Psychiatric morbidity, illicit drug use and adherence to zidovudine (AZT) among injection drug users with HIV disease

Plasma HIV-1 RNA viral load rebound among people who inject drugs receiving antiretroviral therapy (ART) in a Canadian setting: an ethno-epidemiological study

Background

People who inject drugs (PWID) living with HIV often experience sub-optimal antiretroviral therapy (ART) treatment outcomes, including HIV plasma viral load (PVL) rebound. While previous studies have identified risk factors for PVL rebound among PWID, no study has examined the perspectives of PWID who have experienced PVL rebound episodes. We conducted an ethno-epidemiological study to investigate the circumstances surrounding the emergence of rebound episodes among PWID in Vancouver, BC, Canada.

Methods

Comprehensive clinical records linked to a community-based prospective observational cohort of HIV-positive drug users were used to identify PWID who had recently experienced viral rebound. In-depth qualitative interviews with 16 male and 11 female participants explored participant perspectives regarding the emergence of viral rebound. A timeline depicting each participant’s HIV viral load and adherence to ART was used to elicit discussion of circumstances surrounding viral rebound.

Findings

Viral rebound episodes were shaped by interplay between various individual, social, and environmental factors that disrupted routines facilitating adherence. Structural-environmental influences resulting in non-adherence included housing transitions, changes in drug use patterns and intense drug scene involvement, and inadequate care for co-morbid health conditions. Social-environmental influences on ART adherence included poor interactions between care providers and patients producing non-adherence, and understandings of HIV treatment that fostered intentional treatment discontinuation.

Conclusions

This study describes key pathways which led to rebound episodes among PWID receiving ART and illustrates how environmental forces may increase vulnerability for non-adherence leading to treatment failure. Our findings have potential to help inform interventions and supports that address social-structural forces that foster non-adherence among PWID.

Social and structural factors associated with HIV disease progression among illicit drug users: a systematic review

OBJECTIVE

To systematically review factors associated with HIV disease progression among illicit drug users, focusing on exposures exogenous to individuals that likely shape access and adherence to HIV treatment.

DESIGN

A systematic review of peer-reviewed English-language studies among HIV-seropositive illicit drug users with at least one of these endpoint of interest: a diagnosis of AIDS; death; changes/differences in CD4 cell counts; or changes/differences in plasma HIV-1 RNA levels.

METHODS

Articles were included if they reported factors associated with an outcome of interest among a group of illicit drug users. Studies were identified, screened and selected using systematic methods.

RESULTS

Of 2668 studies matching the search criteria, 58 (2%) met the inclusion criteria, all but one from North America or western Europe. Overall, 41 (71%) studies contained significant individual-level clinical characteristics or behaviors (e.g. illicit drug use) associated with disease progression. Fifteen studies (26%) identified significant social, physical, economic or policy-level exposures, including incarceration, housing status or lack of legal income.

CONCLUSION

Although past studies demonstrate important environmental exposures that appear to shape access to care and subsequent disease progression, the limited literature to examine these factors demonstrates the need for future research to consider risk environment characteristics and the role they may play in shaping health outcomes from HIV infection among drug users through determining access and adherence to evidence-based care.

The relationship between injection and noninjection drug use and HIV disease progression

BACKGROUND

Injection drug use is associated with poor HIV outcomes even among persons receiving highly active antiretroviral therapy (HAART), but there are limited data on the relationship between noninjection drug use and HIV disease progression.

METHODS

We conducted an observational study of HIV-infected persons entering care between January 1, 1999, and December 31, 2004, with follow-up through December 31, 2005.

RESULTS

There were 1,712 persons in the study cohort: 262 with a history of injection drug use, 785 with a history of noninjection drug use, and 665 with no history of drug use; 56% were White, and 24% were females. Median follow-up was 2.1 years, 33% had HAART prior to first visit, 40% initiated first HAART during the study period, and 306 (17.9%) had an AIDS-defining event or died. Adjusting for gender, age, race, prior antiretroviral use, CD4 cell count, and HIV-1 RNA, patients with a history of injection drug use were more likely to advance to AIDS or death than nonusers (adjusted hazard ratio [HR] = 1.97, 95% confidence interval [CI] = 1.43-2.70, p < .01). There was no statistically significant difference of disease progression between noninjection drug users and nonusers (HR = 1.19, 95% CI = 0.92-1.56, p = .19). An analysis among the subgroup who initiated their first HAART during the study period (n = 687) showed a similar pattern (injection drug users: HR = 1.83, 95% CI = 1.09-3.06, p = .02; noninjection drug users: HR = 1.21, 95% CI = 0.81-1.80, p = .35). Seventy-four patients had active injection drug use during the study period, 768 active noninjection drug use, and 870 no substance use. Analyses based on active drug use during the study period did not substantially differ from those based on history of drug use.

CONCLUSIONS

This study shows no relationship between noninjection drug use and HIV disease progression. This study is limited by using history of drug use and combining different types of drugs. Further studies ascertaining specific type and extent of noninjection drug use prospectively, and with longer follow-up, are needed.

Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: a review of the literature

Adherence to antiretroviral medications is central to reducing morbidity and mortality among people living with HIV/AIDS. Relatively few studies published to date address HIV adherence among special populations. The purpose of this article is to review the existing literature on HIV antiretroviral adherence, with an emphasis on studies among the triply diagnosed population of people living with HIV/AIDS, mental illness, and chemical dependency. In order to reflect the most current information available, data from conference proceedings, federally funded studies in progress, and the academic literature are presented for consideration.

The impact of incarceration upon adherence to HIV treatment among HIV-positive injection drug users: a qualitative study

INTRODUCTION

HIV-positive injection drug users (IDU) often do not derive the full benefits of highly active antiretroviral therapy (HAART). Among IDU, recent incarceration has been associated with discontinuation of HAART for non-clinical reasons. We sought to qualitatively evaluate experiences with HAART among HIV-positive IDU who had been recently incarcerated within provincial prisons in British Columbia in order to identify factors influencing adherence to treatment.

METHODS

Twelve in-depth qualitative interviews were conducted with males recruited from a cohort study (ACCESS) involving over 450 HIV-positive IDU. All participants had been incarcerated after initiating HAART. Audio-recorded interviews were conducted to examine experiences of taking HAART in prison, with particular attention to adherence and experiences of treatment discontinuation.

FINDINGS

Participant accounts described situations where adherence to HIV treatment was compromised in custody. A small number of participants reported treatment interruptions that lasted over a week when they were unable to obtain HIV medications through institutional healthcare. Short-term interruptions in treatment were said to be common during intake into the correctional system and at the point of release from custody. High levels of HIV discrimination motivate prisoners to hide the fact that they are HIV-positive by making efforts to take medications discreetly, which may result in missed doses.

