Individual, Interpersonal, and Structural Correlates of Effective HAART Use Among Urban Active Injection Drug Users
ABSTRACT Among individuals receiving highly active antiretroviral therapy (HAART), injection drug users (IDUs) are less likely to achieve HIV suppression. The present study examined individual-level, interpersonal, and structural factors associated with achieving undetectable plasma viral load (UVL) among US IDUs receiving recommended HAART. Data were from baseline assessments of the INSPIRE (Interventions for Seropositive Injectors-Research and Evaluation) study, a 4-site, secondary HIV prevention intervention for heterosexually active IDUs. Of 1113 study participants at baseline, 42% (n = 466) were currently taking recommended HAART (34% were female, 69% non-Hispanic black, 26% recently homeless; median age was 43 years), of whom 132 (28%) had a UVL. Logistic regression revealed that among those on recommended HAART, adjusted odds of UVL were at least 3 times higher among those with high social support, stable housing, and CD4 > 200; UVL was approximately 60% higher among those reporting better patient-provider communication. Outpatient drug treatment and non-Hispanic black race and an interaction between current drug use and social support were marginally negatively significant. Among those with high perceived support, noncurrent drug users compared with current drug users had a greater likelihood of UVL; current drug use was not associated with UVL among those with low support. Depressive symptoms (Brief Symptom Inventory) were not significant. Results suggest the major role of social support in facilitating effective HAART use in this population and suggest that active drug use may interfere with HAART use by adversely affecting social support. Interventions promoting social support functioning, patient-provider communication, stable housing, and drug abuse treatment may facilitate effective HAART use in this vulnerable population.
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- "Provision of HIV care to IDUs is challenging. Barriers to accessing care, including national drug policies and strategies that lead to marginalisation of IDUs (Rhodes et al. 2003; Wood et al. 2007), along with social instability and homelessness (Bassetti et al. 1999; Chander et al. 2006; Knowlton et al. 2006) and with patient (Bassetti et al. 1999; Kerr et al. 2005) or physician (Bassetti et al. 1999; Gross et al. 2002) reluctance to start ART "
ABSTRACT: Objectives To identify factors influencing mortality in an HIV programme providing care to large numbers of injecting drug users (IDUs) and patients co-infected with hepatitis C (HCV). Methods A longitudinal analysis of monitoring data from HIV-infected adults who started antiretroviral therapy (ART) between 2003 and 2009 was performed. Mortality and programme attrition rates within 2 years of ART initiation were estimated. Associations with individual-level factors were assessed with multivariable Cox and piece-wise Cox regression. Results A total of 1671 person-years of follow-up from 1014 individuals was analysed. Thirty-four percent of patients were women and 33% were current or ex-IDUs. 36.2% of patients (90.8% of IDUs) were co-infected with HCV. Two-year all-cause mortality rate was 5.4 per 100 person-years (95% CI, 4.4-6.7). Most HIV-related deaths occurred within 6 months of ART start (36, 67.9%), but only 5 (25.0%) non-HIV-related deaths were recorded during this period. Mortality was higher in older patients (HR = 2.50; 95% CI, 1.42-4.40 for ≥40 compared to 15-29 years), and in those with initial BMI < 18.5 kg/m(2) (HR = 3.38; 95% CI, 1.82-5.32), poor adherence to treatment (HR = 5.13; 95% CI, 2.47-10.65 during the second year of therapy), or low initial CD4 cell count (HR = 4.55; 95% CI, 1.54-13.41 for <100 compared to ≥100 cells/μl). Risk of death was not associated with IDU status (P = 0.38). Conclusion Increased mortality was associated with late presentation of patients. In this programme, death rates were similar regardless of injection drug exposure, supporting the notion that satisfactory treatment outcomes can be achieved when comprehensive care is provided to these patients.Tropical Medicine & International Health 08/2012; 17(10). DOI:10.1111/j.1365-3156.2012.03056.x · 2.30 Impact Factor
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- "The availability of effective therapy and the apparent clinical failure secondary to nonadherence practices especially among vulnerable populations call for a better understanding of how to improve adherence. Studies suggest that social and familial support can be crucial for increasing adherence (Arnsten et al., 2007; Beals, Wight, Aneshensel, Murphy, & Miller-Martinez, 2006; Fisher, Cornman, Norton, & Fisher, 2006; Knowlton et al., 2006; Mostashari, Riley, Selwyn, & Altice, 1998; Ogden, Esim, & Grown, 2006; Siegel, Raveis, & Karus, 1994; Siegel, Raveis, Houts, & Mor, 1991; Smith-Rohrberg, Mezger, Walton, Bruce, & Altice, 2006). Successful collaboration between patients and their caregivers, which is likely to provide that social support, involves an understanding of the medical perceptions of the different participants but these latter have been insufficiently described in the literature. "
