Uptake and adherence to highly active antiretroviral therapy among HIV-infected people with alcohol and other substance use problems: the impact of substance abuse treatment

Aim We examined the association of substance abuse treatment with uptake, adherence and virological response to highly active antiretroviral therapy (HAART) among HIV‐infected people with a history of alcohol problems. Design Prospective cohort study. Methods A standardized questionnaire was administered to 349 HIV‐infected participants with a history of alcohol problems regarding demographics, substance use, use of substance abuse treatment and uptake of and adherence to HAART. These subjects were followed every 6 months for up to seven occasions. We defined substance abuse treatment services as any of the following in the past 6 months: 12 weeks in a half‐way house or residential facility; 12 visits to a substance abuse counselor or mental health professional; or participation in any methadone maintenance program. Our outcome variables were uptake of antiretroviral therapy, 30‐day self‐reported adherence and HIV viral load suppression. Findings At baseline, 59% (205/349) of subjects were receiving HAART. Engagement in substance abuse treatment was independently associated with receiving antiretroviral therapy (adjusted OR; 95% CI: 1.70; 1.03–2.83). Substance abuse treatment was not associated with 30‐day adherence or HIV viral load suppression. More depressive symptoms (0.48; 0.32–0.78) and use of drugs or alcohol in the previous 30 days (0.17; 0.11–0.28) were associated with worse 30‐day adherence. HIV viral load suppression was positively associated with higher doses of antiretroviral medication (1.29; 1.15–1.45) and older age (1.04; 1.00–1.07) and negatively associated with use of drugs or alcohol in the previous 30 days (0.51; 0.33–0.78). Conclusion Substance abuse treatment was associated with receipt of HAART; however, it was not associated with adherence or HIV viral load suppression. Substance abuse treatment programs may provide an opportunity for HIV‐infected people with alcohol or drug problems to openly address issues of HIV care including enhancing adherence to HAART.     

Social-cognitive correlates of antiretroviral therapy adherence among HIV-infected individuals receiving infectious disease care in a medium-sized northeastern US city

High levels of antiretroviral therapy (ART) adherence are required to achieve optimal viral suppression. To better understand mechanisms associated with ART adherence, this study characterized demographic and social-cognitive correlates of ART adherence among HIV-infected individuals from a medium-sized northeastern US city (n=116; 42% female; 43% African-American). Participants completed an audio computer-assisted self-interviewing survey assessing demographics, social-cognitive constructs, and ART adherence, and the participants' most recent viral load was obtained from their medical charts. Suboptimal ART adherence (taking less than 95% of prescribed medications during the past month) was reported by 39% of participants and was associated with being female, being a minority, and having a detectable viral load. In a hierarchical logistic regression analysis, greater than 95% ART adherence was associated with higher levels of adherence self-efficacy (AOR =1.1; p=0.015), higher perceived normative beliefs about the importance of ART adherence (AOR=1.3; p=0.03), and lower concern about missing ART doses (AOR=0.63; p=0.002). Adherence did not differ based on ART outcome expectancies, ART attitudes, or the perceived necessity of ART. In fact, most participants endorsed positive attitudes and expectancies regarding the need for and effectiveness of ART. Taken together, results indicate that suboptimal adherence remains high among HIV-infected minority women, a subpopulation that experiences particularly high rates of chronic stress due to both illness-specific stressors and broader environmental stressors. Consistent with social-cognitive theory, adherence problems in our sample were linked with deficits in self-efficacy as well as perceived norms and behavioral intentions that do not support a goal of 100% adherence. We suggest that interventions to improve adherence informed by social-cognitive theory (1) target patients who are at risk for adherence problems, (2) provide a supportive environment that promotes high rates of adherence, and (3) address inaccurate beliefs regarding optimal adherence levels.     