CONCLUSIONS

The current study identified contextual factors within correctional environments that hinder individuals' ability to adhere to HAART. These findings also indicate that improved health services and coordination with community care providers are needed to enhance the quality of HIV treatment within correctional environments.

Major depression in patients with HIV/AIDS and substance abuse

Previous research has been inconsistent in documenting a strong relationship between depression and HIV/AIDS, although a recent meta-analysis of studies examining this issue indicates that rates of depression are modestly higher for this population. For the current study, conducted from 2001-2004, we sought to examine rates and types of depressive symptoms in a cohort of patients receiving HIV care at two urban medical centers. These patients were participants in an intervention study examining adherence and mental health in persons triply diagnosed with psychiatric disorders, substance use disorders, and HIV/AIDS. Nearly three quarters of these participants were people of color, two thirds described their sexual orientation as heterosexual, and the vast majority were unemployed. We sought to examine the relationship of depression to patients' adherence to antiretroviral medication regimens (highly active antiretroviral therapy [HAART]). Results obtained from structured clinical interviews and self-report questionnaires indicated that study participants experienced high rates of depressive symptoms, and that 72.9% of participants met criteria for major depressive disorder (MDD). The results of this study offer a detailed view of the incidence and nature of MDDs and depressive symptoms for an urban sample of substance-abusing adults with HIV/AIDS. Given the degree to which depressive symptoms and MDD appear to be prevalent for this group, as well as the observation that these symptoms are amenable to treatment, future research should focus on identifying helpful strategies and interventions for treating these symptoms, effective ways of providing linkages to care, and ways in which standardized assessment and treatment protocols might be adapted to better suit this population.

Adherence to hepatitis C treatment in recovering heroin users maintained on methadone

OBJECTIVES

Injection drug users are often denied hepatitis C (HCV) treatment due to concerns about adherence, despite limited data about the impact of such common issues as psychiatric illness and intercurrent drug use. We sought to define the impact of these and other potential adherence barriers in a real-world sample of recovering drug users.

METHODS

We conducted a prospective observational study of 71 methadone-maintained patients who received interferon and ribavirin combination therapy in a community-based clinic with expertise in treating addictive disorders. Adherence measures were conducted with monthly interview, medication counts, and urine toxicology testing.

RESULTS

Overall, 48 (68%) were adherent, and adherent patients were significantly more likely to achieve a sustained virologic response (42 vs. 4% in nonadherent patients). Patients with and without a prior psychiatric history were similarly adherent (64 vs. 72%, respectively, P>0.5), and the initiation of new psychiatric medications during HCV treatment was associated with improved adherence overall (P=0.02) and in patients that did not report a preexisting psychiatric diagnosis (P=0.04). Trend towards reduced adherence in patients without a period of abstinence was seen before initiating HCV treatment, 46 vs. 72% of those who had been abstinent for at least 1 month (P=0.10). Although occasional drug users were similarly adherent to those who were completely abstinent, patients who relapsed to regular drug use showed a significantly lower level of adherence (P=0.03).

CONCLUSIONS

We conclude that the majority of methadone-maintained drug users can adhere to HCV treatment, even those with psychiatric illness and relatively limited pretreatment drug abstinence. Lack of pre-HCV treatment drug abstinence and regular drug use during HCV treatment may be relative barriers to medication adherence, but the initiation of psychiatric medications during HCV treatment may be a helpful intervention. This report provides further evidence for an individualized approach to HCV treatment that does not categorically exclude patients with potential barriers such as mental illness and limited drug abstinence.

An HIV-preventive intervention for youth living with HIV

As the number of youth infected with HIV rises, secondary prevention programs are needed to help youth living with HIV meet three goals: (a) increase self-care behaviors, medical adherence, and health-related interactions; (b) reduce transmission acts; and (c) enhance their quality of life. This article describes an intervention program for youth living with HIV. Youth engage in small-group activities with other infected peers to modify their behavioral patterns. The intervention aims to (a) reduce substance use and sexual behaviors that may transmit or enhance transmission of the HIV virus; (b) reduce negative impacts of substance use on seeking and utilizing health care, assertiveness, and adherence to health regimens; and (c) enhance the quality of life to maintain behavior changes over time. Interventions that target youth living with HIV are warranted. A variety of delivery strategies are discussed for secondary interventions.

Sero-positive African Americans' beliefs about alcohol and their impact on anti-retroviral adherence

Alcohol consumption has been associated with HIV disease progression; yet, the nature of this association is poorly understood. This study sought to determine the influence of patient beliefs about alcohol on ART adherence, and elucidate clinician beliefs about drinking and taking ART. Most patients (85%) believed alcohol and ART do not mix. The three alcohol consumption groups, light, moderate, and heavy, differed in their beliefs about drinking and ART with 64% of light and 55% of moderate drinkers skipping ART when drinking compared to 29% of heavy drinkers. Beliefs were derived from folk models of alcohol-ART interaction. Patients 50 and older were less likely to skip ART when drinking. Alcohol appears to affect adherence through decisions to forgo ART when drinking not through drunken forgetfulness. Furthermore, over one-half of clinicians believed alcohol and ART should not be taken together. These findings have implications for patient care and physician training.

Determinants of HAART discontinuation among injection drug users

The objective of this study was to identify psychosocial determinants of, and self-reported reasons for, HAART discontinuation among HIV-positive injection drug users (IDUs). We examined correlates between sociodemographic characteristics, drug use and risk behaviors, outcome expectations, adherence self-efficacy, social support and HAART discontinuation among 160 HIV-positive participants in the Vancouver Injection Drug Users' Study (VIDUS). Logistic regression was used to identify the factors independently associated with discontinuation of HAART. Seventy-one (44%) study participants discontinued HAART during the study period. Factors independently associated with discontinuation of HAART included recent incarceration (OR = 4.84, p = 0.022), negative outcome expectations (OR = 1.41, p = 0.001), adherence efficacy expectations (OR = 0.70, p = 0.003) and self-regulatory efficacy (OR = 0.86, p = 0.050). The most frequently cited reasons provided for discontinuing HAART were being in jail (44%) and medication side effects (41%). The results of this study suggest that psychological constructs derived from self-efficacy theory are highly germane to the understanding of HAART discontinuation behavior and interventions that may change it. Incarceration may result in interruptions in HAART among IDUs, and programmatic changes may be needed to promote optimal retention on HAART among incarcerated HIV-infected IDUs.

