Abstract
BackgroundBarriers to HIV treatment among injection drug users (IDU) are a major public health concern. However, there remain few long-term studies investigating key demographic and behavioral factors - and gender differences in particular - that may pose barriers to antiretroviral therapy (ART), especially in settings with universal healthcare. We evaluated access and adherence to ART in a long-term cohort of HIV-positive IDU in a setting where medical care and antiretroviral therapy are provided free of charge through a universal healthcare system.MethodsWe evaluated baseline antiretroviral use and subsequent adherence to ART among a Canadian cohort of HIV-positive IDU. We used generalized estimating equation logistic regression to evaluate factors associated with 95% adherence to antiretroviral therapy estimated based on prescription refill compliance.ResultsBetween May 1996 and April 2008, 545 IDU participants were followed for a median of 23.8 months (Inter-quartile range: 8.5 - 91.6), among whom 341 (63%) were male and 204 (37%) were female. Within the six-month period prior to the baseline interview, 133 (39%) men and 62 (30%) women were on ART (p = 0.042). After adjusting for clinical characteristics as well as drug use patterns measured longitudinally throughout follow-up, female gender was independently associated with a lower likelihood of being 95% adherent to ART (Odds Ratio [OR] = 0.70; 95% Confidence Interval: 0.53-0.93).ConclusionsDespite universal access to free HIV treatment and medical care, female IDU were less likely to access and adhere to antiretroviral therapy, a finding that was independent of drug use and clinical characteristics. These data suggest that interventions to improve access to HIV treatment among IDU must be tailored to address unique barriers to antiretroviral therapy faced by female IDU.
Highlights
Barriers to HIV treatment among injection drug users (IDU) are a major public health concern
The present study demonstrates that female IDU are approximately 30% less likely to adhere to antiretroviral therapy (ART), an association that persisted after intensive covariate adjustment
To our knowledge this is the first long-term study to assess key demographic and behavioural factors associated with ART adherence within a communityrecruited cohort and within a context of a universal healthcare system, and implies that barriers to adherence among female IDU that are not explained by financial barriers
Summary
Barriers to HIV treatment among injection drug users (IDU) are a major public health concern. There remain few long-term studies investigating key demographic and behavioral factors - and gender differences in particular - that may pose barriers to antiretroviral therapy (ART), especially in settings with universal healthcare. We evaluated access and adherence to ART in a long-term cohort of HIV-positive IDU in a setting where medical care and antiretroviral therapy are provided free of charge through a universal healthcare system. Recent injection drug use is associated with both non-adherence to ART and HIV disease progression [7,8], and many IDU live in unstable housing, have undiagnosed or untreated mental illness, high rates of incarceration, and street-involved survival-lifestyles, which may all complicate delivery of HIV-related treatments [9,10]. There remain few longterm, prospective studies assessing gender as a factor that affects adherence conducted within a setting of universal healthcare
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