables (all p>0.05).

CONCLUSIONS

Active injecting at the time of ART initiation was associated with lower plasma HIV-1 RNA suppression rates; however, there was no difference in suppression rates when drug use patterns were examined over time. These findings imply that adherence interventions for active injectors should optimally be applied at the time of ART initiation.

Young age predicts poor antiretroviral adherence and viral load suppression among injection drug users

Previous studies of adherence to antiretroviral therapy (ART) for HIV among young injection drug users (IDU) have been limited because financial barriers to care disproportionately affect youth, thus confounding results. This study examines adherence among IDU in a unique setting where all medical care is provided free-of-charge. From May 1996 to April 2008, we followed a prospective cohort of 545 HIV-positive IDU of 18 years of age or older in Vancouver, Canada. Using generalized estimating equations (GEE), we studied the association between age and adherence (obtaining ART≥95% of the prescribed time), controlling for potential confounders. Using Cox proportional hazards regression, we also studied the effect of age on time to viral load suppression (<500 copies per milliliter), and examined adherence as a mediating variable. Five hundred forty-five participants were followed for a median of 23.8 months (interquartile range [IQR]=8.5-91.6 months). Odds of adherence were significantly lower among younger IDU (adjusted odds ratio [AOR]=0.76 per 10 years younger; 95% confidence interval [CI], 0.65-0.89). Younger IDU were also less likely to achieve viral load suppression (adjusted hazard ratio [AHR]=0.75 per 10 years younger; 95% CI, 0.64-0.88). Adding adherence to the model eliminated this association with age, supporting the role of adherence as a mediating variable. Despite absence of financial barriers, younger IDU remain less likely to adhere to ART, resulting in inferior viral load suppression. Interventions should carefully address the unique needs of young HIV-positive IDU.

Provider and clinic-level correlates of deferring antiretroviral therapy for people who inject drugs: a survey of North American HIV providers

Background

Injection drug users (IDUs) face numerous obstacles to receiving optimal HIV care, and have been shown to underutilize antiretroviral therapy (ART). We sought to estimate the degree to which providers of HIV care defer initiation of ART because of injection drug use and to identify clinic and provider-level factors associated with resistance to prescribing ART to IDUs.

Methods

We administered an Internet-based survey to 662 regular prescribers of ART in the United States and Canada. Questionnaire items assessed characteristics of providers' personal demographics and training, site of clinical practice and attitudes about drug use. Respondents then rated whether they would likely prescribe or defer ART for hypothetical patients in a series of scenarios involving varying levels of drug use and HIV disease stage.

Results

Survey responses were received from 43% of providers invited by email and direct mail, and 8.5% of providers invited by direct mail only. Overall, 24.2% of providers reported that they would defer ART for an HIV-infected patient with a CD4+ cell count of 200 cells/mm³ if the patient actively injected drugs, and 52.4% would defer ART if the patient injected daily. Physicians were more likely than non-physician providers to defer ART if a patient injected drugs (adjusted odds ratio 2.6, 95% CI 1.4-4.9). Other predictors of deferring ART for active IDUs were having fewer years of experience in HIV care, regularly caring for fewer than 20 HIV-infected patients, and working at a clinic serving a population with low prevalence of injection drug use. Likelihood of deferring ART was directly proportional to both CD4+ cell count and increased frequency of injecting.

Conclusions

Many providers of HIV care defer initiation of antiretroviral therapy for patients who inject drugs, even in the setting of advanced immunologic suppression. Providers with more experience of treating HIV, those in high injection drug use prevalence areas and non-physician providers may be more willing to prescribe ART despite on-going injection drug use. Because of limitations, including low response rate and use of a convenience sample, these findings may not be generalizable to all HIV care providers in North America.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19-0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29-0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45-0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24-5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22-3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28-2.87), homelessness (AOR = 2.40, CI = 1.60-3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88-3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08-2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.

Does initiation of HIV antiretroviral therapy influence patterns of syringe lending among injection drug users?

