Adherence to antiretroviral therapy among HIV-infected drug users: a meta-analysis

A Latent Class Analysis of Substance Use and Longitudinal HIV RNA Patterns Among PWH in DC Cohort

People with HIV (PWH) with substance use disorders (SUD) have worse health outcomes than PWH without SUD. Our objective was to characterize substance use patterns and their impact on longitudinal HIV RNA trajectories among those enrolled in an observational study of PWH in care in Washington, DC. Substance use by type (alcohol, cannabis, opioid, stimulant, hallucinogen, inhalant, sedative) was used to identify shared patterns of substance use using Latent Class Analysis (LCA). A multinomial logistic regression model evaluated the association between the resulting substance use classes and the membership probability in longitudinal HIV RNA trajectory groups. There were 30.1% of participants with at least one substance reported. LCA resulted in a three-class model: (1) Low-Level Substance Use, (2) Opioid Use, and (3) Polysubstance. The Opioid and Polysubstance Use classes were more likely to have a mental health diagnosis (45.4% and 53.5%; p < 0.0001). Members in the Opioid Use class were older (median age of 54.9 years (IQR 50.3-59.2) than both the Polysubstance and Low-Level Substance Use Classes (p < 0.0001). There were 3 HIV RNA trajectory groups: (1) Undetectable, (2) Suppressed, and (3) Unsuppressed HIV RNA over 18 months of follow-up. The probability of being in the unsuppressed HIV RNA group trajectory when a member of the Opioid Use or Polysubstance Use classes was 2.5 times and 1.5 times greater than the Low-Level Substance Use class, respectively. The Opioid Use and Polysubstance Use classes, with higher-risk drug use, should be approached with more targeted HIV-related care to improve outcomes.

Perceptions of Long-Acting Injectable Antiretroviral Therapy Among People Living with HIV Who Use Drugs and Service Providers: a Qualitative Analysis in Rhode Island

Long-acting injectable antiretroviral therapy (LAI-ART) is a novel method to deliver HIV treatment, and the first regimen was approved in the USA in 2021. LAI-ART may mitigate barriers to oral treatment adherence, but little is known about LAI-ART perceptions among people living with HIV (PLWH) who use drugs, despite these populations facing greater barriers to treatment retention and ART adherence. We assessed LAI-ART perceptions and implementation considerations among PLWH who use drugs and health and ancillary service providers in Rhode Island. Data was collected from November 2021 to September 2022, and include in-depth interviews with 15 PLWH who use drugs and two focus groups with HIV clinical providers (n = 8) and ancillary service providers (n = 5) working with PLWH who use drugs. Data were analyzed thematically, with attention paid to how levels of structural vulnerability and social-structural environments shaped participants' LAI-ART perceptions and the HIV care continuum. Willingness to consider LAI-ART was impacted by HIV outcomes (e.g., viral suppression) and previous experiences with oral regimens, with those on stable regimens reluctant to consider alternative therapies. However, LAI-ART was seen as potentially improving HIV outcomes for PLWH who use drugs and enhancing people's quality of life by reducing stress related to daily pill-taking. Recommendations for optimal implementation of LAI-ART varied across participants and included decentralized approaches to delivery. HIV care delivery must consider the needs of PLWH who use drugs. Developing patient-centered and community-based delivery approaches to LAI-ART may address adherence challenges specific to PLWH who use drugs.

HIV Late Presenters in Asia: Management and Public Health Challenges

Many individuals are diagnosed with human immunodeficiency virus (HIV) infection at an advanced stage of illness and are considered late presenters. We define late presentation as a CD4 cell count below 350 cells/mm³ at the time of HIV diagnosis, or presenting with an AIDS-defining illness regardless of CD4 count. Across Asia, an estimated 34-72% of people diagnosed with HIV are late presenters. HIV late presenters generally have a higher disease burden and higher comorbidity such as opportunistic infections than those who are diagnosed earlier. They also have a higher mortality rate and generally exhibit poorer immune recovery following combined antiretroviral therapy (cART). As such, late HIV presentation leads to increased resource burden and costs to healthcare systems. HIV late presentation also poses an increased risk of community transmission since the transmission rate from people unaware of their HIV status is approximately 3.5 times higher than that of early presenters. There are several factors which contribute to HIV late presentation. Fear of stigmatisation and discrimination are significant barriers to both testing and accessing treatment. A lack of perceived risk and a lack of knowledge by individuals also contribute to late presentation. Lack of referral for testing by healthcare providers is another identified barrier in China and may extend to other regions across Asia. Effective strategies are still needed to reduce the incidence of late presentation across Asia. Key areas of focus should be increasing community awareness of the risk of HIV, reducing stigma and discrimination in testing, and educating healthcare professionals on the need for early testing and on the most effective ways to engage with people living with HIV. Recent initiatives such as intensified patient adherence support programs and HIV self-testing also have the potential to improve access to testing and reduce late diagnosis.

Economic, social, and clinic influences on opioid treatment program retention in Dar es Salaam, Tanzania: a qualitative study

BACKGROUND

Medications for opioid use disorder (MOUD) are associated with positive health outcomes. People remaining on MOUD have a reduced likelihood of drug overdose and mortality. Tanzania supports a national opioid treatment program (OTP) offering MOUD, but retention is a continual challenge. To date, most research on MOUD retention in Tanzania and other Sub-Saharan Africa settings has been focused on the individual-level, with little attention to economic, social, and clinic-level factors.

METHODS

We qualitatively examined economic, social, and clinic factors that affect retention on MOUD, specifically methadone maintenance therapy, among former and current clients attending an OTP clinic Dar es Salaam, Tanzania. We conducted in-depth interviews with a total of 40 current and former clients receiving MOUD and four focus groups with an additional 35 current clients on MOUD between January and April 2020. We utilized a thematic analysis approach.

RESULTS

Daily OTP clinic attendance posed a financial burden to current and former clients and was a barrier to remaining on MOUD. Though treatment is free, clients described struggles to attend clinic, including being able to afford transportation. Female clients were differentially impacted, as sex work was the most common income-generating activity that they participated in, which presented its own set of unique challenges, including barriers to attending during set clinic hours. Drug use stigma acted as a barrier to MOUD and prevented clients from securing a job, rebuilding trust within the community, and accessing transportation to attend the clinic. Being able to rebuild trust with family facilitated remaining on MOUD, as family provided social and financial support. Caretaking responsibilities and familial expectations among female clients conflicted with MOUD adherence. Finally, clinic level factors, such as clinic dispensing hours and punitive consequences for breaking rules, posed barriers to clients on MOUD.

CONCLUSION

Social and structural factors, both within (e.g., clinic policies) and outside of (e.g., transportation) the clinic impact MOUD retention. Our findings can inform interventions and policies to address economic and social barriers to MOUD, that can contribute to sustained recovery.

Patient and Provider Perspectives on a Novel, Low-Threshold HIV PrEP Program for People Who Inject Drugs Experiencing Homelessness

BACKGROUND

HIV outbreaks among people who inject drugs (PWID) and experience homelessness are increasing across the USA. Despite high levels of need, multilevel barriers to accessing antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention persist for this population. The Boston Health Care for the Homeless Program (BHCHP) initiated a low-threshold, outreach-based program to support engagement in PrEP services among PWID experiencing homelessness.

METHODS

To inform dissemination efforts, we explored patient and provider perspectives on key program components. From March to December 2020, we conducted semi-structured qualitative interviews with current and former BHCHP PrEP program participants and prescribers, patient navigators, and outreach workers (i.e., providers). Thematic analysis explored perspectives on key program components.

RESULTS

Participants (n = 21) and providers (n = 11) identified the following five key components of BHCHP's PrEP program that they perceived to be particularly helpful for supporting patient engagement in PrEP services: (1) community-driven PrEP education; (2) low-threshold, accessible programming including same-day PrEP prescribing; (3) tailored prescribing supports (e.g., on-site pharmacy, short-term prescriptions, medication storage); (4) intensive outreach and navigation; and (5) trusting, respectful patient-provider relationships.

DISCUSSION

Findings suggest that more patient-centered services formed the basis of BHCHP's innovative, successful PrEP program. While contextual challenges including competing public health emergencies and homeless encampment "sweeps" necessitate ongoing programmatic adaptations, lessons from BHCHP's PrEP program can inform PrEP delivery in a range of community-based settings serving this population, including syringe service programs and shelters.

Implementation of a Dyad-Based Intervention to Improve Antiretroviral Therapy Adherence Among HIV-Positive People Who Inject Drugs in Kazakhstan: A Randomized Trial

Purpose

HIV-positive people who inject drugs (PWID) in Kazakhstan face many challenges to antiretroviral therapy (ART) adherence. Interventions that leverage social support from an intimate partner, family member, or friend may be effective in improving ART adherence among this population. The purpose of this paper is to describe the implementation process of a dyad-based intervention among HIV-positive PWID and their treatment support partners.

Method

Sixty-six HIV-positive PWID and 66 of their treatment support partners will be enrolled in this pilot randomized controlled trial in Almaty, Kazakhstan, and randomized as dyads to receive an adapted version of the SMART Couples intervention or standard of care.