Risk factors for recent nonfatal overdose among HIV-infected Russians who inject drugs

Overdoses and HIV infection are common among Russians who inject drugs, yet risk factors have not been studied. We analyzed baseline data of 294 participants with 30-day injection drug use from an HIV secondary prevention trial for persons reporting “heavy” alcohol use (National Institute on Alcohol Abuse and Alcoholism [NIAAA] risky drinking definition) and risky sex in the past 6 months. The outcome was any self-reported overdose in the previous 3 months. We examined demographic, HIV-related, criminal justice, mental health, substance use, and injection risk factors. Participants' characteristics included median age 29 years, 117/294 (40%) female, and median CD4 cell count 345/µl. Over three quarters 223/294 (76%) reported a history of overdose and 47/294 (16%) reported overdose in the past 3 months. Past month injection frequency (adjusted odds ratio [AOR] 4.77, 95% confidence interval [CI]: 1.63–14.0 highest vs. lowest quartile; AOR 3.58, 95% CI: 1.20–10.69 second highest vs. lowest quartile) and anti-retroviral therapy (ART) at time of interview (AOR 3.96 95% CI: 1.33–11.83) were associated with 3-month overdose. Nonfatal overdose among HIV-infected Russians who inject drugs is common. Risk factors include injection frequency and anti-retroviral therapy (ART), which warrant further study. Overdose prevention efforts are needed among HIV-infected Russians who inject drugs.     

Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users

Despite a burgeoning literature on adherence to HIV therapies, few studies have examined the impact of ongoing drug use on adherence and viral suppression, and none of these have utilized electronic monitors to quantify adherence among drug users. We used 262 electronic monitors to measure adherence with all antiretrovirals in 85 HIV-infected current and former drug users, and found that active cocaine use, female gender, not receiving Social Security benefits, not being married, screening positive for depression, and the tendency to use alcohol or drugs to cope with stress were all significantly associated with poor adherence. The strongest predictor of poor adherence and, in turn, failure to maintain viral suppression, was active cocaine use. Overall adherence among active cocaine users was 27%, compared to 68% among subjects who reported no cocaine use during the 6-month study period. Consequently, 13% of active cocaine users maintained viral suppression, compared to 46% of nonusers. Interventions to improve adherence should focus on reducing cocaine use, developing adaptive coping skills, and identifying and treating depression.     

Alcohol-antiretroviral therapy interactive toxicity beliefs and daily medication adherence and alcohol use among people living with HIV

Alcohol-antiretroviral therapy (ART) interactive toxicity beliefs reflect perceived adverse outcomes of mixing alcohol and ART. Previous research has shown a significant relationship between alcohol-ART interactive toxicity beliefs and ART non-adherence, over and above other correlates of non-adherence such as human immunodeficiency virus (HIV)symptoms and frequency of alcohol use. Most past studies have collected data over extended periods and have not determined if alcohol use and missed medications occur at the day-level among people holding interactive toxicity beliefs. Previous daily analyses, however, have been limited by self-reported adherence and relatively short periods of observation. To address these gaps in the literature, men and women living with HIV in Atlanta, GA, were enrolled in a 45-day observational cohort study. Daily alcohol use was collected using two-way interactive text message surveys and daily adherence was collected via the Wisepill device. Fifty-seven participants completed a measure of alcohol-ART interactive toxicity beliefs and contributed 2565 days of daily data. Participants who endorsed high levels of interactive toxicity beliefs had significantly more days when they missed doses of medication. Alcohol-antiretroviral toxicity beliefs predicted missing doses of medication on days when participants were drinking and on days when they were not drinking. Multilevel multivariate regressions showed that these toxicity beliefs predicted daily missed doses of medication over and above quantity of alcohol consumed, depression and general medication concerns. This study replicates and extends previous literature and indicates the necessity of addressing alcohol-ART toxicity beliefs within adherence interventions.     

Association of social stress,illicit drug use,and health beliefs with nonadherence to antiretroviral therapy

