0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Contribution |

Highly Active Antiretroviral Therapy and Survival in HIV-Infected Injection Drug Users FREE

Evan Wood, MD, PhD; Robert S. Hogg, PhD; Viviane Dias Lima, PhD; Thomas Kerr, PhD; Benita Yip, BSc (Pharm); Brandon D. L. Marshall, MSc; Julio S. G. Montaner, MD, FRCPC
[+] Author Affiliations

Author Affiliations: British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver; Faculty of Medicine, University of British Columbia, Vancouver (Drs Wood, Lima, Kerr, and Montaner); and Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia (Dr Hogg).


JAMA. 2008;300(5):550-554. doi:10.1001/jama.300.5.550.
Text Size: A A A
Published online

Context Highly active antiretroviral therapy (HAART) is often withheld from injection drug users (IDUs) infected with the human immunodeficiency virus (HIV) based on the belief that their unstable lifestyles may predetermine a markedly inferior outcome with HAART. However, long-term evaluations of HIV treatment outcomes among IDUs in comparison with other risk groups are not available.

Objective To compare survival rates among HIV-infected patients initiating HAART with and without a history of injection drug use.

Design, Setting, and Patients Population-based, prospective cohort study (HAART Observational Medical Evaluation and Research [HOMER]) of 3116 antiretroviral-naive HIV-infected patients in a province-wide HIV/AIDS treatment program in British Columbia, Canada. Of the 3116 patients, 915 were IDUs (29.4%), 579 were female (18.6%), and the median age was 39.4 years (interquartile range, 33.3-46.4 years). Treatment with HAART was initiated between August 1, 1996, and June 30, 2006. The median duration of follow-up was 5.3 years (interquartile range, 2.8-8.3 years) for IDUs and 4.3 years (interquartile range, 2.0-7.6 years) for non-IDUs. Patients were followed up until June 30, 2007. Data were analyzed between November 1, 2007, and May 26, 2008.

Main Outcome Measure All-cause mortality.

Results Overall, 622 individuals died (20.0%) during the study period (232 IDUs and 390 non-IDUs), for a crude mortality rate of 20.0% (95% confidence interval [CI], 18.4%-21.5%). At 84 months after the initiation of HAART, the product limit estimate of the cumulative all-cause mortality rate was similar between the 915 IDUs (26.5%; 95% CI, 23.2%-29.8%) and 2201 non-IDUs (21.6%; 95% CI, 16.9%-26.2%) (Wilcoxon P = .47). In multivariate time-updated Cox regression, the hazard ratio of mortality was similar between IDUs and non-IDUs (1.09; 95% CI, 0.92-1.29).

Conclusion In this study population, injection drug use was not associated with decreased survival among HIV-infected patients initiating HAART.

Figures in this Article

Since the mid-1990s, substantial reductions in morbidity and mortality related to the human immunodeficiency virus (HIV) have been documented among HIV-infected persons receiving highly active antiretroviral therapy (HAART).13 However, a large number of prior reports have demonstrated that because of issues of social instability related to illicit drug addiction,4 HIV-infected injection drug users (IDUs) may not be deriving the full benefits of HAART.58 For instance, prior studies have shown that IDUs are less likely to be prescribed HAART,912 and a recent international collaboration demonstrated that a history of injection drug use was an independent predictor of worse outcome with HAART.3 These reports may have contributed to an increasingly prevalent belief among clinicians that IDUs may be significantly less likely to benefit from antiretroviral therapy, and prior studies have shown that clinicians commonly withhold HAART from IDUs.1315

Earlier reports, however, have been limited by a number of important confounders. For example, it has been acknowledged that failure to examine causes of death in this population may bias the results because IDUs are known to have a higher risk of mortality from causes unrelated to HIV (eg, illicit drug overdoses).3,6,16 Other studies have been limited by having been conducted in the context of medical systems with significant financial barriers to HIV/AIDS care, which may disproportionately affect IDUs.3,8,9

This study was conducted to compare patterns of mortality between patients with and without a history of injection drug use among a cohort of antiretroviral-naive patients initiating HAART in a setting with free HIV/AIDS care.

