Ladak Farah, Socias Eugenia, Nolan Seonaid, Dong Huiru, Kerr Thomas, Wood Evan, Montaner Julio, Milloy M-J
Department of General Surgery, University of Alberta, Edmonton, AB, Canada.
British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.
Antivir Ther. 2019;24(1):19-25. doi: 10.3851/IMP3265.
Active illicit drug use can present a barrier to the medical management of HIV infection by complicating adherence to antiretroviral therapy (ART). Plasma HIV-1 RNA viral load (VL) rebound, defined as a period of detectable HIV VL following ART and VL suppression, can lead to the generation of viral resistance and potential treatment failure. We sought to investigate the contribution of substance use patterns on rates of VL rebound.
We used data from the ACCESS study, a long-running community-recruited prospective cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, a setting of universal no-cost HIV treatment. We analysed time to VL rebound (that is, two consecutive observations ≥1,000 copies/ml) after ART initiation and sustained viral suppression (that is, two consecutive observations <50 copies/ml) using extended Cox regression models with a recurrent events framework.
Between May 1996 and November 2013, 564 ART-exposed participants achieved at least one instance of VL suppression and contributed 1,893.8 person-years of observation. Over follow-up, 198 (35.1%) participants experienced ≥ one instance of VL rebound. In adjusted analyses, VL rebound was associated with younger age (adjusted hazard ratio [AHR] =0.97, 95% CI: 0.95, 0.98), heroin injection (≥ daily versus < daily, AHR =1.52, 95% CI: 1.01, 2.30), crack use (≥ daily versus < daily, AHR = 1.73, 95% CI: 1.08, 1.92) and heavy alcohol use (≥ four versus < four drinks/day, AHR =1.97, 95% CI: 1.17, 3.31).
The present study suggests that in addition to heavy alcohol use, high-intensity illicit drug use, particularly ≥ daily heroin injection and ≥ daily crack smoking are risk factors for VL rebound. In addition to the impact of high-intensity drug use on health-care engagement and ART adherence, some evidence exists on the direct impact of psychoactive substances on ART metabolism and the natural progression of HIV disease. At-risk individuals should be provided additional supports to preserve virological control and maintain the benefits of ART.
积极使用非法药物会使抗逆转录病毒疗法（ART）的依从性变得复杂，从而给艾滋病毒感染的医疗管理带来障碍。血浆HIV-1 RNA病毒载量（VL）反弹，定义为ART及VL抑制后可检测到HIV VL的时期，可导致病毒耐药性的产生及潜在的治疗失败。我们试图调查物质使用模式对VL反弹率的影响。
我们使用了ACCESS研究的数据，该研究是一项长期的、通过社区招募的前瞻性队列研究，研究对象为加拿大温哥华使用非法药物的艾滋病毒阳性者，当地提供免费的艾滋病毒治疗。我们使用带有复发事件框架的扩展Cox回归模型，分析了ART启动及持续病毒抑制（即连续两次观察<50拷贝/毫升）后至VL反弹的时间（即连续两次观察≥1000拷贝/毫升）。
在1996年5月至2013年11月期间，564名接受ART治疗的参与者至少有一次VL抑制，并贡献了1893.8人年的观察数据。在随访期间，198名（35.1%）参与者经历了≥一次VL反弹。在调整分析中，VL反弹与年龄较小（调整后风险比[AHR]=0.97，95%置信区间：0.95，0.98）、注射海洛因（≥每日与<每日，AHR =1.52，95%置信区间：1.01，2.30）、使用快克可卡因（≥每日与<每日，AHR =1.73，95%置信区间：1.08，1.92）及大量饮酒（≥四杯与<四杯/天，AHR =1.97，95%置信区间：1.17，3.31）有关。
本研究表明，除大量饮酒外，高强度非法药物使用，尤其是≥每日注射海洛因和≥每日吸食快克可卡因是VL反弹的危险因素。除了高强度药物使用对医疗参与和ART依从性的影响外，有一些证据表明精神活性物质对ART代谢及艾滋病毒疾病自然进展有直接影响。应向高危个体提供额外支持，以维持病毒学控制并保持ART的益处。