OBJECTIVE: To assess the roles of socioeconomic status, social stability, social stress, health beliefs, and illicit drug use with nonadherence to antiretroviral therapy. DESIGN: Cross-sectional study. SETTING: Urban hospital clinic. PARTICIPANTS: One hundred ninety-six consecutive HIV-infected patients taking at least 1 antiretroviral medication, awaiting a visit with their primary care provider. METHODS: Patients were interviewed while waiting for a clinic appointment and were asked to fill out a 4-part survey with questions regarding antiretroviral adherence, illicit drug use, health beliefs, and social situation. Adherence was defined as the percentage of doses taken, i.e., the number of doses taken divided by the number of doses prescribed over a 2-week interval. Univariate and multivariate logistic regressions were performed to identify factors associated with nonadherence in different patient subgroups. MAIN RESULTS: Nonadherence to antiretroviral therapy was associated with active illicit drug use (adjusted odds ratio [AOR], 2.31; 95% confidence interval [95% CI], 1.17 to 4.58), eating fewer than 2 meals per day (AOR, 3.31; 95% CI, 1.11 to 9.92), and feeling as though pressures outside of the clinic affected patient's ability to take antiretroviral medications as prescribed (AOR, 2.22; 95% CI, 0.99 to 4.97). In patients with a history of injection drug use, nonadherence to antiretroviral therapy was independently associated with eating fewer than 2 meals per day (AOR, 17.54; 95% CI, 1.92 to 160.4) and active illicit drug use (AOR, 4.18; 95% CI, 1.68 to 10.75). In patients without any injection drug use, nonadherence was only associated with feeling as though pressures outside of clinic affected patient's ability to take antiretroviral medications as prescribed (AOR, 3.55; 95% CI, 1.07 to 11.76). Male-to-male sexual contact was associated with lower nonadherence in patients with an HIV risk factor other than injection drug use (AOR, 0.35; 95% CI, 0.13 to 0.95). A history of drug use but no illicit drug use within 6 months of the interview was not associated with an increased rate of nonadherence. CONCLUSIONS: Although our sample size was limited and variables that are not significant in subgroup analysis may still be associated with adherence, our results suggest that correlates of nonadherence are HIV risk factor specific. Strategies to increase antiretroviral adherence in HIV-infected patients should include social support interventions targeted at different risk factors for different patient groups.     

Syndemic effect of mental illness and substance use on viral suppression among recently-incarcerated,HIV-infected individuals in the CARE+ Corrections study

Few studies on HIV-related syndemics of co-occurring and mutually reinforcing psychosocial conditions have assessed clinical outcomes in criminal justice (CJ)-involved populations. Baseline data from the CARE+ Corrections study were used to quantify co-occurring mental illness and substance use and examine syndemic effects on viral suppression among 106 CJ-involved HIV-infected individuals. Ninety-one (86%) reported a mental illness diagnosis, 30 (28%) reported hazardous alcohol use, and 61 (58%) were drug dependent. Eighteen (17%) experienced all three conditions. Drug dependence was clustered with mental illness (prevalence odds ratio [POR] 3.20, 95% CI 1.01–10.14) and hazardous alcohol use (POR 2.61, 95% CI 1.03–6.56). The association between syndemic score, representing the number of conditions reported by each individual, and viral suppression was not statistically significant, although 86% of participants with none of these conditions were virally suppressed, compared to 56% of those with all three (p?=?0.56). Mental illness and substance use were concentrated in this sample, indicating a need for integrated care services.     

Unreported alcohol use was common but did not impact hepatitis C cure in HIV‐infected persons who use drugs

We investigated the prevalence and impact of heavy alcohol use on the hepatitis C virus (HCV) care continuum amongst HIV/HCV co‐infected persons who use drugs. In the CHAMPS study, 144 HIV/HCV co‐infected persons were randomized to contingent cash incentives, peer mentors and usual care to evaluate the impact on HCV care. Alcohol use was ascertained using the 10‐item AUDIT (hazardous: male ≥8, female ≥4) and phosphatidylethanol (PEth) (heavy: ≥50 ng/mL), an alcohol biomarker. Log binomial regression was used to evaluate the association between heavy alcohol use and failure to initiate treatment and to achieve sustained virologic response (SVR). Of the 135 participants with PEth data, median age was 55 years, 59% were male, 92% were Black, 91% reported a history of drug use, and 97% were on antiretroviral therapy. Hazardous drinking was reported on AUDIT by 28% of participants, and 35% had heavy alcohol use by PEth. Of the 47 individuals with a PEth ≥50 ng/mL, 23 (49%) reported no or minimal alcohol use by AUDIT. HCV treatment was initiated in 103 of 135 participants, and SVR was achieved in 92%. PEth ≥50 ng/mL (Relative Risk [RR] 0.72, 95% CI 0.35‐1.48) was not significantly associated with failure to initiate HCV treatment or failure to achieve SVR (RR 0.85, 95% CI 0.46‐1.57).In conclusion, alcohol use was common and frequently not detected by self‐report. However, heavy alcohol use, even when measured objectively, was not associated with failure to initiate HCV treatment or to achieve cure.     