The HAART Observational Medical Evaluation and Research (HOMER) study is a prospective observational cohort of all antiretroviral-naive patients aged 18 years or older initiating HAART in British Columbia, Canada, and has been described in detail elsewhere.2,17 Briefly, all antiretroviral-naive patients initiating HAART in the province are automatically enrolled into the study. The cohort is followed up in a unique environment with a centralized free antiretroviral distribution program and a province-wide vital statistics registry. This allows for an accurate ascertainment of cause of death for all participants as well as the opportunity to study outcomes from HIV treatment in a setting in which all financial barriers to all HIV/AIDS and other medical care are eliminated.2,17

In the present study, analyses were restricted to antiretroviral-naive HIV-infected men and women who were first prescribed triple drug antiretroviral therapy between August 1996 and June 2006, and who were followed up to June 30, 2007. Data were analyzed between November 1, 2007, and May 26, 2008. Participants were initially prescribed HAART with regimens composed of 2 nucleoside/nucleotide reverse-transcriptase inhibitors, plus a nonnucleoside reverse-transcriptase inhibitor, or a nonboosted protease inhibitor, or a ritonavir-boosted protease inhibitor, at the discretion of the enrolling physician.

The primary end point for this analysis was time to death. Deaths that occurred during the follow-up period were ascertained on a continuous basis from physician reports and through record linkages accomplished in conjunction with the British Columbia Division of Vital Statistics. The external linkage limited losses to follow-up and enabled all patients to be followed up until death or the end of the study period even if they discontinued HAART. In the primary analysis, we evaluated all-cause mortality. Causes of death that were unlikely to be attributable to HIV infection were defined as accidental causes of death, and we conducted subanalyses in which these deaths were censored at the time of death and classified as nonevents. As previously,2,17 accidental causes of death were defined by examining causes of death based on the International Statistical Classification of Diseases and Related Health Problems codes version 10.18 We hypothesized a priori that because IDUs may be more likely to experience accidental mortality from non–HIV-related causes, such as illicit drug overdoses, mortality rates would be most similar after accidental causes were treated as nonevents.

As an initial analysis, the baseline composition of the study cohort was compared and stratified by history of injection drug use. Characteristics of the baseline study population were compared using the Pearson χ2 test for dichotomous variables and the Wilcoxon rank-sum test for continuous variables.

For the comparison of unadjusted survival rates, Kaplan-Meier methods were used and patients were stratified based on history of injection drug use at enrollment. Cumulative mortality was compared at each 12-month interval by calculating 95% confidence intervals (CIs) using the Greenwood method.19 Based on exploratory analyses, we found that the assumption of proportional hazards was violated, and therefore the Wilcoxon test was used to compare the Kaplan-Meier survival curves.1921 To visually present the product limit estimates of the cumulative mortality rate while a reasonable proportion of the cohort remained under follow-up, Kaplan-Meier curves were generated to show survival over the first 84 months, and 95% CIs were calculated around the survival probabilities at each 12-month interval (including 84 months). However, the statistical comparison of the survival curves included all follow-up data for all participants.

Time-updated Cox regression models were used to calculate adjusted hazard ratios of mortality because the differences between IDUs and non-IDUs could confound a comparison of survival patterns.1921 Of note, the proportional hazards assumption was not relevant to the Cox regression analysis when time-updated covariates were used in the model.20 Potential confounders considered were defined identical to those in our prior reports2,17 and included age, sex, a prior diagnosis of AIDS (yes vs no), protease inhibitor use in the initial regimen (yes vs no), date of therapy initiation (before or after July 1, 1997), physician experience (per 100 patients enrolled), baseline CD4 cell count (<50, 50-199, or ≥200 cells/μL), baseline HIV RNA levels (log10 transformed), and 95% antiretroviral adherence (yes vs no).

Adjustment for protease inhibitor use in the initial regimen was performed due to potential differences in HAART prescribing practices for IDUs vs non-IDUs, and date of therapy initiation was adjusted for because July 1, 1997, represents the date that the province's therapeutic guidelines were revised to recommend HAART (rather than dual therapy) for all patients regardless of baseline plasma HIV RNA level.2,17 As previously described,2 adherence was estimated based on prescription refill compliance and time-updated based on compliance during each 6-month period from the antiretroviral start date.22

Potential confounders were selected for inclusion in the final models using a conservative backward-selection approach that considered the magnitude of change in the coefficient of the injection drug use variable. Specifically, starting with a fixed model, which considered all available variables, potential confounders were dropped one at a time, using the relative change in the coefficient for the variable related to the injection drug use variable as a criterion, until the maximum change from the full model exceeded 5%.23,24

The HIV/AIDS drug treatment program and the HOMER cohort, including mandated analyses deriving from them, such as those presented herein, have been vetted and approved by the University of British Columbia Research Ethics Board at its St Paul's Hospital site. Individuals in HOMER were not required to provide written informed consent for the purposes of the analyses presented herein. These administrative analyses occur within the context of a universal health care system in which individuals receive medical care, laboratory monitoring, and antiretrovirals free of charge. The ethical approval includes publication in scientific journals and presentations at scientific meetings.