Community outreach with weekly delivery of anti-retroviral drugs compared to cognitive-behavioural health care team-based approach to improve adherence among indigent women newly starting HAART

Sustained virological suppression requires adherence to >95% of doses of therapy. Overall there is paucity of data on adherence interventions among women and post-intervention outcomes. In this pilot study, we evaluated a novel strategy of weekly delivery of medications (Directly Delivered Therapy: DDT) for six months using an outreach worker (ORW), among ARV naïve indigent women starting HAART and compared the 'during intervention' and 'post-intervention' outcomes to the health care team (a nurse educator, a case worker, a pharmacist and social worker/drug addictions counsellor) based approach termed Adherence Coordination Services (ACS) and the Standard of Care (SoC) historical referent group. The baseline characteristics of the three groups were comparable. The proportion of women who achieved sustained virologic suppression in 4-8 month period for DDT; ACS and SoC groups were 86% (18/21); 54% (6/11); and 36% (8/22) (P<0.004); and in the 10-14 month period were 80% (12/15); 54% (6/11) and 45%(10/22) (P=0.036 for DDT vs. SoC). Retention rate in the DDT was 87%, and 92% of 307 ORW visits were kept, and post-intervention satisfaction was high. Short-term weekly delivery of medications using a community based liaison is a feasible, acceptable and a cost-effective strategy for improving both short-term and perhaps long-term adherence among women initiating their first HAART regimen.

Adherence to zidovudine for the prevention of perinatal transmission in HIV-infected pregnant women: the impact of social network factors, side effects, and perceived treatment efficacy

Adherence to zidovudine (ZDV) prophylaxis among 78 pregnant HIV-infected women was measured with 2 physiologic markers. Long-term adherence was measured with blood assays for macrocytosis, a clinical indicator of ZDV use; 53 women (67.9%) were adherent. Short-term adherence was measured with urine assays for ZDV; 48 women (61.5%) were adherent. Comparison of urine assay and interview data indicated that 29% had not taken the last dose that they reported. Participation in HIV support groups and disclosure to the participant's mother were associated with better adherence. These social network factors may enable HIV-infected pregnant women to cope more effectively with the multiple stressors they face and facilitate prenatal care.

Drug use patterns and adherence to treatment among HIV-positive patients: evidence from a large sample of French outpatients (ANRS-EN12-VESPA 2003)

PURPOSE

To study the relationship between drug use and adherence to highly active antiretroviral therapy (HAART) among HIV-positive people, with two alternative measures of drug use: a set of drug uses considered independent and patterns capturing combinations of drug uses.

METHODS

A cross-sectional survey conducted among a nationally representative sample of 4963 HIV-positive people randomly recruited in 102 French hospital departments delivering HIV care. The researchers modelled non-adherence to HAART with a set of binary indicators of drug use (model I) or comprehensive patterns obtained with a cluster analysis (model II).

RESULTS

In model 1, heroin use, injection drug use, and cocaine/amphetamine/ecstasy use were not significant predictors of poor adherence in contrast with nicotine dependence, cannabis use, and amyl nitrate use. In model II, non-adherence to HAART was more prevalent among profiles characterised by alcohol abuse and multiple addictions, including nicotine dependence and use of various illicit drugs.

CONCLUSIONS

Nicotine dependence, cannabis use, and amyl nitrate use are associated with non-adherence only if they are embedded in drug use patterns characterised by alcohol abuse or heroin use. The results also illustrate the interest in investigating the effects of drug use patterns on behavioural outcomes, rather than measuring independent effects of various drug use indicators that are highly correlated.

Longitudinal trends in antiretroviral use in a cohort of men and women in Ontario, Canada

Initial studies have shown impaired access to antiretrovirals and slower adoption of new therapies by women. It is unclear if similar treatment delays still occur, especially in those with a publicly funded health care system in Ontario, Canada. The objectives of this study were (1) to evaluate longitudinal patterns of antiretroviral use in patients with HIV in Ontario and (2) to determine if gender differences exist in access to and uptake of antiretroviral drugs over time. A retrospective medical chart review was undertaken. One hundred four HIV-positive patients were recruited from nine hospital-based HIV outpatient clinics throughout Ontario. From time of study enrollment in 1999-2001 to the first clinic visit (8.1 +/- 3.2 years; range, 2.3-16.8 years), CD4+ T-cell counts, date of and agents used in initial antiretroviral regimen, and first HAART regimen were evaluated by gender. Kaplan-Meier plots were used to evaluate time to drug initiation from known HIV diagnosis. Serial cross sections of numbers and types of antiretroviral drugs prescribed in March, June, September, and December 1988 to 2001 were also compared as was number of regimens used. There were few differences between men and women in antiretroviral use; both initiated therapy within 2.2 +/- 2.3 years of HIV diagnosis at an average CD4 counts of 300.3 +/- 150.1 cells per microliter. Antiretroviral treatment regimens changed over time, with limited variation by gender. In the period immediately surrounding the first highly active antiretroviral therapy (HAART) recommendations by the U.S. Department of Health and Human Services in July 1997, significantly more antiretroviral drugs were prescribed for men than women. Antiretroviral prescribing in patients attending hospital- based HIV outpatient programs in Ontario is consistent with antiretroviral treatment guidelines over time, without substantial differences in antiretroviral access and use by gender.

Validation of a brief screening instrument for substance abuse and mental illness in HIV-positive patients

BACKGROUND

Substance abuse (SA) and mental illness (MI) commonly co-occur with HIV infection in the United States and have important implications for clinical management of HIV/AIDS. Yet SA/MI often go untreated due in part to a lack of practical, validated screening tools.

SETTING

HIV clinic in academic medical center.

METHODS

The 16-item SA/MI Symptoms Screener (SAMISS) targets SA/MI in HIV-positive patients. Consecutive consenting HIV-positive patients completed the SAMISS and then a reference standard diagnostic tool, SCID, the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).

RESULTS

Twenty percent of participants (29/148) had an SA diagnosis and 41% (59/143) had an MI diagnosis in the past year on the SCID; 48% (68/143) had 1 or both. Thirty-seven percent (55/148) screened positive for SA and 69% (99/143) screened positive for MI on the SAMISS. The SAMISS had 86% (95% CI: 68%-96%) sensitivity and 75% (66%-82%) specificity for SA and 95% (86%-99%) sensitivity and 49% (38%-60%) specificity for MI. Patients with SA were likely to show up as false positives for MI and vice versa.

CONCLUSION

The SAMISS functioned well as a first-line screening tool for SA/MI in this HIV clinic population. It missed few cases and was easily incorporated into a busy clinical setting. Persons screening positive require a more rigorous confirmatory psychiatric evaluation.

AIDS optimism, condom fatigue, or self-esteem? Explaining unsafe sex among gay and bisexual men

This study examines leading explanations for unsafe sex in light of in-depth interviews with 102 high-risk gay and bisexual men in Toronto to see how well they engage with the social circumstances and reasoning processes of men in their sexual relationships. We argue that there is an inadequate fit between some of the leading explanations and the discursive accounts provided by high risk men themselves. Their accounts focus on unsafe sex occurring as a resolution to condom and erectile difficulties, through momentary lapses and trade offs, out of personal turmoil and depression, and as a byproduct of strategies of disclosure and intuiting safety. This study examines, in particular the circumstances and rationales associated with men who identify their practices as "barebacking." We conclude with recommendations for communicating prevention messages to those most at risk based on the self-understandings of gay and bisexual men who most frequently practice unprotected sex.

