Association of ongoing drug and alcohol use with non-adherence to antiretroviral therapy and higher risk of AIDS and death: results from ACTG 362

Abstract

Drug and alcohol use have been associated with a worse prognosis in short-term and cross-sectional analyses of HIV-infected populations, but longitudinal effects on adherence to antiretroviral therapy (ART) and clinical outcomes in advanced AIDS are less well characterized. We assessed self-reported drug and alcohol use in AIDS patients, and examined their association with non-adherence and death or disease progression in a multicenter observational study. We defined non-adherence as reporting missed ART doses in the 48 hours before study visits. The association between drug use and ART non-adherence was evaluated using repeated measures generalized estimating equation (GEE) models. The association between drug and alcohol use and time to new AIDS diagnosis or death was evaluated via Cox regression models, controlling for covariates including ART adherence. Of 643 participants enrolled between 1997 and 1999 and followed through 2007, at entry 39% reported ever using cocaine, 24% amphetamines, and 10% heroin. Ongoing drug use during study follow-up was reported by 9% using cocaine, 4% amphetamines, and 1% heroin. Hard drug (cocaine, amphetamines, or heroin) users had 2.1 times higher odds (p=0.001) of ART non-adherence in GEE models and 2.5 times higher risk (p=0.04) of AIDS progression or death in Cox models. Use of hard drugs was attenuated as a risk factor for AIDS progression or death after controlling for non-adherence during follow-up (HR = 2.11, p=0.08), but was still suggestive of a possible adherence-independent mechanism of harm. This study highlights the need to continuously screen and treat patients for drug use as a part of ongoing HIV care.

Keywords:

• substance use
• drug use
• alcohol use
• HIV/AIDS
• outcomes
• adherence
• antiretroviral therapy
• mortality

