Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting

M. J. Milloy, Thomas Kerr, David Bangsberg, Jane Buxton, Surita Parashar, Silvia Guillemi, Julio Montaner, Evan Wood

Research output: Contribution to journalArticle

66 Citations (Scopus)

Abstract

Despite the advent of effective antiretroviral therapy (ART), HIV-seropositive injection drug users (IDU) continue to suffer from elevated levels of morbidity and mortality. Evidence is needed to identify social- and structural-level barriers to effective ART. We investigated the impact of homelessness on plasma HIV RNA response among illicit drug users initiating ART in a setting with free and universal access to HIV care. We accessed data from a long-running prospective cohort of community-recruited IDU linked to comprehensive HIV clinical monitoring and ART dispensation records. Using Cox proportional hazards with recurrent events modeling, we estimated the independent effect of homelessness on time to plasma HIV viral load suppression. Between May 1996 and September 2009, 247 antiretroviral naïve individuals initiated ART and contributed 1755 person-years of follow-up. Among these individuals, the incidence density of plasma HIV RNA suppression less than 500 copies/mm 3 was 56.7 (95% confidence interval [CI]: 46.9-66.0) per 100 person-years. In unadjusted analyses, homelessness was strongly associated with lower rates suppression (hazard ratio=0.56, 95% CI: 0.40-0.78, p=0.001), however, after adjustment for adherence this association was no longer significant (adjusted hazard ratio=0.79, 95% CI: 0.56-1.11, p=0.177). Homelessness poses a significant structural barrier to effective HIV treatment. However, since this relationship appears to be mediated by lower levels of ART adherence, interventions to improve adherence among members of this vulnerable population are needed.

Original languageEnglish (US)
Pages (from-to)60-67
Number of pages8
JournalAIDS Patient Care and STDs
Volume26
Issue number1
DOIs
StatePublished - Jan 1 2012
Externally publishedYes

Fingerprint

Homeless Persons
Street Drugs
Drug Users
HIV
Confidence Intervals
Therapeutics
RNA
Injections
Vulnerable Populations
Viral Load
Morbidity
Mortality
Incidence

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Infectious Diseases

Cite this

Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting. / Milloy, M. J.; Kerr, Thomas; Bangsberg, David; Buxton, Jane; Parashar, Surita; Guillemi, Silvia; Montaner, Julio; Wood, Evan.

In: AIDS Patient Care and STDs, Vol. 26, No. 1, 01.01.2012, p. 60-67.

Research output: Contribution to journalArticle

Milloy, M. J. ; Kerr, Thomas ; Bangsberg, David ; Buxton, Jane ; Parashar, Surita ; Guillemi, Silvia ; Montaner, Julio ; Wood, Evan. / Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting. In: AIDS Patient Care and STDs. 2012 ; Vol. 26, No. 1. pp. 60-67.
@article{077dd905e1af47278ea16bcbcddcf71e,
title = "Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting",
abstract = "Despite the advent of effective antiretroviral therapy (ART), HIV-seropositive injection drug users (IDU) continue to suffer from elevated levels of morbidity and mortality. Evidence is needed to identify social- and structural-level barriers to effective ART. We investigated the impact of homelessness on plasma HIV RNA response among illicit drug users initiating ART in a setting with free and universal access to HIV care. We accessed data from a long-running prospective cohort of community-recruited IDU linked to comprehensive HIV clinical monitoring and ART dispensation records. Using Cox proportional hazards with recurrent events modeling, we estimated the independent effect of homelessness on time to plasma HIV viral load suppression. Between May 1996 and September 2009, 247 antiretroviral na{\"i}ve individuals initiated ART and contributed 1755 person-years of follow-up. Among these individuals, the incidence density of plasma HIV RNA suppression less than 500 copies/mm 3 was 56.7 (95{\%} confidence interval [CI]: 46.9-66.0) per 100 person-years. In unadjusted analyses, homelessness was strongly associated with lower rates suppression (hazard ratio=0.56, 95{\%} CI: 0.40-0.78, p=0.001), however, after adjustment for adherence this association was no longer significant (adjusted hazard ratio=0.79, 95{\%} CI: 0.56-1.11, p=0.177). Homelessness poses a significant structural barrier to effective HIV treatment. However, since this relationship appears to be mediated by lower levels of ART adherence, interventions to improve adherence among members of this vulnerable population are needed.",
author = "Milloy, {M. J.} and Thomas Kerr and David Bangsberg and Jane Buxton and Surita Parashar and Silvia Guillemi and Julio Montaner and Evan Wood",
year = "2012",
month = "1",
day = "1",
doi = "10.1089/apc.2011.0169",
language = "English (US)",
volume = "26",
pages = "60--67",
journal = "AIDS Patient Care and STDs",
issn = "1087-2914",
publisher = "Mary Ann Liebert Inc.",
number = "1",