Results

Several implementation strategies were used to facilitate intervention delivery, including remote delivery, training of staff, supervision, technical assistance, quality assurance, and collection of assessments through diverse sources.

Discussion

This trial responds to a need for dyad-based ART adherence interventions adapted specifically for HIV-positive PWID.

HIV treatment, antiretroviral adherence and AIDS mortality in people who inject drugs: a scoping review

BACKGROUND

People who inject drugs (PWID) are a key population for the prevention and care of HIV infection.

METHODS

This scoping review covers recent (post-2010) systematic reviews on engagement of PWID in sequential stages of HIV care from uptake, to achieving viral suppression, and to avoiding AIDS-related mortality.

RESULTS

We found that data on engagement of PWID into antiretroviral therapy (ART) were particularly scarce, but generally indicated very low engagement in ART. Studies of adherence and achieving viral suppression showed varying results, with PWID sometimes doing as well as other patient groups. The severity of social, medical and psychiatric disability in this population poses significant treatment challenges and leads to a marked gap in AIDS mortality between PWID and other population groups.

CONCLUSIONS

Given the multi-level barriers, it will be difficult to reach current targets (UNAIDS fast-track targets of 95-95-95) for ART for PWID in many locations. We suggest giving priority to reducing the likelihood that HIV seropositive PWID will transmit HIV to others and reducing morbidity and mortality from HIV infection and from other comorbidities.

Assessing the Temporality Between Transitions onto Opioid Agonist Therapy and Engagement with Antiretroviral Therapy in a Cohort of HIV-Positive People Who Use Opioids Daily

A robust evidence-base describes the beneficial association between opioid agonist therapy (OAT) and HIV-related outcomes among people living with HIV and opioid use disorder. While some evidence suggests the stabilizing effect of OAT on antiretroviral therapy (ART) treatment engagement, less is understood about the potential for an inverse relationship. We sought to examine the relationship between transitions in ART engagement and transitions onto OAT. We used data from a prospective cohort of people living with HIV who use drugs in Vancouver, Canada-a setting with no-cost access to ART and low or no-cost access to OAT among low-income residents. Restricting the sample to those who reported daily or greater opioid use, we used generalized linear mixed-effects models to estimate the relationships between our primary outcome of transitions onto OAT (methadone or buprenorphine/naloxone) and transitions (1) onto ART and (2) into ART adherence. Subsequent analyses assessed the temporal sequencing of transitions. Between 2005 and 2017, among 433 participants, 48.3% reported transitioning onto OAT at least once. In concurrent analyses, transitions onto ART were positively and significantly associated with transitions onto OAT. Temporal sequencing revealed that transitions into OAT were also positively and significantly associated with subsequent transitions onto ART. OAT's potential to facilitate the uptake of ART points to the continued need to scale-up low-threshold, client-centered substance use services integrated alongside HIV care.

Characteristics of psychosocial interventions to improve ART adherence in people living with HIV: A systematic review

The HIV/AIDS pandemic continues to be a significant global public health crisis. The main HIV/AIDS treatment is the antiretroviral therapy (ART), which is highly effective but depends on the patient's adherence to be successful. However, the adherence to antiretroviral therapy remains unsatisfactory across different populations, which raises considerable difficulties at both individual and collective levels. Suboptimal adherence to ART can be overcome through multidisciplinary management that includes evidence-based psychosocial interventions. Existing reviews on these interventions have focused mainly on studies with experimental designs, overlooking valuable interventions whose evidence comes from different study designs. Here, we aimed to carry out a comprehensive review of the current research on psychosocial interventions for ART adherence and their characteristics including studies with different designs. We conducted a systematic review following PRISMA guidelines. We searched five databases (Pubmed, EBSCO, LILACS, WoS and SCIELO) for articles reporting a psychosocial intervention to improve treatment adherence for people living with HIV (adults). The quality of each study was analyzed with standardized tools, and data were summarized using a narrative synthesis method. Twenty-three articles were identified for inclusion, and they demonstrated good to fair quality. Individual counseling was the most frequent intervention, followed by SMS reminders, education, and group support. Most interventions combined different strategies and self-efficacy was the most common underlying theoretical framework. This review provides insight into the main characteristics of current psychosocial interventions designed to improve ART treatment adherence. PROSPERO number: CRD42021252449.

Recreational Drug Use in People Living with HIV in Spain: Factors Associated with Drug Use and the Impact on Clinical Outcomes

We analysed the impact of recreational drug use (RDU) on different outcomes in people living with HIV (PLHIV). A multicentre retrospective cohort study was performed with two cohorts of PLHIV included: people using recreational drugs (PURD) vs. people not using recreational drugs (PNURD). Overall, 275 PLHIV were included. RDU was associated with men having sex with men (OR 4.14, 95% CI [1.14, 5.19]), previous sexually transmitted infections (OR 4.00, 95% CI [1.97, 8.13]), and current smoking (OR 2.74, 95% CI [1.44, 5.19]). While the CD₄/CD₈ ratio increased amongst PNURD during the follow-up year, it decreased amongst PURD (p = 0.050). PURD presented lower scores of self-reported and multi-interval antiretroviral adherence (p = 0.017, and p = 0.006, respectively), emotional well-being (p < 0.0001), and regular follow-up (p = 0.059), but paid more visits to the emergency unit (p = 0.046). RDU worsens clinical, immunological, and mental health outcomes amongst PLHIV.

Daily and near-daily cannabis use is associated with HIV viral load suppression in people living with HIV who use cocaine

Disparities remain in HIV viral load (VL) suppression between people living with HIV (PLWH) who use cocaine and those who do not. It is not known how cannabis use affects VL suppression in PLWH who use cocaine. We evaluated the relationship between cannabis use and VL suppression among PLWH who use cocaine. We conducted a secondary data analysis of 119 baseline interviews from a randomized controlled trial in the Bronx, NY (6/2012 to 1/2017). Participants were adult PLWH prescribed antiretrovirals for ≥16 weeks, who endorsed imperfect antiretroviral adherence and used cocaine in the past 30-days. In bivariate and multivariable regression analyses, we examined how cannabis use, is associated with VL suppression among PLWH who use cocaine. Participants were a mean age of 50 years; most were male (64%) and non-Hispanic black (55%). Participants with VL suppression used cocaine less frequently than those with no VL suppression (p < 0.01); cannabis use was not significantly different. In regression analysis, compared with no use, daily/near-daily cannabis use was associated with VL suppression (aOR = 4.2, 95% CI: 1.1-16.6, p < 0.05). Less-frequent cannabis use was not associated with VL suppression. Further investigation is needed to understand how cannabis use impacts HIV outcomes among PLWH who use cocaine.

Illness perceptions, social support and antiretroviral medication adherence in people living with HIV in the greater Accra region, Ghana

AIM

To assess how illness perceptions and social support influence antiretroviral medication adherence in a HIV patient population in Ghana.

DESIGN

This study used a correlational research design with cross-sectional data.

METHOD

A total of 235 people living with HIV at two general hospitals in the Greater Accra Region of Ghana provided data on illness perceptions, social support and medication adherence. Hierarchical multiple regression test was used to analyse the data.

RESULTS

Illness perceptions' facets of timeline, personal control and treatment control were negatively associated with medication adherence, whereas emotional response was positively associated with adherence. Further, significant other support was negatively associated with adherence. Family and friend support were not associated with adherence. The findings offer preliminary evidence that illness perceptions may have utility for medication adherence in a HIV patient population in Ghana.

Health-related quality of life and its predictors among adults living with HIV/AIDS and receiving antiretroviral therapy in Pakistan

BACKGROUND

Health-related quality of life (HRQoL) is considered to be the fourth 90 of UNAIDS 90-90-90 target to monitor the effects of combination antiretroviral therapy (ART). ART has significantly increased the life expectancy of people living with HIV/AIDS (PLWHA). However, the impact of chronic infection on HRQoL remains unclear, while factors influencing the HRQoL may vary from one country to another. The current study aimed to assess HRQoL and its associated factors among PLWHA receiving ART in Pakistan.

METHODS

A cross-sectional descriptive study was conducted among PLWHA attending an ART centre of a tertiary care hospital in Islamabad, Pakistan. HRQoL was assessed using a validated Urdu version of EuroQol 5 dimensions 3 level (EQ-5D-3L) and its Visual Analogue Scale (EQ-VAS).

RESULTS

Of the 602 patients included in the analyses, 59.5% (n = 358) reported no impairment in self-care, while 63.1% (n = 380) were extremely anxious/depressed. The overall mean EQ-5D utility score and visual analogue scale (EQ-VAS) score were 0.388 (SD: 0.41) and 66.20 (SD: 17.22), respectively. Multivariate linear regression analysis revealed that the factors significantly associated with HRQoL were: female gender; age  > 50 years; having primary and secondary education;  > 1 year since HIV diagnosis; HIV serostatus AIDS-converted; higher CD 4 T lymphocytes count; detectable viral load; and increased time to ART.

