Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 32405-32409 603

different drug regimens including PI change. PI used were: saquinavir in 40 drug
regimens (75.5%) and indinavir in 13 (24.5%). We observed total adherence in 28
patients (52.8%), partial adherence in 11 (20.8%) and interruption in 14 (26.4%).
The main reasons for non-adherence were: forgetfulness in 9 cases (17%), delay
in receiving drugs in 5 (9.4%) and intolerance in 5 (9.4%). In the comparative
analysis of the adherence between men and women we observed rates of 66.7%
and 30% respectively (p = 0.005). Total adherence occurred in 51.6% of white
patients and in 56.2% of non-white patients (p > 0.05).
Conclusions: Total adherence to PI use occurred in just half of the patients.
The main reason for non-adherence was forgetfulness what emphasizes the
importance of informing well the patients about the drug regiments. Adherence
rate observed in women was significantly lower than the one observed in men.
32405 The CMA experience: Applying combination antiretroviral
therapy in a US inner city, advanced AIDS population.
Will viral rebound translate to increased costs?
Donna Gallagher1, J.A. Helliger2, R.J. Master2. 1471 California Street,
Newtonville MA; 2community Medical Alliance, Boston MA, USA
Community Medical Alliance (CMA) is a care system integrated with a managed
care organization that contracts with Massachusetts MEDICAID on a prepaid capitation basis to provide the entire array of services to Medicaid eligible individuals
with advanced AIDS. This system relies on a nurse-practitioner (NP) and physician team approach with major emphasis on home based care. Since 1992, CMA
has provided care for 20% of the Boston area, Medicaid eligible individuals with
advanced AIDS. Patient demographics include 35% women, 60% IDU, 42% with
active mental health and/or substance abuse problems and 18% intermittently
homeless or living in supported housing arrangements. Prior to widespread use of
combination antiretroviral therapy (ART), n = 110 advanced AIDS patients in 1995
averaged 1.4 hospitalizations, 14.5 hospital days and $46,804 medical service
expenditures (excluding oral pharmacy) per enrollee per year and had an overall
mortality of 62 per 100 enrollee years. During 1996, hospital admissions dropped
to 0.4 admissions, 5 days and $21,404 per member per year respectively, and
mortality decreased from a peak in 1995 of 62, to 12 deaths per 100 enrollee
years in 1996. We attribute this change to combination ART supported by an
intensive adherence effort by the homecare NP teams. Median CD4+ cell count
has climbed from 85 cells/ul at enrollment to 151 cells/ul but only 39% (41 of 104)
of individuals on ART have current plasma HIV-1 RNA below quantitation (<500
copies/ml), and 29% (40) are intolerant, unable or unwilling to take ART. Adjusted
for the total patients enrolled, only 28% (41/144) are maximally suppressed on
ART. Few individuals have returned to the work force, and increasing use of
substance abuse and mental health services are reported.
Conclusions: In this urban population with advanced AIDS, ART delivered by
a home-based nurse practioner model has dramatically reduced hospitalizations,
and mortality. The high rate of drug failure in a socially complex population with
advanced AIDS may predict increasing hospitalization rates, mortality and health
care expenditure. Comprehensive 1997 health care utilization and cost data will
be presented and analyzed by clinical AIDS severity, CD4 and viral load.
389*/32406 Protease inhibitors (PI) in the HIV+ homeless and
marginally housed (H/M): Good adherence but
rarely prescribed
David Bangsberg12, M. Robertson3, E. Charlebois3, J. Tulsky3, F.M. Hecht3,
J. Bamberger4, A.R. Moss3. 1995 Potrero Ave. Ward 95 Room 513 San
Francisco California 94110; 2Center for AIDS Prev Studioes SFGH/UCSF San
Francisco CA; 3Univ. of California San Francisco San Francisco CA;
4Department of Public Health San Francisco CA, USA
Objectives: Combination therapy with PIs is sometimes withheld from poor or
marginalized populations because of concerns about adherence to therapy. We
report on the prevalence of PI use and adherence to PI therapy in the REACH
cohort, a prospective cohort of HIV-positive H/M persons.
Design: Prospective cohort study.
Methods: We recruited a representative cohort of 154 HIV-positive persons
from lunch lines, shelters and hotels charging -400/mo in San Francisco. We
characterized antiretroviral (ARV) use as (a) combination therapy with a PI and
2 reverse transcriptase inhibitors (PI + 2RTI), (b) RTI therapy alone and (c) no
therapy. Adherence was measured by self-report of doses missed. We validated
self-reported adherence by drug plasma levels.
Results: 87% of eligible subjects agreed to be followed. Cohort retention was
82% at one year. At baseline, 7% were on PI/RTI therapy and 25% on RTIs
alone. There was no increase in baseline use PIs over time. Among those in the
cohort, PI use increased to 30% at one year of followup. The median drug exposure was 4.5 months. Prevalence of each PI was: nelfinavir-43%, indinavir-37%,
saquinavir-17%, nelfinavir/saquinavir-2% and ritonavir-0% Of these, 20 subjects
had.-6 months of PI exposure (median = 10.2 mo).
Street and shelter dwellers were less likely to receive PIs at baseline than hotel
dwellers (3% vs. 8%; p = 0.05) and women less likely than men (0% vs. 9% p =

0.03). There was marginally less PI use at baseline in injection drug users (IDU)
compared to non users (5% vs. 11%). (p = 0.06).
80% of subjects on PI therapy report missing less than 2 doses per week (n =
23). 88% of adherent subjects had detectable drug in their plasma (n = 18).
Conclusions: (1) Baseline access to PIs in the H/M population was poor (7%)
compared to levels of 50-70% reported in standard clinical settings. PI use was
increased by being followed in the REACH cohort.

