Effects of Alcohol and Crack Cocaine Use on Virological and Immunological Disease Progression in a Cohort of U.S. Women with HIV/AIDS Judith A. Cook, Ph.D. University of Illinois at Chicago Department of Psychiatry Presented at AIDS 2006 XVI International AIDS Conference Toronto, Canada August 15, 2006

Collaborators Jane K. Burke-Miller Dennis D. Grey Mardge H. Cohen Robert Cook David Vlahav Farzana Kapadia Tracey Wilson Rebecca Schwartz Elizabeth Golub Kathy Anastos Claudia Ponath Lakshmi Goparaju Jean Richardson Funded by U.S. National Institute of Allergy & Infectious Diseases & National Institute on Drug Abuse

Study Background  Heavy and at-risk alcohol use are associated with lesser likelihood of HAART use & adherence (R. Cook et al., 2001; Samet et al., 2004)  Crack/cocaine use is associated with lesser likelihood of HAART use & adherence (J. Cook et al, 2006)  Some evidence suggests that alcohol use & crack/cocaine use are associated with faster HIV disease progression & AIDS-related mortality (Samet et al., 2003; Farbris et al., 2000; J. Cook et al., 2002)  Given the foregoing, do alcohol & crack/cocaine use, together or separately, have an effect on disease progression that is independent of their effects on HAART use & adherence?

Direct or Indirect Effects of Alcohol & Crack Use on HIV Disease Progression? At-Risk Alcohol + Crack Use Crack Use Alone At-Risk Alcohol Use Alone HAART Use & Adherence HIV Disease Progression ? ? ? ? ? ?

Study Purpose To explore whether alcohol and crack/cocaine use, alone or in combination, are associated with HIV- positive women’s virologic and immunologic disease progression

Hypotheses Women using alcohol, crack/cocaine, or both have higher HIV RNA viral loads and negative CD4 cell count slopes over time. These effects are not modified by the influence of highly active antiretroviral therapy (HAART) use and adherence.

Women’s Interagency HIV Study* (WIHS)  Cohort study of HIV-positive women recruited in 6 cities: Chicago, Los Angeles, San Francisco, Bronx, Brooklyn, Washington, DC  Data collection bi-annually beginning in 1994 until present  In-person interviews, physical exam, blood work, gynecological exam  Data come from 1996 through 2002 *Funded by U.S. National Institute of Allergy & Infectious Diseases & National Institute on Drug Abuse

Characteristics of WIHS Cohort Used in Analysis (N=1,691) African American56% Hispanic/Latina24% Caucasian18% Other 2% High School Ed63% Average Age = 37 years On HAART68% ARV Adherence>=95%66% IDU 7% Tobacco Use56% Income <$12,000/yr62% Probable depression41% Viral Load >100,00019% CD4<200 6% Current time Study baseline

Independent & Dependent Variables Alcohol use measured by self-reported number of drinks per week (with 8+ drinks per week defined as “at-risk drinking” per NIAAA guidelines) Crack use measured as any self-reported use in the past 6 months Plasma HIV-RNA copies categorized as >100,000 vs. <100,000 CD4 slope calculated from biannual CD4 counts

Control Variables study site time age race/ethnicity income education tobacco use injection drug use depressive symptoms CD4 as appropriate HIV RNA as appropriate

Use of Alcohol and Crack/Cocaine at Baseline

HIV RNA Viral Load Over Time by Use of Crack/Cocaine & At-Risk Drinking Study Visit ( ) Mean HIV RNA Viral Load

CD4 Over Time by Use of Crack/Cocaine & At-Risk Drinking Study Visit ( ) Mean CD4 Level

Effects of At-Risk Alcohol & Crack Use on HAART Use & Adherence a Variable HAART USE ADHERENCE At-risk alcohol + crack-0.64***-0.65** At-risk alcohol alone-0.59***-0.60** Crack alone-0.45***-0.58** a Mixed effects logistic regression controlling for time, age, African American, Latina, income, education, tobacco use, IDU, depressive symptoms * p<.05, **p<.01, ***p<.001

Effects of At-Risk Alcohol & Crack Use on HIV RNA Viral Load & CD4 Slope a Variable HIV RNA Viral Load b CD4 c Slope At-risk alcohol + crack0.69***-0.09* At-risk alcohol alone ns Crack alone0.10 ns a Mixed effects regression controlling for time, age, African American, Latina, income, education, tobacco use, IDU, depressive symptoms b Controls for CD4 100,000 * p<.05, **p<.01, ***p<.001, +p<.10

Effects of At-Risk Alcohol & Crack on HIV Disease Progression Controlling for HAART Use & Adherence a Variable Viral Load b CD4 Slope c At-risk alcohol + crack1.08*-0.13* At-risk alcohol alone0.20 ns Crack alone 0.41 ns -0.08* HAART -2.29***-0.01 ns Adherent -0.41*-0.03 ns a Mixed effects regression controlling for time, age, African American, Latina, income, education, tobacco use, IDU, depressive symptoms b Controls for CD4 100,000 *p<.05, **p<.01, ***p<.001, +p<.10

Conclusions  HIV+ women engaging in at-risk alcohol use & crack/cocaine use are at considerable risk of rapid virological & immunological disease progression  The effects of at-risk alcohol & crack use are independent of HAART use & adherence  Alcohol & crack use may affect disease progression through health behaviors (nutrition, exercise), psychological factors (depression, anxiety), HAART use & adherence, or through direct biological effects