Context.— The US Public Health Service and the International AIDS Society–USA
recently published recommendations for antiretroviral therapy (ART) for persons
infected with human immunodeficiency virus (HIV); however, anecdotal evidence
suggests that HIV-infected injection drug users (IDUs) may not be receiving
optimal care as defined by the recommendations.
Objective.— To assess ART use in HIV-infected IDUs.
Design.— A cross-sectional survey of self-reported ART use between July 1996
and June 1997 in IDUs.
Setting.— A community-based clinic affiliated with Johns Hopkins University, Baltimore,
Participants.— A total of 404 HIV-infected IDUs with CD4+ cell counts less
than 0.50×109/L recruited into a longitudinal study in 1988
Main Outcome Measure.— Self-reported ART use was assessed: no current therapy, monotherapy,
or combination therapy with or without a protease inhibitor.
Results.— One half (199/404 [49%]) of patients reported no recent ART. A total
of 14% (58/404) had monotherapy, 23% (90/404) were receiving combination therapy
without a protease inhibitor, and 14% (57/404) had triple-combination therapy
with a protease inhibitor. A multivariate analysis of factors associated with
ART showed that care continuity and recent HIV-related outpatient visit (odds
ratio [OR], 4.30; 95% confidence interval [CI], 2.36-7.81 and OR, 2.84; 95%
CI, 1.66-4.88, respectively), CD4+ cell count of less than 0.20×109 (OR, 2.41; 95% CI, 1.51-3.84), no current drug use and being in drug
treatment (OR, 2.16; 95% CI, 1.34-3.47; OR, 2.12; 95% CI, 1.23-3.66, respectively),
and unemployment (OR, 2.31; 95% CI, 1.21-4.40) were associated with reporting
ART use. In other analysis, less likely to receive protease inhibitors were
current drug injectors (OR, 0.5; 95% CI, 0.3-1.0) and those recently incarcerated
(OR, 0.2; 95% CI, 0.03-0.9), but patients with acquired immunodeficiency syndrome
were more likely to receive protease inhibitors (OR, 2.0; 95% CI, 0.9-4.6).
Protease inhibitor use doubled (P<.01) from July
and December 1996 to January and June 1997 (7.7% and 14.8%, respectively).
Conclusions.— Those IDUs infected with HIV who were not receiving ART tended to be
active drug users without clinical disease who have less contact with health
care providers. Although we do not have information on clinical judgment regarding
treatment decisions or whether persons were prescribed therapy not taken,
the proportion of subjects reporting receiving ART suggests that strategies
for improving treatment in this population are indicated. Expanding simultaneous
treatment services for HIV infection and substance abuse would enhance the
response to these related epidemics.