title: Temporal trends in highly active antiretroviral therapy initiation among injection drug users in Baltimore, Maryland, 1996-2008.
abstract: BACKGROUND
  We characterized temporal trends in highly active antiretroviral therapy (HAART) initiation (1996-2008) among treatment-eligible persons in a community-based cohort of current and former injection drug users (IDUs) in Baltimore, Maryland.
  
  
  METHODS
  The AIDS Linked to the IntraVenous Experience (ALIVE) cohort has been observing human immunodeficiency virus (HIV)-positive IDUs since 1988. HAART eligibility was defined as the first visit after 1 January 1996 at which the patient's CD4(+) cell count was <350 cells/microL. Temporal trends and predictors of HAART initiation were examined using chi(2) tests for trend and lognormal survival models.
  
  
  RESULTS
  The median age of 582 HAART-eligible IDUs was 41 years; 75% of the subjects were male, 97% were African American, and 60% were active IDUs. Of these 582 individuals, 345 initiated HAART over 1803 person-years (19.2 subjects per 100 person-years; 95% confidence interval, 17.2-21.3 subjects per 100 person-years); there was no statistically significant temporal trend in HAART initiation. Independent predictors of delayed initiation included heavy injection drug use; having a prior AIDS diagnosis, having a lower CD4(+) cell count, having a usual source of care, and having health insurance were predictors of more-rapid initiation. The delay between eligibility and initiation decreased among those who became eligible most recently (2003-2007), compared with those in earlier periods (1996-2002); however, a substantial number of patients who became eligible in recent years either initiated HAART after a substantial delay or did not initiate HAART at all.
  
  
  CONCLUSIONS
  We failed to observe substantial improvement in HAART initiation among current and former IDUs over a 12-year period; heavy use of injection drugs remains the major barrier to HAART initiation and to consistent HIV care. The fact that many IDUs initiate HAART after a significant delay or do not initiate it at all raises concern that disparities in HIV care for IDUs remain at a time of simplified antiretroviral regimens and increasing adoption of earlier treatment.
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. shmehta@jhsph.edu
authors.forename: Shruti H
authors.initials: SH
authors.lastname: Mehta
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Kirk
authors.forename: Jacquie
authors.initials: J
authors.lastname: Astemborski
authors.forename: Noya
authors.initials: N
authors.lastname: Galai
authors.forename: David D
authors.initials: DD
authors.lastname: Celentano
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000639:trends*; D015142:Baltimore / Q000453:epidemiology; D018791:CD4 Lymphocyte Count; D055030:Drug Users / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged
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