Mental disorders and drug abuse in persons living with HIV/AIDS

This article reviews the literature on the prevalence of mental and substance use disorders among persons living with HIV/AIDS. Drug use, both injection and non-injection, substantially increases the risk for HIV infection. While injection drug users have the highest prevalence rates for HIV, substantially elevated rates of HIV infection are also present among crack cocaine users and individuals with substance use disorders generally. Persons with HIV/AIDS and a mental and/or substance use disorder have highly variable patterns of accessing services. Persons with HIV/AIDS who have a serious mental illness are more highly involved with services than other groups. Most individuals with co-occurring disorders report some involvement with outpatient primary medical care, although ancillary services such as mental health and substance abuse treatment, transportation assistance, and case management improve involvement in medical care. Women with HIV/AIDS and co-occurring mental and substance use disorders experience unique vulnerabilities, particularly those related to exposure to traumatic events. Given the complexity of needs with which triply or multiply diagnosed individuals present, effective treatment programmes are likely to be those that provide some degree of integrated care.

Psychosocial mediators of antiretroviral nonadherence in HIV-positive adults with substance use and mental health problems

This study used data from 1,889 HIV-positive patients on antiretroviral (ARV) medications who participated in the HIV Cost and Services Utilization Study to investigate whether nonadherence to ARV medications among patients with mental health and substance use problems could be explained by difficulty getting and negative attitudes toward ARV medications, poor fit of the regimen with lifestyle, lack of instruction and cues for remembering the regimen from a health care provider, and poor support from others for taking ARV medications. Difficulty getting ARV medications and poor fit with lifestyle were significant mediators of nonadherence for patients with a probable psychiatric disorder. Difficulty getting medication was a mediator for heavy drinkers, and poor fit with lifestyle was a mediator for drug users who drank heavily. Further research is needed to identify and address the barriers to adherence in these populations.

Provider barriers to prescribing HAART to medically-eligible HIV-infected drug users

We aimed to identify factors associated with a medical provider's resistance to prescribing HAART to medically-eligible HIV-infected illicit drug users. In four US cities, a mailed, self-administered survey queried 420 HIV care providers about patients' characteristics and barriers to care. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were estimated using logistic regression. Providers identified as resistant to prescribing HAART to medically-eligible HIV-infected illicit drug users were more likely to be non-physicians (AOR=1.89, 95% CI: 1.04-3.46), to work in populations with a high prevalence of both mental illness (AOR=2.42; 95% CI: 1.11-5.26) and injection drug use (AOR=1.82 95% CI: 1.02-3.25) and were deterred from prescribing HAART by patients' limited ability to keep appointments, (AOR=3.19; 95% CI: 1.39-7.37), alcoholism (AOR=1.92; 95% CI: 1.04-3.55) and homelessness (AOR=1.81; 95% CI: 1.07-3.06). Providers working in populations with a high injection drug use prevalence commonly reported higher prevalence of non-injection drug use, alcohol problems and mental illness, and higher antiretroviral therapy refusal rates within their patient populations. Our findings underscore the challenges to providers who treat HIV-infected drug users and suggest that their care and treatment would benefit from on-site drug treatment, mental health and social services.

Psychosocial factors associated with adherence to antiretroviral medications in a sample of HIV-positive African American drug users

The purpose of the study was to investigate factors affecting antiretroviral adherence among African American drug users, specifically to identify associations between self-reported adherence levels and psychosocial measures selected with guidance from the Transactional Model of Stress and Coping (TMSC). The study was conducted using data collected from 137 HIV-positive African American drug users who were receiving antiretroviral medications at the time they were interviewed. Bivariate associations were investigated using correlational analyses and variables showing a significant correlation with adherence were entered into a multivariate regression model. The multivariate model showed only perceived efficacy of antiretrovirals and one measure of perceived barriers, simply forgetting to take medications, were independently related to adherence. These preliminary findings suggest that theoretical approaches to understanding antiretroviral adherence must address a range of variables, including but not limited to behavioural practices, cognitive appraisals, affective responses and social support. Further studies using the complete TMSC are recommended.

Methamphetamine abuse as a barrier to HIV medication adherence among gay and bisexual men

Medication adherence among persons with HIV infection is important not only because of the effect of non-adherence on an individual's health but also because non-adherence can lead to medication-resistant viral strains. However, adherence to HIV medications is difficult due to complex dosing regimens and side effects. This paper is a qualitative analysis of HIV medication adherence among gay and bisexual methamphetamine-abusing men enrolled in an outpatient drug treatment research project. As part of an open-ended, semi-structured interview, 23 HIV-infected men discussed the effects of their methamphetamine use on their medication adherence. Substance-use barriers to adherence were coded into two main themes: (1) planned non-adherence and (2) unplanned non-adherence. Planned non-adherence was a strategy for coping with demanding HIV medication schedules, or was linked to sexual behaviours while using methamphetamine or to fears of interaction effects from mixing methamphetamine with HIV medications. Participants did not define their medication regimen adjustments as non-adherence but as a way to achieve a sense of control over their lives. Unplanned non-adherence was linked to methamphetamine-related disruptions in food and sleep schedules. Findings are helpful in designing culturally specific HIV medication adherence interventions for this population.

Correlates of depressive symptoms among HIV-positive injection drug users: the role of social support

Using cross-sectional data from an ethnically diverse sample of HIV-positive injection drug users (IDUs), we sought to identify correlates of depressive symptoms. We were particularly interested in whether perceived social support was associated with depression among HIV-positive IDUs and whether social support buffered adverse effects of other correlates. Data were collected from a sample of HIV-positive IDUs recruited from a variety of venues in the New York City and San Francisco metropolitan areas in the USA. Multiple regression analysis identified four significant correlates of depressive symptoms. Perceived social support and having a regular place for HIV medical care were significantly associated with lower levels of depressive symptoms, while history of mental health problems and non-injection polydrug use were significantly associated with higher levels of depressive symptoms. Moreover, a significant interaction effect was found between social support and non-injection polydrug use, indicating that social support buffers the association between non-injection polydrug use and depression. These results suggest that increasing social support might be a useful tool for HIV-positive IDUs in reducing depression and the adverse effect of non-injection polydrug use.

Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users

The introduction of highly active antiretroviral therapy (HAART) has resulted in marked reductions in mortality and acquired immunodeficiency syndrome (AIDS) incidence across all risk groups; however, the proportionate decrease among injecting drug users (IDUs) has been less impressive. Much of the disparity in benefit to IDUs has been a consequence of decreased access to and receipt of potent antiretroviral combinations. Strategies to increase access to and utilization of HAART have included entry into drug treatment and abstinence. Unfortunately, as few as 15%-20% of active drug users in the United States, and in many other countries, are in drug treatment at any one time. We report a pilot project among out-of-drug treatment IDUs infected with human immunodeficiency virus (HIV); HIV therapy was successfully provided to active heroin injectors using the Community Health Care Van (CHCV) at sites of needle exchange. Subjects were willing to initiate, but were not receiving, recommended HIV therapy and were not interested in formal drug treatment. Antiretroviral therapy regimens were selected and linked to heroin injection timing. Weekly visits were scheduled by CHCV staff to assess adverse side effects and encourage adherence. Of the 13 participants, the mean baseline HIV-1 RNA level and CD4 lymphocyte count were 162,369 (log 5.21) copies per milliliter and 265 cells per milliliter, respectively. By 6 months, the proportion whose HIV-1 RNA was below the limits of detection (<400 copies/mL) was 85% (N=11); 77% (N=10) had nondetectable levels by 9 months. By 12 months, 54% (N=7) had a persistently nondetectable viral load, and the net increase in CD4 lymphocyte count was 150 cells per milliliter. As an additional and unintended benefit of this pilot project, 9 (69%) subjects chose to enter drug treatment after achieving a nondetectable viral load. Entry into drug treatment was associated with durability of viral suppression. This small pilot study suggests that health services based on needle exchange may enhance access to HAART among out-of-treatment HIV-infected IDUs. In addition, it demonstrates that this population can benefit from this therapy with the support of a nontraditional, community-based health intervention.

Longitudinal study of mental health and psychosocial predictors of medical treatment adherence in mothers living with HIV disease

Cross-sectional studies to date that examine psychosocial correlates of antiretroviral adherence have insufficiently addressed the challenges of long-term adherence. This longitudinal study examined mental health, substance abuse, and psychosocial predictors of long-term adherence to antiretroviral medications and medical appointments among HIV-seropositive mothers recruited from an infectious disease clinic of a large urban medical center. Individual interviews were conducted at baseline and two follow-up points, 8 to 18 months after enrollment. Based on a model of health behavior, we examined psychiatric and psychosocial predictors of adherence to antiretroviral medications and medical appointments over time. Presence of a psychiatric disorder, negative stressful life events, more household members, and parenting stress were significantly associated with both missed pills and missed medical appointments at follow-up. Baseline substance abuse was associated with missed pills at follow-up and lack of disclosure to family members at baseline was associated with missed medical appointments at follow-up. These findings suggest that interventions that integrate mental health, substance abuse and medical care may be important to improving the medical adherence and health of HIV-seropositive women, particularly in multistressed populations with substantial caregiving and other life demands.

Substance use and mental health correlates of nonadherence to antiretroviral medications in a sample of patients with human immunodeficiency virus infection

PURPOSE

Mental health and substance use problems are common among patients infected with human immunodeficiency virus (HIV) and may impede adherence to antiretroviral regimens. This study investigated associations of antiretroviral medication nonadherence with specific types of psychiatric disorders and drug use, and varying levels of alcohol use.

METHODS

Data were drawn from a survey of a national probability sample of 2267 (representing 181,557) adults enrolled in the HIV Cost and Services Utilization Study. This study focused on 1910 patients who reported their antiretroviral medication adherence during the past week.

RESULTS

Patients with depression (odds ratio [OR] = 1.7; 95% confidence interval [CI]: 1.3 to 2.3), generalized anxiety disorder (OR = 2.4; 95% CI: 1.2 to 5.0), or panic disorder (OR = 2.0; 95% CI: 1.4 to 3.0) were more likely to be nonadherent than those without a psychiatric disorder. Nonadherence was also associated with use of cocaine (OR = 2.2; 95% CI: 1.2 to 3.8), marijuana (OR = 1.7; 95% CI: 1.2 to 2.3), amphetamines (OR = 2.3; 95% CI: 1.2 to 4.2), or sedatives (OR = 1.6; 95% CI: 1.0 to 2.4) in the previous month. Compared with patients who did not drink, those who were moderate (OR = 1.6; 95% CI: 1.3 to 2.0), heavy (OR = 1.7; 95% CI: 1.3 to 2.3), or frequent heavy (OR = 2.7; 95% CI: 1.7 to 4.5) drinkers were more likely to be nonadherent. These associations could not be explained by demographic, clinical, and treatment factors.

CONCLUSION

These findings suggest the need for screening and treatment for mental health and substance use problems among HIV-positive patients to improve adherence to antiretroviral medications.

Using motivational interviewing to promote adherence to antiretroviral medications: a pilot study

This report describes a pilot study of a nursing intervention to increase adherence to combination therapy. The intervention was based on motivational interviewing (MI). Participants completed a baseline assessment using the computer-administered self-interview with audio (ACASI) data collection method and then were randomly assigned to the MI intervention or control condition. Nurse counselors met with participants in the MI intervention group for three adherence sessions. Two months following baseline, participants completed a follow-up assessment. Mean scores on ratings of missed medications were lower for participants in the intervention group than those in the control group. Although there were no significant differences in the number of medications missed during the past 4 days, participants in the MI group reported being more likely to follow the medication regimen as prescribed by their health care provider. The pilot study provided useful information about the acceptability of ACASI and the adequacy of intervention procedures. The results of this pilot study show promise for the use of MI as an intervention to promote adherence to antiretroviral medications.

Prevention and treatment of hepatitis C in injection drug users

Injection drug users constitute the largest group of persons infected with the hepatitis C virus (HCV) in the United States, and most new infections occur in drug users. Controlling hepatitis C in the U.S. population, therefore, will require developing, testing, and implementing effective prevention and treatment strategies for persons who inject drugs. Fortunately, a substantial body of research and clinical experience exists on the prevention and management of chronic viral diseases among injection drug users. The need to implement interventions to stop the spread of HCV among drug users is critical. The capacity of substance-use treatment programs need to be expanded to accommodate all who want and need treatment. Physicians and pharmacists should be educated in how to provide access to sterile syringes and to teach safe injection techniques, both of which are lifesaving interventions. The treatment of hepatitis C in drug users requires an interdisciplinary approach that brings together expertise in treating hepatitis and caring for drug users. Treatment decisions should be made individually by patients with their physicians, based on a balanced assessment of risks and benefits and the patient's personal values. Physicians should carefully assess, monitor, and support adherence and mental health in all patients, regardless of whether drug use is known or suspected. Research is needed to better understand how best to prevent and treat hepatitis C in substance users. In the meantime, substantial progress can be made if existing knowledge and resources are brought to bear.

