Highly active antiretroviral therapy among HIV-infected people with alcohol and substance misuse problems: the impact of substance abuse treatment.

Abstract

The aims of a recent study published in Addiction were ‘to examine the association of substance abuse treatment with the uptake adherence and virological response to highly active antiretroviral therapy (HAART), among HIV infected people with alcohol and other substance abuse problems’ (Palepu et al. 2004). In this article the authors report that substance abuse treatment was found to be associated with the receipt of HAART, however, it was not found to be associated with adherence, or HIV viral load suppression. They go on to suggest that efforts to maximize the effect of substance abuse treatment programs on adherence to antiretrovirals and HIV treatment outcomes among HIV infected people with alcohol and drug problems, merit further examination in clinical trials. We would like to draw your attention to an article by Clarke et al. (2002) which examines the use of directly observed therapy (DOT) for injecting drug users with HIV infection. This prospective observational study was conducted in order to determine the efficacy of directly observed antiretroviral therapy, which was provided in conjunction with daily-observed methadone maintenance therapy. The authors report that at 48 weeks, 51% of antiretroviral-experienced patients and 65% of antiretroviral-naïve patients had achieved maximum viral suppression. This study was conducted in a methadone maintenance treatment clinic where patients are required to attend daily until stable with respect to their drug use. Patients are dispensed all medications on site under observation and are also offered continued counselling, social support, as well as regular psychiatric and medical reviews. A liaison service also operates between this service and the department of genitourinary medicine and infectious diseases at the regional hospital where the mainstay of treatment for HIV positive patients is provided. Although HAART has been a major breakthrough in the treatment of patients with HIV, many studies report that adherence remains a barrier to successful antiretroviral therapy, as rates of >95% are necessary in order for it to be effective. Patients have been reported to offer a range of reasons for non-adherence, and one of the most frequently reported is that they simply forget (Bartlett 2002). Other additional barriers to adherence often include substance misuse, depression, other psychiatric disorders, regime complexity, and side-effects. Consistent participation in methadone maintenance therapy has already been shown to be associated with a higher probability of antiretroviral use and, among antiretroviral users, more consistent use of antiretrovirals (Sambamoorthi et al. 2000). In the above treatment setting, many of these barriers to the adherence of HAART are also addressed, and this in conjunction with DOT appears to be effective, and should therefore be considered a potential option for providing HAART to this group of patients.