Developing a Directly Administered Antiretroviral Therapy Intervention for HIV-Infected Drug Users: Implications for Program Replication

Abstract

Directly administered antiretroviral therapy (DAART) is one approach to improving adherence to among human immunodeficiency virus (HIV)-infected drug users. We evaluated the essential features of a community-based DAART intervention in a randomized, controlled trial of DAART versus self-administered therapy. Of the initial 72 subjects, 78% were racial minorities, and 32% were women. Social and medical comorbidities among subjects included homelessness (35% of subjects), lack of interpersonal support (86%), major depression (57%), and alcoholism (36%). At baseline, the median CD4+ cell count was 403 cells/mL and the median HIV-1 RNA load was 146,333 copies/mL (log10 5.31 copies/mL). During the prior 6 months, 33% of subjects had missed a medical appointment, and 47% had visited an emergency department. Although most subjects (67%) preferred to take their own medications, 76% would accept DAART if it were made compulsory. A methadone clinic was the DAART venue acceptable to the fewest subjects (36%), and a mobile syringe-exchange program was acceptable to the most subjects (83%). Adherence was higher for supervised than for unsupervised medication administration (P<.0001), a finding that supports use of daily supervision of once-daily regimens. Moreover, DAART should incorporate enhanced elements such as convenience, flexibility, confidentiality, cues and reminders, responsive pharmacy and medical services, and specialized training for staff.

Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature

“…This highlights the need for future multisite studies with consistent methodologies to determine how geographical and population differences influence outcomes. Deering et al [20] To determine if a peer intervention will increase access and adherence to HAART Study located outside of the USA Rueda et al [23] To conduct a systematic review of the literature on the effectiveness of patient support and education to improve HAART adherence Not all studies used community health workers, and not all studies were located in the USA Simoni et al [21] To summarize the literature on behavioural interventions to promote HAART adherence Studies were not all located in the USA Altice et al [26] To assess adherence outcomes in directly observed HAART compared with standard of care No biological outcomes Shelton et al [45] To determine if HIV case managers improve adherence to HAART No biological outcomes Amico et al [46] To conduct a quantitative review of published trials on HAART adherence interventions Not all studies used community health workers; not all studies reported biological outcomes Ivers et al [22] To summarize the literature on HAART programmes in resource-poor settings Studies were not all located in the USA Wohl et al [47] To determine if treatment support programmes improve adherence to HAART No biological outcomes Altice et al [48] To develop a directly observed HAART programme for HIV-infected drug users The intervention used a community outreach van but did not specifically utilize community health workers Broadhead et al [49] To determine if injecting drug users can carry out the work of professional outreach workers effectively…”

Perceived stigma among patients receiving antiretroviral treatment: A prospective randomised trial comparing an m-DOT strategy with standard-of- care in Kenya

“…Unlike other adherence interventions, m-DOT helps address daily challenges to pill-taking, provides emotional and informational support, and is a strong link with health care services (Mukherjee et al, 2006). This strategy has been found to be feasible and successful in supporting adherence in community-based ART programmes in resource-constrained settings and for patients in closed settings such as long-term care facilities, prisoners and for people enrolled in methadone clinics in developed countries (Altice et al, 2004;Christopher, 2006;Farmer et al, 2001;Liechty & Bangsberg, 2003;Pearson et al, 2007;Santos, Adeyemi, & Tenorio, 2006;Sarna et al, 2008).…”

Delay in the Initiation of HAART, Poorer Virological Response, and Higher Mortality among HIV-Infected Injecting Drug Users in Spain

“…In fact, a lower and delayed population effectiveness of HAART among IDUs has been described in our setting. 13 Furthermore, even among those who have accessed the hospital system, IDUs often have higher physical and mental morbidity related to their drug addiction, 19,20 which may also compromise their adherence to the treatment. 21,22 All these facts may lead to lower uptake of treatment and poorer responses to HAART, which might have a bearing on IDU mortality.…”