| BACKGROUNDThe treatment and care of HIV-infected injecting drug users (TDUs) are still an intractable public health problem. Both methadone maintenance therapy (MMT) and antiretroviral therapy (ART) are important methods to improve the health outcomes of IDUs. Growing scientific evidence has demonstrated that methadone maintenance therapy (MMT) increases initiation and adherence to ART and reduces mortality among IDUs. China has established a national MMT program as well as an ART program. The effects of the two programs were evaluated independently. Reports of combined treatment effects are rare.PURPOSESTo analyze the effects of ART as well as MMT and the associated risk factors among HIV-infected IDUs.METHODSTwo observational cohorts were established among HIV-infected IDUs. All HIV-infected IDUs who initiated ART at29selected ART clinics in2011were included in the ART cohort. Subjects who were clients at63selected MMT clinics and met the ART criteria (CD4<350cells/μl) in2011were selected as the MMT cohort. Some subjects received methadone and ART concurrently at the selected clinics. The subjects who received MMT and ART concurrently are included in the MMT cohort as well as the ART cohort. One year prospective follow-up was performed. Mortality and virologic success rate of the ART cohort and associated risk factors were analyzed. Mortality and methadone maintenance rate of the MMT cohort and associated risk factors were analyzed.RESULTSA total of1633cases were enrolled in the ART cohort in2011from29ART clinics. There were324cases that received MMT and ART concurrently,625cases were concomitant with ongoing drug use, and684cases of discontinued drug use. Of the total cases,80.3%were still on treatment at1-year follow-up,13.5%had discontinued ART, and6.2%had died. The mortality rates for cases that were concurrently enrolled in MMT, that reported ongoing drug use, and that reported discontinued drug use were5.5/100person-years,15.2/100person-years, and1.7/100person-years, respectively. Cox proportional hazard models were used to estimate the adjusted mortality hazard ratios. Unemployment [AHR=23.5(95%CI:3.3-170.4)], concomitant ongoing drug use [AHR=6.2(95%CI:3.1-12.3)], concomitant MMT [AHR=2.7(95%CI:1.2-6.0)], low-level treatment facility [county level:AHR=6.2(95%CI:1.7-23.0), prefecture level:AHR=4.9(95%CI:1.3-17.9)], male [HR=2.2(95%CI:1-1-4.5)3, hemoglobin<120g/l [AHR=2.2(95%CI:1.4-3.3)], and CD4<200/μL [AHR=2.1(95%CI:1.3-3.4)] were independently associated with mortality.A total of1070cases in the ART cohort had viral load results at1year:83.6%achieved virologic suppression (<400copies/ml). The virologic suppression rates among those who had been concomitant with MMT and ongoing drug use were the same (79.6%), and lower than those who had discontinued drug use (87.7%). In a multivariate logistic regression analysis, being unmarried or divorced [AOR=1.63 (95%CI:1.13-2.35)], unemployment [AOR=1.64(95%CI:1.05-2.56)], being of a minority ethnicity [AOR=1.95(95%CI:1.33-2.88)], concomitant MMT [AOR=1.65(95%CI:1.02-2.66)], concomitant ongoing drug use [AOR=1.68(95%CI:1.10-2.57)], and receiving services at ART facilities affiliated with a Center for Disease Control and Prevention [AOR=2.53(95%CI:1.30-4.94)] were independent predictors of virologic failure.The MMT cohort included324cases were enrolled in concurrent MMT and ART as well as185ART-naive cases. At the1-year follow-up, the total mortality was5.5/100person-years and7.4/100person-years among cases receiving concurrent ART and ART-naive cases, respectively. Using Cox proportional hazard models, CD4<200/μl [AHR:5.5(95%CI:2.2-13.9)] was found to be the only factor that was independently associated with mortality.Among cases of receiving concurrent ART, the mean methadone dose was72.8mg/day (IQR:50.3-106.9), and the MMT compliance rate was66.1%(IQR:26.2%-94.0%). Among ART-naive cases, the mean methadone dose was55.7mg/day (IQR:35.3-80.0), and the MMT compliance rate was60.9%(IQR:9.8%-92.1%). In multivariate logistic regression analysis, high daily methadone doses (≥60mg/day)[AOR=3.07(95%CI:2.06-4.57)] and CD4count between200and350cells/μl [AOR=1.60(95%CI:1.07-2.39)] were significantly associated with high compliance on methadone (≥50%).CONCLUSIONSFor HIV-infected IDUs receiving ART, discontinuation of drug use was strongly associated with optimal outcomes. Cases on MMT had a more significant decrease in mortality compared to ongoing drug users. Virologic suppression should be improved among cases receiving concurrent MMT and cases reporting ongoing drug use. High daily methadone dosage was associated with high compliance rate on MMT. ART was not associated with reduced MMT compliance rates.The integration and collaboration between MMT and ART services should be strengthened to improve the quality of both programs. Strategies should be taken to alleviate the interaction of ART drugs and MMT as well as offering direct administration of ART in MMT clinics. Other factors related to improving services, including employment and capacity of treatment facilities, should also draw more concern. |
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