Abstract
BackgroundCrack cocaine use is known to contribute to poor adherence to antiretroviral medications; however, little is known about facilitators of or barriers to effective HIV treatment use among HIV-infected crack cocaine users. We sought to identify correlates of optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA viral load (pVL) suppression among this population.MethodsData from a prospective cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, were linked to comprehensive HIV clinical monitoring and pharmacy dispensation records. We used multivariable generalized linear mixed-effects modelling to longitudinally identify factors associated with ≥95 % adherence to pharmacy refills for antiretroviral medications and pVL <50 copies/mL among crack cocaine users exposed to highly-active antiretroviral therapy (HAART).ResultsAmong 438 HAART-exposed crack cocaine users between 2005 and 2013, 240 (54.8 %) had ≥95 % pharmacy refill adherence in the previous 6 months at baseline. In multivariable analyses, homelessness (adjusted odds ratio [AOR]: 0.58), ≥daily crack cocaine smoking (AOR: 0.64), and ≥ daily heroin use (AOR: 0.43) were independently associated with optimal pharmacy refill adherence (all p < 0.05). The results for pVL non-detectability were consistent with those of medication adherence, except that longer history of HAART (AOR: 1.06), receiving a single tablet-per-day regimen (AOR: 3.02) and participation in opioid substitution therapies was independently associated with pVL non-detectability (AOR: 1.55) (all p < 0.05).ConclusionsHomelessness, and daily crack cocaine and/or heroin use were independently and negatively associated with optimal HAART-related outcomes. With the exception of opioid substitution therapies, no addiction treatment modalities assessed appeared to facilitate medication adherence or viral suppression. Evidence-based treatment options for crack cocaine use that also confer benefits to HAART need to be developed.
Highlights
Crack cocaine use is known to contribute to poor adherence to antiretroviral medications; little is known about facilitators of or barriers to effective HIV treatment use among HIV-infected crack cocaine users
Since our study aimed to identify the set of variables that best explains a higher odds of optimal pharmacy refill adherence and plasma HIV RNA viral load (pVL) non-detectability, respectively, we used a priori-defined statistical protocol based on the examination of the Akaike information criterion (AIC) and Type III p-values to construct multivariable generalized linear mixed-effects modelling (GLMM) logistic regression models
In total, 438 Highly-active antiretroviral therapy (HAART)-exposed crack cocaine users were included in this study, of whom 293 (66.9 %) were male and 239 (54.6 %) self-reported Caucasian ancestry
Summary
Crack cocaine use is known to contribute to poor adherence to antiretroviral medications; little is known about facilitators of or barriers to effective HIV treatment use among HIV-infected crack cocaine users. In 2014, the Treatment-as-Prevention (TasP) approach, which aims to expand access and adherence to HAART among people living with HIV and thereby prevent HIV transmission, was incorporated into the global HIV/ AIDS response strategies by the Joint United Nations Programme on HIV/AIDS [11]. This is likely a potentially effective HIV prevention approach to address HIV transmission associated with persistent high-risk behaviour among HIV-infected crack cocaine users [12]. A more recent study found that stimulant users, those who used cocaine/crack cocaine, had seven times higher odds of HAART adherence failure (i.e.,
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