HIV Positive Stimulant Users Benefit from Antiretroviral Therapy

People with HIV who use methamphetamine or other stimulant drugs do well on antiretroviral therapy (ART) and appear not to be at greater risk than non-users for AIDS-related or all-cause death overall, but those who use stimulants more than half the time did have a higher risk of progression to AIDS or death, according to a study published in the September 30 Journal of Acquired Immune Deficiency Syndromes.

Adam Carrico from the University of California at San Francisco School of Nursing and colleagues looked at outcomes among gay and bisexual men with HIV who started ART in the Multicenter AIDS Cohort Study (MACS). They compared rates of AIDS-related death, death due to all causes, and progression to AIDS for stimulant users and non-users, as well as across different frequencies of use (0%, 1%-49%, 50%-99%, or 100% of study visits).

Among the 1313 men who started ART, there was no significant association of any level of stimulant use with all-cause mortality. A competing risks analysis found no link between any level of stimulant use and either AIDS-related or non-AIDS mortality considered separately. However, among the 648 men who did not yet have AIDS when they started ART, those who reported stimulant use at 50% or more of study visits had a 1.5-fold higher risk of progression to AIDS or all-cause mortality.

"Comprehensive approaches are needed to optimize the effectiveness of [highly active] HAART with stimulant-using [men who have sex with men]," the study authors concluded.

Below is an edited excerpt from a UCSF news release describing the research in more detail.

Antiretroviral Therapy Benefits HIV-infected Stimulant Users, UCSF Study Shows

October 10, 2014 -- New clinical research from UC San Francisco shows that 341 HIV-infected men who reported using stimulants such as methamphetamine or cocaine derived life-saving benefits from being on antiretroviral therapy that were comparable to those of HIV-infected men who do not use stimulants.

That said, those who reported using stimulants at more than half of at least two study visits did have modestly increased chances of progressing to AIDS or dying after starting antiretroviral therapy compared to non-users. The data was collected between 1996 and 2012.

"Patients with HIV who use stimulants and other substances often experience difficulties with accessing antiretroviral therapy, partially due to the concerns of healthcare providers that they will not be able take their medications as directed. Findings from this study demonstrate that many stimulant users take their antiretroviral therapy at levels sufficient to avoid negative clinical outcomes. When we look at overall mortality, antiretroviral therapy leads to similar clinical benefits for both stimulant users and non-users, notwithstanding stimulant use," said the study’s primary investigator, Adam W. Carrico, PhD, UCSF assistant professor of nursing.

The research is available starting in October online ahead of print in the Journal of Acquired Immune Deficiency Syndromes. The study included 1,313 HIV-infected men who have sex with men within the Multicenter AIDS Cohort Study, an ongoing nationwide prospective study of HIV infection among men who have sex with men in the U.S.

"If we are to achieve the goals of the President’s National HIV/AIDS Strategy and UNAIDS to end the HIV/AIDS epidemic, we will need to treat HIV-positive active substance users for their HIV while encouraging them to stop or reduce their substance use. Programs integrating substance abuse services with HIV clinical care may both improve health outcomes for patients and reduce new infections," said Carrico.

The UCSF Division of HIV/AIDS at San Francisco General Hospital has created an integrated care delivery system that could serve as a model for other clinics, added Carrico. The HIV primary care clinic utilizes a patient-centered team care approach that includes substance abuse services for stimulant and opioid users, along with mental health services, all located onsite. STOP, the "stimulant treatment outpatient program," within the clinic provides outpatient substance abuse and mental health treatment integrated with patients’ primary medical care.

"The pattern of use varies and the real issue is whether patients can take their antiretrovirals as prescribed. We find that some patients are able to start taking antiretrovirals very reliably before they are able to decrease or stop their stimulant use, which often requires more complex behavioral, emotional, interpersonal and environmental changes. Being in an HIV primary care setting allows us to engage stimulant users even if they are not ready to go to specialty substance abuse programs or support groups," said Valerie Gruber, PhD, STOP director and UCSF professor of psychiatry.

10/17/14

Reference

AW Carrico, S Shoptaw, C Cox, MW Plankey, et al. Stimulant Use and Progression to AIDS or Mortality After The Initiation of Highly Active Anti-Retroviral Therapy. Journal of Acquired Immune Deficiency Syndromes. September 30, 2014 (Epub ahead of print).

Other Source

J Sheehy, UCSF. Antiretroviral Therapy Benefits HIV-infected Stimulant Users, UCSF Study Shows. News release. October 10, 2014.