(2) H/M persons prescribed PIs report relatively good adherence, validated by
plasma drug levels.
(3) Access to PIs should be expanded in the homeless and marginally housed.
499*/32407 Virologic response to antiretroviral therapy among
HIV-infected injection drug users
Sharon Mannheimer, Wafaa El-Sadr, J. Flowers, H. Safavi, J. Curtis. Harlem
Hospital/Columbia University 506 Lenox Ave. RM. 3101A, New York NY10037,
USA
Objectives: To assess the impact of antiretroviral therapy among HIV-infected
injection drug users (IDUs) in a methadone maintenance treatment program
(MMTP) and to examine factors which may be associated with achieving undetectable HIV RNA levels.
Design: Retrospective chart review
Methods: Adult HIV-infected persons receiving HIV primary care on-site at
the two Harlem Hospital-affiliated MMTPs were included. Information collected
included patient demographic characteristics, antiretroviral regimens, and recent
HIV RNA levels (using Roche Amplicor PCR assay) and CD4 lymphocyte counts.
Data was analyzed using Epi-lnfo (version 6.02).
Results: Charts were available for 74 (99%) of the 75 patients. Patients were
38% women, 66% African American and 31% Latino. Mean CD4 was 369 (range
4-1070), with 75% of CD4 counts.<500 cells/mm3 and 25% - 200. Fifty-eight
(78%) of the 74 patients were receiving antiretroviral therapy. Antiretroviral regimens consisted of a mean of 2.6 medications (range 1-4) and 8.9 pills daily
(range 2-17), with 67% including a protease inhibitor. No association was found
between antiretroviral use and gender, race or CD4 count. The mean HIV RNA
level among patients receiving antiretroviral therapy was 23,704 copies/mL (range.400-225,000). Twenty-one (40%) of the 52 patients with available HIV RNA results while on therapy achieved undetectable HIV RNA levels (<400 copies/mL).
No association was found between undetectable HIV RNA and gender, race,
or CD4 count, while there was a trend toward more patients receiving protease
inhibitors having undetectable HIV RNA levels (p = 0.08).
Conclusion: HIV-infected former IDUs receiving antiretroviral medications
through on-site primary care at an MMTP were able to achieve undetectable
HIV RNA levels. This suggests that former IDUs are capable of adherence with
complex antiretroviral regimens, and that such medications should not be withheld
based on a history of injection drug use.
501*/32408 1 Prisons and public health: Emerging issues in HIV
treatment adherence
Linda Frank. Univ of Pittsburgh, Jail & Prison Committee, American Public
Health Association Pittsburgh PA 15261, USA
Issue: The development of more effective HIV treatment places added responsibilities on prison healthcare providers and administrators. The importance of
adherence to treatment and the development of viral resistance from disruption of
dosing of medications, places an added burden and enhanced public health role
requiring additional prison education and training as well as changes in policies
and procedures.
Project: In order to address the complexity of current HIV clinical management, a comprehensive approach to correctional education and consultation is
essential. Healthcare provider and all staff coming in contact with inmates receiving combination therapy must have the current clinical information. Altering
the prison healthcare system to meet this challenge must include: 1) education
of healthcare providers, counselors, and security staff on the HIV treatment; 2)
peer-based inmate education on treatment and prevention; and 3) training of
parole staff on HIV treatment and the critical issue of treatment adherence.
Results: This comprehensive model requires that prisons have access to
consultation and technical assistance from universities providing care for the development of curricula, clinical guidelines and standards for HIV care, consultation
on policy development, and healthcare provider and peer education programs.
This approach can be an effective method of assuring that treatment adherence is
emphasized with inmates and providers with integration of adherence principles
and interventions into the systems' policies and procedures.
Lessons Learned: Ongoing healthcare provider education on new treatments,
development of peer-based inmate education, and early identification of infected
inmates, can enhance overall HIV care for inmates and reduce the risk of transmission of viral resistant HIV strains cause by poor adherence to treatment
regimens.
503*/32409 Health status and co-morbidity of HIV+ and HIVout-of-treatment injection drug users (IDUs)
Frederick Altice, K. Khooshnood, K.M. Blankenship, C.T. Roan, M. Kravitz. Yale
University AIDS Program 135 College ST #323 New Haven CT 06510, USA
Objective: To compare the medical complications of HIV+ and HIV drug injectors.

Methods: Demographic and health utilization data were analyzed for 216
out-of-drug treatment IDUs, recruited (4/97-9/97) using a modified snowball
methodology. Medical complications were grouped as chronic (asthma, diabetes,
hypertension, seizure disorder, etc), injection-related infections (cellulitis, abscess, osteomyelitis, bacteremia, etc), mental illness (depression, schizophrenia,
suicide attempt, etc), and other conditions.