Stimulant Use and AIDS Progression After HAART
Stimulant Use and AIDS Progression After HAART
Background HIV-positive persons who use stimulants (eg, methamphetamine) experience profound health disparities, but it remains unclear whether these persist after highly active antiretroviral therapy (HAART) initiation. Conducted within the Multicenter AIDS Cohort Study, this investigation examined whether stimulant use is associated with progression to AIDS or all-cause mortality after the initiation of HAART.
Methods Using marginal structural modeling, the cumulative proportion of visits where any stimulant use was reported (ie, 0%, 1%–49%, 50%–99%, and 100%) was examined as a time-varying predictor of (1) all-cause mortality and (2) AIDS or all-cause mortality.
Results Among the 1313 men who have sex with men (MSM) who initiated HAART, findings showed no significant association of any level of stimulant use with all-cause mortality. A competing risk analysis indicated that no level of stimulant use was associated with increased AIDS-related or non-AIDS mortality separately. Among the 648 participants without AIDS at HAART initiation, a secondary analysis indicated that stimulant use at 50% or more of study visits was associated with a 1.5-fold increase in the odds of progression to AIDS or all-cause mortality (adjusted odds ratio = 1.54; 95% confidence interval: 1.02 to 2.33; P < 0.05).
Conclusions HIV-positive stimulant-using MSM receiving HAART seem to face no greater overall risks for all-cause, AIDS-related, or non-AIDS mortality compared with nonusers. However, men without AIDS at HAART initiation who more frequently reported stimulant use demonstrated modestly increased odds of progression to AIDS or all-cause mortality. Comprehensive approaches are needed to optimize the effectiveness of HAART with stimulant-using MSM.
HIV-positive persons who use stimulants (eg, methamphetamine, cocaine, and crack cocaine) are at an elevated risk for more rapid HIV disease progression, although the underlying biologic or behavioral mechanisms for this disturbance have not been clearly elucidated. There is evidence that substance users are less likely to access highly active antiretroviral therapy (HAART), and stimulant users initiate HAART at lower T-helper (CD4) cell counts than their peers who do not use substances. HIV-positive persons who engage in more regular stimulant use are also at greater risk for poorer adherence to HAART, which contributes to elevated viral load, greater risk of onward HIV transmission, and potentially faster HIV disease progression.
Studies conducted to date have not consistently observed that stimulant users on HAART experience more negative health outcomes. One recent investigation with a cohort of substance users found that crack cocaine use predicted a greater rate of CD4 cell count decline to less than 200 cells per microliter, an effect that was most pronounced among those who were not prescribed HAART at baseline. Kapadia et al also reported that stimulant-using women experienced a 2-fold faster rate of progression to AIDS and concurrently lower rates of HAART initiation. Consistent with these results, another study conducted with this cohort of women observed that persistent and intermittent crack cocaine users were more likely to develop an AIDS-defining illness (ADI), but only persistent crack cocaine users displayed a 3-fold greater AIDS-related mortality rate after controlling for adherence to HAART. In contrast, a study with a cohort of homeless and marginally housed persons with high rates of HAART utilization did not observe a significant association of current crack cocaine use with all-cause mortality. Because many studies have examined the effects of stimulant use irrespective of when or whether HAART was started, it is difficult to determine the extent to which negative health outcomes among stimulant users are attributable to delayed initiation of HAART or poorer adherence to HAART.
To inform evidence-based practice, this study examined whether time-varying stimulant use independently predicted increased risk of HIV disease progression outcomes after the initiation of HAART in the Multicenter AIDS Cohort Study (MACS). We hypothesized that stimulant use would be independently associated with increased all-cause mortality as well as progression to AIDS or all-cause mortality after accounting for HAART adherence.
Abstract and Introduction
Abstract
Background HIV-positive persons who use stimulants (eg, methamphetamine) experience profound health disparities, but it remains unclear whether these persist after highly active antiretroviral therapy (HAART) initiation. Conducted within the Multicenter AIDS Cohort Study, this investigation examined whether stimulant use is associated with progression to AIDS or all-cause mortality after the initiation of HAART.
Methods Using marginal structural modeling, the cumulative proportion of visits where any stimulant use was reported (ie, 0%, 1%–49%, 50%–99%, and 100%) was examined as a time-varying predictor of (1) all-cause mortality and (2) AIDS or all-cause mortality.
Results Among the 1313 men who have sex with men (MSM) who initiated HAART, findings showed no significant association of any level of stimulant use with all-cause mortality. A competing risk analysis indicated that no level of stimulant use was associated with increased AIDS-related or non-AIDS mortality separately. Among the 648 participants without AIDS at HAART initiation, a secondary analysis indicated that stimulant use at 50% or more of study visits was associated with a 1.5-fold increase in the odds of progression to AIDS or all-cause mortality (adjusted odds ratio = 1.54; 95% confidence interval: 1.02 to 2.33; P < 0.05).
Conclusions HIV-positive stimulant-using MSM receiving HAART seem to face no greater overall risks for all-cause, AIDS-related, or non-AIDS mortality compared with nonusers. However, men without AIDS at HAART initiation who more frequently reported stimulant use demonstrated modestly increased odds of progression to AIDS or all-cause mortality. Comprehensive approaches are needed to optimize the effectiveness of HAART with stimulant-using MSM.
Introduction
HIV-positive persons who use stimulants (eg, methamphetamine, cocaine, and crack cocaine) are at an elevated risk for more rapid HIV disease progression, although the underlying biologic or behavioral mechanisms for this disturbance have not been clearly elucidated. There is evidence that substance users are less likely to access highly active antiretroviral therapy (HAART), and stimulant users initiate HAART at lower T-helper (CD4) cell counts than their peers who do not use substances. HIV-positive persons who engage in more regular stimulant use are also at greater risk for poorer adherence to HAART, which contributes to elevated viral load, greater risk of onward HIV transmission, and potentially faster HIV disease progression.
Studies conducted to date have not consistently observed that stimulant users on HAART experience more negative health outcomes. One recent investigation with a cohort of substance users found that crack cocaine use predicted a greater rate of CD4 cell count decline to less than 200 cells per microliter, an effect that was most pronounced among those who were not prescribed HAART at baseline. Kapadia et al also reported that stimulant-using women experienced a 2-fold faster rate of progression to AIDS and concurrently lower rates of HAART initiation. Consistent with these results, another study conducted with this cohort of women observed that persistent and intermittent crack cocaine users were more likely to develop an AIDS-defining illness (ADI), but only persistent crack cocaine users displayed a 3-fold greater AIDS-related mortality rate after controlling for adherence to HAART. In contrast, a study with a cohort of homeless and marginally housed persons with high rates of HAART utilization did not observe a significant association of current crack cocaine use with all-cause mortality. Because many studies have examined the effects of stimulant use irrespective of when or whether HAART was started, it is difficult to determine the extent to which negative health outcomes among stimulant users are attributable to delayed initiation of HAART or poorer adherence to HAART.
To inform evidence-based practice, this study examined whether time-varying stimulant use independently predicted increased risk of HIV disease progression outcomes after the initiation of HAART in the Multicenter AIDS Cohort Study (MACS). We hypothesized that stimulant use would be independently associated with increased all-cause mortality as well as progression to AIDS or all-cause mortality after accounting for HAART adherence.
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