The delivery of antiretroviral therapy (ART) to injection drug users (IDU) may be influenced by provider concerns regarding the potential for increased HIV-related risk behavior following the initiation of HIV treatment. We evaluated whether ART initiation was associated with changes in syringe lending patterns among a long-term prospective cohort of HIV-positive IDU in Vancouver, Canada. Among 380 ART-naïve individuals eligible for this analysis, the median age was 34.2 (interquartile range [IQR] 27.7-40.8), 171 (45.0%) were female, and the median follow-up duration was 60 months (IQR=18-113). Between May 1996 and April 2008, 260 (68.4%) participants initiated ART. In a generalized linear mixed-effects model which compared each individual's likelihood of sharing syringes prior to and following the initiation of ART, syringe lending was not significantly associated with ART initiation in unadjusted (odds ratio=0.72, 95% CI: 0.38-1.36) or adjusted (odds ratio=0.78, 95% CI: 0.42-1.45) analyses. Concerns regarding increased injection risk behaviors following the initiation of ART were not observed in this setting.

HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study

BACKGROUND

Having opioid dependence and HIV infection are associated with poor HIV-related treatment outcomes.

METHODS

HIV-infected, opioid-dependent subjects (N = 295) recruited from 10 clinical sites initiated buprenorphine/naloxone (BUP/NX) and were assessed at baseline and quarterly for 12 months. Primary outcomes included receiving antiretroviral therapy (ART), HIV-1 RNA suppression, and mean changes in CD4 lymphocyte count. Analyses were stratified for the 119 subjects not on ART at baseline. Generalized estimating equations were deployed to examine time-dependent correlates for each outcome.

RESULTS

At baseline, subjects on ART (N = 176) were more likely than those not on ART (N = 119) to be older, heterosexual, have lower alcohol addiction severity scores, and lower HIV-1 RNA levels; they were less likely to be homeless and report sexual risk behaviors. Subjects initiating BUP/NX (N = 295) were significantly more likely to initiate or remain on ART and improve CD4 counts over time compared with baseline; however, these improvements were not significantly improved by longer retention on BUP/NX. Retention on BUP/NX for three or more quarters was, however, significantly associated with increased likelihood of initiating ART (β = 1.34 [1.18, 1.53]) and achieve viral suppression (β = 1.25 [1.10, 1.42]) for the 64 of 119 (54%) subjects not on ART at baseline compared with the 55 subjects not retained on BUP/NX. In longitudinal analyses, being on ART was positively associated with increasing time of observation from baseline and higher mental health quality of life scores (β = 1.25 [1.06, 1.46]) and negatively associated with being homo- or bisexual (β = 0.55 [0.35, 0.97]), homeless (β = 0.58 [0.34, 0.98]), and increasing levels of alcohol addiction severity (β = 0.17 [0.03, 0.88]). The strongest correlate of achieving viral suppression was being on ART (β = 10.27 [5.79, 18.23]). Female gender (β = 1.91 [1.07, 3.41]), Hispanic ethnicity (β = 2.82 [1.44, 5.49]), and increased general health quality of life (β = 1.02 [1.00,1.04]) were also independently correlated with viral suppression. Improvements in CD4 lymphocyte count were significantly associated with being on ART and increased over time.

CONCLUSIONS

Initiating BUP/NX in HIV clinical care settings is feasible and correlated with initiation of ART and improved CD4 lymphocyte counts. Longer retention on BPN/NX was not associated with improved prescription of ART, viral suppression, or CD4 lymphocyte counts for the overall sample in which the majority was already prescribed ART at baseline. Among those retained on BUP/NX, HIV treatment outcomes did not worsen and were sustained. Increasing time on BUP/NX, however, was especially important for improving HIV treatment outcomes for those not on ART at baseline, the group at highest risk for clinical deterioration. Retaining subjects on BUP/NX is an important goal for sustaining HIV treatment outcomes for those on ART and improving them for those who are not. Comorbid substance use disorders (especially alcohol), mental health problems, and quality-of-life indicators independently contributed to HIV treatment outcomes among HIV-infected persons with opioid dependence, suggesting the need for multidisciplinary treatment strategies for this population.