The statistical analyses were conducted using SAS software version 9.1.3 (SAS Institute Inc, Cary, North Carolina). Because this was an observational study, a priori statistical power and sample size calculations were not conducted. The analyses involved 3116 individuals and 622 deaths; thus, we were confident that there was sufficient statistical power to adequately test for clinically relevant differences in mortality between patients with and without a history of injection drug use. The tests of significance were 2-sided, and a P value of less than .05 was used to indicate that an association was statistically significant.

During the study period (between August 1, 1996, and June 30, 2006), 3372 patients initiated HAART, among whom 256 individuals (7.6%) were excluded from the HOMER cohort for not having a baseline CD4 cell count and a plasma HIV RNA level available within 6 months prior to the start of antiretroviral therapy. Those excluded were more likely to be male (P<.001) and younger (P = .004), but there was no difference according to injection drug use status. These individuals were not eligible for the study and were not included in the Kaplan-Meier estimation analyses to avoid differing sample sizes between these and multivariate analyses. As noted, the group did not statistically differ by injection drug use status and such analyses would be expected to contribute little to the overall study.

Among the study sample of 3116 individuals, 915 were IDUs (29.4%), 579 were female (18.6%), and the median age was 39.4 years (interquartile range, 33.3-46.4 years). The median duration of follow-up was 5.3 years (interquartile range, 2.8-8.3 years) for IDUs and 4.3 years (interquartile range, 2.0-7.6 years) for non-IDUs. The Table shows the baseline characteristics of study participants stratified by history of injection drug use. In comparison with non-IDUs, patients with a history of injection drug use were more likely to have less-experienced physicians (P<.001), be female (P<.001), and be younger (P<.001). During the first year of follow-up, IDUs (40.7% vs 62.8%; P<.001) and female participants (37.8% vs 60.5%; P<.001) were less likely to be 95% adherent. Consistent with previous analyses,2,22 adherent patients had improved survival (data not shown).

Table Graphic Jump LocationTable. Baseline Characteristics of 3116 Antiretroviral-Naive Patients Initiating HAART Between August 1996 and June 2006

Overall, among the study sample of 3116 individuals, 622 individuals died (20.0%; 95% CI, 18.4%-21.5%) during the study period (232 IDUs and 390 non-IDUs). When causes of death were examined, 535 were deemed nonaccidental (86%) based on a review of the International Statistical Classification of Diseases and Related Health Problems codes,18 of which 373 were deemed to be due to HIV (70.0%), 26 due to cardiovascular causes (4.2%), 21 due to liver disease (3.4%), 17 due to malignancies (2.7%), and 98 were coded as being due to various other medical causes (15.8%). Among the 87 deaths defined as accidental (14.0%), there were 62 accidental poisonings (71.2%), 16 suicides (18.4%), 6 traumas (6.9%), and 3 other causes (3.4%). As anticipated, accidental causes of death were more common among IDUs than among non-IDUs (49 [21.1%] vs 38 [9.7%], respectively; P = .003).

As shown in the Figure, through 84 months after the initiation of HAART, the product limit estimate of the cumulative all-cause mortality rate was not statistically different between the 915 IDUs (26.5%; 95% CI, 23.2%-29.8%) and 2201 non-IDUs (21.6%; 95% CI, 16.9%-26.2%) (Wilcoxon P = .47). In multivariate time-updated Cox regression, the hazard ratio of mortality between IDUs and non-IDUs was 1.09 (95% CI, 0.92-1.29) after adjustment for age, sex, baseline AIDS diagnosis, baseline CD4 cell count, adherence, and physician experience.