Prevention and treatment of hepatitis C in injection drug users

Injection drug users constitute the largest group of persons infected with the hepatitis C virus (HCV) in the United States, and most new infections occur in drug users. Controlling hepatitis C in the U.S. population, therefore, will require developing, testing, and implementing effective prevention and treatment strategies for persons who inject drugs. Fortunately, a substantial body of research and clinical experience exists on the prevention and management of chronic viral diseases among injection drug users. The need to implement interventions to stop the spread of HCV among drug users is critical. The capacity of substance-use treatment programs need to be expanded to accommodate all who want and need treatment. Physicians and pharmacists should be educated in how to provide access to sterile syringes and to teach safe injection techniques, both of which are lifesaving interventions. The treatment of hepatitis C in drug users requires an interdisciplinary approach that brings together expertise in treating hepatitis and caring for drug users. Treatment decisions should be made individually by patients with their physicians, based on a balanced assessment of risks and benefits and the patient's personal values. Physicians should carefully assess, monitor, and support adherence and mental health in all patients, regardless of whether drug use is known or suspected. Research is needed to better understand how best to prevent and treat hepatitis C in substance users. In the meantime, substantial progress can be made if existing knowledge and resources are brought to bear.

HIV transmission risk behaviors among HIV-positive individuals: stress and coping in the aftermath of 9/11

Using case studies, this article discusses a nursing approach for working with HIV-positive clients who have experienced stress as the result of the 9/11 attack on the United States. The stress and coping framework developed by Lazarus and Folkman is used to guide nursing care.

[Adherence to antiretroviral drug therapy. A systematic review]

BACKGROUND

We performed a systematic review of the medical literature in order to determine the level of adherence to antiretroviral therapy and its relation with the social, demographic, and clinical characteristics of patients.

METHOD

Systematic search of published primary studies in MEDLINE, EMBASE and IME and review of reports presented in main congresses related to infectious diseases and AIDS. Observational and intervention studies carried out in adult patients between 1990 and the first semester of 2001 were selected following descriptive and quality criteria. Both English language and Spanish language reports were analyzed.

RESULTS

30 studies fulfilled previously established requirements. Most studies show high adherence levels between 50% and 80% patients, with a range between 28% and 82%. In univariate or multivariate analyses, factors associated with worse adherence levels were as follows: females, younger people, low education level, low income, active drug consumption, lack of self-perception of the efficacy of antiretroviral agents, stress and lack of motivation, high number of tablets and complexity of administration guidelines. Most prospective studies show a good correlation between adherence and control of HIV infection determined by the measurement of the viral load.

CONCLUSIONS

The number of primary studies with methodological quality is limited and future works must be performed under strict design conditions. Most studies show that a high proportion of patients, between 20% and 50%, do not have optimal levels of adherence. Patients with higher adherence levels exhibit greater clinical effectivity. Social, demographic, psychological and other factors related to the lack of adherence must be taken into account in order to improve the compliance in these patients.

Individual and system level factors associated with treatment nonadherence in human immunodeficiency virus-infected men and women

Antiretroviral treatment nonadherence is complex, implicating more than a patient's ability and motivation to be compliant. The bulk of the research to date focuses on individual level barriers with less emphasis on the many system level factors that potentially impact patients' adherence behaviors. This study examined the effects of system enabling factors in addition to the frequently studied individual predisposing and enabling factors upon nonadherence to treatment. One hundred eighty-two patients from five community-based clinics were interviewed and their medical charts examined. Patients' self-reported nonadherence was correlated with clinicians' assessments of medication and appointment nonadherence. Seven individual predisposing factors (gender, ethnicity, birthplace, years of education, HIV Overview of Problems-Evaluation System [HOPES] psychosocial, Hospital Anxiety and Depression Scale [HADS] anxiety, and HADS depression scores) were found to be significantly associated with treatment adherence/nonadherence. Individual enabling factors (hopefulness and access to health care), as well as treatment by clinic staff, a system enabling factor, were significantly associated with adherence/nonadherence. In a multivariate analysis, six factors - age (younger), gender (female), birth outside the United States, level of hopefulness (lower), access to health care (lower), and treatment by clinic staff (poorer) - accounted for 19.3% of the variance in nonadherence. Results of this study indicated that several individual predisposing and enabling factors were potential predictors of treatment nonadherence; however, system enabling factors, e.g., treatment by clinic staff were also associated with treatment nonadherence. Further studies are needed to examine the complex relationships of individual and system related factors in predicting treatment nonadherence.

Longitudinal assessment of the effects of drug and alcohol abuse on HIV-1 treatment outcomes in an urban clinic

OBJECTIVE

To assess the temporal association of changes in substance abuse with antiretroviral therapy use and adherence, HIV-1 RNA suppression, and CD4 cell count changes in patients attending an urban clinic.

DESIGN

Prospective cohort study.

METHODS

Six-hundred and ninety-five HIV-1-infected individuals, who completed two or more semi-annual standardized surveys and in whom antiretroviral therapy was indicated, were included in the analysis. Surveys addressed antiretroviral therapy use and adherence, and use of illicit drugs and alcohol. Substance abuse was defined as active heroin, cocaine, or heavy alcohol use in the 6 months preceding survey. The units of analysis were consecutive pairs of surveys (couplets) in individual participants. Couplets in which participants denied substance abuse in both surveys were compared to couplets in which participants switched from non-use to substance abuse, and couplets in which participants reported substance abuse in both surveys were compared to couplets where participants switched from substance abuse to non-use.

RESULTS

Switching from non-use to substance abuse was strongly associated with worsening antiretroviral therapy use and adherence, less frequent HIV-1 RNA suppression, and blunted CD4 cell increases, compared to remaining free of substance abuse. Alternatively, switching from substance abuse to non-use was strongly associated with improvements in antiretroviral therapy use and adherence, and HIV-1 treatment outcomes, compared to persisting with substance abuse.

CONCLUSIONS

This longitudinal study highlights the dynamic nature of substance abuse and its temporal association with the effectiveness of HIV-1 treatment in patients attending an inner-city clinic.

Drug users and HIV-combination therapy (HAART): factors which impede or facilitate adherence

The current highly active antiretroviral therapy (HAART), i.e., triple combination treatment including a protease inhibitor, allows for long-term suppression of HIV-replication. The intake guidelines, however, are very strict and, like many other HIV positive patients, drug users have problems in achieving good therapy compliance. As a result, the effectiveness of the medication therapy is seriously jeopardized. This qualitative study, involving in-depth interviews with 27 "hard drug" users in Amsterdam, seeks to provide better insights into the extent of adherence to HAART. In addition, factors that impede or facilitate adherence have been listed in order to develop and improve strategies. The study shows that almost half of the "hard drug" users interviewed do not adhere to the therapy. A large number of determinants for adherence were identified at the level of medication, the individual, and the environment. Many of these determinants can be influenced, which means that they can provide clues for the effective implementation of measures that may enhance effectiveness of treatment.

