|
Decreasing initiation of HAART therapy and reduced immunologic competence among injection drug users, 1996-2006, Baltimore, MD USA
Presented by Shruti Mehta, United States.
D. Celentano, J. Astemborski, S. Mehta, G. Kirk
Johns Hopkins Bloomberg School of Public Health, Epidemiology, Baltimore, United States
Background: HAART has dramatically changed HIV treatment. Injection drug users (IDU) were slow to start HAART, a result of physician reticence, concern over suboptimal adherence, and factors associated with chaotic lifestyles. As HAART has evolved and regimens simplified, IDUs would be anticipated to adopt current HIV treatment recommendations.
Methods: The ALIVE Study, a natural history study among IDUs in Baltimore, MD, opened enrollment in 1988-89 for those > 18 years with a history of injection in the prior 10 years; additional recruitment took place in 1994-95 and 1997. Participants were seen at 6-month interval visits, where behavioral risk factors were assessed, HIV treatments documented, blood drawn and locator information updated. We used Poisson regression to identify predictors of initiating HAART from January 1996 to December 2006.
Results: 629 (75% male, 97% African American, mean age 41 years, 60% active injectors) HIV-infected participants became HAART eligible (CD4 <350 cells/ml3): 332 (53%) initiated HAART, 82 (13%) died and 143 (22.7%) were lost to follow-up before initiating HAART. Initiation was primarily PI-based (66.7%), although use of NNRTI-based HAART (21.7% overall) increased over time. There was no temporal trend in rates of HAART initiation over time. In fact, time from HAART eligibility to initiation increased over this period (p<0.0001) and CD4 counts at initiation decreased (p<0001). Multivariable results showed older age, less frequent drug use, lower CD4 count, appropriate outpatient medical care, having a primary care provider and health insurance were independently associated with HAART initiation.
Conclusions: IDUs continue to lag behind other HAART-indicated patients in accessing appropriate pharmacotherapy, in part reflecting health care access issues and unresolved substance abuse. The declining trajectory in timely use of HAART as well as diminished immunologic functioning at the time of initiation raise concern that disparities in HIV care for IDUs are widening.
|