title: HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study.
abstract: BACKGROUND
  Having opioid dependence and HIV infection are associated with poor HIV-related treatment outcomes.
  
  
  METHODS
  HIV-infected, opioid-dependent subjects (N = 295) recruited from 10 clinical sites initiated buprenorphine/naloxone (BUP/NX) and were assessed at baseline and quarterly for 12 months. Primary outcomes included receiving antiretroviral therapy (ART), HIV-1 RNA suppression, and mean changes in CD4 lymphocyte count. Analyses were stratified for the 119 subjects not on ART at baseline. Generalized estimating equations were deployed to examine time-dependent correlates for each outcome.
  
  
  RESULTS
  At baseline, subjects on ART (N = 176) were more likely than those not on ART (N = 119) to be older, heterosexual, have lower alcohol addiction severity scores, and lower HIV-1 RNA levels; they were less likely to be homeless and report sexual risk behaviors. Subjects initiating BUP/NX (N = 295) were significantly more likely to initiate or remain on ART and improve CD4 counts over time compared with baseline; however, these improvements were not significantly improved by longer retention on BUP/NX. Retention on BUP/NX for three or more quarters was, however, significantly associated with increased likelihood of initiating ART (β = 1.34 [1.18, 1.53]) and achieve viral suppression (β = 1.25 [1.10, 1.42]) for the 64 of 119 (54%) subjects not on ART at baseline compared with the 55 subjects not retained on BUP/NX. In longitudinal analyses, being on ART was positively associated with increasing time of observation from baseline and higher mental health quality of life scores (β = 1.25 [1.06, 1.46]) and negatively associated with being homo- or bisexual (β = 0.55 [0.35, 0.97]), homeless (β = 0.58 [0.34, 0.98]), and increasing levels of alcohol addiction severity (β = 0.17 [0.03, 0.88]). The strongest correlate of achieving viral suppression was being on ART (β = 10.27 [5.79, 18.23]). Female gender (β = 1.91 [1.07, 3.41]), Hispanic ethnicity (β = 2.82 [1.44, 5.49]), and increased general health quality of life (β = 1.02 [1.00,1.04]) were also independently correlated with viral suppression. Improvements in CD4 lymphocyte count were significantly associated with being on ART and increased over time.
  
  
  CONCLUSIONS
  Initiating BUP/NX in HIV clinical care settings is feasible and correlated with initiation of ART and improved CD4 lymphocyte counts. Longer retention on BPN/NX was not associated with improved prescription of ART, viral suppression, or CD4 lymphocyte counts for the overall sample in which the majority was already prescribed ART at baseline. Among those retained on BUP/NX, HIV treatment outcomes did not worsen and were sustained. Increasing time on BUP/NX, however, was especially important for improving HIV treatment outcomes for those not on ART at baseline, the group at highest risk for clinical deterioration. Retaining subjects on BUP/NX is an important goal for sustaining HIV treatment outcomes for those on ART and improving them for those who are not. Comorbid substance use disorders (especially alcohol), mental health problems, and quality-of-life indicators independently contributed to HIV treatment outcomes among HIV-infected persons with opioid dependence, suggesting the need for multidisciplinary treatment strategies for this population.
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA. frederick.altice@yale.edu
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
authors.forename: R Douglas
authors.initials: RD
authors.lastname: Bruce
authors.forename: Gregory M
authors.initials: GM
authors.lastname: Lucas
authors.forename: Paula J
authors.initials: PJ
authors.lastname: Lum
authors.forename: P Todd
authors.initials: PT
authors.lastname: Korthuis
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Flanigan
authors.forename: Chinazo O
authors.initials: CO
authors.lastname: Cunningham
authors.forename: Lynn E
authors.initials: LE
authors.lastname: Sullivan
authors.forename: Pamela
authors.initials: P
authors.lastname: Vergara-Rodriguez
authors.forename: David A
authors.initials: DA
authors.lastname: Fiellin
authors.forename: Adan
authors.initials: A
authors.lastname: Cajina
authors.forename: Michael
authors.initials: M
authors.lastname: Botsko
authors.forename: Vijay
authors.initials: V
authors.lastname: Nandi
authors.forename: Marc N
authors.initials: MN
authors.lastname: Gourevitch
authors.forename: Ruth
authors.initials: R
authors.lastname: Finkelstein
mesh_terms: D000437:Alcoholism; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D002047:Buprenorphine / Q000627:therapeutic use*; D000069479:Buprenorphine, Naloxone Drug Combination; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy; D015497:HIV-1 / Q000378:metabolism; D006801:Humans; D008297:Male; D008875:Middle Aged; D009270:Naloxone / Q000627:therapeutic use*; D009292:Narcotic Antagonists / Q000627:therapeutic use; D058850:Opiate Substitution Treatment; D009293:Opioid-Related Disorders / Q000150:complications* / Q000188:drug therapy; D012367:RNA, Viral / Q000097:blood; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents; D000069479:Buprenorphine, Naloxone Drug Combination; D009292:Narcotic Antagonists; D012367:RNA, Viral; D009270:Naloxone; D002047:Buprenorphine