Adherence, drug use, and treatment failure in a methadone-clinic-based program of directly administered antiretroviral therapy.
ABSTRACT Supervised dosing is a cornerstone of tuberculosis treatment. HIV treatment strategies that use directly administered antiretroviral therapy (DAART) are increasingly being assessed. In a prospective single-arm clinical trial, we enrolled methadone-maintained, HIV-infected participants to receive supervised doses of antiretroviral therapy (ART) on days when they received methadone. Other ART doses were self-administered. In this analysis we examined factors associated with retention to DAART, adherence to supervised doses, and virologic failure. Factors associated with retention to DAART were assessed with the Kaplan-Meier method and Cox proportional hazards models. Factors associated with nonadherence with supervised dosing and with virologic failure were assessed by logistic regression and techniques for longitudinal data analysis. A total of 16,453 supervised doses were administered to 88 participants over a median follow-up of 9.4 months. The median participant adherence with supervised dosing was 83%. Active drug use, determined by urine drug screens, was associated twofold increased risks of both intervention dropout and nonadherence with supervised doses. Adherence with supervised doses was strongly associated with virologic failure. Because DAART was administered only on methadone dosing days, fewer than half of the total ART doses were scheduled to be supervised in most participants. The percent of doses that was scheduled to be supervised was not associated with either adherence or with virologic failure. Given that a relatively small proportion of the total ART doses were supervised in many patients, future studies should assess how DAART affects adherence with nonsupervised doses and retention to ART.
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ABSTRACT: Aim: Interactions between HIV and opioid-dependence therapies are known to occur. We sought to determine if such interactions occurred between methadone and elvitegravir boosted with cobicistat.Methods: We performed a within-subject open labeled pharmacokinetic and pharmacodynamic study in eleven HIV-seronegative subjects stabilized on at least 2 weeks of methadone. Subjects underwent baseline and steady-state evaluation of the effect of elvitegravir 150 mg qD boosted with 150 mg qD of cobicistat (EVG/COBI) on methadone pharmacokinetic parameters. Safety and pharmacodynamics were monitored throughout the study.Results: Compared to baseline values, R-methadone mean AUCtau (5550 vs. 6210 hr*ng/mL) and mean Cmax (316 vs. 337 ng/mL) did not significantly increase in the presence of EVG/COBI. Compared to baseline values, S-methadone mean AUCtau (7040 vs. 7540 hr*ng/mL) and mean Cmax (446 vs. 452 ng/mL) did not significantly increase in the presence of EVG/COBI. The AUCtau, Cmax and Ctau of elvitegravir and cobicistat did not significantly differ from historical controls. Opioid withdrawal or overdose was not observed among subjects in this study.Conclusion: The addition of EVG/COBI to stabilized patients receiving methadone did not affect methadone pharmacodynamics. The two can be safely co-administered.Antimicrobial Agents and Chemotherapy 09/2013; DOI:10.1128/AAC.01229-13 · 4.45 Impact Factor
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ABSTRACT: Antiretroviral therapy (ART) has reduced the rates and changed the causes of hospital admission. However, human immunodeficiency virus-positive intravenous drug users (HIV-IDU) continue to have increased hospitalizations and discharge diagnosis are less defined in the late ART era. Our aim was to examine ART use, HIV-1 RNA suppression, and hospital discharge diagnoses among HIV-IDU admitted to an urban hospital. A retrospective analysis was made of HIV-IDU admitted for medical causes for the first time (2006-2010). Surgical, obstetric, or mental (except HIV-associated neurocognitive disorder) diagnoses were excluded. Clinical characteristics, number of admissions, and primary discharge diagnoses were determined for each patient. Three hundred and seventy-five admissions were recorded among 197 hospitalized HIV-IDU. Lifetime prevalence of ART use was 83.2% (164 of 197) and the rate of HIV-1 RNA <50 copies/mL was 38.1% (75 of 197). Primary discharge diagnosis groups were as follows: bacterial infections (59.2%), chronic end-organ damage (16.8%), complications derived from injected drug use (16.8%), malignancies (9.1%), and opportunistic infections (6.6%). Chronic end-organ damage was diagnosed more frequently in patients with HIV-1 RNA <50 copies/mL (36% vs 4.9%; P < .000), and complications derived from injected drug use (23.8% vs 5.3%; P < .0008) and acquired immune deficiency syndrome (AIDS) opportunistic infections (19.8% vs 1.3% P < .019) were usually diagnosed in patients with HIV-1 RNA detectable viral load. Human immunodeficiency virus-positive intravenous drug users are admitted to hospitals mainly for non-AIDS-related illnesses; however, sustained HIV-1 RNA viral load suppression is poor and determines hospital discharge diagnoses. Providers need to be aware of the management of HIV-related comorbidities and reinforce strategies to improve ART retention in this population.03/2014; 1(1):ofu010. DOI:10.1093/ofid/ofu010
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ABSTRACT: This paper provides a review of the current literature addressing substance abuse treatment in persons living with HIV/AIDS. Clinical management of HIV must account for the "triple diagnosis" of HIV, psychiatric diagnosis, and substance use disorders and requires integrated treatment services that focus beyond just mitigation of substance use and psychiatric and medical symptoms but also address other health behaviors. Because clinical management of HIV/AIDS has shifted significantly with the advent of highly active antiretroviral therapies (HAART) in the mid 1990's, a literature review focusing on literature published since 2000, and using relevant key words was conducted using a wide range of literature search databases. This literature review was complemented by studies to expand on specific treatment modalities for which there was a dearth of literature addressing HIV infected cohorts and to provide discussion of issues around substance abuse treatment as an HIV prevention tool. Existing models of substance abuse treatment including cognitive behavioral therapy and motivational interviewing have proven to be useful for enhancing adherence and reducing substance use in outpatient populations, while methadone maintenance and directly observed treatment have been useful with specific subgroups of users. Contextualization of services heightens the likelihood of successful outcomes and relapse prevention.Behavioral Medicine 11/2013; DOI:10.1080/08964289.2013.866540 · 1.14 Impact Factor