title: A randomized clinical trial of community-based directly observed therapy as an adherence intervention for HAART among substance users.
abstract: BACKGROUND
  Adherence interventions for HAART can impact challenging populations, such as active substance users. Community-based modified directly observed therapy (MDOT) is a promising approach that needs to be critically evaluated.
  
  
  METHODS
  This study was a randomized clinical trial. HIV seropositive substance users were randomized to either standard of care (SOC) or MDOT, stratified by HAART experience. All participants were placed on a once-daily regimen and were met by an outreach worker for all 7 days during the first 3 months. We used an intent-to-treat analysis to evaluate differences in viral load suppression [> 2 log drop in plasma viral load (PVL) or PVL < 50] and changes in PVL and CD4 cell count from baseline to 3 months.
  
  
  RESULTS
  A total of 87 participants were enrolled (43 in SOC, 44 in MDOT), Using repeated measures logistic regression, MDOT participants were more likely to achieve PVL suppression (odds ratio, 2.16; 95% confidence interval, 1.0-4.7), driven primarily by those HAART experienced (odds ratio, 2.88; 95% confidence interval, 1.2-7.0). A significant treatment effect was also found in CD4 cell count change (P < 0.05). No differences were found by arm in undetectable PVL.
  
  
  CONCLUSIONS
  This study provides evidence that MDOT is an effective strategy to reduce viral load and increase CD4 cell counts in HAART experienced substance users. MDOT should be included in the spectrum of options to enhance adherence in this population.
authors.affiliation: Arthur Ashe Institute for Urban Health, Brown University, Providence, RI, USA. gmacalino@arthurasheinstitute.org
authors.forename: Grace E
authors.initials: GE
authors.lastname: Macalino
authors.forename: Joseph W
authors.initials: JW
authors.lastname: Hogan
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Mitty
authors.forename: Lauri B
authors.initials: LB
authors.lastname: Bazerman
authors.forename: Alison K
authors.initials: AK
authors.lastname: Delong
authors.forename: Helen
authors.initials: H
authors.lastname: Loewenthal
authors.forename: Angela M
authors.initials: AM
authors.lastname: Caliendo
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Flanigan
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D023801:Directly Observed Therapy; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000523:psychology; D015497:HIV-1; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D019966:Substance-Related Disorders / Q000188:drug therapy / Q000821:virology*; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents