Factors associated with antiretroviral utilization among HIV-infected crack cocaine users in Atlanta and Miami Open Access

Abstract

Despite availability of antiretroviral therapy (ART), HIV-infected drug users, particularly
crack cocaine users, continue to have high HIV-related morbidity and mortality. The
purpose of this study was to determine factors associated with ART utilization among
HIV-infected crack cocaine users. A cross-sectional analysis was conducted using the
baseline data for hospitalized HIV-infected crack cocaine users recruited for Project
HOPE (Hospital Visit is an Opportunity for Prevention and Engagement with HIV-
positive Crack Users) in Atlanta and Miami, who were eligible for ART (reported or
documented any lifetime use of ART or CD4 <350 cells/µl). Among 350 eligible
participants, mean age was 44.9 years (SD 7.0), 49% were male, 90% were black, and
81% were heterosexual. Median CD4 count was 144 cells/µl, and 78 of 350 (22%) were
taking ART. Of the participants taking ART, 60% had undetectable HIV-1 viral load,
representing 9% of the eligible population. Multivariable logistic regression was
conducted to examine the relationship between homelessness and ART utilization.
Current homelessness was negatively associated with ART utilization on bivariate and
multivariable analyses (adjusted OR 0.31, 95% CI 0.16-0.60). A model to predict ART
utilization was developed for Atlanta participants and tested for generalizability among
Miami participants; variables chosen for this model included age, race, gender, insurance,
homelessness, depression, crack use frequency, and alcohol use frequency. AUC for
Atlanta was 0.814 and Miami was 0.577. When visits to HIV primary care were added to
the model, AUC for Atlanta was 0.84 and for Miami was 0.678. Viral load suppression
was modeled among ART users. None of the measured covariates, including age,
gender, race, city, alcohol use, marijuana use, crack use, depression, HIV knowledge,
patient-provider relationship, homelessness, and trust, were independently associated
with viral load suppression. For HIV-infected crack cocaine users, structural factors may
be as important as individual and interpersonal factors in facilitating ART utilization.
Only 9% of HIV-infected crack cocaine users had viral suppression, but among those on
ART, 60% achieved viral suppression. Future public health programs in the US should
focus on improving uptake of ART and achieving viral suppression among crack cocaine
users.

Table of Contents

INTRODUCTION...........................................................................1

HIV-infected crack cocaine users....................................................1

Intersecting epidemics: homelessness, substance abuse, and HIV.......2

Factors affecting antiretroviral utilization.........................................3

METHODS....................................................................................5

Specific aims and hypotheses.........................................................5

Design.........................................................................................6

Subjects and enrollment.................................................................6

Procedure.....................................................................................7

Variables......................................................................................8

Sample size calculation.................................................................10

Data analysis...............................................................................10

Aim 1..........................................................................................10

Aim 2..........................................................................................11

Aim 3..........................................................................................12

Aim 4..........................................................................................12

RESULTS.....................................................................................14

Sample description.......................................................................14

Aim 1..........................................................................................14

Aim 2..........................................................................................14

Aim 3..........................................................................................16

Aim 4..........................................................................................17

DISCUSSION................................................................................18

REFERENCES................................................................................25

TABLES........................................................................................32

FIGURES......................................................................................48

About this Master's Thesis

Rights statement

• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Laney Graduate School
Department	Clinical Research Curriculum Program
Degree	MS
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Medicine and Surgery
Keyword	HIV antiretroviral therapy vulnerable populations drug abuse Southeast AIDS crack cocaine
Committee Chair / Thesis Advisor	Del Rio, Carlos, Emory University
Committee Members	Manatunga, Amita, Emory University Klein, Mitchel, Emory University

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