Acknowledgements

We thank the study participants and the following institutions and individuals for their participation in ACTG 362: Bev Putnam, MSN and Graham Ray, MSN – University of Colorado Health Sciences Center (A6101): CTU Grant nos. AI69450, AI054907, and GCRC Grant no. RR025780; Harold Kessler, MD and Elke Narkiewicz, RN – Rush Presbyterian/St. Luke's (A2702): CTU Grant no. AI25915; Baiba Berzins, MPH – Northwestern University (Site A2701): CTU Grant no. AI06947; Oluwatoyin Adeyemi, MD – Cook County CORE Center (A2705): CTU Grant no. AI25915; Susan Cahill, RN and Julie Hoffman, RN – University of California, San Diego Antiviral Res (A0701): CTU Grant no. AI69432; Robert A. Salata, MD and Patricia Walton BSN RN – Case Western University (A2501): CTU Grant no. AI69501; Akron City Hospital, Summa Health Systems (A2506); Jody Lawrence, MD and Mary Payne, BS, BA, RN – UCSF, San Francisco General Hospital (A0801): CTU Grant no. 5UO1 AI069502-03; Jane Reid, RNc, MS, ANP and Carol Greisberger, RN – University of Rochester Medical Center (A1101): CTU Grant no. AI27658 and GCRC Grant no. RR00044; Tammy O'Hara, RN and Gene Morse, PharmD – University of Buffalo (A1102); Jane Norris, PA-C and Sandra Valle, PA-c – Stanford University (A0501): CTU Grant no. AI 69556; Connie A. Funk, RN, MPH and Frances Canchola, RN – University of Southern California (A1201): CTU Grant no. AI27673; Susan L. Koletar, MD and Kathy Watson, RN – Ohio State University (A2301): CTU Grant no. 1U01 AI 69474; Charlene Gaca, RN and Timothy Cooley, MD – Boston Medical Center (A0104): CTU Grant no. AI069472; Mallory Witt, MD and Sadia Shaik – Harbor UCLA Medical Center (A0603): CTU Grant no. AI069424; Janet Forcht, RN and Judith Aberg, MD – New York University/NYC HHC at Bellevue Hospital Center (A0401): CTU Grant nos. AI27665 and AI069532; GCRC Grant no. RR00096; Marshall Glesby and Valery Hughes – Cornell University (A2201) Weill Medical College: GCRC Grant no. RR00047; Memorial Sloan-Kettering (A2202); Sheryl Storey, PA-C and Jeff Schouten, MD – University of Washington, Seattle (A1401): Grant no. AI27664; Henry H. Balfour, Jr., MD and Christine Fietzer, RN, BSN – University of Minnesota (A1501): Grant no. AI27661, University of Alabama at Birmingham (A5801); Clifford Gunthel, MD and Ericka R. Patrick, MSN – Emory University HIV/AIDS Clinical Trials Unit (A5802): CTU Grant no. A1069418; Richard B. Pollard, MD and Gerianne Casey, RN – University of Texas, Galveston (A6301): CTU Grant no. AI032782; Mark Rodriguez, RN and Lisa Kessels, RN, ACRN, CCRC – Washington University (A2101): CTU Grant no. AI25903; Judith Feinberg, MD and Tammy Mansfield, RN ACRN – University of Cincinnati College of Medicine (A2401): CTU Grant no. AI069513; Mitchell Goldman, MD and Beth Zwickl, RN, MSN – Indiana University (A2601): CTU Grant no. AI025859; Wishard Memorial Hospital (A2603); Carol Dukes Hamilton, MD and Joan Riddle, RN – Duke University Medical Center (A1601): CTU Grant no. 5U01 AI069 484-02; Charles van der Horst, MD and David Ragan, RN – University of North Carolina University of North Carolina (A3201) CTU Grant no. 5-U01 AI069423-03; GCRC M01 RR000046-48; cfar P30 AI050410(-11); Nancy Hanks, RN, University of Hawaii and Debra Ogata-Arakaki, RN, University of Hawaii (A5201): CTU Grant no. AI34853; Ellen Chusid, PhD and Walter Weiss, PA – Mount Sinai Medical Center (A1801); Mary Waldron, MD and Donna Mildvan, MD – Beth Israel Medical Center (A2851): CTU Grant no. AI46370; John McNeil, MD – Howard University (A5301): Grant no. AI34835; Rob Roy MacGregor, MD and Kathryn Maffei, RN – University of Pennsylvania, PA (A6201): CTU Grant no. AI069467; Ilene Wiggins, RN and Andrea Weiss, RPh – Johns Hopkins University (A0201): CTU Grant no. AI27668, GCRC Grant no. RR00052; John Mellors, MD and Barbara Rutecki, MSN, MPH, CRNP – Pitts CRS (A1001): CTU Grant no. AI069494; Susan Swindells, MBBS and Frances Van Meter, APRN – University of Nebraska Medical Center (A1505): CTU Grant no. AI27661; Rebecca A. Clark, MD, PhD – Charity Hospital/Tulane University (A1702); James Paul Steinberg, MD – Emory University Comprehensive Hemophilia Program (A9413). Sylvia Stoudt, RN and Dennis Israelski, MD – Willow Clinic Menlo Park (A0507): CTU Grant no. AI69556; Neel French, MD – Louis A Weiss Memorial Hospital (A2708): CTU Grant no. AI25915; Debbie Slamowitz, RN and Patricia Cain, RN – Santa Clara Valley Medical Center, San Jose (A0506): CTU Grant no. AI69556; Sylvia Stoudt, RN and Dennis Israelski, MD – San Mateo County AIDS Program (A0505): CTU Grant no. AI69556; Ardis Moe, MD and Suzette A. Chafey, RN, BSN, MPH – UCLA Medical Center (A0601): CTU Grant no. 5 U01 AI 069424-03; Michael Conklin, RN NP and Ge-Youl Kim, RN BSN – Connect Care (A2102): CTU Grant no. AI25903; Mary Albrecht, MD and Carol Silver, RN; Clyde Crumpacker, MD and Carol Delaney, RN (Site A0102) – Beth Israel Deaconess (A0103): CTU Grant no. AI069472; Harvard Massachusetts General (A0101); Craig Lindquist, MD, PhD and Deborah Mullaney-Fricke-Marin Country Department of Health, San Rafael, CA (A0809): CTU Grant no. AI27663. This study was conducted under the Clinicaltrails.gov no. NCT00000883. This paper was presented in part as an oral presentation at the fourth International Conference on HIV Treatment Adherence, 7 April 2009, Miami.