Longitudinal predictors of depressive symptoms among low income injection drug users

Effects of changes in physical health status and drug use, and prior social support on depressive symptoms were assessed in low income injection drug users. Data are from participants (n = 503) enrolled at baseline (1994-1995) who remained at one-year follow-up (79%), of whom 37% were HIV-positive and 36% female. Physical health was measured by HIV symptoms, AIDS, CD4 count and functional limitation (IADLs). One-third scored high on depressive symptoms (CES-D > or = 16) at one-year follow-up, representing no statistically significant change from baseline (38%). In multiple logistic regression, after controlling for baseline depression scores (OR = 6.11, p < 0.001) and drug use (OR = 1.20, p = 0.192), baseline functional limitation (OR = 3.28, p < 0.001) and declining functioning (OR = 3.60, p < 0.001) were positively, and quitting drug use was negatively, associated with depressive symptoms at follow-up. Low social support at baseline (OR = 0.58, p < 0.10) was marginally predictive of depressive symptoms. Depressive symptoms did not differ by gender. For HIV-positive respondents, functional limitation was predictive of depressive symptoms, but HIV illness and drug use were not. Facilitating drug treatment and preventive medical care may aid in reducing depression in this population. For HIV-positive drug users, drug treatment prior to AIDS may help reduce depressive symptoms, with potential implications for HIV service utilization and medical adherence.

Suicide probability and psychological morbidity secondary to HIV infection: a control study of HIV-seropositive, hepatitis C virus (HCV)-seropositive and HIV/HCV-seronegative injecting drug users

BACKGROUND

Suicide ideation and psychological morbidity among HIV-positive patients has been the object of intense research. No study has investigated this area among injecting drug users (IDUs) infected with HIV and those infected with the hepatitis C virus (HCV), which has the same patterns of transmission of the HIV and may favour HIV replication and, possibly, HIV disease progression.

METHODS

In order to examine the prevalence and characteristics of suicide ideation and psychological morbidity associated with HIV and HCV infection in IDUs, a sample of HIV+ (n=81), HIV-/HCV+ (n=62) and HIV-/HCV- (n=152) subjects completed the Suicide Probability Scale (SPS), The Brief Symptom Inventory (BSI) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

No difference was found between the groups as far as the mean scores on SPS and the risk of suicide (no-low risk category: 70.7% HIV+, 56.09% HCV+, 65.6% HIV-/HCV-). Estimated psychological morbidity (BSI) (26.9% HIV+, 27.1% HCV+, 25.4% of HIV-/HCV-) and BSI and HADS scores were comparable across the groups.

CONCLUSIONS

Suicide ideation, psychological morbidity and anxiety and depression symptoms seemed not to be directly influenced by HIV-serostatus. Careful assessment of psychological symptoms and suicide ideas among IDUs, as a vulnerable segment of population at risk of HIV and HCV infections, needs to be routinely carried out in clinical settings.

Problem drinking and medication adherence among persons with HIV infection

OBJECTIVE

To examine the relation between problem drinking and medication adherence among persons with HIV infection.

DESIGN

Cross-sectional survey.

SETTING/PARTICIPANTS

Two hundred twelve persons with HIV infection who visited 2 outpatient clinics between December 1997 and February 1998.

MEASUREMENTS AND MAIN RESULTS

Nineteen percent of subjects reported problem drinking during the previous month, 14% missed at least 1 dose of medication within the previous 24 hours, and 30% did not take their medications as scheduled during the previous week. Problem drinkers were slightly more likely to report a missed dose (17% vs 12 %, P =.38) and significantly more likely to report taking medicines off schedule (45% vs 26%, P =.02). Among drinking subtypes, taking medications off schedule was significantly associated with both heavy drinking (high quantity/frequency) (adjusted odds ratio [OR], 4.70; 95% confidence interval [95% CI], 1.49 to 14.84; P <.05) and hazardous drinking (adjusted OR, 2.64; 95% CI, 1.07 to 6.53; P <.05). Problem drinkers were more likely to report missing medications because of forgetting (48% vs 35%, P =.10), running out of medications (15% vs 8%, P =.16), and consuming alcohol or drugs (26 % vs 3 %, P <.001).

CONCLUSION

Problem drinking is associated with decreased medication adherence, particularly with taking medications off schedule during the previous week. Clinicians should assess for alcohol problems, link alcohol use severity to potential adherence problems, and monitor outcomes in both alcohol consumption and medication adherence.

Eligibility policies for the state AIDS drug assistance programs

Drug treatments for HIV infection and related opportunistic infections have had dramatic impacts on the morbidity and mortality associated with HIV disease. HIV drug therapies are essential to the survival and to improved quality of life for individuals with HIV. However, not all people with HIV disease are receiving these medications. The state AIDS drug assistance programs (ADAPs) can provide access to drug therapies for many people with HIV disease who lack adequate drug coverage. This research presents the results of a national survey that identified eligibility-related policies implemented by .48 state ADAPs during 1998 and 1999. The survey assessed the number of people receiving ADAP coverage, the percentage of ADAP beneficiaries who are women, financial and medical eligibility requirements, characteristics of the application process, any implementation of waiting lists, and any coordination of the ADAPs with other public programs.

Factors influencing physicians' judgments of adherence and treatment decisions for patients with HIV disease

New medications for HIV reduce mortality and morbidity but require strict adherence. Thus, physicians treating HIV-positive patients must weigh both disease severity and likelihood of adherence when deciding whether to start patients on treatment. A national sample of 495 physicians surveyed via mail responded to clinical scenarios depicting HIV-positive patients and indicated whether they would start patients on medication (response rate = 53%). Scenarios varied on the patient characteristics of gender, disease severity, ethnicity, and risk group. Physicians predicted that patients with less severe disease, former injection drug users, and African American men would be less likely to adhere. Perceived adherence and disease severity influenced treatment decisions. Results are discussed in the context of attitudes about minority groups and injection drug users, which may influence adherence judgments in practice settings. Psychological research to identify better methods of predicting medication adherence may serve to inform medical decision making.

Taking antiretroviral therapy for HIV infection: learning from patients' stories

OBJECTIVE

To describe how people with HIV understand and experience the problem of adhering to antiretroviral medication regimens.

DESIGN

We performed a qualitative study based on interviews with HIV-infected patients, including 46 clients of AIDS service organizations, who were sampled according to age, ethnicity, and injection drug use history, and a convenience sample of 15 patients. Interviews were conducted in English or Spanish and were audiotaped and transcribed.

