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Abstract
BackgroundAlthough the survival benefits of antiretroviral therapy (ART) for the treatment of HIV infection are well established, the clinical management of HIV disease continues to present major challenges. There are particular concerns regarding access to appropriate HIV treatment among HIV-infected injection drug users (IDU).MethodsIn a prospective cohort study of HIV-infected IDU in Vancouver, Canada, we examined initial ART regimens vis-à-vis the provincial government's therapeutic guidelines at the time ART was initiated. Briefly, there have been four sets of guidelines: Era 1 (1992 to November 1995; double-drug (dual NRTIs) ART for patients with a CD4 cell count of 350 or less); Era 2 (December 1995 to May 1996; double-drug therapy for patients with a CD4+ cell count of 500 or less); Era 3 (June 1996 to June 1997; triple-drug therapy (dual NRTIs with a PI or NNRTI) for patients who had a plasma viral load of > 100,000 HIV-1 RNA copies/mL; dual therapy with two NRTIs for those with a plasma viral load of 5,000 to 100,000 HIV-1 RNA copies/mL); Era 4 (since July 1997; universal use of triple drug therapy as first-line treatment).ResultsBetween May 1996 and May 2003, 431 HIV-infected individuals were enrolled into the cohort. By May 31, 2003, 291 (67.5%) individuals had initiated ART. We noted instances of inappropriate antiretroviral prescription in each guideline era, with 9 (53%) in Era 1, 3 (12%) in Era 2, 22 (28%) in Era 3, and 23 (15%) in Era 4. Of the 57 subjects who received an inappropriate ART regimen initially, 14 never received the appropriate therapy; among the remaining 43, the median time to the initiation of a guideline-appropriate ART regimen was 12 months (inter-quartile range 5 – 20).ConclusionThe present study identified measurable rates of guideline-inappropriate ART prescription for patients who were injection drug users. Rates were highest in the era of dual therapy, although high rates persisted into the triple-therapy era. As therapeutic guidelines continue to evolve, it is critical that mechanisms be put in place to ensure prescription of ART combinations for IDU that are consistent with current expert recommendations.
Highlights
The survival benefits of antiretroviral therapy (ART) for the treatment of HIV infection are well established, the clinical management of HIV disease continues to present major challenges
The primary endpoint of interest in the present analysis was the content of the initial ART regimen, and we were interested in the rate of antiretroviral therapy use that was inconsistent with the recommendations of the province's therapeutic guidelines at the time antiretroviral therapy was initiated
Between May 1996 and May 2003, 431 HIV infected individuals were enrolled into the Barriers to Antiretroviral Therapy (BART) cohort
Summary
The survival benefits of antiretroviral therapy (ART) for the treatment of HIV infection are well established, the clinical management of HIV disease continues to present major challenges. There are particular concerns regarding access to appropriate HIV treatment among HIVinfected injection drug users (IDU). Since the introduction of antiretroviral therapy (ART) in the mid-1990s, the survival benefits of this treatment for the management of HIV infection have been well established [1,2,3,4]. Previous studies have demonstrated that persons initially prescribed non-HAART regimens consisting of only one or two antiretroviral drugs have a lesser virologic response [19, 20], as well as significantly shorter survival than persons who initiate therapy with HAART [21, 22]. Since the advent of ART, there have been growing concerns regarding access to HIV treatment among HIVinfected injection drug users (IDU) [6,7]. We examined the rate of ART in a prospective cohort of HIV-infected injection drug users and examined the prevalence of ART prescriptions that were inappropriate, given the recommendations of therapeutic guidelines at the time ART was initiated
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