Place holder to copy figure label and caption
Figure. Mortality Rate Among 3116 Antiretroviral-Naive Patients Initiating HAART
Graphic Jump Location

Overall, there were 622 deaths and the analysis of nonaccidental mortality censored 87 deaths (14.0%) as nonevents among which 62 deaths (71.2%) were accidental poisonings, 16 were suicides (18.3%), 6 were traumas (<0.1%), and 3 were classified as other (<0.1%). Survival curves were compared using the Wilcoxon test and all follow-up data for all participants. Error bars indicate 95% confidence intervals; HAART, highly active antiretroviral therapy; IDU, injection drug user.

Subanalyses were conducted for the purpose of focusing on causes of death that were more likely attributable to HIV infection; the 87 accidental causes of death (14.0%) were censored as nonevents. As shown in the Figure, through 84 months after the initiation of HAART, the product limit estimate of the cumulative nonaccidental mortality rate was not statistically different between the 915 IDUs (22.4%; 95% CI, 19.2%-25.5%) and 2201 non-IDUs (19.1%; 95% CI, 17.1%-21.0%) (Wilcoxon P = .96). In the multivariate Cox regression, the hazard ratio of nonaccidental mortality between the IDUs and non-IDUs was 1.06 (95% CI, 0.88-1.27) after adjustment for age, sex, baseline AIDS diagnosis, baseline CD4 cell count, adherence, and physician experience.

The present study demonstrated mortality rates that were not significantly different between HIV-infected IDUs and non-IDUs initiating HAART in a population-based setting. Although subtle differences in survival began to emerge by 84 months, 5-year survival was virtually identical in the analysis that censored accidental causes of death (Figure). Mortality rates were not statistically different even when all-cause mortality and the entire follow-up duration were considered.

While observational studies are often considered to be limited with respect to evaluating treatment modalities, the present study is well suited for comparing real-world outcomes from HAART among IDUs and non-IDUs in a populational setting. Furthermore, the local context provides an excellent opportunity to compare survival patterns in a setting in which the potentially confounding effects of financial barriers to medical care are removed. Although it is not possible to know if the HOMER cohort is entirely representative of all HIV-infected individuals in the province, surveillance estimates indicate that similar proportions of IDUs and non-IDUs are included in the HOMER cohort.25

This study has several limitations. Most importantly, because this is an observational study, no conclusions about causality can be made. In addition, although our multivariate analyses adjusted for the key clinical and behavioral predictors of survival, unmeasured confounders may not have been adjusted for. For instance, although the vast majority of IDUs in the province use HAART without adherence-support programs, there are small, daily administered HAART programs accessed by some of the most unstable and mentally ill individuals.26

A further limitation is that we only had baseline data on injection drug use and we were not able to assess the impact of ongoing drug use. Finally, it is important to stress that we only considered patients who were prescribed HAART, and we have previously shown how IDUs are more likely to die without accessing HIV treatment.10 Thus, if we compared survival between all HIV-infected individuals in our setting, it is likely that mortality rates would be higher among IDUs.

Although our findings cannot be generalized outside of the HOMER cohort, as efforts to improve use of HAART among IDUs expand,27 the fact that survival patterns were not significantly different between IDUs and non-IDUs should help to challenge the increasingly prevalent belief that IDUs may be markedly less likely to benefit from HAART.13,14 Based on these results, we conclude that HAART regimens may have effectiveness at a populational level that is not significantly different regarding the survival of individuals with and without a history of injection drug use.

Corresponding Author: Julio S. G. Montaner, MD, FRCPC, AIDS Research Program, University of British Columbia and St Paul's Hospital, 667-1081 Burrard St, Vancouver, BC V6Z 1Y6 Canada (jmontaner@cfenet.ubc.ca).

Author Contributions: Dr Montaner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Wood, Hogg, Kerr, Montaner.

Acquisition of data: Wood, Hogg, Kerr, Yip.

Analysis and interpretation of data: Wood, Lima, Yip, Marshall.

Drafting of the manuscript: Wood.

Critical revision of the manuscript for important intellectual content: Wood, Hogg, Lima, Kerr, Yip, Marshall, Montaner.

Statistical analysis: Wood, Lima, Yip, Marshall.

Obtained funding: Wood, Hogg, Kerr.

Administrative, technical, or material support: Hogg, Lima, Kerr.

Study supervision: Wood, Montaner.