HIV-positive patients' discussion of oral health with their HIV primary care providers in Miami, Florida

Over 90% of HIV-positive persons will have at least one oral manifestation of HIV disease during the course of infection. Clinical guidelines suggest that examination of the oral cavity should be included in initial and interim physical examinations of all HIV-infected patients by their HIV care providers. Clinically significant manifestations of oral disease may impact prescribed treatment regimens. The objective of this analysis was to describe HIV-positive patients' discussion of oral health and dental health with their HIV primary care providers and the correlates of this discussion. We used cross-sectional data from the baseline of a randomized trial testing the efficacy of a risk reduction intervention. Participants were HIV-positive male and female patients attending five HIV primary care clinics in Miami-Dade County, Florida, USA. Overall, 37% of patients did not discuss oral health with their provider. After controlling for age, gender, education, and clinic, odds of discussion of oral health for respondents with five or more primary care visits in the past year were half the odds of those with fewer visits (odds ratio (OR)=0.525, 95% confidence interval (CI): 0.336, 0.821). Odds of discussion for men reporting illicit drug use were 35% of that for non-drug using men (OR=0.353, 95% CI: 0.186, 0.671). Odds of discussion were 1.4 times greater for each additional health topic discussed (e.g., nutrition and smoking) (95% CI: 1.317, 1.544). Given that more than one-third of patients reported no discussion of oral health with HIV primary care providers in the past year, there is a need to increase the focus on oral health in the HIV primary care setting.

Antiretroviral therapy in Malaysia: identifying barriers to universal access

Despite a good public healthcare infrastructure and greater availability of antiretroviral drugs in Malaysia since 2005, the number of HIV-infected patients receiving treatment remains disproportionately small. Barriers to greater access include a lack of trained human resources to deliver antiretroviral therapy (ART) in a highly individualized and specialized model and, until recently, a lack of treatment for substance abuse in a predominantly injecting drug-use epidemic. However, one of the biggest barriers, and perhaps the most challenging to overcome, is the stigma and discrimination towards HIV-infected people, especially injecting drug users, which prevented many from accessing treatment and care. Increasing and improved access to ART for HIV-infected patients will entail a multipronged strategy that includes the decentralization of clinical care, increased and ongoing training of healthcare workers and support staff, and a comprehensive and intensive effort to reduce stigma and discrimination. Creation of an enabling environment through public education and a well-trained and nonprejudicial healthcare work force, coupled with policy and legal reforms, are essential in ensuring a greater and sustainable access to ART for all.

Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study

OBJECTIVE

To examine the relation between plasma HIV-1 RNA concentrations in the community and HIV incidence among injecting drug users.

DESIGN

Prospective cohort study.

SETTING

Inner city community in Vancouver, Canada.

PARTICIPANTS

Injecting drug users, with and without HIV, followed up every six months between 1 May 1996 and 30 June 2007.

MAIN OUTCOME MEASURES

Estimated community plasma HIV-1 RNA in the six months before each HIV negative participant's follow-up visit. Associated HIV incidence.

RESULTS

Among 622 injecting drug users with HIV, 12 435 measurements of plasma HIV-1 RNA were obtained. Among 1429 injecting drug users without HIV, there were 155 HIV seroconversions, resulting in an incidence density of 2.49 (95% confidence interval 2.09 to 2.88) per 100 person years. In a Cox model that adjusted for unsafe sexual behaviours and sharing used syringes, the estimated community plasma HIV-1 RNA concentration remained independently associated with the time to HIV seroconversion (hazard ratio 3.32 (1.82 to 6.08, P<0.001), per log(10) increase). When the follow-up period was limited to observations after 1 January 1988 (when the median plasma HIV RNA concentration was <20 000 copies/ml), the median viral load was no longer statistically associated with HIV incidence (1.70 (0.79 to 3.67, P=0.175), per log(10) increase).

