Prospective Cohort Study Among Injection Drug Users Who Accepted Highly Active Antiretroviral Therapy In China

BackgroundThe cumulative number of people living with HIV (PLHIV) reported at the end of October 2007 was 223, 501, among whom, 38.5 percent were infected via injection drug use (EDU). EDU is still one of the main modes transmissions. As the peak AIDS morbidity and mortality approaches, highly active antiretroviral therapy (HAART) becomes an effective measure to control HEV/AIDS transmission and save the lives of PLHIV. Provision of HAART to injection drug users can reduce the risk of transmission of HIV from IDUs to the general population. However, improving the efficacy of HAART in the IDU population faces particular challenges due to co morbidities including substance addiction.Objective1. To investigate the efficacy of HAART and its influencing factors in a prospective cohort study of IDUs in China.2. To investigation the reason for discontinuation of HAART among IDUs in China.Methods1. This prospective cohort study was conducted among three hospitals in Urumqi city and four hospitals in Yining county and Huocheng county, all in Xinjiang province. The eligible patients were recruited from August 1, 2007 to February 29, 2008. En addition, patients from the Number 3 People's Hospital in Hengyang city Hunan province were also included in the cohort. The recruit period for Hengyang city was from January 1, 2008 to August 31, 2008. All treatment naive patients initiate HAART in the hospital for eligibility assessment. The eligible patients are then followed-up every 3 months from baseline. Patient information about HAART and blood test for CD₄⁺T lymphocyte count and plasma viral load is taken during every visit. Information on the socio-demographic characteristics, medical history, drug use, risk behaviors, and adherence were collected.2. Qualitative investigation was conducted to determine the reason for discontinuation of HAART. The doctor contacted patients who discontinued HAART and obtained permission to conduct an interview. Investigators interviewed patients in a separate room. The investigation content included the recent health situation of the patients, the former situation of HAART, and the reason for HAART discontinuation.Result1. There were 180 eligible patients in the study. There were 127 (70.5%) patients who completed six months of follow-up; of the remaining 53 (29.4%) patients who discontinued HAART, 16 died and 37 were lost to follow-up. The rate of HAART continuation was 76.1% (137/180) and 70.5%( 127/180)at the three month and six month interviews, respectively. The multivariate logistic regression model showed marriage (Odds Ratio [OR], 2.82; 95% Confidence Interval [CI],1.42-5.59) and WHO HIV clinical stage (OR, 2.38; 95% CI 1.19-4.75) were significantly associated with HAART continuation.There were 127 (70.5%) IDUs completed six months follow-up in the study. There were 12 (9.8%) patients who demonstrated immunologic failure during the course of HAART. In the multivariate logistic regression model, baseline CD₄+ T lymphocyte count less than 50 cells/ul(OR, 0.13; 95%CI, 0.03-0.48)and taking part in interviews less 7 times in half of year (OR, 0.12; 95% CI, 0.02-0.63) were associated with immunologic failure.In the investigation, 92 (72.4%) patients achieved virologic suppression. The multivariable logistic regression showed taking parting in interview over 7 times in half of year (OR, 3.53; 95% CI, 1.38-9.01) and adherence over 95% (OR, 5.42; 95% CI, 2.07-14.21) during HAART were significantly associated with undetectable plasma viral load.There were 75 (59.1%) patients continuing HAART with adherence over 95% in the study. Upon multivariable logistic regression, baseline CD4+ T lymphocyte count less than 200 cells/ul (OR, 0.39; 95%CI, 0.18-0.84),taking parting in interview over 7 times in half of year (OR, 1.99; 95%CI, 0.90-4.41) and had mastered knowledge of HAART (OR, 1.99; 95%CI, 0.92-4.31) were significant with adherence over 95% during the whole HAART.In the investigation, we found that the patients' situation had improved after initiating HAART. Their CD4+ T lymphocyte count had increased. Compared to baseline, more patients had stopped using intravenous drugs and began methadone treatment. In addition, a greater number of patients mastered the core knowledge of HAART compared to baseline. All these improvements were significant.2. Twenty IDUs who discontinued HAART participated in the interview. The main reasons for discontinuation of HAART were: current drug use 45% (9/20), overwhelmed by the multitude of pills 15.0% (3/20), termination after improvement in health10% (2/20), family poverty 10% (2/20), medicine side effects 10% (2/20), social and family discrimination 10% (2/20), and lack of confidence in the efficacy of HAART 10% (2/20).ConclusionThe observed efficacy of HAART among IDUs in Xinjiang and Hunan province is similar to that observed by research of other IDU populations, but low relative that observed in non-drug user populations. The rate of HAART discontinuation is high. Seldom taking part in interview and poor adherence are the main influencing factors of HAART efficacy. Currently drug use lead to poor immunologic and virologic responses in HAART. Implementing measures such as drug addiction treatment and methadone maintenance therapy may reduce the rate of HAART discontinuation and improve the adherence and thus efficacy of HAART.