}

TY - JOUR

T1 - Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting

AU - Milloy, M. J.

AU - Kerr, Thomas

AU - Bangsberg, David

AU - Buxton, Jane

AU - Parashar, Surita

AU - Guillemi, Silvia

AU - Montaner, Julio

AU - Wood, Evan

PY - 2012/1/1

Y1 - 2012/1/1

N2 - Despite the advent of effective antiretroviral therapy (ART), HIV-seropositive injection drug users (IDU) continue to suffer from elevated levels of morbidity and mortality. Evidence is needed to identify social- and structural-level barriers to effective ART. We investigated the impact of homelessness on plasma HIV RNA response among illicit drug users initiating ART in a setting with free and universal access to HIV care. We accessed data from a long-running prospective cohort of community-recruited IDU linked to comprehensive HIV clinical monitoring and ART dispensation records. Using Cox proportional hazards with recurrent events modeling, we estimated the independent effect of homelessness on time to plasma HIV viral load suppression. Between May 1996 and September 2009, 247 antiretroviral naïve individuals initiated ART and contributed 1755 person-years of follow-up. Among these individuals, the incidence density of plasma HIV RNA suppression less than 500 copies/mm 3 was 56.7 (95% confidence interval [CI]: 46.9-66.0) per 100 person-years. In unadjusted analyses, homelessness was strongly associated with lower rates suppression (hazard ratio=0.56, 95% CI: 0.40-0.78, p=0.001), however, after adjustment for adherence this association was no longer significant (adjusted hazard ratio=0.79, 95% CI: 0.56-1.11, p=0.177). Homelessness poses a significant structural barrier to effective HIV treatment. However, since this relationship appears to be mediated by lower levels of ART adherence, interventions to improve adherence among members of this vulnerable population are needed.

AB - Despite the advent of effective antiretroviral therapy (ART), HIV-seropositive injection drug users (IDU) continue to suffer from elevated levels of morbidity and mortality. Evidence is needed to identify social- and structural-level barriers to effective ART. We investigated the impact of homelessness on plasma HIV RNA response among illicit drug users initiating ART in a setting with free and universal access to HIV care. We accessed data from a long-running prospective cohort of community-recruited IDU linked to comprehensive HIV clinical monitoring and ART dispensation records. Using Cox proportional hazards with recurrent events modeling, we estimated the independent effect of homelessness on time to plasma HIV viral load suppression. Between May 1996 and September 2009, 247 antiretroviral naïve individuals initiated ART and contributed 1755 person-years of follow-up. Among these individuals, the incidence density of plasma HIV RNA suppression less than 500 copies/mm 3 was 56.7 (95% confidence interval [CI]: 46.9-66.0) per 100 person-years. In unadjusted analyses, homelessness was strongly associated with lower rates suppression (hazard ratio=0.56, 95% CI: 0.40-0.78, p=0.001), however, after adjustment for adherence this association was no longer significant (adjusted hazard ratio=0.79, 95% CI: 0.56-1.11, p=0.177). Homelessness poses a significant structural barrier to effective HIV treatment. However, since this relationship appears to be mediated by lower levels of ART adherence, interventions to improve adherence among members of this vulnerable population are needed.

UR - http://www.scopus.com/inward/record.url?scp=84555188169&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84555188169&partnerID=8YFLogxK

U2 - 10.1089/apc.2011.0169

DO - 10.1089/apc.2011.0169

M3 - Article

C2 - 22107040

AN - SCOPUS:84555188169

VL - 26

SP - 60

EP - 67

JO - AIDS Patient Care and STDs

JF - AIDS Patient Care and STDs

SN - 1087-2914

IS - 1

ER -