A literature review of original research articles on adherence to antiretroviral therapy (ART) in developed countries, covering January 2000 to June 2011, was conducted to determine if gender differences exist in the prevalence of nonadherence to ART. Of the 1,255 articles reviewed, only 189 included data on the proportion of the study population that was adherent and only 57 (30.2%) of these reported proportional adherence values by gender. While comparing articles was challenging because of varied reporting strategies, women generally exhibit poorer adherence than men. Thirty of the 44 articles (68.2%) that reported comparative data on adherence by gender found women to be less adherent than men. Ten articles (17.5%) reported significant differences in proportional adherence by gender, nine of which showed women to be less adherent than men. These findings suggest that in multiple studies from developed countries, female gender often predicts lower adherence. The unique circumstances of HIV-positive women require specialized care to increase adherence to ART.

ObjectiveWe sought to determine the incidence and factors associated with development of diabetes mellitus (DM) in older HIV-infected individuals.Research design and methodsWe analyzed data from people living with HIV (PLWH) ≥50 years of age enrolled in a large urban HIV outpatient clinic in Vancouver, British Columbia. Patients were categorized as having DM if they had random blood sugar ≥11.1 mmol/L, fasting blood sugar ≥7 mmol/L, HbA1C ≥6.5%, antidiabetic medication use during the follow-up period, or medical chart review confirming diagnosis of DM. We estimated the probability of developing DM, adjusting for demographic and clinical factors, using a logistic regression model.ResultsAmong 1065 PLWH followed for a median of 13 years (25th and 75th percentile (Q1–Q3): 9-18), the incidence of DM was 1.61/100 person-years follow-up. In the analysis of factors associated with new-onset DM (n=703), 88% were male, 38% had a history of injection drug use, 43% were hepatitis C coinfected, and median body mass index was 24 kg/m2 (Q1–Q3: 21–27). Median age at antiretroviral therapy (ART) initiation was 48 years (Q1–Q3: 43–53) and at DM diagnosis was 55 years (Q1–Q3: 50–61). Patients who started ART in 1997–1999 and had a longer exposure to older ART were at the highest risk of developing DM.ConclusionsAmong PLWH aged ≥50 years, the incidence of DM was 1.39 times higher than men in the general Canadian population of similar age. ART initiated in the early years of the epidemic and exposure to older ART appeared to be the main drivers of the development of DM.

HIV-positive people who use illicit drugs typically achieve lower levels of adherence to antiretroviral therapy and experience higher rates of sub-optimal HIV/AIDS treatment outcomes. Given the dearth of longitudinal research into ART adherence dynamics, we sought to identify factors associated with transitioning into and out of optimal adherence to ART in a longitudinal study of HIV-infected people who use illicit drugs (PWUD) in a setting of universal no-cost HIV/AIDS treatment. Using data from a prospective cohort of community-recruited HIV-positive illicit drug users confidentially linked to comprehensive HIV/AIDS treatment records, we estimated longitudinal factors associated with losing or gaining ≥ 95% adherence in the previous six months using two generalized linear mixed-effects models. Among 703 HIV-infected ART-exposed PWUD, becoming non-adherent was associated with periods of homelessness (Adjusted Odds Ratio [AOR] = 2.52, 95% Confidence Interval [95% CI]: 1.56 - 4.07), active injection drug use (AOR = 1.25, 95% CI: 1.01 - 1.56) and incarceration (AOR = 1.54, 95% CI: 1.10 - 2.17). Periods of sex work (AOR = 0.51, 95% CI: 0.34 - 0.75) and injection drug use (AOR = 0.62, 95% CI: 0.50 - 0.77) were barriers to becoming optimally adherent. Methadone maintenance therapy (MMT) was associated with becoming optimally adherent (AOR = 1.87, 95% CI: 1.50 - 2.33) and was protective against becoming non-adherent (AOR = 0.52, 95% CI: 0.41 - 0.65). In conclusion, we identified several behavioural, social and structural factors that shape adherence patterns among PWUD. Our findings highlight the need to consider these contextual factors in interventions that support the effective delivery of ART to this population.

Objective Given that people who use illicit drugs (PWUD) often engage in prohibited income generation to support their basic needs, we sought to examine the role of these activities in shaping antiretroviral therapy (ART) adherence and plasma HIV RNA-1 viral load suppression among HIV-infected PWUD. Design Longitudinal analyses among HIV-positive, ART exposed PWUD in the AIDS Care Cohort to evaluate Exposure to Survival Services prospective cohort study (2005–2013). Methods Generalized linear mixed effects and mediation analyses examined the relationship between prohibited income generation (e.g. sex work, drug dealing, theft, street-based income) and virologic suppression (plasma viral load ≤ 50 copies/mL plasma) adjusting for adherence and potential confounders. Results Among 687 HIV-infected PWUD, 391 (56.9%) individuals reported prohibited income generation activity during the study period. In multivariate analyses, prohibited income generation remained independently and negatively associated with virologic suppression (adjusted odds ratio: 0.68, 95% confidence interval: 0.52–0.88) following adjustment for hypothesized confounders, including high-intensity drug use, ART adherence and homelessness. While partially mediated by ART adherence, the relationship between prohibited income generation and virologic suppression was maintained in mediation analyses (Sobel statistic = −1.95, p=0.05). Conclusions Involvement in prohibited income generation decreases the likelihood of virologic suppression directly and indirectly through its negative association with ART adherence. These findings suggest that linkages between socio-economic marginalization, the criminalization of illicit drug use and insufficient employment opportunities may produce barriers to access and retention in care. Programmatic and policy interventions that decrease socio-economic vulnerability may therefore reduce HIV-related morbidity, mortality and onward transmission.