Rates of antiretroviral resistance among HIV-infected patients with and without a history of injection drug use
British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada. AIDS
(Impact Factor: 5.55).
08/2005; 19(11):1189-95. DOI: 10.1097/01.aids.0000176219.48484.f1
There exist concerns regarding the potential for elevated rates of antiretroviral resistance among HIV-infected injection drug users (IDUs) prescribed highly active antiretroviral therapy (HAART), however, no population-based study has examined if IDUs have elevated rates of antiretroviral resistance in comparison to non-IDUs.
To evaluate the time to the development of antiretroviral resistance among antiretroviral-naive patients with and without a history of injection drug use.
In British Columbia there is a province-wide HIV/AIDS treatment program that provides antiretrovirals free of charge. We examined all antiretroviral-naive patients initiating HAART between 1 August 1996 and 30 September 2000 and who were followed to 31 March 2002. The main outcome measure was the time to class-specific antiretroviral resistance. Cumulative antiretroviral resistance rates among IDUs and non-IDUs were evaluated using Kaplan-Meier methods and relative hazards were estimated using Cox regression.
Overall, 1191 antiretroviral-naive patients initiated HAART during the study period. Resistance mutations were observed in 298 (25%) subjects during the first 30 months of HAART. In comparison with non-IDUs, the risk of protease inhibitor resistance [relative hazard (RH), 0.9; 95% confidence interval (CI), 0.5-1.6] and non-nucleoside reverse transcriptase inhibitor resistance (RH, 1.5; 95% CI, 1.0-2.2) were similar among IDUs, and there were no differences in the rates of resistance to the sub-classes of nucleoside reverse transcriptase inhibitors.
Resistance to all major classes of antiretrovirals were similar among IDUs and non-IDUs after 30 months of follow-up. These findings should help to allay fears that prescribing HAART to IDUs may result in elevated rates of resistance.
Available from: Bridget K. Ambrose
- "Despite this, we and others have observed survival benefits of ART among IDUs with advanced HIV/AIDS that approaches that observed in other risk groups [7,8]. Studies in other contexts with universal access to ART have demonstrated similar mortality and rates of antiretroviral resistance among IDUs and non-IDUs [9,10], suggesting that the availability of interventions to support adherence and address co-morbid substance abuse may effectively eliminate the ART-related disparities observed in other settings . "
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ABSTRACT: 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.
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.
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.
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.
Available from: Daniel Wolfe
- "Clinicians remain reluctant to treat IDUs in part because they fear IDU inability to adhere to ARV and the development of viral resistance (WHO, 2006). These misgivings continue despite research showing that IDUs can achieve adherence to and benefit from ARV comparable to that of other patients (Mocroft et al., 1999; Nemes, 2000; Peretti-Watel et al., 2006; Wood et al., 2004); that resistance is comparable amongst IDUs and non-IDUs receiving ARV (Wood et al., 2005); and that drug resistance has been found in developing countries where active IDUs have been excluded from treatment or where HIV is not concentrated amongst injectors (Li et al., 2005; Tee et al., 2006). In developed countries, measures to increase IDU adherence have included reminders and support delivered by peer counselors (Broadhead et al., 2002); directly observed ARV delivered with opiate substitution treatment, at needle exchange programmes, or in specialized residential facilities (Clarke et al., 2002; Greenberg et al., 1999; Lucas et al., 2004; Macalino et al., 2004); and outpatient and hospital-based " case management " offering IDUs help negotiating health systems and support with issues such as HIV disclosure to family members (Dobkin, 2004; Kushel et al., 2006; UNAIDS, 2006). "
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ABSTRACT: Offered proper support, injection drug users (IDUs) can achieve the same levels of adherence to and clinical benefit from antiretroviral treatment (ARV) as other patients with HIV. Nonetheless, in countries of Asia and the former Soviet Union where IDUs represent the largest share of HIV cases, IDUs have been disproportionately less likely to receive ARV. While analysis of adherence amongst IDUs has focused on individual patient ability to adhere to medical regimens, HIV treatment systems themselves are in need of examination. Structural impediments to provision of ARV for IDUs include competing, vertical systems of care; compulsory drug treatment and rehabilitation services that often offer neither ARV nor effective treatment for chemical dependence; lack of opiate substitution treatments demonstrated to increase adherence to ARV; and policies that explicitly or implicitly discourage ARV delivery to active IDUs. Labeling active drug users as socially untrustworthy or unproductive, health systems can create a series of paradoxes that ensure confirmation of these stereotypes. Needed reforms include professional education and public campaigns that emphasize IDU capacity for health protection and responsible choice; recognition that the chronic nature of injecting drug use and its links to HIV infection require development of ARV treatment delivery that includes active drug users; and integrated treatment that strengthens links between health providers and builds on, rather than seeks to bypass, IDU social networks and organizations.
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