Among persons living with HIV in the United States, injection drug users (IDUs) have been shown to under-utilize HIV-oriented medical care and tend to have inferior outcomes when treated with antiretroviral therapy (ART). In order to reduce HIV-related disparities in health outcomes, a better understanding of the underlying determinants of ART effectiveness is needed. Through completion of three linked studies, this research examined the clinical, socioeconomic and behavioral factors that influence ART utilization and effectiveness among IDUs. Using data from an ongoing, community-based, longitudinal cohort study, we have systematically evaluated each domain in the spectrum of HIV care, including (1) linkage and retention in care, (2) initiation of ART, and (3) maintenance of virologic suppression. Since 1988, the AIDS Linked to the Intravenous Experience (ALIVE) study has followed 1,535 HIV-infected IDUs, using semiannual, in-person assessments to collect sociodemographic, clinical and behavioral information, and to create a specimen repository for future laboratory-based research. For analyses of linkage and retention in care, the relevant outcomes were ascertained through participant self-report of attendance at HIV clinical care visits and utilization of ART. Provider and clinic-level factors related to the initiation of ART were examined by administering a 120-item, internet-based survey to 662 HIV care providers throughout the United States and Canada. Virologic responses to ART were evaluated using quantitative measurements of plasma HIV RNA from specimens collected from ALIVE participants at every semiannual assessment. Statistical modeling for longitudinal and cross-sectional data allowed estimation of measures of association among hypothesized predictors of suboptimal HIV care and each of the outcomes of interest. The main study results demonstrated that determinants of ART effectiveness exist and several levels. Individual-level factors such as frequent illicit drug use, provider-level factors including negative attitudes about drug users, and structural forces such as the high frequency of incarceration were shown in the various analyses to predict unfavorable treatment-related outcomes. Based on these results, incarceration was identified as a risk factor for suboptimal HIV care in need of further study. The relevant literature was reviewed and an agenda for future research proposed.
|Advisor:||Kirk, Gregory D.|
|Commitee:||Hendrix, Craig, Lawrence, Robert S., Treisman, Glenn J.|
|School:||The Johns Hopkins University|
|School Location:||United States -- Maryland|
|Source:||DAI-B 74/10(E), Dissertation Abstracts International|
|Subjects:||Medicine, Public health|
|Keywords:||Clinical care, Criminal justice systems, HIV/AIDS, Injection drug users, Retention in care, Substance abuse|
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