CONCLUSIONS

The current findings have shown that PLWHA in Pakistan adherent to ART had a good overall HRQoL, though with significantly higher depression. Some of the factors identified are amenable to institution-based interventions while mitigating depression to enhance the HRQoL of PLWHA in Pakistan. The HRQoL determined in this study could be useful for future economic evaluation studies for ART and in designing future interventions.

HIV treatment outcomes among people who acquired HIV via injecting drug use in the Asia-Pacific region: a longitudinal cohort study

INTRODUCTION

Data on HIV treatment outcomes in people who inject drugs (PWID) in the Asia‐Pacific are sparse despite the high burden of drug use. We assessed immunological and virological responses, AIDS‐defining events and mortality among PWID receiving antiretroviral therapy (ART).

METHODS

We investigated HIV treatment outcomes among people who acquired HIV via injecting drug use in the TREAT Asia HIV Observational Database (TAHOD) between January 2003 and March 2019. Trends in CD4 count and viral suppression (VS, HIV viral load <1000 copies/mL) were assessed. Factors associated with mean CD4 changes were analysed using repeated measures linear regression, and combined AIDS event and mortality were analysed using survival analysis.

RESULTS

Of 622 PWID from 12 countries in the Asia‐Pacific, 93% were male and the median age at ART initiation was 31 years (IQR, 28 to 34). The median pre‐ART CD4 count was 71 cells/µL. CD4 counts increased over time, with a mean difference of 401 (95% CI, 372 to 457) cells/µL at year‐10 (n = 78). Higher follow‐up HIV viral load and pre‐ART CD4 counts were associated with smaller increases in CD4 counts. Among 361 PWID with ≥1 viral load after six months on ART, proportions with VS were 82%, 88% and 93% at 2‐, 5‐ and 10‐years following ART initiation. There were 52 new AIDS‐defining events and 50 deaths during 3347 person‐years of follow‐up (PYS) (incidence 3.05/100 PYS, 95% CI, 2.51 to 3.70). Previous AIDS or TB diagnosis, lower current CD4 count and adherence <95% were associated with combined new AIDS‐defining event and death.

CONCLUSIONS

Despite improved outcomes over time, our findings highlight the need for rapid ART initiation and adherence support among PWID within Asian settings.

Women's Decision-Making about PrEP for HIV Prevention in Drug Treatment Contexts

Despite pre-exposure prophylaxis’s (PrEP) efficacy for HIV prevention, uptake has been low among women with substance use disorders (SUDs) and attributed to women’s lack of awareness. In semistructured interviews with 20 women with SUD and 15 key stakeholders at drug treatment centers, we assessed PrEP awareness and health-related decision-making. Women often misestimated their own HIV risk and were not aware of PrEP as a personally relevant option. Although women possessed key decision-making skills, behavior was ultimately shaped by their level of motivation to engage in HIV prevention. Motivation was challenged by competing priorities, minimization of perceived risk, and anticipated stigma. Providers were familiar but lacked experience with PrEP and were concerned about women’s abilities to action plan in early recovery. HIV prevention for women with SUD should focus on immediately intervenable targets such as making PrEP meaningful to women and pursuing long-term systemic changes in policy and culture. Efforts can be facilitated by partnering with drug treatment centers to reach women and implement PrEP interventions.

Joint Modeling in Detecting Predictors of CD4 Cell Count and Status of Tuberculosis Among People Living with HIV/AIDS Under HAART at Felege Hiwot Teaching and Specialized Hospital, North-West Ethiopia

Background

Globally, for individuals infected with HIV, the presence of other infections including TB tends to increase the rate of HIV replication. Of the 8.8 million TB cases worldwide, an estimated 1.1 million (13%) were found to be co-infected with HIV. This research was conducted with the objective to identify potential predictors for the status of TB and CD4 cell count under PLWHIV at Felege Hiwot Specialized Hospital, North-west Ethiopia.

Methods

A retrospective repeated measurement was taken from a sample of 226 HIV patients. Separate and joint models were conducted for data analysis of CD4 cell count and TB status of people living with HIV.

Results

The descriptive statistics indicated that among the HIV patients receiving HAART, 26.6% had additional TB. AIDS clinical stage, weight, and hemoglobin level had a significant positive association with CD4 cell count, but a negative association with TB status. Weight and CD4 cell count have a negative relationship with the event of HIV/TB co-infection. Hence, the expected number of CD4 cell count of HIV patients who were co-infected with TB was decreased by 2.34 as compared to people living with HIV without TB. As visiting times of patients to hospitals for treatment increased by one unit, the odds of being co-infected with TB was decreased by 0.05, and the expected number of CD4 cell count was increased by 0.2. As patients’ age increased by one year, the expected number of CD4 cell count was decreased by 0.025 cells per/mm³.

Conclusion

Having lower CD4 cell count, lower weight, late WHO clinical stage, being non-adherent, having opportunistic infection, having lower hemoglobin, being ambulatory and bedridden were associated with a higher risk of co-infection of HIV/TB and were indicators of progression of the disease.

Adherence to antiretroviral therapy among HIV positive men who inject drugs in Pakistan

BACKGROUND

People who inject drugs (PWID) living with HIV have poorer adherence to HIV antiretroviral therapy (ART) and elevated mortality compared to other populations. Little is known about factors associated with adherence among PWID in low-and middle-income countries, including in countries where opioid agonist therapy (OAT) is unavailable. We aimed to estimate ART adherence among men who inject drugs (MWID) living with HIV in Pakistan and identify factors independently associated with adherence.

METHODS

Nai Zindagi Trust (NZT) provides a range of HIV prevention, testing and treatment services to PWID in Pakistan. This study utilized data from HIV positive MWID who received ART refill/s from public sector ART Centres via NZT's Social Mobilizer Adherence Support Unit between September 2016 and December 2018. Multivariable logistic regression modelled factors independently associated with ART adherence.

RESULTS

Among 5,482 HIV positive MWID registered with NZT who had attended the AAU and were supplied with ART refills between September 2016 and December 2018., 55% were adherent to ART. Independent predictors of adherence were being married (AOR 1.38, 95% CI:1.23-1.55, p<0.001) and >5 years of education compared to those with no education (AOR 1.19, 95% CI:1.05-1.35, p = 0.005). MWID living on the street at night had lower adjusted odds of ART adherence (AOR 0.75, 95% CI:0.62-0.91, p = 0.003).

CONCLUSIONS

Findings indicate that MWID living with HIV continue to face barriers to ART adherence in Pakistan. Despite considerable evidence supporting the impact of OAT in increasing ART adherence among PWID, OAT remains illegal and inaccessible in Pakistan. Evidence-based interventions, including OAT, are needed to increase adherence and improve clinical outcomes, health equity and survival among PWID living with HIV in Pakistan.

Factors Affecting Social Support Status of People Living with HIV/AIDS at Selected Hospitals of North Shewa Zone, Amhara Region, Ethiopia

Background

Globally, millions of people are affected by human immunodeficiency virus (HIV). Acquired immunodeficiency was linked with psychosocial problems, whereby stigma and discrimination are the most common. Therefore, this study was aimed at assessing the level of the social support problem in people living with human immunodeficiency virus (PLHIV) and factors associated with it at selected hospitals of North Shewa Zone, Amhara Region, Ethiopia.

Method

An institution-based cross-sectional study design was employed. A total of 422 PLHIV were involved in the study. A multidimensional perceived social support scale (MPSSS) for the measurement of social support problems was implemented. Systematic random sampling was used to recruit the study population after selecting study areas by lottery methods. Multivariate logistic regression analyses were performed via SPSS software. The statistical association was declared at a p value of less than 0.05 in the final model.

Result

The prevalence of poor social support among study participants was 12.6%. Poor adherence to their antiretrovirus drugs was highly associated with poor social support (AOR = 2.06, 95% CI: 1.36, 3.13). Moreover, psychological distress (AOR = 4.67, 95% CI: 2.02, 10.81) and perceived stigma (AOR = 1.78, 95% CI: 1.18, 2.70) were positively associated.

Conclusion

The burden of poor social support is increasingly affecting the lives of PLHIV. Poor social support in PLHIV is more magnified by poor adherence, having psychological distress, and perceived stigma.

Stopping, starting, and sustaining HIV antiretroviral therapy: a mixed-methods exploration among African American/Black and Latino long-term survivors of HIV in an urban context

Background

Although periods of HIV antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained. Yet, little is known about factors that contribute to such ART non-persistence among long-term HIV survivors. The present study applied a convergent parallel mixed-methods design to explore the phenomena of stopping/starting and sustaining ART, focusing on low-socioeconomic status African American or Black and Latino persons living with HIV (PLWH) who face the greatest challenges.

Methods

Participants (N = 512) had poor engagement in HIV care and detectable HIV viral load. All received structured assessments and N = 48 were randomly selected for in-depth interviews. Quantitative analysis using negative binomial regression uncovered associations among multi-level factors and the number of times ART was stopped/started and the longest duration of sustained ART. Qualitative data were analyzed using a directed content analysis approach and results were integrated.