Financial Disclosures: Dr Hogg reported receiving funding for research and continuing medical education programs from Abbott, Boehringer Ingelheim, and GlaxoSmithKline. Dr Montaner reported receiving educational grants from and serving as an ad hoc advisor to or speaking at various events sponsored by Abbott Laboratories, Agouron Pharmaceuticals Inc, Boehringer Ingelheim Pharmaceuticals Inc, Borean Pharma AS, Bristol-Myers Squibb, DuPont Pharma, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Immune Response Corporation, Incyte, Janssen-Ortho Inc, Kucera Pharmaceutical Company, Merck Frosst Laboratories, Pfizer Canada Inc, Sanofi Pasteur, Shire Biochem Inc, Tibotec Pharmaceuticals Ltd, and Trimeris Inc. No other authors reported disclosures.

Funding/Support: Dr Kerr is supported by a Canadian Institutes of Health Research New Investigator Award and a Michael Smith Foundation for Health Research Scholar Award. Dr Dias Lima is supported by the Canadian Institutes of Health Research through a fellowship award.

Role of the Sponsor: The Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Additional Contributions: We thank Kathy Li, MSc, Peter Vann, BA, Deborah Graham, LLB, and Kelly Hsu, BA (British Columbia Centre for Excellence in HIV/AIDS, Vancouver) for their administrative support. No compensation was received directly related to clerical support for this study. We also thank the US National Institute on Drug Abuse.

Hammer SM, Squires KE, Hughes MD,  et al; AIDS Clinical Trials Group 320 Study Team.  A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less.  N Engl J Med. 1997;337(11):725-733
PubMed   |  Link to Article
Wood E, Hogg RS, Yip B, Harrigan PR, O'Shaughnessy MV, Montaner JS. Effect of medication adherence on survival of HIV-infected adults who start highly active antiretroviral therapy when the CD4+ cell count is 0.200 to 0.350 x 10(9) cells/L.  Ann Intern Med. 2003;139(10):810-816
PubMed   |  Link to Article
Egger M, May M, Chene G,  et al.  Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies.  Lancet. 2002;360(9327):119-129
PubMed   |  Link to Article
Chander G, Himelhoch S, Moore RD. Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy.  Drugs. 2006;66(6):769-789
PubMed   |  Link to Article
Wood E, Kerr T, Montaner JS. HIV treatment, injection drug use, and illicit drug policies.  Lancet. 2007;370(9581):8-10
PubMed   |  Link to Article
Lert F, Kazatchkine MD. Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview.  Int J Drug Policy. 2007;18(4):255-261
PubMed   |  Link to Article
Aceijas C, Oppenheimer E, Stimson GV, Ashcroft RE, Matic S, Hickman M. Antiretroviral treatment for injecting drug users in developing and transitional countries 1 year before the end of the “treating 3 million by 2005: making it happen: the WHO strategy” (“3 by 5”).  Addiction. 2006;101(9):1246-1253
PubMed   |  Link to Article
Poundstone KE, Chaisson RE, Moore RD. Differences in HIV disease progression by injection drug use and by sex in the era of highly active antiretroviral therapy.  AIDS. 2001;15(9):1115-1123
PubMed   |  Link to Article
Shapiro MF, Morton SC, McCaffrey DF,  et al.  Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study.  JAMA. 1999;281(24):2305-2315
PubMed   |  Link to Article