PARTICIPANTS

Of 52 respondents who had prescriptions for antiretroviral therapy, 25 were randomly selected for in-depth analysis. Of these, 5 reported having an AIDS diagnosis, 15 reported symptoms they attributed to HIV, and 5 reported having no symptoms of HIV disease.

MEASUREMENTS AND MAIN RESULTS

Investigators prepared structured abstracts of interviews to extract adherence-related data. One investigator compared the abstracts with the original transcripts to confirm the interpretations, and used the abstracts to organize and classify the findings. Most subjects (84%) reported recent nonadherent behavior, including ceasing treatment, medication "holidays," sleeping through doses, forgetting doses, skipping doses due to side effects, and following highly asymmetric schedules. Initially, most reported that they were not significantly nonadherent, and many did not consider their behavior nonadherent. Only a minority clearly understood the possible consequences of missing doses. Most said they had not discussed their nonadherence with their physicians.

CONCLUSIONS

Many people rationalize their difficulty in adhering to HIV treatment by deciding that the standard of adherence they can readily achieve is appropriate. Physicians should inquire about adherence-related behavior in specific detail, and ensure that patients understand the consequences of not meeting an appropriate standard.

Socioeconomic status and survival of persons with AIDS before and after the introduction of highly active antiretroviral therapy. Lazio AIDS Surveillance Collaborative Group

We estimated the AIDS survival by neighborhood socioeconomic status before (1993-1995) and after (1996-1997) the introduction of highly active antiretroviral therapy in Rome, Italy, in a retrospective cohort of persons with AIDS followed through July 31, 1998. Participants included 1,474 persons with AIDS residing in Rome who were diagnosed in 1993-1997. We calculated hazard ratios (HRs) of death for two diagnostic periods (before and after highly active antiretroviral therapy was introduced) by neighborhood socioeconomic status categorized into four levels (level I = highest socioeconomic status), using the Cox model and adjusting for gender, age, intravenous drug use, CD4 cell count at diagnosis, AIDS-defining disease, and hospital of diagnosis. Thirty-four per cent of persons with AIDS (N = 503) had survived as of mid-1998. For persons with AIDS diagnosed in 1993-1995, we found little difference in the risk of death by neighborhood socioeconomic status. For 1996-1997, the risk of death was greater for persons with lower neighborhood socioeconomic status, especially for levels III and IV [HR = 2.81 (95% confidence interval = 1.38-5.76), and HR = 2.55 (95% confidence interval = 1.27-5.14), respectively, compared with level I]. Stratified analyses showed that the greatest difference was found for women and drug users. In conclusion, even in a country with universal health coverage that provides therapy at no cost, differences in survival of persons with AIDS have emerged by neighborhood socioeconomic status since highly active antiretroviral therapy was introduced. Inequalities in health-care access or in medical management, or poor adherence to treatment, could explain the observed heterogeneity.

Impact of protease inhibitors and other antiretroviral treatments on acquired immunodeficiency syndrome survival in San Francisco, California, 1987-1996

The authors assessed temporal trends in acquired immunodeficiency syndrome (AIDS) survival for 15,271 persons in San Francisco, California, diagnosed between 1987 and 1996 with an opportunistic illness included in the 1987 AIDS case definition. Predictors of survival were evaluated for 5,686 persons who were diagnosed between 1993 and 1996 and met the 1993 AIDS case definition. Median survival was 19 months for persons diagnosed between 1987 and 1989, 17 months for persons diagnosed between 1990 and 1992, 15 months for persons diagnosed between 1993 and 1994, and 31 months for persons diagnosed between 1995 and 1996. Decreased mortality was associated with use of antiretroviral therapy without protease inhibitors before AIDS (relative hazard (RH) = 0.88, 95% confidence interval (CI): 0.8, 1.0) and after AIDS (RH = 0.83, 95% CI: 0.7, 0.9) and use of antiretroviral agents with protease inhibitors before AIDS (RH = 0.25, 95% CI: 0.2, 0.3) and after AIDS (RH = 0.36, 95% CI: 0.3, 0.4). Increased mortality was found for persons aged > or = 40 years (RH = 1.43, 95% CI: 1.3, 1.6), persons initially diagnosed with an opportunistic illness (RH = 1.97, 95% CI: 1.8, 2.2), and homosexual injection drug users (RH = 1.33, 95% CI: 1.2, 1.5). Survival after AIDS has increased. Treatment with antiretroviral agents, particularly protease inhibitors, strongly predicts improved survival.

HIV drug adherence: special situations

Among the highly diverse population of persons living with HIV/AIDS are individuals with particularly challenging life circumstances that can be called "special situations." Substance abuse and homelessness are examples of special situations that require additional consideration when attempting to determine the appropriateness of prescribing complex antiretroviral regimens. When individual cases are examined in the context of relevant models of care and the principles of those models applied, such clinical decisions can be made with the patient. Withholding protease inhibitors from an entire population group, it is argued, is the epitome of practicing bad medicine.

Predictors of self-reported adherence and plasma HIV concentrations in patients on multidrug antiretroviral regimens

BACKGROUND

Adherence to prescribed medications is a central feature of good clinical HIV care, but little is known about the factors associated with multidrug antiretroviral adherence, or about how such adherence is related to plasma HIV suppression.

METHODS

We collected data from 133 HIV-infected adults receiving antiretroviral therapy. Study subjects completed customized adherence self-report instruments and provided blood samples to measure plasma HIV-1 RNA concentrations and CD4+ lymphocyte counts. Regression models were used to determine the independent predictors of antiretroviral adherence and plasma HIV concentration, and the relationships between the two.

RESULTS

Adherence was poor (average, <80% antiretrovirals/day) in 28% (95% confidence interval [CI], 20%-36%), fair (80%-99% per day) in 23% (95% CI, 15%-30%), and excellent (100% per day) in 50% (95% CI, 41%-58%) of study subjects. Mean decreases in HIV-1 concentration from highest-ever levels were 1.3, 1.6, and 2.0 log10 copies/ml in these three groups, respectively (chi2; p < .02). Two-stage least squares regression demonstrated a -1.3 log difference in viral load associated with each category improvement in adherence. In multivariate models, confidence in medication-taking ability, or perceived self-efficacy, and convenience of the medication regimen, or "fit" with routine and daily activities, were also associated with greater medication adherence (odds ratios [OR] 5.3; 95% CI, 2.4-11.8, and 9.0; 95% CI, 1.8-45.3, respectively). The latter was also independently associated with a lower plasma HIV concentration (p < .02).

CONCLUSIONS

Nonadherence to combination antiretroviral medications is common and is associated with increased levels of plasma HIV. Programs and clinical efforts to improve medication taking should strive to integrate medications better into patients' daily routines and to improve patients' confidence in their ability to take medications correctly.