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Mortality higher among HIV-positive patients during illicit drug use
  NEW YORK (Reuters Health, 03/06/06) - HIV-infected patients who persistently use cocaine and heroin are at increased risk of opportunistic infections, disease progression, and death compared with nonusers, investigators in Baltimore report. Among patients who use illicit drugs intermittently, their risk is as high as that of persistent users while they are using, but the risk drops when they are abstinent.
To assess the longitudinal association of drug use with HIV disease progression, Dr. Gregory M. Lucas, at the Johns Hopkins University School of Medicine, and his associates surveyed patients every 6 months using confidential computer-based interviews, starting in 1998.
As reported in the American Journal of Epidemiology for March 1, the 1851 participants included 1028 nonusers, 588 intermittent users (defined as using drugs a median of 14 days in the prior 6 months), and 235 persistent users (using drugs a median of 27 days in the prior 6 months).
At 3 years, the estimated survival rates were 87% for nonusers, 80% for intermittent users and 68% for persistent users (p < 0.0001 compared with nonusers).
After adjustment for age, race, gender, nadir CD4 cell count, and peak HIV RNA level, the hazard ratio of death was 1.9 among intermittent users and 2.9 for persistent users.
During periods of abstinence the risk of developing new opportunistic infections was similar to that of nonusers (odds ratio 1.4). The risk was closer to that of persistent users (OR 2.1) when intermittent users were actively using drugs (OR 2.3).
Results were similar for disease progression, with Ors of 1.3, 1.6 and 1.9, respectively, compared with nonusers.
Dr. Lucas's team theorizes that the effects of drug abuse on disease progression may be mediated by biological effects, such as increased HIV replication and impaired lymphocyte function, or by reducing access to care and adherence to therapy.
"Treatment paradigms that integrate HIV-1 treatment, substance abuse treatment, and psychiatric care should be emphasized" for patients who use cocaine or heroin, the authors maintain. Sublingual buprenorphine for the management of opioid dependence may be particularly helpful for this population.
Am J Epidemiol 2006;163:412-419.
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