Adherence, Drug Use, and Treatment Failure in a Methadone-Clinic–Based Program of Directly Administered Antiretroviral Therapy

Abstract

Supervised dosing is a cornerstone of tuberculosis treatment. HIV treatment strategies that use directly administered antiretroviral therapy (DAART) are increasingly being assessed. In a prospective single-arm clinical trial, we enrolled methadone-maintained, HIV-infected participants to receive supervised doses of antiretroviral therapy (ART) on days when they received methadone. Other ART doses were self-administered. In this analysis we examined factors associated with retention to DAART, adherence to supervised doses, and virologic failure. Factors associated with retention to DAART were assessed with the Kaplan-Meier method and Cox proportional hazards models. Factors associated with nonadherence with supervised dosing and with virologic failure were assessed by logistic regression and techniques for longitudinal data analysis. A total of 16,453 supervised doses were administered to 88 participants over a median follow-up of 9.4 months. The median participant adherence with supervised dosing was 83%. Active drug use, determined by urine drug screens, was associated twofold increased risks of both intervention dropout and nonadherence with supervised doses. Adherence with supervised doses was strongly associated with virologic failure. Because DAART was administered only on methadone dosing days, fewer than half of the total ART doses were scheduled to be supervised in most participants. The percent of doses that was scheduled to be supervised was not associated with either adherence or with virologic failure. Given that a relatively small proportion of the total ART doses were supervised in many patients, future studies should assess how DAART affects adherence with nonsupervised doses and retention to ART.

Initiation, Adherence, and Retention in a Randomized Controlled Trial of Directly Administered Antiretroviral Therapy

“…These numbers compare with those in the published literature: 48% retention among participants in a 12-month DAART program at a methadone clinic (Lucas et al 2006b); 79% among a general (i.e., non-drug-using) population receiving 6 months of DAART through six-public clinics (Wohl et al 2006); and 45% among a drug-using population in a six-month DAART program (Mitty et al 2005). Similarly, the overall adherence is similar to the 83% median adherence of observed doses in the DAART program in which DAART was linked to receipt of methadone (Lucas et al 2007). …”

“…In a different program linked to a methadone clinic, of several demographic and social variables, positive urine toxicology screens were the only predictor of decreased retention. This was likely the result of participants being expelled from the methadone program if they were found to be using illicit drugs (Lucas et al 2007). Although one might expect ongoing heroin and cocaine use to be important predisposing factors, these have not been strongly associated with outcomes (Conway et al 2004;.…”

Adherence to Antiretroviral Therapy in Patients Participating in a Graduated Cost Recovery Program at an HIV Care Center in South India

“…A number of participants in this study were on daily dose schedules; therefore the use of 3-day recall was felt to provide more information without compromising accuracy. Also, other factors such as cognitive and psychological function, substance abuse, health beliefs, stigma, and social support which have been reported to affect adherence rates were not able to be analyzed independently in this study [20,[33][34][35][36][37][38][39]. Nonetheless, these data suggest that the efforts to support the costs of medication and the placement of treatment centers in convenient locations may be most important to ensure optimal utilization of first line HAART in resource-constrained environments.…”

Substance Use: Impact on Adherence and HIV Medical Treatment

“…A recent 24-week randomized controlled trial comparing DAART + MMT to MMT + self-administered ART also supports beneficial treatment gains in terms of ART adherence and HIV viral suppression [110••]. In addition, previous work suggests that active substance use and nonadherence to supervised dosing is significantly related to dropping out of DAART in persons with HIV/AIDS on MMT [111]. Collectively, these results suggest that DAART + MMT is effective in reducing substance use behavior, promoting ART adherence, and improving disease status, and that active substance use may be a barrier to remaining in this method of care.…”