Results

Participants were diagnosed 18.2 years ago on average (SD = 8.6), started ART a median five times (Q1 = 3, Q3 = 10), and the median longest duration of sustained ART was 18 months (Q1 = 6, Q3 = 36). Factors associated with higher rates of stops/starts were male sex, transgender identity, cannabis use at moderate-to-high-risk levels, and ART- and care-related stigma. Factors associated with lower rates of stops/starts were older age, more years since diagnosis, motivation for care, and lifetime injection drug use (IDU). Factors associated with longer durations of sustained ART were Latino/Hispanic ethnicity, motivation for ART and care, and recent IDU. Factors associated with a shorter duration were African American/Black race, alcohol use at moderate-to-high-risk levels, and social support. Qualitative results uncovered a convergence of intersecting risk factors for stopping/starting ART and challenges inherent in managing HIV over decades in the context of poverty. These included unstable housing, which contributed to social isolation, mental health distress, and substance use concerns, the latter prompting selling (“diverting”) ART. Primarily complementary quantitative and qualitative findings described mechanisms by which risk/protective factors operated and ways PLWH successfully restart and/or sustain ART.

Conclusions

The field focuses substantially on ART adherence, but greater attention to reducing the frequency of ART non-persistence is needed, along with creating social/structural conditions favorable for sustained ART.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10464-x.

A qualitative investigation of HIV treatment dispensing models and impacts on adherence among people living with HIV who use drugs

Antiretroviral therapy (ART) dispensing is strongly associated with treatment adherence. Among illicit drug-using populations, whom experience greater structural barriers to adherence, directly administered antiretroviral therapy (DAAT) is often regarded as a stronger predictor of optimal adherence over self-administered medications. In Vancouver, Canada, people living with HIV (PLHIV) who use drugs and live in low-income housing are a critical population for treatment support. This group is typically able to access two key DAAT models, daily delivery and daily pickup, in addition to ART self-administration. This ethno-epidemiological qualitative study explores how key dispensing models impact ART adherence among PLHIV who use drugs living in low-income housing, and how this is framed by structural vulnerability. Semi-structured interviews lasting 30-45 minutes were conducted between February and May 2018 with 31 PLHIV who use drugs recruited from an ongoing prospective cohort of PLHIV who use drugs. Interviews were audio-recorded, transcribed verbatim, and analyzed using QSR International's NVivo 12 software. Interviews focused on housing, drug use, and HIV management. Models that constrained agency were found to have negative impacts on adherence and quality of life. Treatment interruptions were framed by structural vulnerabilities (e.g., housing vulnerability) that impacted ability to maintain adherence under certain dispensing models, and led participants to consider other models. Participants using DAAT models which accounted for their structural vulnerabilities (e.g., mobility issues, housing instability), credited these models for their treatment adherence, but also acknowledged factors that constrained agency, and the negative impacts this could have on both adherence, and quality of life. Being able to integrate ART into an established routine is key to supporting ART adherence. ART models that account for the structural vulnerability of PLHIV who use drugs and live in low-income housing are necessary and housing-based supports could be critical, but the impacts of such models on agency must be considered to ensure optimal adherence.

HIV and syphilis infections and associated factors among patients in treatment at a Specialist Alcohol, Tobacco, and Drugs Center in São Paulo's "Cracolândia"

INTRODUCTION

This study describes the epidemiological scenario of human immunodeficiency virus (HIV) and syphilis at the biggest specialist drug addiction center in Brazil. The great challenge is to find strategies to reduce the impact of inequality and discrimination and develop policies to protect individuals living with - or at risk of - infections.

METHODS

During the period from January 1 to May 31, 2016, a cross-sectional study was conducted on which all patients (N = 806) seeking inpatient treatment were enrolled. A structured diagnostic interview and rapid tests were conducted initially, and diagnoses were confirmed by tests conducted at a venereal disease research laboratory (VDRL).

RESULTS

HIV and syphilis rates were 5.86% and 21.9%, respectively. Women were nearly 2.5 times more likely to have syphilis. HIV infection was associated with unprotected sex (odds ratio [OR]: 3.27, p = 0.003, 95% confidence interval [95%CI]: 1.51-7.11), and suicidal ideation (OR: 6.63, p = 0.001, 95%CI: 3.37-14.0). Although only 1.86% reported injecting drugs at any point during their lifetimes, this variable was associated with both HIV and syphilis. Elevated rates of HIV and syphilis were observed in the context of this severe social vulnerability scenario.

CONCLUSION

The risk factors identified as associated with HIV and syphilis should be taken into consideration for implementation of specific prevention strategies including early diagnosis and treatment of sexually transmitted infections (STI) to tackle the rapid spread of STIs in this population.

Changes in Internalized Stigma and HIV Health Outcomes in Individuals New to HIV Care: The Mediating Roles of Depression and Treatment Self-Efficacy

There is limited research on the effects of stigma on health outcomes among new-to-HIV care individuals. We examined the effect of changes in internalized stigma over time on health behaviors and outcomes such as viral suppression, antiretroviral therapy (ART) adherence, and visit adherence among new-to-HIV care individuals. We also analyzed the mediating effects of adherence self-efficacy and depressive symptoms in these associations. Participants were 186 persons living with HIV who initiated care at four HIV clinical sites in the United States and had diverse geographical and ethnic backgrounds. Baseline and 48-week follow-up assessments included measures of internalized stigma, ART adherence, depressive symptoms, and adherence self-efficacy. HIV visit adherence and viral load data were extracted from clinic records. Age, race, gender, insurance status, and site were controlled in all analyses. Logistic regression analyses were used to examine predictors of adherence and viral suppression. Change (decrease) in internalized stigma was calculated by subtracting follow-up internalized stigma scores from baseline scores and served as the main predictor. Mediation analyses included calculation of 95% confidence intervals for the indirect effects using bootstrapping. Decreases in internalized stigma over time were positively associated with viral suppression, ART adherence, and visit adherence. Adherence self-efficacy significantly mediated these effects of decrease in internalized stigma on all outcomes. Depressive symptoms only mediated the association between decrease in internalized stigma and ART adherence. Interventions that address internalized stigma and depressive symptoms, as well as adherence self-efficacy, may significantly improve adherence and viral suppression outcomes for individuals new to HIV care.

Abstinence-reinforcing contingency management improves HIV viral load suppression among HIV-infected people who use drugs: A randomized controlled trial

BACKGROUND

HIV-infected people who use drugs (PWUD) have poor HIV outcomes. Few studies tested interventions to improve HIV outcomes among PWUD. Abstinence-reinforcing contingency management (CM) reduces drug use and could also improve HIV outcomes.

METHODS

From 2012-2017, we conducted a randomized controlled trial testing whether a 16-week abstinence-reinforcing CM intervention improved HIV viral load (VL) among HIV-infected adults using opioids or cocaine. In the CM intervention, drug-free urines led to escalating value of vouchers ($2.50-$80/voucher, $1320 total maximum). In intention-to-treat mixed-effects linear and logistic regression analyses, we examined whether the CM intervention improved log₁₀ VL (primary outcome), abstinence and antiretroviral adherence (secondary outcomes).

RESULTS

Thirty-seven participants were randomized to the CM intervention and 36 to control. Median age was 49.2 years; most were male (61.6%) and non-Hispanic black (46.6%). In CM (vs. control) participants, mean reduction in log₁₀ VL was greater (-0.16 log₁₀ VL copies/mL per 4-week period; 95% CI: -0.29 to -0.03, p < 0.05). Over 16 weeks, CM participants had a mean reduction of 0.64 copies/mL in log₁₀ VL greater than control participants. The CM intervention was not significantly associated with abstinence or adherence.

CONCLUSIONS

This is the first study to demonstrate improvements in HIV VL via an abstinence-reinforcing CM intervention. Because the CM intervention did not significantly affect abstinence or adherence, the mechanism of its effect is unclear. To end the HIV epidemic, innovative strategies must address individuals with poor HIV outcomes. Abstinence-reinforcing CM may be one potential strategy to improve HIV outcomes among a select group of PWUD.

Perspectives of clients and providers on factors influencing opioid agonist treatment uptake among HIV-positive people who use drugs in Indonesia, Ukraine, and Vietnam: HPTN 074 study

BACKGROUND

Opioid agonist treatment (OAT) is an effective method of addiction treatment and HIV prevention. However, globally, people who inject drugs (PWID) have insufficient OAT uptake. To expand OAT access and uptake, policymakers, program developers and healthcare providers should be aware of barriers to and facilitators of OAT uptake among PWID.

METHODS

As a part of the HPTN 074 study, which assessed the feasibility of an intervention to facilitate HIV treatment and OAT in PWID living with HIV in Indonesia, Ukraine, and Vietnam, we conducted in-depth interviews with 37 HIV-positive PWID and 25 healthcare providers to explore barriers to and facilitators of OAT uptake. All interviews were audio-recorded, transcribed, translated into English, and coded in NVivo for analysis. We developed matrices to identify emergent themes and patterns.

RESULTS

Despite some reported country-specific factors, PWID and healthcare providers at all geographic locations reported similar barriers to OAT initiation, such as complicated procedures to initiate OAT, problematic clinic access, lack of information on OAT, misconceptions about methadone, financial burden, and stigma toward PWID. However, while PWID reported fear of drug interaction (OAT and antiretroviral therapy), providers perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and OAT. Motivation for a life change and social support were reported to be facilitators.