ABSTRACT: Even with advances in the medical management of HIV/AIDS, it remains an important cause of morbidity and mortality. Network members are a source of support and may be designated as the patient's surrogate therapeutic decision maker. However, little is known about the role of caregivers regarding highly active antiretroviral therapy (HAART) and adherence to medication, especially among low income and medically underserved HIV-infected individuals. The objective of this analysis was to explore patients and their caregivers' understanding, insight, and perceptions of HAART. This was a qualitative study conducted in an urban teaching hospital in the Bronx, NY, consisting of 144 adults with advanced HIV/AIDS and their informal/familial caregivers. Patients and caregivers completed in-depth interviews and brief questionnaires. The data were analyzed using standard qualitative techniques. Themes related to HAART efficacy, side effects, and adherence were identified in the discussions with both patients and their care providers. Looking for consistencies and discordant reports of patients-caregivers dyadic experience with HAART and their association with healthcare sentiment, it was found that the accounts of both members of the dyad were more likely to reflect positive feelings about the patient's healthcare experience when they shared perceptions about the treatment, and were more likely to have a negative viewpoint when the dyad was discordant about treatment. These findings support the importance for HIV healthcare providers to include both patients and their caregivers in discussions about HAART, in order to improve their understanding of and satisfaction with the medication, and, to ultimately contribute to patients' adherence. The study also suggests that healthcare teams may enhance dialog with patients and caregivers to create therapeutic decisions to accommodate the priorities and values of the patient and their family. Clinical, educational, and evaluating tools need to be further developed and evaluation to facilitate this process.AIDS Care 12/2009; 21(12):1528-36. DOI:10.1080/09540120902923113 · 1.60 Impact Factor
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- "Potential explanations for this unexpected result include our small sample size or poor validity of our depression measure. Though this measure has been used among drug users (Knowlton et al., 2006), we did not evaluate performance of the subscale in our sample. Empirical studies are needed to understand the relationship between pain, depression symptom severity and antiretroviral adherence. "
ABSTRACT: The goals of this study were to examine the association between pain and antiretroviral adherence and to estimate the mediating effect of adherence self-efficacy and depression symptom severity. Surveys using audio computer-assisted self-interview were conducted among 70 HIV-infected current and former drug users enrolled in a methadone program. We assessed antiretroviral adherence and adherence self-efficacy using questions from the Adult Clinical Trials Group survey. We considered participants adherent if they reported taking at least 95% of prescribed antiretrovirals over the past seven days. We assessed depression symptom severity using the depression subscale of the Brief Symptom Inventory. Participants reported pain of any duration in response to a question from the Brief Pain Inventory. Participants reporting pain were 87% less likely to be classified as adherent compared to those without pain (Unadjusted OR = 0.13, 95%CI: 0.03-0.52). When we examined adherence self-efficacy as a mediator of the relationship between pain and adherence, criteria for partial mediation were met. Adjusting for self-efficacy, the beta coefficient for pain decreased by 23% but the independent relationship between pain and antiretroviral adherence was maintained. Mediation criteria were not met when we examined the mediating effect of depression symptom severity on the relationship between pain and adherence. Adjusting for depression symptom severity, the beta coefficient for pain decreased by 9% and the relationship between pain and antiretroviral adherence remained significant. Our results indicate that neither adherence self-efficacy nor depression symptom severity fully mediated the relationship between pain and adherence. HIV providers should recognize the potential impact of pain on antiretroviral adherence among current and former drug users.AIDS Care 03/2009; 21(2):244-8. DOI:10.1080/09540120802001697 · 1.60 Impact Factor