Lack of virologic suppression is associated with lower HIV-related disclosure stigma in people living with HIV

ABSTRACT

Stigma remains a leading barrier to HIV care. To determine the influence of disclosure stigma (DS), fear of disclosing one’s serostatus, on virologic suppression, a cross-sectional study was performed at the largest publicly-funded HIV clinic in South Texas. A survey was administered to participants who were: ≥18 years old, living with HIV, and receiving antiretroviral therapy. Surveys included demographics, adherence questionnaire, and a validated HIV-stigma scale with DS as the sum of 10 items ranked 0–3, with score of 30 indicating highest stigma. The primary outcome was lack of virologic suppression (LOVS): most recent HIV-1 RNA?>?20 copies/ml. A bivariate analyses examined predictors of DS, dichotomized at the median. Depression score, perceived stress, and lack of friend/family support were associated with DS. Logistic regression models examined the relationship between DS, as a continuous variable, and LOVS. For 275 participants (69% Hispanic), median DS score was 18.5. DS was significantly inversely associated with LOVS (aOR 0.94 per 1 scale point; CI 0.89, 0.99) after adjustment for age, gender/sexual orientation, race/ethnicity, and drug use. The unanticipated inverse association between DS and LOVS highlights the complexity of this relationship. However, the balance of data in this cohort demonstrate an overall negative impact of DS.     

Substance use and its impact on care outcomes among HIV-infected individuals in Manitoba

The high prevalence of substance use among HIV-infected individuals creates numerous challenges to patient care. This study was undertaken in order to understand the impact of substance use on care outcomes for HIV-infected individuals in Manitoba. Clinical records of 564 HIV-infected individuals in care at Health Sciences Centre in Winnipeg, Manitoba were reviewed. Clinical data were extracted from patient charts for substance users (illicit substance users, alcohol abusers and chronic users of opioids or benzodiazepines) and non-users. Substance users and non-users were analysed using chi-square analysis and logistic regression models to compare basic socio-demographic and clinic variables. Chi-square and analysis of variance were used to compare a subset of substance users based on similar socio-demographic and clinical characteristics. Among HIV-infected individuals in Manitoba, 38% were substance users with over-representation by Aboriginals, females, young adults and residents of Winnipeg's core areas. Opioids and benzodiazepines were the most commonly used substances with the majority of substance users having used multiple classes of substances in their lifetime. Substance users were more likely than non-users to have missed clinic appointments. Among substance users, missed appointments were more common among those who self-identified as Aboriginal, female, young adults, residents of Winnipeg's core areas, heterosexuals and those who had abused alcohol or cocaine/crack. Aboriginal substance users were also less likely to achieve viral load suppression compared to non-Aboriginal substance users. With the high prevalence of substance use among HIV-infected individuals in Manitoba, it is important to identify at-risk individuals in order to implement appropriate care strategies and improve treatment adherence and health outcomes.     

Not all non-drinkers with HIV are equal: demographic and clinical comparisons among current non-drinkers with and without a history of prior alcohol use disorders*

Studies of persons living with HIV (PLWH) have compared current non-drinkers to at-risk drinkers without differentiating whether current non-drinkers had a prior alcohol use disorder (AUD). The purpose of this study was to compare current non-drinkers with and without a prior AUD on demographic and clinical characteristics to understand the impact of combining them. We included data from six sites across the US from 1/2013 to 3/2015. Patients completed tablet-based clinical assessments at routine clinic appointments using the most recent assessment. Current non-drinkers were identified by AUDIT-C scores of 0. We identified a prior probable AUD by a prior AUD diagnosis in the electronic medical record (EMR) or a report of attendance at alcohol treatment in the clinical assessment. We used multivariate logistic regression to examine factors associated with prior AUD. Among 2235 PLWH who were current non-drinkers, 36% had a prior AUD with more patients with an AUD identified by the clinical assessment than the EMR. Higher proportions with a prior AUD were male, depressed, and reported current drug use compared to non-drinkers without a prior AUD. Former cocaine/crack (70% vs. 25%), methamphetamine/crystal (49% vs. 16%), and opioid/heroin use (35% vs. 7%) were more commonly reported by those with a prior AUD. In adjusted analyses, male sex, past methamphetamine/crystal use, past marijuana use, past opioid/heroin use, past and current cocaine/crack use, and cigarette use were associated with a prior AUD. In conclusion, this study found that among non-drinking PLWH in routine clinical care, 36% had a prior AUD. We found key differences between those with and without prior AUD in demographic and clinical characteristics, including drug use and depression. These results suggest that non-drinkers are heterogeneous and need further differentiation in studies and that prior alcohol misuse (including alcohol treatment) should be included in behavioural health assessments as part of clinical care.     