CONCLUSION

These results highlight a need for support for PWID to initiate and retain in drug treatment. To expand OAT in all three countries, it is necessary to facilitate access and ensure low-threshold, financially affordable OAT programs for PWID, accompanied with supporting interventions. PWID attitudes and beliefs about OAT indicate the need for informational campaigns to counter misinformation and stigma associated with addiction and OAT (especially methadone).

Longitudinal patterns of illicit drug use, antiretroviral therapy exposure and plasma HIV-1 RNA viral load among HIV-positive people who use illicit drugs

OBJECTIVES

HIV-positive people who use illicit drugs (PWUD) experience elevated rates of HIV-associated morbidity and mortality compared with members of other key affected populations. Although suboptimal levels of access and adherence to antiretroviral therapy (ART) are common among HIV-positive PWUD, there is a need for studies investigating the possible biological impacts of noninjection illicit drug use among people living with HIV in real-world settings.

METHODS

We accessed data from the ACCESS study, an ongoing prospective cohort of illicit drug users with systematic HIV viral load monitoring in a setting with universal care and ART dispensation records. We used multivariable generalized linear mixed models to estimate the longitudinal associations between noninjection use of crack cocaine, powder cocaine, opioids, methamphetamine, cannabis and alcohol on plasma HIV-1 RNA viral load, adjusted for ART exposure and relevant confounders.

RESULTS

Between 2005 and 2018, 843 individuals from the ACCESS cohort were included and contributed to 8698 interviews. At baseline, the mean age was 43 years, 566 (67%) reported male sex and 659 (78%) used crack cocaine in the previous 6 months. In multivariable models adjusted for ART exposure, only crack cocaine use in the last 6 months was found to be significantly associated with higher HIV viral load.

CONCLUSION

We observed significantly higher HIV viral load during periods of crack cocaine use independent of ART exposure. Our findings support further research to investigate the possible biological mechanisms of this effect.

Problem opioid use and HIV primary care engagement among hospitalized people who use drugs and/or alcohol

BACKGROUND

There is growing public health concern around the potential impact of the opioid crisis on efforts to eradicate HIV. This secondary analysis seeks to determine if those who report opioids as their primary problem drug compared to those who report other drugs and/or alcohol differ in engagement in HIV primary care among a sample of hospitalized people with HIV (PWH) who use drugs and/or alcohol, a traditionally marginalized and difficult to engage population key to ending the HIV epidemic.

SETTING AND PARTICIPANTS

A total of 801 participants (67% male; 75% Black, non-Hispanic; mean age 44.2) with uncontrolled HIV and reported drug and/or alcohol use were recruited from 11 hospitals around the U.S. in cities with high HIV prevalence from 2012 to 2014 for a multisite clinical trial to improve HIV viral suppression.

METHODS

A generalized linear model compared those who reported opioids as their primary problem drug to those who reported other problem drugs and/or alcohol on their previous engagement in HIV primary care, controlling for age, sex, race, education, income, any previous drug and/or alcohol treatment, length of time since diagnosis, and study site.

RESULTS

A total of 95 (11.9%) participants reported opioids as their primary problem drug. In adjusted models, those who reported opioids were significantly less likely to have ever engaged in HIV primary care than those who reported no problem drug use (adjusted risk ratio, ARR = 0.84, 95% Confidence Interval, CI 0.73, 0.98), stimulants (ARR = 0.84, 95% CI 0.74, 0.95), and polydrug use but no alcohol (ARR = 0.79, 95% CI 0.68, 0.93). While not statistically significant, the trend in the estimates of the remaining drug and/or alcohol categories (alcohol, cannabis, polydrug use with alcohol, and [but excluding the estimate for] other), point to a similar phenomena-those who identify opioids as their primary problem drug are engaging in HIV primary care less.

CONCLUSIONS

These findings suggest that for hospitalized PWH who use drugs and/or alcohol, tailored and expanded efforts are especially needed to link those who report problem opioid use to HIV primary care. Trial registration This study was funded by National Institutes of Health (NIH) grant: U10-DA01372011 (Project HOPE-Hospital Visit as Opportunity for Prevention and Engagement for HIV-Infected Drug Users; Metsch); which is also a registered clinical trial under the Clinical Trials Network (CTN-0049). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Personal Approach to Treatment Choices for HIV (PATCH): Randomized Controlled Trial of a Brief Motivational Enhancement Intervention to Improve Medication Adherence in Persons with HIV

This pilot randomized controlled trial evaluated the feasibility and efficacy of a brief motivational enhancement intervention to improve adherence to antiretroviral therapy in persons with HIV called Personal Approach to Treatment Choices for HIV (PATCH). We compared PATCH to an active control condition on self-reported adherence, clinical outcomes, and psychosocial outcomes. Participants were 34 individuals (61.8% male, M_age = 47.1) receiving HIV-related services who were suboptimally engaged in care. Participants completed baseline measures, participated in either PATCH or a stress reduction skills control intervention, and completed post-treatment and 3-month follow-up assessments. Results revealed no differences between conditions on adherence or clinical outcomes. At post-treatment, PATCH participants reported greater improvements in alcohol use, psychiatric symptoms, subjective mental functioning, and emotion-focused coping; improvements in subjective mental functioning were maintained at 3-months. Results suggest that motivational enhancement interventions can improve psychosocial outcomes for people with HIV. That some improvements were not maintained at follow-up suggests that effects wane over time and longer treatment may be indicated for lasting effects.

Drug use and HIV medication adherence in people living with HIV

BACKGROUND

Opioid and cocaine use epidemics continue to be substantial in the United States and intersect with the HIV epidemic. Antiretroviral medication (ARV) adherence is critical for optimum HIV outcomes. While previous research explored harm reduction strategies to prevent HIV spread for people who use drugs (PWUD), little is known about strategies used by PWUD living with HIV to maintain ARV adherence. Methods: We explored whether PWUD modify their drug use explicitly to maintain ARV adherence, and identified factors associated with this process. We conducted 23 semi-structured interviews. Data were analyzed using a modified framework analysis approach. Results: Participants had a mean age of 54 years and were predominantly male (70%) and non-Hispanic black (65%). Most described periods of being able to adhere to ARVs while still using drugs, difficulty adhering to ARVs while using drugs, and abstinence/near abstinence from drug use. In exploring factors that influenced changes in drug use and ARV adherence behaviors, we noted consistent acknowledgment of the roles of family, partners, or providers. Conclusions: PWUD living with HIV often modify their drug use to improve ARV adherence. Providers caring for this population might consider family or group education models to encourage harm reduction to improve outcomes.

Stimulant Use and Study Protocol Completion: Assessing the Ability of Men Who Have Sex with Men to Collect Dried Blood Spots for Laboratory Measurement of HIV Viral Load

Stimulant use is associated with higher HIV viral load (VL) and sexual HIV transmission risk among men who have sex with men (MSM) living with HIV. There is little research on willingness of drug users living with HIV to fully participate in studies, especially those involving self-collection of biomarker data. This study presents findings from an at-home dried blood spot collection study measuring laboratory-quantified VL among U.S. HIV-positive MSM who reported high-risk sexual behavior and/or suboptimal antiretroviral therapy (ART) adherence to assess the association between drug-use behavior and (1) ability to complete a study protocol and (2) VL outcomes. Among recruited participants (n = 766), 35% reported stimulant drug use (amphetamines, cocaine, crack, crystal meth, ecstasy, or a combination of stimulant drugs), 39% reported using other drugs (heroin, marijuana, prescription opioids, and others), and 27% reported no drug use in the past 3 months. In all, 61% of enrolled participants completed the study protocol. Stimulant drug users were less likely (ARR 0.84; 95% CI 0.72-0.98) to complete the protocol than other drug users. Furthermore, other drug users were significantly less likely than non-drug users (ARR 0.52; 95% CI 0.28-0.97) to have an HIV VL result ≥ 1500 copies/mL. This study provides important estimates regarding the likelihood of participation in biomedical research activities among HIV-positive MSM with varying drug-use behaviors, showing that it is feasible to conduct such biomedical studies with drug-using MSM who report high-risk sexual behavior and struggle with their ART adherence.

Cross-sectional evaluation of perceived health care provider engagement, self-efficacy, and ART adherence in people living with HIV/AIDS

Despite advancements in the treatment and prevention of HIV/AIDS, adherence to antiretroviral therapy (ART) remains suboptimal. Research indicates that health care provider (HCP) engagement is related to adherence, yet little is known about the specific pathways that underlie this relation. This cross-sectional study examined the relation between perceived HCP engagement and ART adherence in people living with HIV/AIDS (PLWHA), as well as the role of adherence self-efficacy in this relation. Participants (N = 207) completed self-report measures assessing monthly ART adherence, perceived ability to take ART as prescribed, and perceptions of HCP engagement. Results of a path analysis revealed a direct positive relation between perceived HCP engagement and ART adherence, and a significant indirect relation of perceived HCP engagement to ART adherence through adherence self-efficacy. Higher perceived HCP engagement was related to greater adherence self-efficacy, which, in turn was related to higher ART adherence. Findings are consistent with research demonstrating that HCP support leads to increased motivation to engage in treatment and extends past work on the importance of positive patient-provider relationships. Notably, results suggest that increasing patient perceptions of HCP engagement may be one way to boost adherence self-efficacy and improve ART adherence in PLWHA.