CONCLUSIONS

A longitudinal measure of community plasma HIV-1 RNA concentration was correlated with the community HIV incidence rate and predicted HIV incidence independent of unsafe sexual behaviours and sharing used syringes. If these findings are confirmed, they could help to inform both HIV prevention and treatment interventions.

The impact of methadone or buprenorphine treatment and ongoing injection on highly active antiretroviral therapy (HAART) adherence: evidence from the MANIF2000 cohort study

AIMS

To date, no data exist assessing the impact of either methadone or buprenorphine on adherence to highly active antiretroviral therapy (HAART) in the long term. This study was conducted in order to evaluate whether receiving take-home methadone and buprenorphine may ensure better adherence to HAART in individuals infected with human immunodeficiency virus (HIV) through injection drug use (IDU).

DESIGN

Longitudinal data on adherence, opioid substitution treatment (OST) and patient behaviours starting from their first HAART prescription were collected for 276 individuals HIV-infected through drug use (n=1558 visits).

SETTING

Out-patient hospital services delivering HIV care in Marseilles, Avignon, Nice and Ile de France.

MEASUREMENTS

At any given visit, patients were classified both according to the type of OST received and ongoing injection. Patients who reported no injection and no OST over the whole study period were considered as 'abstinent' and used as a reference category. A logit model based on generalized estimation equations (GEE) was used to identify predictors of non-adherence.

FINDINGS

After adjustment for alcohol consumption, depression and self-reported side effects, patients ceasing injection during OST and abstinent patients exhibited comparable adherence. Patients reporting injection, on OST or not, had a twofold and threefold risk, respectively, of non-adherence compared with abstinent patients (P<0.01 linear trend). Duration on OST without injecting was associated significantly with virological success.

CONCLUSIONS

Both access to and effectiveness of OST contribute to sustaining adherence to HAART in HIV-infected IDUs. These results advocate strongly the need of wider use of OST in countries scaling-up HAART where HIV is driven by IDUs.

A review of barriers and facilitators of HIV treatment among injection drug users

Globally, injection drug use continues to account for a substantial proportion of HIV infections. There have not, however, been any evidence-based reviews of the barriers and facilitators of HIV treatment among injection drug users. For this review, published studies were extracted from nine academic databases, with no language or date specified in the search criteria. Existing evidence demonstrates that, although injection drug users often have worse outcomes from HIV treatment than non-injection drug users, major antiretroviral-associated survival gains still have been observed among this population. Inferior outcomes are explained by a range of barriers to antiretroviral access and adherence, which often stem from the negative influences of illicit drug policies, as well as issues within medical systems, including lack of physician education about substance abuse. Evidence demonstrates that several under-utilized interventions and novel antiretroviral delivery modalities have helped to greatly address these barriers in several settings, and there is sufficient evidence to support immediate scale-up of these programmes. These interventions include coupling antiretroviral therapy with opioid substitution therapies as well as directly administered antiretroviral therapy programmes. Of particular interest for future evaluation is the coupling of HIV treatment programmes within comprehensive services, which also provide low-threshold (harm reduction) HIV prevention programmes. Scale-up of evidence-based HIV treatment and prevention to injection drug users, however, will require increasing political will among both national policy-makers and international public health agencies.

Alcohol use, depressive symptoms and the receipt of antiretroviral therapy in southwest Uganda

Alcohol use and depressive symptoms are associated with reduced access to antiretroviral therapy (ART) in the developed world. Whether alcohol use and depressive symptoms limit access to ART in resource-limited settings is unknown. This cross-sectional study examined the association between alcohol use, depressive symptoms and the receipt of ART among randomly selected HIV-positive persons presenting for primary health care services at an outpatient HIV clinic in Uganda. Depressive symptoms were defined by the Hopkins Symptom Checklist and alcohol use was measured through frequency of consumption questions. Antiretroviral use was assessed using a standardized survey and confirmed by medical record review. Predictors of ART use were determined via logistic regression. Among 421 HIV-infected patients, factors associated with the receipt of ART were having at least primary education, having an opportunistic infection in the last 3 months, and not drinking within the last year.