Wood E, Montaner JS, Schechter MT, Tyndall MW, O'Shaughnessy MV, Hogg RS. Prevalence and correlates of untreated HIV-1 infection in the era of modern antiretroviral therapy.  J Infect Dis. 2003;188(8):1164-1170
PubMed   |  Link to Article
Bruce RD, Altice FL. Clinical care of the HIV-infected drug user.  Infect Dis Clin North Am. 2007;21(1):149-179
PubMed   |  Link to Article
Mocroft A, Madge S, Johnson AM,  et al.  A comparison of exposure groups in the EuroSIDA study: starting highly active antiretroviral therapy (HAART), response to HAART, and survival.  J Acquir Immune Defic Syndr. 1999;22(4):369-378
PubMed   |  Link to Article
Maisels L, Steinberg J, Tobias C. An investigation of why eligible patients do not receive HAART.  AIDS Patient Care STDS. 2001;15(4):185-191
PubMed   |  Link to Article
Loughlin A, Metsch L, Gardner L, Anderson-Mahoney P, Barrigan M, Strathdee S. Provider barriers to prescribing HAART to medically-eligible HIV-infected drug users.  AIDS Care. 2004;16(4):485-500
PubMed   |  Link to Article
Ding L, Landon BE, Wilson IB, Wong MD, Shapiro MF, Cleary PD. Predictors and consequences of negative physician attitudes toward HIV-infected injection drug users.  Arch Intern Med. 2005;165(6):618-623
PubMed   |  Link to Article
Mocroft A, Gatell J, Reiss P,  et al.  Causes of death in HIV infection: the key determinant to define the clinical response to anti-HIV therapy.  AIDS. 2004;18(17):2333-2337
PubMed   |  Link to Article
Hogg RS, Yip B, Chan KJ,  et al.  Rates of disease progression by baseline CD4 cell count and viral load after initiating triple-drug therapy.  JAMA. 2001;286(20):2568-2577
PubMed   |  Link to Article
World Health Organization.  International Statistical Classification of Diseases and Related Health Problems version for 2007. http://www.who.int/classifications/apps/icd/icd10online/. Accessibility verified June 26, 2008
Collett D. Modelling Survival Data in Medical Research. New York, NY: Chapman & Hall; 1994
Allison PD. Survival Analysis Using SAS: A Practical Guide. 7th ed. Cary, NC: SAS Press; 2004
Parmar MK, Machin D. Survival Analysis: A Practical Approach. New York, NY: Wiley; 1995
Gross R, Yip B, Lo Re V III,  et al.  A simple, dynamic measure of antiretroviral therapy adherence predicts failure to maintain HIV-1 suppression.  J Infect Dis. 2006;194(8):1108-1114
PubMed   |  Link to Article
Lima VD, Geller J, Bangsberg DR,  et al.  The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART.  AIDS. 2007;21(9):1175-1183
PubMed   |  Link to Article
Maldonado G, Greenland S. Simulation study of confounder-selection strategies.  Am J Epidemiol. 1993;138(11):923-936
PubMed
Public Health Agency of Canada.  Estimates of HIV prevalence and incidence in Canada 2005. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/06vol32/dr3215ea.html. Accessed May 25, 2006
Tyndall MW, McNally M, Lai C,  et al.  Directly observed therapy programmes for anti-retroviral treatment amongst injection drug users in Vancouver: access, adherence and outcomes.  Int J Drug Policy. 2007;18(4):281-287
PubMed   |  Link to Article
Ball AL. Universal access to HIV/AIDS treatment for injecting drug users: keeping the promise.  Int J Drug Policy. 2007;18(4):241-245
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure. Mortality Rate Among 3116 Antiretroviral-Naive Patients Initiating HAART
Graphic Jump Location