Undiagnosed HIV among people who inject drugs in Manipur,India

Manipur is a geographically isolated state of India characterised by a high HIV prevalence among people who inject drugs (PWID). A low-to-moderate lifetime rate of HIV testing has been documented amongst PWID in Manipur. Little is known about the extent of undiagnosed HIV in this setting and whether uptake of HIV testing (and knowledge of a positive diagnosis) leads HIV-positive PWID to change their risk behaviours. The cross-sectional data (n = 821) analysed for this paper were collected in 2009 for the Integrated Behavioural and Biological Assessment (IBBA) using interviewer-administered questionnaires and the collection of de-linked blood and urine samples. Almost one-third (30.7%) of the participants tested HIV positive. The majority knew where to obtain a confidential HIV test (80.7%), however, half of the HIV-positive participants had either never had an HIV test (37.7%), or had undertaken a test without collecting the result (12.7%). Almost one-quarter (23.4%) of the HIV-positive participants and 17.4% of the HIV-negative participants had shared a needle/syringe with at least one other injector during the preceding month. Encouragingly, HIV-positive participants were significantly more likely than HIV-negative participants to use condoms with their regular sexual partners, however, there was still a high proportion of HIV-positive participants who did not use a condom at last sex with their regular (47.2%) or casual (48.0%) partners. Having taken an HIV test and collected the result was associated with a reduction in HIV-risk behaviours among HIV-positive participants, but not among HIV-negative participants. In conclusion, we found that a substantial proportion of the HIV-positive PWID in Manipur were not aware of their positive status, and risky injecting and sexual practices were commonplace. However, HIV-positive PWID appear to reduce their high-risk behaviours when they become aware of their HIV status highlighting the importance of taking HIV testing coverage to scale.     

Unsafe sexual behaviour associated with hazardous alcohol use among street-involved youth

While risky sexual behaviours related to illicit drug use among street youth have been explored, the impacts of alcohol use have received less attention. This longitudinal study examined hazardous alcohol use among a population of street-involved youth, with particular attention to sexual and drug-related risk behaviours. Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved youth in Vancouver, Canada. The outcome of interest was hazardous alcohol use defined by the US National Institute on Alcohol Abuse and Alcoholism. We used generalized estimating equations (GEEs) analyses to identify factors associated with hazardous alcohol use. Between 2005 and 2014, 1149 drug-using youth were recruited and 629 (55%) reported hazardous alcohol use in the previous 6 months during study follow-up. In multivariable GEE analyses, unprotected sex (adjusted odds ratio [AOR]?=?1.28, 95% confidence interval [95% CI]?=?1.12–1.46) and homelessness (AOR?=?1.35, 95% CI?=?1.19–1.54) were independently associated with hazardous alcohol use (all p?p?相似文献   

The effect of history of injection drug use and alcoholism on HIV disease progression

The effectiveness of highly active antiretroviral therapy (HAART) in preventing disease progression can be negatively influenced by the high prevalence of substance use among patients. Here, we quantify the effect of history of injection drug use and alcoholism on virologic and immunologic response to HAART. Clinical and survey data, collected at the start of HAART and at the interview date, were based on the study Longitudinal Investigations into Supportive and Ancillary Health Services (LISA) in British Columbia, Canada. Substance use was a three-level categorical variable, combining information on history of alcohol dependence and of injection drug use, defined as: no history of alcohol and injection drug use; history of alcohol or injection drug use; and history of both alcohol and injection drug use. Virologic response (pVL) was defined by ≥2 log₁₀ copy/mL drop in a viral load. Immunologic response was defined as an increase in CD4 cell count percent of ≥100%. We used cumulative logit modeling for ordinal responses to address our objective. Of the 537 HIV-infected patients, 112 (21%) were characterized as having a history of both alcohol and injection drug use, 173 (32%) were nonadherent (<95%), 196 (36%) had a CD4⁺/pVL⁺ (Best) response, 180 (34%) a CD4⁺/pVL^? or a CD4^? /pVL⁺ (Incomplete) response, and 161 (30%) a CD4^? /pVL^? (Worst) response. For individuals with history of both alcohol and injection drug use, the estimated probability of non-adherence was 0.61, and (0.15, 0.25, 0.60) of Best, Incomplete and Worse responses, respectively. Screening and detection of substance dependence will identify individuals at high-risk for nonadherence and ideally prevent their HIV disease from progressing to advanced stages where HIV disease can become difficult to manage.