HIV-positive patients' discussion of alcohol use with their HIV primary care providers

OBJECTIVES

We investigated the prevalence of HIV-positive patients discussing alcohol use with their HIV primary care providers and factors associated with these discussions.

METHODS

We recruited 1225 adult participants from 10 HIV care clinics in three large US cities from May 2004 to 2005. Multivariate logistic regression analysis was used to assess the associations between self-reported rates of discussion of alcohol use with HIV primary care providers in the past 12 months and the CAGE screening measure of problem drinking and sociodemographic variables.

RESULTS

Thirty-five percent of participants reported discussion of alcohol use with their primary care providers. The odds of reporting discussion of alcohol were three times greater for problem drinkers than for non-drinkers, but only 52% of problem drinkers reported such a discussion in the prior 12 months. Sociodemographic factors associated with discussion of alcohol use (after controlling for problem drinking) were being younger than 40, male, being non-white Hispanic (compared with being Hispanic), being in poorer health, and having a better patient-provider relationship.

CONCLUSIONS

Efforts are needed to increase the focus on alcohol use in the HIV primary care setting, especially with problem drinkers. Interventions addressing provider training or brief interventions that address alcohol use by HIV-positive patients in the HIV primary care setting should be considered as possible approaches to address this issue.

HIV, homelessness, and public health: critical issues and a call for increased action

Homelessness and housing instability are significant public health issues that increase the risks of HIV acquisition and transmission and adversely affect the health of people living with HIV. This article highlights the contributions of selected papers in this special issue of AIDS and Behavior and considers them within the broader context of prior research on the associations between housing status and HIV risk, use of HIV medical care, adherence to HIV treatment, and the physical health of HIV-seropositive persons. Special recognition is given to the roles of interrelated health problems, such as substance abuse, poor mental health, and physical and sexual abuse, that often co-occur and exacerbate the challenges faced by those who are homeless or unstably housed. Taken as a whole, the findings indicate a critical need for public health programs to develop strategies that address the fundamental causes of HIV risk among homeless and unstably housed persons and, for those living with HIV, contribute to their risk of disease progression. Such strategies should include "mid-stream" and "upstream" approaches that address the underlying causes of these risks. The successful implementation of these strategies will require leadership and the formation of new partnerships on the part of public health agencies. Such efforts, however, may have significant effects on the individuals and communities most affected by HIV/AIDS.

Integration and co-location of HIV/AIDS, tuberculosis and drug treatment services

Injection drug use (IDU) plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active IDU negatively impacts treatment access, adherence and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic and curative services to these complex patient populations. We propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis (TB) and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug-drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to IDUs, and training community health workers capable of cost effectively delivering these services.

The medical management of opioid dependence in HIV primary care settings

Injecting drug use is a common mode of transmission among persons with HIV/AIDS. Many HIV-infected patients meet diagnostic criteria for opioid dependence, a chronic and relapsing brain disorder. Most HIV providers, however, receive little training in substance use disorders. Opioid agonist therapy (OAT) has a stabilizing effect on opioid-dependent patients and is associated with greater acceptance of antiretroviral (ARV) therapy, higher ARV adherence, and greater engagement in HIV-related health care. Although methadone maintenance has been the OAT gold standard, methadone is available for the treatment of opioid dependence only in strictly regulated narcotic treatment programs. Buprenorphine, a partial opioid agonist approved for the office-based treatment of opioid dependence in 2002, may result in better health and substance use treatment outcomes for patients with HIV disease.

