1. Correlates of adherence to antiretroviral therapy in a cohort of HIV-positive drug users receiving antiretroviral therapy in Hanoi, Vietnam MR Jordan 1, H Sheehan 1, ND Hien 2, TTM Lien 2, N Terrin 3, NV Trung 2, NTB Ha 2, DV Duong 2, C Wanke 1, NV Kinh 2, AM Tang 1 1 Tufts University School of Medicine, Boston, USA; 2 National Hospital of Tropical Diseases, Hanoi, Viet Nam; 3 Tufts Medical Center, Boston; USA

2. Background (1) The first case of HIV in Vietnam was reported in 1990 In 2006, 280,000 had been reported representing an overall prevalence of 0.5% among adults (aged 15-49 years) Injection drug users (IDU) account for more than 56% of all reported HIV infections 1 HIV prevalence in IDU estimated at 29%-34.0 %, with wide geographical variation 2 1 1 Nguyen et al. Addiction 2008; 2 Matehers et al. Lancet, 2008

3. Background (2) In 2005, Vietnam began rapid ART scale-up supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR) As of end 2009, over 36,000 adults and 2,000 children were receiving ART 1 In 2009, Vietnam strengthened its commitment to provide ART to IDUs and strengthen harm reduction programs 2 1 Vietnam Authority of HIV/AIDS Control, 2010; 2 Guidelines for HIV care and treatment, Hanoi Vietnam, 2009

4. Background (3) Rates of viral suppression in Vietnamese drug users (DU) comparable to rates seen in other populations 1 Optimal adherence to ART required for viral suppression and prevention of HIVDR 2-5 Previous studies have identified active drug use, poor social supports, and hazardous alcohol use as correlates of poor adherence to ART 6-10 1 Jordan et al. Int J STD AIDS 2009; 2 Oyugi et al. IDS 2007; 3 Bangsberg et al. Current HIV/AIDS report 2007; 4 Bangsberg et al. AIDS 2006; 5 Lewis et al. AIDS care 2006; 6 Chandler et al JAIDS 2006; 7 Arnsten J Gen Int Med 2002; 8 Jaquet Addiction 2010; Hendershot et al. J AIDS 2000; Do IAS 2010 TUPDX103

5. Objective Purpose to assess correlates of adherence to ART in a cohort of DUs receiving ART at a large urban clinic in Hanoi, Vietnam Hypotheses: active drug use, hazardous alcohol use, lack of social support are correlates of poor ART adherence

6. Methods (1) Between June and November 2006, 300 HIV infected and uninfected patients were enrolled into a 36- month prospective study on HIV and nutrition This analysis focuses on 100 HIV positive patients receiving ART for at least 6 months prior to enrolment Patients enrolled from outpatient clinic at the National Hospital of Tropical Diseases, Hanoi, Vietnam

7. Methods (2) Inclusion criteria  HIV positive  Age ≥18  Received ART at NHTD for at least six months  History of injection drug use within the previous 5-years  Informed consent signed consent Study approval by the Institutional Review Board of Tufts University (Boston) and ethical review board of the Hanoi School of Public Health

8. Data collection HIV-1 RNA; CD4+ cell count HCV Ab, HBsAg Fasting blood draw: triglycerides, total cholesterol, LDL, HDL, insulin, glucose, vitamins A, E, zinc, and selenium Body composition: height, weight, skinfold measures, circumferences, and BIA 24-hour dietary recall Lifestyle Questionnaire

9. Likert Scale Thinking back over the past 30 days, on average how would you rate your ability to take all your medications as prescribed? Please place an “X” on the line below at the point showing your best guess as to how much of your total antiretroviral medications you have taken in the past 30 days. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Visual Analogue Scale

10. CharacteristicN=100 Age (years)29.86 ± 4.86 Male gender100 Prison (ever)23 Married73 Heterosexual96 >13 years education78 Any drug use last 6 months48 Current injection drug use (last 6 months) 22 Baseline characteristics (1)

11. CharacteristicN=100 Drug use in lifetime (ever) Marijuana45 Heroin (injected)90 Heroin (smoked)91 Sedatives77 Amphetamines9 Current cigarette smoker84 Hazardous drinker (NIAAA)* 37 Baseline characteristics (2) *National Institute on Alcohol and Alcoholism

12. N=100 Duration of ART at baseline (months) 16.2 ± 12.7 ART regimen First-line95% Second-line3% Other1% Baseline characteristics (3)

13. Baseline characteristics (4) N=100 CD4 cells/mm 3 Study baseline189 ± 110 Viral load Viral load < 50 copies/mL59 (59%) Viral load < 1000 copies/mL73 (73%)

14. Baseline characteristics (5) N=100 VAS (% med in past 30d)96 ± 12% Adherence (VAS > 95%)85 (85%) Ability to take meds in past 30d Excellent59 Very good24 Good10 Fair5 Poor2

15. VAS Distribution among virally suppressed participants La et al. 4 th Intl Conf HIV Treatment Adherence, 2009

16. Likert Distribution among virally suppressed participants La et al. 4 th Intl Conf HIV Treatment Adherence, 2009

17. Outcome: Adherence, Likert scale; dichotomized as Excellent/Very Good vs. Good/Fair/Poor Analysis includes data from 524 visits with complete questionnaire and adherence data Statistical model: repeated measures logistic regression (SAS V 9.2) Statistical Analysis

18. Statistical Analysis (2) Correlates of adherence examined: Drug use Alcohol use Living situation (alone vs. with others) Duration of ART (years) Self-reported symptoms (nausea, vomiting, stomach pain, fever, white patches, mouth lip gum pain)

19. Results CharacteristicUnadjusted OR (95% CI) Adjusted OR (95% CI) Live alone2.98 (0.91 - 9.80)______ IDU last 6 months 1.63 (1.03-2.58)______ Hazardous alcohol usage 0.94 ( 0.64 -1.38)______ DU last 6 mo1.64 (1.13-2.37)1.77 (1.19 - 2.62) Years on ART1.39 (1.13 – 1.71)1.42 (1.16 - 1.74)

20. Summary Results demonstrate a significant correlation between poorer adherence:  Active drug use in the last 6 months  Duration of ART

21. Conclusion Strengthening of harm reduction programs for HIV infected DUs and scale-up of methadone maintenance may support initiation and adherence to ART among IDU in Vietnam Programmatic supports for adherence beyond the first 12 months of therapy may be indicated Additional operational research/interventions aimed at building social capital and decreasing stigma may support long-term adherence to ART

22. Acknowledgements Tufts University School of Medicine  Sherwood Gorbach  James Hellinger  Rony Barbara National institutes of Health  K23 AI074423 (PI Jordan)  P30DA013868 (PI Gorbach)  R01DA022163 (PI Gorbach) Patients who participated in the study National Hospital of Tropical Disease  Dung Nguyen  Huong Le  Ha N. Nguyen  Trang Van  Phuong Nguyen  Hai Pham  Hoa Le  Khuong T.Pham  Thuc T. Nguyen  Tien Q. Luu