Overall, there were 622 deaths and the analysis of nonaccidental mortality censored 87 deaths (14.0%) as nonevents among which 62 deaths (71.2%) were accidental poisonings, 16 were suicides (18.3%), 6 were traumas (<0.1%), and 3 were classified as other (<0.1%). Survival curves were compared using the Wilcoxon test and all follow-up data for all participants. Error bars indicate 95% confidence intervals; HAART, highly active antiretroviral therapy; IDU, injection drug user.

Tables

Table Graphic Jump LocationTable. Baseline Characteristics of 3116 Antiretroviral-Naive Patients Initiating HAART Between August 1996 and June 2006

References

Hammer SM, Squires KE, Hughes MD,  et al; AIDS Clinical Trials Group 320 Study Team.  A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less.  N Engl J Med. 1997;337(11):725-733
PubMed   |  Link to Article
Wood E, Hogg RS, Yip B, Harrigan PR, O'Shaughnessy MV, Montaner JS. Effect of medication adherence on survival of HIV-infected adults who start highly active antiretroviral therapy when the CD4+ cell count is 0.200 to 0.350 x 10(9) cells/L.  Ann Intern Med. 2003;139(10):810-816
PubMed   |  Link to Article
Egger M, May M, Chene G,  et al.  Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies.  Lancet. 2002;360(9327):119-129
PubMed   |  Link to Article
Chander G, Himelhoch S, Moore RD. Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy.  Drugs. 2006;66(6):769-789
PubMed   |  Link to Article
Wood E, Kerr T, Montaner JS. HIV treatment, injection drug use, and illicit drug policies.  Lancet. 2007;370(9581):8-10
PubMed   |  Link to Article
Lert F, Kazatchkine MD. Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview.  Int J Drug Policy. 2007;18(4):255-261
PubMed   |  Link to Article
Aceijas C, Oppenheimer E, Stimson GV, Ashcroft RE, Matic S, Hickman M. Antiretroviral treatment for injecting drug users in developing and transitional countries 1 year before the end of the “treating 3 million by 2005: making it happen: the WHO strategy” (“3 by 5”).  Addiction. 2006;101(9):1246-1253
PubMed   |  Link to Article
Poundstone KE, Chaisson RE, Moore RD. Differences in HIV disease progression by injection drug use and by sex in the era of highly active antiretroviral therapy.  AIDS. 2001;15(9):1115-1123
PubMed   |  Link to Article
Shapiro MF, Morton SC, McCaffrey DF,  et al.  Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study.  JAMA. 1999;281(24):2305-2315
PubMed   |  Link to Article
Wood E, Montaner JS, Schechter MT, Tyndall MW, O'Shaughnessy MV, Hogg RS. Prevalence and correlates of untreated HIV-1 infection in the era of modern antiretroviral therapy.  J Infect Dis. 2003;188(8):1164-1170
PubMed   |  Link to Article
Bruce RD, Altice FL. Clinical care of the HIV-infected drug user.  Infect Dis Clin North Am. 2007;21(1):149-179
PubMed   |  Link to Article
Mocroft A, Madge S, Johnson AM,  et al.  A comparison of exposure groups in the EuroSIDA study: starting highly active antiretroviral therapy (HAART), response to HAART, and survival.  J Acquir Immune Defic Syndr. 1999;22(4):369-378
PubMed   |  Link to Article
Maisels L, Steinberg J, Tobias C. An investigation of why eligible patients do not receive HAART.  AIDS Patient Care STDS. 2001;15(4):185-191
PubMed   |  Link to Article
Loughlin A, Metsch L, Gardner L, Anderson-Mahoney P, Barrigan M, Strathdee S. Provider barriers to prescribing HAART to medically-eligible HIV-infected drug users.  AIDS Care. 2004;16(4):485-500
PubMed   |  Link to Article
Ding L, Landon BE, Wilson IB, Wong MD, Shapiro MF, Cleary PD. Predictors and consequences of negative physician attitudes toward HIV-infected injection drug users.  Arch Intern Med. 2005;165(6):618-623
PubMed   |  Link to Article
Mocroft A, Gatell J, Reiss P,  et al.  Causes of death in HIV infection: the key determinant to define the clinical response to anti-HIV therapy.  AIDS. 2004;18(17):2333-2337
PubMed   |  Link to Article
Hogg RS, Yip B, Chan KJ,  et al.  Rates of disease progression by baseline CD4 cell count and viral load after initiating triple-drug therapy.  JAMA. 2001;286(20):2568-2577
PubMed   |  Link to Article
World Health Organization.  International Statistical Classification of Diseases and Related Health Problems version for 2007. http://www.who.int/classifications/apps/icd/icd10online/. Accessibility verified June 26, 2008
Collett D. Modelling Survival Data in Medical Research. New York, NY: Chapman & Hall; 1994
Allison PD. Survival Analysis Using SAS: A Practical Guide. 7th ed. Cary, NC: SAS Press; 2004
Parmar MK, Machin D. Survival Analysis: A Practical Approach. New York, NY: Wiley; 1995
Gross R, Yip B, Lo Re V III,  et al.  A simple, dynamic measure of antiretroviral therapy adherence predicts failure to maintain HIV-1 suppression.  J Infect Dis. 2006;194(8):1108-1114
PubMed   |  Link to Article
Lima VD, Geller J, Bangsberg DR,  et al.  The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART.  AIDS. 2007;21(9):1175-1183
PubMed   |  Link to Article
Maldonado G, Greenland S. Simulation study of confounder-selection strategies.  Am J Epidemiol. 1993;138(11):923-936
PubMed
Public Health Agency of Canada.  Estimates of HIV prevalence and incidence in Canada 2005. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/06vol32/dr3215ea.html. Accessed May 25, 2006
Tyndall MW, McNally M, Lai C,  et al.  Directly observed therapy programmes for anti-retroviral treatment amongst injection drug users in Vancouver: access, adherence and outcomes.  Int J Drug Policy. 2007;18(4):281-287
PubMed   |  Link to Article
Ball AL. Universal access to HIV/AIDS treatment for injecting drug users: keeping the promise.  Int J Drug Policy. 2007;18(4):241-245
PubMed   |  Link to Article
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 82

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com