Additive deleterious effects of methamphetamine dependence and immunosuppression on neuropsychological functioning in HIV infection

Methamphetamine (MA) dependence and HIV infection are independently associated with cerebral dysfunction, especially within frontal-basal ganglia circuits. Recent evidence indicates that MA dependence has an additive effect on neuropsychological (NP) deficits associated with HIV infection. This study extends prior findings by examining the combined effects of MA dependence (MA+) and immunosuppression (i.e., CD4 lymphocyte count <200) on NP functioning in 284 HIV+ individuals. Prevalence of NP impairment was examined in four demographically comparable groups: (1) MA+/CD4 < 200; (2) MA+/CD4 > or = 200; (3) MA-/CD4 < 200; and (4) MA-/CD4 > or = 200. Results revealed that both MA dependence and immunosuppression were significant predictors of NP impairment. More importantly, additive effects were evident whereby the MA+/CD4 < 200 group exhibited the highest rate of NP impairment. Findings indicate that MA dependence conveys an additive deleterious impact on NP status in immunosuppressed persons with HIV infection, perhaps reflecting the combined effects of neuropathophysiological mechanisms in fronto-striatal circuits.

Highly active antiretroviral therapy (HAART) among HIV-infected drug users: a prospective cohort study of sexual risk and injecting behaviour

AIMS

To study sexual risk and injecting behaviour among HIV-infected drug users (DU) receiving highly active antiretroviral therapy (HAART).

DESIGN AND SETTING

As part of an ongoing prospective cohort study, HIV-infected DU who commenced HAART (n=67) were matched with those not starting HAART (n=130) on CD4 cell counts, duration of cohort participation, age and calendar year of visit. Immunological and virological responses of the HAART-treated DU were compared with the HAART-treated homosexual men from the same cohort (n=212).

MEASUREMENTS

Trends in behaviour and therapeutic response were tested with a logistic regression model adjusted for repeated measurements and a piecewise random effects model, respectively.

FINDINGS

Non-HAART users reported more episodes of injecting than HAART users. In both groups injecting declined over time with no effect of HAART initiation. Before HAART initiation an increase in sexual risk behaviour was observed among those who had been assigned to receive HAART; their sexual risk behaviour declined thereafter. No change in sexual risk behaviour was found among non-HAART users. Relative to homosexual men, DU had a similar initial therapeutic response, but DU started HAART at lower CD4 cell counts and higher viral load levels. Conclusion DU who are treated with HAART are not increasing their risk behaviour, and their early response to HAART is similar to homosexual men. However, before the treated DU received HAART they were seen to inject less often than those not treated with HAART. This suggests that selection of potential HAART starters is based on limited drug use. Although the DU who commence HAART are a selected group, our results show that HIV-infected DU can be treated effectively.

Nonfinancial Factors Associated With Decreased Plasma Viral Load Testing in Ontario, Canada

OBJECTIVE

To examine whether individual characteristics were associated with differential use of viral load testing when testing is available without charge to all HIV-positive patients with provincial health insurance.

METHODS

Individuals enrolled in the HIV Ontario Observational Database with complete medication records and health insurance numbers for linkage were studied. Generalized estimating equation regression models were used to examine the relationship between time-varying covariates such as plasma viral load levels, CD4 counts, and antiretroviral regimen characteristics and the number of days between viral load tests and the occurrence of an interval of >or=6 or 9 months between tests.

RESULTS

A total of 1032 individuals were included in the analysis with a median follow-up of 4.6 years and a median of 18 viral load tests. In multivariate analyses, clinically important gaps in viral load testing were more likely among injection drug users (odds ratio [OR]=1.86, P<0.0001), in more recent years (P<0.01) and for individuals not using antiretrovirals (OR=1.70, P<0.0001) and less likely among individuals using >4 antiretrovirals (OR=0.62, P<0.0001). Results were similar when the outcome was the number of days between tests.

CONCLUSIONS

Injection drug users, younger individuals, and residents of Toronto used fewer viral load tests than other individuals, even when financial barriers to testing were removed.