Barriers to HIV care and Antiretroviral Treatment (ART) among HIV-infected Crack Users in the United States Christine Bell 1 Gabriel Cardenas 2 Tanisha Sullivan 1 Tamy Kuper 2 Lauren Gooden 2 Jessica Kaplan 1 Elizabeth Scharf 1 Allan Rodriguez 2 Carlos del Rio 1 Lisa Metsch Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, and Emory CFAR and the Department of Epidemiology 2 University of Miami Miller School of Medicine, Department of Epidemiology and Public Health and Medicine and U. Miami D-CFAR.

Background About 1 in 4 persons living with HIV are not regularly attending HIV primary care About 1 in 4 persons living with HIV are not regularly attending HIV primary care HIV-infected drug users are less likely to utilize HIV primary care and receive HAART HIV-infected drug users are less likely to utilize HIV primary care and receive HAART HIV-infected drug users also have higher rates of hospitalization and are more likely to leave the hospital against medical advice HIV-infected drug users also have higher rates of hospitalization and are more likely to leave the hospital against medical advice Use of crack cocaine continues to flourish in many inner-cities in the U.S. Use of crack cocaine continues to flourish in many inner-cities in the U.S.

Study objectives To describe barriers to HIV care and antiretroviral treatment among HIV infected crack users hospitalized in Grady Memorial Hospital (Atlanta) and Jackson Memorial Hospital (Miami). To describe barriers to HIV care and antiretroviral treatment among HIV infected crack users hospitalized in Grady Memorial Hospital (Atlanta) and Jackson Memorial Hospital (Miami). To assess factors associated with ever having had an HIV primary care provider To assess factors associated with ever having had an HIV primary care provider To assess association with ever having received Antiretroviral Treatment (ART) To assess association with ever having received Antiretroviral Treatment (ART)

Methods Structured interviews were conducted with HIV-infected crack users who were admitted to two inner city hospitals in the US between August 2006 – January Structured interviews were conducted with HIV-infected crack users who were admitted to two inner city hospitals in the US between August 2006 – January Interview eligibility criteria Interview eligibility criteria Hospitalized HIV patient at GMH or JMH were screened prior to interview to establish: Hospitalized HIV patient at GMH or JMH were screened prior to interview to establish: 1) Sexual intercourse in the past 6 months 2) Crack-cocaine use in the past year Data Analysis Data Analysis Logistic regression analyses were used to identify significant associations among the variables. IRB approval was obtained from Emory IRB and Miami IRB IRB approval was obtained from Emory IRB and Miami IRB and full informed consent was obtained from study participants before interview.

Demographic characteristics of study participants Atlanta: Grady Hospital 141 study participants 141 study participants 55% female, 45% male 55% female, 45% male 92% Black, 8% Other 92% Black, 8% Other Average age: 44 years old Average age: 44 years old Miami: Jackson Hospital 80 study participants 80 study participants 48% female, 52% male 48% female, 52% male 86% Black, 14% Other 86% Black, 14% Other Average age: 43 years old Average age: 43 years oldOverall < $5000 annual income: 70% < $5000 annual income: 70% > 5 yrs since HIV diagnosis: 69% > 5 yrs since HIV diagnosis: 69% Homeless: 49% Homeless: 49% Jackson Memorial Hospital Grady Memorial Hospital

History of HIV care and treatment No Yes No

Have you ever gone to a doctor or clinic for HIV care?** Low Income Population (N=150) Study variableOdds Ratio, 95% Confidence Interval Atlanta*0.118 (0.036, 0.383) Female*0.394 (0.151, 1.03) 40 or older*0.679 (0.254, 1.812) Black/African American*0.838 (0.197, 3.568) Ever participated in drug treatment4.151 (1.666, ) Receives disability funding5.053 (1.443, ) *Variables forced into model **After adjusting for site, gender, age, and ethnicity

Variables not found to have a significant association with going to HIV care in our data* Education level■ Attitude toward HIV care Education level■ Attitude toward HIV care Provider responsiveness■ Level of crack/alcohol consumption Provider responsiveness■ Level of crack/alcohol consumption Putting off HIV care due to drugs/alcohol■ Housing stability Putting off HIV care due to drugs/alcohol■ Housing stability Unprotected sex in previous 6 months■ Level of depression Unprotected sex in previous 6 months■ Level of depression Referral to a case manager■ Having children Referral to a case manager■ Having children Social support Social support History of incarceration History of incarceration Level of HIV knowledge Level of HIV knowledge *Variables not selected by backward stepwise at the 0.05 significance level to be associated in multivariate form with the dependent variable.

Have you ever taken medications for your HIV?** (N=189) Study variableOdds Ratio, 95% Confidence Interval Atlanta*0.347 (0.147, 0.816) Female*0.64 (0.292, 1.399) 40 or older*1.733 (0.747, 4.023) Black/African American*0.757 (0.232, 2.475) > 5 years since HIV diagnosis5.729 (2.544, ) Been helped into HIV care2.291 (1.039, 5.05) Ever participated in drug treatment3.711 (1.619, 5.05) *Variables forced into model **After adjusting for site, gender, age, and ethnicity

Variables not found to have a significant association with taking HIV medications in our data* Education level ■ Having children Education level ■ Having children Income ■ Self-efficacy for taking HIV meds Income ■ Self-efficacy for taking HIV meds Putting off HIV care because of ■ Attitude for taking HIV meds Putting off HIV care because of ■ Attitude for taking HIV meds drugs/alcohol ■ Level of depression Unprotected sex in previous 6 months Unprotected sex in previous 6 months Referral to a case manager upon diagnosis Referral to a case manager upon diagnosis Social support Social support Empowerment Empowerment Level of crack/alcohol consumption Level of crack/alcohol consumption Housing stability Housing stability *Variables not selected by backward stepwise at the 0.05 significance level to be associated in multivariate form with the dependent variable.

Study Limitations Self report Self report HIV, sexual, drug and social histories provided by study participants were assumed to be accurate Interview bias Interview bias It is possible that participants provided answers that were most pleasing or acceptable to interviewer Other factors related to use of care and treatment Other factors related to use of care and treatment There may be other factors related to utilization of HIV care and treatment among HIV crack users not covered in structured interviews. Interview data has not yet been corroborated with medical chart abstraction.

Implications for HIV public health policy In order to bring HIV infected crack users into primary HIV care, to keep them in care and to allow them to benefit from prevention and treatment interventions… Policy development: A multifaceted intervention is needed that includes: A multifaceted intervention is needed that includes: HIV care management HIV care management Substance abuse treatment and, Substance abuse treatment and, Strategies to improve socioeconomic stability Strategies to improve socioeconomic stability Project HOPE Hospital Visit is an Opportunity for Prevention and Engagement with HIV-positive Crack Users Project HOPE : Hospital Visit is an Opportunity for Prevention and Engagement with HIV-positive Crack Users

Acknowledgements Atlanta Site Funding Carlos del Rio, MD, Co-PI NIH/NIDA (RO1 DA017612) Richard Rothenberg, M.D., Investigator NIH/NIAID (P30 AI050409) Tanisha Sullivan, Project Director Emory Center for AIDS Research (CFAR) Jessica Kaplan, Interviewer NIH/NIAID (1P30 AI023961) Elizabeth Scharf, Interviewer University of Miami Developmental Mary Yohannan, Facilitator Center for AIDS Research (DCFAR) Ossie Williams, Outreach Worker Miami Site Lisa Metsch PhD, PI Allan Rodriguez, MD, Co-PI Toye Brewer, MD, Co-I Margaret Pereyra, PhD, Co-I Shari Messinger, PhD, Biostat Lauren Gooden, MPH, Project Director Gabriel Cardenas, MPH, Data Manager Tamy Kuper, BA Project Director/ Interviewer Ginny Locascio, LPN, Facilitator Cheryl Riles, Interviewer Richard Walker, Outreach Worker