DSM-5 substance use disorder symptom clusters and HIV antiretroviral therapy (ART) adherence

This study examines self-reported 30-day antiretroviral therapy (ART) adherence among 101 people living with HIV and substance use disorders (SUD) in New York City in terms of Diagnostic and Statistical Manual - 5th Edition (DSM-5) SUD symptom clusters: impaired control, social impairment, risky use and pharmacological criteria. Overall, 60.4% met DSM-5 criteria for stimulant, 55.5% for alcohol, 34.7% for cannabis and 25.7% for opioid SUD. Of the 76 participants with a current ART prescription, 75.3% reported at least 90% 30-day adherence. Participants with vs. without alcohol SUD were significantly less likely to report ART adherence (64.3% vs. 88.2%, p = .017). Endorsement of social impairment significantly differed among adherent vs. non-adherent participants with alcohol SUDs (74.1% vs. 100%, p = .038) and with opioid SUDs (94.1% vs. 50.0%, p = .040). Understanding specific SUD symptom clusters may assist providers and patients in developing strategies to improve ART adherence.

HIV-Related Stigma, Motivation to Adhere to Antiretroviral Therapy, and Medication Adherence Among HIV-Positive Methadone-Maintained Patients

BACKGROUND

Opioid agonist therapies with methadone are associated with higher levels of adherence to antiretroviral therapy (ART); yet, no studies have explored factors associated with optimal ART levels in HIV-positive patients on methadone maintenance treatment, including explanatory pathways using mediation analysis.

SETTING

Participants included 121 HIV-positive, methadone-maintained patients who reported HIV-risk behaviors and were taking ART.

METHODS

Participants were assessed using an audio computer-assisted self-interview. Multivariable logistic regression was used to identify significant correlates and PROCESS macro to test the explanatory pathway (ie, mediational effect) for optimal ART adherence.

RESULTS

Among 121 participants, almost 40% reported suboptimal adherence to ART. Optimal ART adherence was significantly associated with being virally suppressed [adjusted odds ratio (aOR) = 6.470, P = 0.038], higher motivation to adhere to ART (aOR = 1.171, P = 0.011), and lower anticipated HIV-related stigma (aOR = 0.384, P = 0.015). Furthermore, results revealed an indirect effect of motivation on the relationship between HIV stigma and ART adherence (effect = -0.121, P = 0.043), thus supporting the mediation effect.

CONCLUSIONS

Our findings underscore the complexities surrounding ART adherence, even in patients on methadone maintenance treatment. These findings provide insights on how to more effectively intervene to optimize HIV treatment outcomes, including HIV treatment-as-prevention initiatives, in methadone-maintained patients.

Opioid Agonist Treatment and Improved Outcomes at Each Stage of the HIV Treatment Cascade in People Who Inject Drugs in Ukraine

BACKGROUND

The HIV treatment cascade is a crucial tool to guide HIV prevention and treatment strategies. The extent to which opioid agonist treatments (OATs) such as methadone and buprenorphine influence this cascade was examined in a nationwide study of people who inject drugs (PWID) in Ukraine.

SETTING

Cross-sectional stratified survey of PWID followed by HIV and hepatitis C virus testing in 5 Ukrainian cities.

METHODS

Opioid-dependent PWID (N = 1613) were sampled from January 2014 to March 2015. Analysis was confined to 520 participants with HIV, with 184 (35.4%) prescribed OAT. Weighted logistic regression models were used to assess independent factors associated with the 5 steps in the HIV treatment cascade.

RESULTS

Compared with PWID not on OAT (N = 336), participants who prescribed OAT (N = 184) were significantly more likely to be diagnosed (91% vs. 71%), linked (81% vs. 52%), and retained (69% vs. 35%) in HIV care, and prescribed (56% vs. 31%) and optimally (>95% of doses) adherent to antiretroviral therapy (41% vs. 22%). Receiving OAT contributed most as an independent factor with every step of the cascade. Other steps in the HIV treatment cascade were influenced by age, depression, and geographical variability.

CONCLUSIONS

OAT remains an essential and effective strategy to not only treat patients with opioid use disorder, but also a crucial strategy to engage PWID in care to meet UNAIDS 90-90-90 targets. Geographical differences suggest local structural impediments. With low OAT coverage prescribed for 2.9% of the estimated 347,000 PWID in Ukraine, OAT expansion requires strategic interventions that target the individual, clinical care settings, policies, and funding.

Enhancing patient navigation with contingent financial incentives for substance use abatement in persons with HIV and substance use

Substance use can interfere with HIV treatment. A previous multisite clinical trial (Metsch et al., 2016) tested 2 behavioral interventions designed to improve treatment engagement in people with comorbid HIV and drug or heavy alcohol use. Clinical trial participants were randomized to treatment as usual (N = 264), patient navigation (PN; N = 266), or PN with contingency management (PN + CM; N = 271) for 6 months. PN + CM patients could earn financial incentives both for entering substance use disorder (SUD) treatment and for submitting urine and breath samples negative for opioids, stimulants, and alcohol. This secondary analysis compared frequencies of treatment entry and sample submission in the PN versus PN + CM groups and examined associations with viral suppression (defined as ≤200 copies/mL). Incentives were associated with a higher percentage of patients entering SUD treatment (PN = 25.5%; PN + CM = 47.6%; p < .001), a higher percentage submitting samples for drug testing (PN median = 2, interquartile range [IQR] = 0.5; PN + CM median = 8, IQR = 5.1; p < .0001) and a higher percentage submitting samples negative for targeted drugs and alcohol (PN median = 1, IQR = 0.3; PN + CM median = 6, IQR = 2.9; p < .0001). Within the PN + CM group, up to 58% of those with high rates of engagement in activities were virally suppressed at 6 months versus 24-29% in subgroups with lowest engagement. In conclusion, CM was feasibly incorporated into PN for persons with HIV and SUD and was associated with higher rates of engagement in targeted substance use abatement activities. CM has the potential to improve health outcomes in this population. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

How does hard-to-reach status affect antiretroviral therapy adherence in the HIV-infected population? Results from a meta-analysis of observational studies

Background

Socially disadvantaged groups, such as drug users, sex workers and homeless individuals, are labelled as “hard-to-reach” (HTR) in public health and medical research. HIV disproportionately impacts these populations, but data on how the HTR status could affect antiretroviral therapy (ART) adherence among HIV-positive people are limited and have not been previously synthesized in a systematic manner. We performed a meta-analysis to explore the association between HTR status and optimal antiretroviral therapy adherence in the HIV-infected population to provide evidence and recommendations regarding ART adherence improvement and HIV infection control and prevention among HTR people.

Methods

The PubMed, EMBASE, and Cochrance Library databases and the bibliographies of relevant studies were systematically searched up to December 2018. Full-text studies published in English were included, and no geographic or race restrictions were applied. Studies that quantitatively assessed the association between HTR status and optimal ART adherence among HIV-infected populations with a status of homelessness, sex work, or drug use were eligible for inclusion. We estimated the pooled odds ratios (ORs) of HTR characteristics related to ART adherence from each eligible study using a random effects model. The sensitivity, heterogeneity and publication bias were assessed.

Results

Our search identified 593 articles, of which 29 studies were eligible and included in this meta-analysis. The studies were carried out between 1993 and 2017 and reported between 1999 and 2018. The results showed that HTR status resulted in a 45% reduction in the odds of achieving optimal ART adherence compared to odds in the general population (OR = 0.55, 95% confidential intervals (CIs) 0.49–0.62), and this significant inverse association was consistently found regardless of study design, exposure measurement, adherence cut-off points, etc. Subgroup analyses revealed that the HTRs tend to be suboptimal adhering during a longer observational period.

Conclusions

HIV treatment adherence is extremely negatively affected by HTR status. It is crucial to develop appropriate interventions to improve ART adherence and health outcomes among HTR people who are HIV-infected.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7135-0) contains supplementary material, which is available to authorized users.

Improving HIV service delivery for people who inject drugs in Kazakhstan: study protocol for the Bridge stepped-wedge trial

BACKGROUND

People who inject drugs (PWID) in Kazakhstan face many barriers to HIV testing as well as to accessing HIV care, to retention in HIV care, and to initiating and adhering to anti-retroviral treatment (ART). Needle and syringe programs (NSPs) are an opportune setting for integrated interventions to link PWID to HIV care.

METHODS

This Hybrid Type II study employs a stepped-wedge design to evaluate both effectiveness and implementation outcomes of Bridge, an intervention to identify, test, and link HIV-positive PWID to HIV care. The study is conducted at 24 NSPs in three different regions of Kazakhstan, to assess outcomes on the individual, organizational, and policy levels.

DISCUSSION

This trial responds to an identified need for new models of HIV service delivery for PWID through harm reduction settings.

