Correlates of adherence to antiretroviral therapy in a cohort of HIV-positive drug users

receiving antiretroviral therapy in Hanoi, Vietnam

MR Jordan1, H Sheehan1, ND Hien2, TTM Lien2, N Terrin3, NV Trung2, NTB Ha2, DV Duong2, C Wanke1, NV Kinh2, AM Tang1

1Tufts University School of Medicine, Boston, USA; 2National Hospital of Tropical Diseases, Hanoi, Viet Nam; 3Tufts Medical Center, Boston; USA

Background (1)

The first case of HIV in Vietnam was reported in 1990

In 2006, 280,000 had been reported representing an overall prevalence of 0.5% among adults (aged 15-49 years)

Injection drug users (IDU) account for more than 56% of all reported HIV infections1

HIV prevalence in IDU estimated at 29%-34.0 %, with wide geographical variation2

11Nguyen et al. Addiction 2008; 2Matehers et al. Lancet, 2008

Background (2)

In 2005, Vietnam began rapid ART scale-up supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR)

As of end 2009, over 36,000 adults and 2,000 children were receiving ART1

In 2009, Vietnam strengthened its commitment to provide ART to IDUs and strengthen harm reduction programs2

1Vietnam Authority of HIV/AIDS Control, 2010; 2Guidelines for HIV care and treatment, Hanoi Vietnam, 2009

Background (3)

Rates of viral suppression in Vietnamese drug users (DU) comparable to rates seen in other populations1

Optimal adherence to ART required for viral suppression and prevention of HIVDR2-5

Previous studies have identified active drug use, poor social supports, and hazardous alcohol use as correlates of poor adherence to ART6-10

1Jordan et al. Int J STD AIDS 2009; 2Oyugi et al. IDS 2007; 3Bangsberg et al. Current HIV/AIDS report 2007; 4Bangsberg et al. AIDS 2006; 5Lewis et al. AIDS care 2006; 6Chandler et al JAIDS 2006; 7Arnsten J Gen Int Med 2002; 8Jaquet Addiction 2010; Hendershot et al. J AIDS 2000; Do IAS 2010 TUPDX103

Objective

Purpose to assess correlates of adherence to ART in a cohort of DUs receiving ART at a large urban clinic in Hanoi, Vietnam

Hypotheses: active drug use, hazardous alcohol use, lack of social support are correlates of poor ART adherence

Methods (1)

Between June and November 2006, 300 HIV infected and uninfected patients were enrolled into a 36-month prospective study on HIV and nutrition

This analysis focuses on 100 HIV positive patients receiving ART for at least 6 months prior to enrolment

Patients enrolled from outpatient clinic at the National Hospital of Tropical Diseases, Hanoi, Vietnam

Methods (2)

Inclusion criteria HIV positive Age ≥18 Received ART at NHTD for at least six months History of injection drug use within the previous 5-years Informed consent signed consent

Study approval by the Institutional Review Board of Tufts University (Boston) and ethical review board of the Hanoi School of Public Health

Data collection

HIV-1 RNA; CD4+ cell count HCV Ab, HBsAg Fasting blood draw: triglycerides, total cholesterol,

LDL, HDL, insulin, glucose, vitamins A, E, zinc, and selenium

Body composition: height, weight, skinfold measures, circumferences, and BIA

24-hour dietary recall Lifestyle Questionnaire

Likert Scale

Thinking back over the past 30 days, on average how would you rate your ability to take all your medications as prescribed?

Please place an “X” on the line below at the point showing your best guess as to how much of your total antiretroviral medications you have taken in the past 30 days.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Visual Analogue Scale

Characteristic N=100

Age (years) 29.86 ± 4.86

Male gender 100

Prison (ever) 23

Married 73Heterosexual 96

>13 years education 78

Any drug use last 6 months 48

Current injection drug use (last 6 months)

22

Baseline characteristics (1)

Characteristic N=100

Drug use in lifetime (ever) Marijuana 45 Heroin (injected) 90 Heroin (smoked) 91 Sedatives 77 Amphetamines 9Current cigarette smoker 84Hazardous drinker (NIAAA)*

37

Baseline characteristics (2)

*National Institute on Alcohol and Alcoholism

N=100

Duration of ART at baseline (months)

16.2 ± 12.7

ART regimen

First-line 95%

Second-line 3%

Other 1%

Baseline characteristics (3)

Baseline characteristics (4)

N=100CD4 cells/mm3

Study baseline 189 ± 110

Viral load Viral load < 50 copies/mL 59 (59%)

Viral load < 1000 copies/mL 73 (73%)

Baseline characteristics (5)N=100

VAS (% med in past 30d) 96 ± 12%

Adherence (VAS > 95%) 85 (85%)

Ability to take meds in past 30d Excellent 59 Very good 24 Good 10 Fair 5 Poor 2

VAS Distribution among virally suppressed participants

0 02

0 03

1 0

66

02

04

06

08

0su

m o

f zb_

vl_

sup

pre

s_lt1

000

.3 .5 .7 .8 .85 .9 .94 .99 1

Number Suppressed (<1000 copies) by VAS

La et al. 4th Intl Conf HIV Treatment Adherence, 2009

Likert Distribution among virally suppressed participants

02

8

14

48

01

02

03

04

05

0su

m o

f zb_

vl_

sup

pre

s_lt1

000

.2 .4 .6 .8 1

Number Suppressed (<1000 copies) by Likert Rating

La et al. 4th Intl Conf HIV Treatment Adherence, 2009

• Outcome: Adherence, Likert scale; dichotomized as Excellent/Very Good vs. Good/Fair/Poor

• Analysis includes data from 524 visits with complete questionnaire and adherence data

• Statistical model: repeated measures logistic regression (SAS V 9.2)

Statistical Analysis

Statistical Analysis (2)

• Correlates of adherence examined: • Drug use• Alcohol use• Living situation (alone vs. with others)• Duration of ART (years)• Self-reported symptoms (nausea, vomiting,

stomach pain, fever, white patches, mouth lip gum pain)

ResultsCharacteristic Unadjusted OR

(95% CI)Adjusted OR

(95% CI)Live alone 2.98 (0.91 - 9.80) ______

IDU last 6 months

1.63 (1.03-2.58) ______

Hazardous alcohol usage

0.94 ( 0.64 -1.38) ______

DU last 6 mo 1.64 (1.13-2.37) 1.77 (1.19 - 2.62)

Years on ART 1.39 (1.13 – 1.71) 1.42 (1.16 - 1.74)

Summary

Results demonstrate a significant correlation between poorer adherence:

Active drug use in the last 6 months Duration of ART

Conclusion

Strengthening of harm reduction programs for HIV infected DUs and scale-up of methadone maintenance may support initiation and adherence to ART among IDU in Vietnam

Programmatic supports for adherence beyond the first 12 months of therapy may be indicated

Additional operational research/interventions aimed at building social capital and decreasing stigma may support long-term adherence to ART

Acknowledgements Tufts University School of

Medicine Sherwood Gorbach James Hellinger Rony Barbara

National institutes of Health K23 AI074423 (PI Jordan) P30DA013868 (PI Gorbach) R01DA022163 (PI Gorbach)

Patients who participated in the study

National Hospital of Tropical Disease Dung Nguyen Huong Le Ha N. Nguyen Trang Van Phuong Nguyen Hai Pham Hoa Le Khuong T.Pham Thuc T. Nguyen Tien Q. Luu