TRIAL REGISTRATION

NCT02796027 on June 10, 2016.

Adherence to antiretroviral therapy for HIV/AIDS in Latin America and the Caribbean: Systematic review and meta-analysis

INTRODUCTION

Optimal adherence to antiretroviral therapy is closely related with suppression of the HIV viral load in plasma, slowing disease progression and decreasing HIV transmission rates. Despite its importance, the estimated proportion of people living with HIV in Latin America and the Caribbean with optimal adherence has not yet been reported in a meta-analysis. Moreover, little is known of the factors leading to poor adherence which may be setting-specific. We present a pooled estimate of adherence to antiretroviral therapy (ART) of people living with HIV in Latin America and Caribbean, report the methods used to measure adherence and describe the factors associated with poor adherence among the selected studies.

METHODS

We electronically searched published studies up to July 2016 on the PubMed, Web of Science and Virtual Health Library (Latin America and the Caribbean Regional Portal); considering the following databases: MEDLINE, LILACS, PAHO and IBECS. Two independent reviewers selected and extracted data on ART adherence and study characteristics. Pooled estimate of adherence was derived using a random-effects model. Risk of bias in individual studies was assessed independently by two investigators using the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS).

RESULTS AND DISCUSSION

The meta-analysis included 53 studies published between 2005 and 2016, which analysed 22,603 people living with HIV in 25 Latin America and Caribbean countries. Overall adherence in Latin America and Caribbean was 70% (95% CI: 63-76; I²  = 98%), similar to levels identified by studies conducted in high-income regions. Self-report was the most frequently used method to measure adherence. Subgroup analysis showed that adherence was higher for the shortest recall time frame used, as well as in countries with lower income level, Gross National Income (GNI) per capita and Human Development Index (HDI). Studies reported diverse adherence barriers, such as alcohol and substance misuse, depression, unemployment and pill burden.

CONCLUSIONS

Our study suggests that adherence to ART in Latin America and Caribbean may be below the sufficient levels required for a successful long-term viral load suppression.

Prevalence and Correlates of Reporting Difficulty Taking Antiretroviral Treatment Among HIV-Positive Illicit Drug Users in Vancouver, Canada: A Longitudinal Analysis

People living with HIV who use illicit drugs continue to experience high rates of suboptimal treatment outcomes from antiretroviral therapy (ART). Although previous studies have identified important behavioural, social and structural barriers to ART adherence, the effects of patient-level factors have not been fully evaluated. Thus, we sought to investigate the prevalence and correlates of reporting ART was difficult to take among a cohort of illicit drug users in Vancouver, Canada. We accessed data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), an ongoing prospective cohort of HIV-positive illicit drug users linked to comprehensive HIV clinical monitoring records. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods in which individuals reported they found ART difficult to take. Between December 2005 and May 2014, 746 ART-exposed illicit drug users were recruited and contributed at least one study interview. Finding ART hard to take was reported by 209 (28.0%) participants at baseline, and 460 (61.7%) participants throughout the study period. Patients ingesting a greater daily pill count (adjusted odds ratio [AOR] = 1.12 per pill, 95% confidence interval [CI] 1.08-1.17) and experiencing barriers to healthcare (AOR = 1.64, 95% CI 1.34-2.01) were more likely to report difficulty taking ART. Patients less likely to report satisfaction with their HIV physician (AOR = 0.76, 95% CI 0.58-1.00) and achieve a non-detectable HIV viral load (AOR = 0.62, 95% CI 0.51-0.74) were more likely to report finding ART hard to take. In this community-recruited cohort of ART-exposed illicit drug users, a substantial proportion reported they found HIV treatment hard to take, which was clearly linked to higher dissatisfaction with healthcare experiences and, most importantly, a lower likelihood of experiencing optimal virologic outcomes. Our findings reveal a number of opportunities to improve HIV treatment experiences and outcomes for people who use illicit drugs, including the use of treatment regimens with lower pill burdens, as well as reducing barriers to healthcare access.

Implementing screening, brief intervention and referral to treatment in a French cohort of people living with HIV: a pilot study

OBJECTIVES

Screening, brief intervention and referral to treatment (SBIRT) is an evidence-based practice used to identify, reduce and prevent problematic use and abuse of, and dependence on, tobacco, alcohol and psychoactive substances. To date, the pertinence of this practice among people living with HIV (PLHIV) is unknown. In this pilot study, we aimed to assess the acceptability of SBIRT in a cohort of HIV-infected out-patients who were asked about their consumption of alcohol, tobacco and psychoactive substances.

METHODS

A monocentric study was performed at the University Hospital of Montpellier. In a 6-month period, 20 trained physicians screened for the consumption of alcohol [using the Alcohol Use Disorders Identification Test (AUDIT)], tobacco (using the Short Fagerstrom Test) and psychoactive substances [using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) V3.0] via an auto-questionnaire and proposed a brief intervention to patients with misusage.

RESULTS

One thousand and eighteen PLHIV completed the questionnaire, and 861 [84.6%; 95% confidence interval (CI) 82.2-86.7%] PLHIV returned it to the physician. Among the latter, 650 patients wished to discuss the answers with their physician (75.5%; 95% CI 72.5-78.3%), and brief interventions were realized in 405 patients (62.3%).

CONCLUSIONS

SBIRT is a simple screening and harm reduction tool that is well accepted by PLHIV in out-patient clinics. This method could be implemented in routine HIV care to screen and manage patients systematically for harmful substance use.

Patient and provider perspectives on implementation barriers and facilitators of an integrated opioid treatment and HIV care intervention

Background

In Dar es Salaam Tanzania, the first opioid treatment program (OTP) in Sub-Saharan Africa, had very high rates of enrollment of people who use drugs (PWUD) but low rates of antiretroviral therapy (ART) initiation among HIV-positive patients. The integrated methadone and anti-retroviral therapy (IMAT) intervention was developed to integrate HIV services into the OTP clinic. The objective of this paper is to better understand the contextual factors that influence the effectiveness of IMAT implementation using the consolidated framework for implementation research (CFIR).

Methods

Semi-structured, in-depth interviews were conducted with 35 HIV-positive OTP patients and 8 OTP providers at the Muhimbili National Hospital OTP clinic 6-months after IMAT implementation. Providers were asked about their reactions to and opinions of the IMAT intervention including its implementation, their role in patient education, intervention procedures, and ART dispensing. Interviews with patients focused on their experiences with the IMAT intervention and adapting to the new protocol. Analysis of interview data was guided by the CFIR.

Results

The CFIR constructs found to be driving forces behind facilitating or impeding IMAT implementation were: intervention characteristics (e.g. complexity, adaptability and evidence related to IMAT), outer setting (e.g. patient needs and resources), and inner setting (e.g. compatibility of IMAT and available resources for IMAT). The most significant barrier to implementation identified in interviews was availability of resources, including workforce limitations and lack of space given patient load. OTP providers and patients felt the design of the IMAT intervention allowed for adaptability to meet the needs of providers and patients.

Conclusions

Understanding the contextual factors that influence implementation is critical to the success of interventions that seek to integrate HIV services into existing programs for key populations such as PWUD. Approximately 4 months after IMAT implementation, the OTP clinic adopted a ‘test-and-treat’ model for HIV-positive PWUD, which significantly impacted clinic workload as well as the care context. In this study we highlight the importance of intervention characteristics and resources, as key facilitators and barriers to implementation, that should be actively integrated into intervention protocols to increase implementation success. Similar interventions in other low-resource settings should address the ways intervention characteristics and contextual factors, such as adaptability, complexity and available resources impact implementation in specific care contexts.

Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions

BACKGROUND

People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). However, PrEP has been underutilized in this population, and PrEP adherence intervention needs are understudied.

METHODS

To inform PrEP intervention development, we reviewed evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID. Guided by a behavioral model of healthcare utilization and using the PICOS framework, we conducted a systematic review in four electronic databases to identify original research studies of ART adherence in HIV-infected PWID in the United States and Canada between Jan 1, 2006-Dec 31, 2016. We synthesized and interpreted findings related to developing recommendations for PrEP adherence interventions for PWID.

RESULTS

After excluding 618 duplicates and screening 1049 unique records, we retained 20 studies of PWID (mean n = 465) with adherence-related outcomes (via pharmacy records: n = 9; self-report: n = 8; biological markers: n = 5; electronic monitoring: n = 2). Predisposing factors (patient-level barriers to adherence) included younger age, female sex, and structural vulnerability (e.g., incarceration, homelessness). Enabling resources (i.e., facilitators) that could be leveraged or promoted by interventions included self-efficacy, substance use treatment, and high-quality patient-provider relationships. Competing needs that require specific intervention strategies or adaptations included markers of poor physical health, mental health comorbidities (e.g., depression), and engagement in transactional sex.

CONCLUSIONS

HIV treatment adherence research carries important lessons for efforts to optimize PrEP adherence among PWID. Despite limitations, this systematic review suggests that strategies are needed to engage highly vulnerable and marginalized sub-groups of this underserved population (e.g., younger PWID, women who inject drugs) in PrEP adherence-related research and programming.

Prevalence and Correlates of Unhealthy Alcohol and Drug Use Among Men Who Have Sex with Men Prescribed HIV Pre-exposure Prophylaxis in Real-World Clinical Settings

Pre-exposure prophylaxis (PrEP) is effective in preventing HIV acquisition among men who have sex with men (MSM). However, little is known about unhealthy substance use among MSM initiating PrEP in real-world settings. Unhealthy substance use is a risk factor for HIV acquisition and non-adherence to treatment, and may also impact PrEP use. MSM who were prescribed PrEP from 2015 to 2017 at clinics in Providence, Rhode Island and New Haven, Connecticut were recruited to participate in a prospective observational study. Structured clinical assessments were used to assess demographics, HIV risk behaviors, and unhealthy alcohol (alcohol use disorders identification test [AUDIT]-C scores ≥ 4) and drug use (use of any drugs in the past 3 months). Bivariate and multivariate analyses were performed to determine demographics and behaviors associated with unhealthy alcohol and drug use. Among 172 MSM initiating PrEP, 64% were white and 40% were 25-34 years old. Participants reported a median of 3 (IQR 2-7) sexual partners in the last 3 months; 20% reported an HIV positive partner. Unhealthy alcohol and any drug use were reported by 54 and 57%, respectively, and 76% reported at least one of the two. The majority of drug use reported was marijuana and poppers (41 and 26% of participants, respectively). Relative to those without unhealthy alcohol use, unhealthy alcohol use was independently associated with any drug use (adjusted odds ratio [AOR] = 2.57, 95% CI 1.32-5.01). Frequent drug use was associated with younger age (< 25 years, AOR 4.27, 95% CI 1.51-12.09). Unhealthy alcohol use is common among MSM taking PrEP. Drug use other than marijuana and poppers was uncommon among our cohort. Further efforts may be needed to understand the influence of unhealthy alcohol and other substance use on PrEP outcomes and to engage MSM who use drugs for PrEP.

Food elimination, food substitution, and nutrient supplementation among ARV-exposed HIV-positive persons in southern Ghana

BACKGROUND

Optimal nutrition is a determinant of health in all persons. In persons living with HIV (PLHIV), nutrition is particularly important. Various factors, including dietary practices, play a role in guaranteeing nutritional health.

OBJECTIVES

We investigated multiple non-prescription drugs use among HIV-positive persons receiving antiretroviral therapy (ART) from four treatment centers in southern Ghana. This paper, however, focuses on nutrient supplement use, food elimination, and food substitution practices by the PLHIV.

METHODS

Using quantitative and qualitative methods, we collected data from 540 HIV-positive persons at the health facility level. This paper focuses on only the quantitative data. Individual study participants were selected using a systematic random sampling procedure. Participants were interviewed after informed consent. We used univariate analysis to generate descriptive tabulations for key variables. Multivariable logistic regression modeling identified predictors of three practices (nutrient supplementation, food elimination, and food substitution). P value less than 0.05 or 95% confidence intervals facilitated determination of statistical significance. All analyses were performed using IBM SPSS Statistics for Windows, version 20.0.

RESULTS

The use of nutrient supplements was a popular practice; 72% of the PLHIV used various kinds. The primary motive for the practice was to boost appetite and to gain weight. A little over 20% of the participants reportedly eliminated certain foods and beverages, while 17% introduced new foods since their initial HIV diagnosis. All the three practices were largely driven by the quest for improved health status. We determined predictors of nutrient supplementation to be ART clinic location and having an ART adherence monitor. Having an ART adherence monitor was significantly associated with reduced odds of nutrient supplementation (AOR = 0.34; 95% CI 0.12-0.95). The only predictor for food elimination was education level (AOR = 0.29; 95% CI 0.30-0.92); predictors of food substitution were ART clinic location (AOR = 0.11; 95% CI 0.02-0.69) and anemia (defined as hemoglobin concentration less than 11.0 g/dl) (AOR = 0.21; 95% CI 0.12-0.85).

CONCLUSIONS

The practice of supplementation is popular among this group of PLHIV. Food elimination and substitution are practiced, albeit in moderation. The predictors identified may prove helpful in provider-client encounters as well as local HIV programming.

Individual, social, and structural factors affecting antiretroviral therapy adherence among HIV-positive people who inject drugs in Kazakhstan

BACKGROUND

HIV-infected people who inject drugs (PWID) are particularly vulnerable to suboptimal ART adherence. The fastest-growing HIV epidemics globally are driven by injection drug use, but only a small percentage of HIV-positive PWID have achieved viral suppression. Virally suppressed individuals have better HIV-related health outcomes and effectively no risk of transmitting HIV to others. Hence, ART adherence is important for both HIV treatment and HIV prevention. There is a paucity of data on barriers and facilitators of ART adherence among PWID in low and middle income countries, which is problematic given the growing HIV epidemics among PWID in these countries.

METHODS

Using the Theory of Triadic Influence, this paper examines individual, interpersonal, and structural barriers and facilitators of ART adherence among HIV-positive PWID in four cities in Kazakhstan. Eight focus groups were conducted (two in each city) with a total of 57 participants. Data were coded and analyzed by three researchers.

RESULTS

We found a number of barriers and facilitators to ART adherence among PWID at the individual, interpersonal, and structural levels. Individual barriers to ART adherence include misperceptions about ART, forgetfulness due to the effects of illicit drug use, and medication side effects. Interpersonal facilitators of ART adherence include social support and good relationships with healthcare providers. Structural barriers include poverty, legal challenges, disruptions in the ART supply, and stigma and discrimination.

CONCLUSION

The paper highlights important factors related to ART adherence for HIV-positive PWID and identifies potential strategies for intervention efforts, including couple-based interventions, electronic reminders, linkage to drug treatment services, and patient navigation. Effectively enhancing adherence to ART among PWID will likely require multi-level approaches and strategies. Further research should be conducted on potential methods and interventions for improving ART adherence among this vulnerable population.

Trends in AIDS Mortality, Retention in Opioid Agonist Therapy, and HIV RNA Suppression in HIV-Infected People Who Injected Drugs from 2000 to 2015

AIDS is a major cause of preventable mortality in HIV-infected people who inject drugs (HIV-PWID). An observational study was conducted to examine trends in AIDS mortality and related factors among HIV-infected individuals who died between 2000 and 2015 at an urban hospital. Overall HIV-mortality was 6.5% (413/6307) with no changes over time (p 0.76). AIDS mortality dropped in HIV-PWID (p 0.02) although it represented 26.4% at the end of study period. Age (per one-year increase) [odds ratio (OR) 0.95], third study period (2010-2015) (OR 0.54), HIV-PWID on opioid agonist therapy (OAT) (OR 0.39), and HIV RNA suppression (OR 0.15) were associated with AIDS mortality. OAT was reported in 58.3% (161/276) and RNA suppression in 30.9% (85/276) of HIV-PWID. OAT non-retention was due to drop-outs [85.2% (98/115)] and rejection [14.8% (17/115)] in HIV-PWID. Therefore, additional strategies are required to improve OAT retention and HIV RNA suppression to continue reducing AIDS mortality.

A meta-analysis of effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa

OBJECTIVE

We evaluated the effectiveness of interventions aimed at improving antiretroviral therapy (ART) adherence during pregnancy in sub-Saharan Africa.

METHODS

For this meta-analysis, the following databases were searched: MEDLINE Complete, Embase, Global Health, CINAHL Complete, and Google Scholar. Randomized and nonrandomized studies were considered for inclusion if they involved an intervention with the intent of improving medication adherence among pregnant women taking ART in sub-Saharan Africa. Databases were searched from inception to the end of August 2017. The primary outcome assessed was adherence to ART, defined as the proportion of women adherent to treatment in the control and intervention groups. Risk ratios and random effect meta-analysis were undertaken, and heterogeneity was examined with the I² statistic.

RESULTS

The systematic search of databases yielded a total of 402 articles, of which 19 studies were selected for meta-analysis with a total of 27,974 participants. Nine types of interventions were identified in the 19 studies to improve ART adherence. The test for the subgroup differences showed that there was a statistically significant difference among the 9 subgroups of interventions, χ² (8)=102.38; p=0.00001. Collectively, in the meta-analysis, the various intervention types made a significant impact on improving medication adherence. The overall effect estimate with 95% CI was as follows: 1.25 (95% CI=1.03, 1.52, p=0.03). The following risk ratio results for meta-analysis were obtained for the three interventions that showed significant impact on adherence; namely social support and structural support, 1.58 (95% CI=1.36, 1.84, p<0.00001); education, social support and structural support=2.60 (95% CI=1.95, 3.45, p<0.00001); and device reminder=1.13 (95% CI=1.05, 1.20, p=0.0004). The proportion of women who were adherent to ART as a result of the interventions was 59.3% compared with 22.5% in the control groups.

CONCLUSION

The use of device reminder, a combination of social support and structural support, and education, social support and structural support has the potential to improve ART adherence during pregnancy. Good quality prospective observational studies and randomized control trials are needed in sub-Saharan Africa to determine the most effective interventions.