title: Socioeconomic marginalization and plasma HIV-1 RNA nondetectability among individuals who use illicit drugs in a Canadian setting.
abstract: OBJECTIVE
  Given that people who use illicit drugs (PWUD) often engage in prohibited income generation to support their basic needs, we sought to examine the role of these activities in shaping antiretroviral therapy (ART) adherence and plasma HIV RNA-1 viral load suppression among HIV-infected PWUD.
  
  
  METHODS
  Longitudinal analyses among HIV-positive, ART-exposed PWUD in the AIDS Care Cohort to evaluate Exposure to Survival Services prospective cohort study (2005-2013).
  
  
  METHODS
  Generalized linear mixed-effects and mediation analyses examined the relationship between prohibited income generation (e.g., sex work, drug dealing, theft, street-based income) and virologic suppression (plasma viral load ≤50 copies/ml plasma) adjusting for adherence and potential confounders.
  
  
  RESULTS
  Among 687 HIV-infected PWUD, 391 (56.9%) individuals reported prohibited income generation activity during the study period. In multivariate analyses, prohibited income generation remained independently and negatively associated with virologic suppression (adjusted odds ratio: 0.68, 95% confidence interval: 0.52-0.88) following adjustment for hypothesized confounders, including high-intensity drug use, ART adherence and homelessness. Although partially mediated by ART adherence, the relationship between prohibited income generation and virologic suppression was maintained in mediation analyses (Sobel statistic = -1.95, P = 0.05).
  
  
  CONCLUSIONS
  Involvement in prohibited income generation decreases the likelihood of virologic suppression directly and indirectly through its negative association with ART adherence. These findings suggest that linkages between socioeconomic marginalization, the criminalization of illicit drug use, and insufficient employment opportunities may produce barriers to access and retention in care. Programmatic and policy interventions that decrease socioeconomic vulnerability may therefore reduce HIV-related morbidity, mortality, and onward transmission.
authors.affiliation: aBritish Columbia Centre for Excellence in HIV/AIDS bDepartment of Sociology cDivision of AIDS, Department of Medicine, University of British Columbia, Vancouver dFaculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
authors.forename: Lindsey A
authors.initials: LA
authors.lastname: Richardson
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Kerr
authors.forename: Sabina
authors.initials: S
authors.lastname: Dobrer
authors.forename: Cathy M
authors.initials: CM
authors.lastname: Puskas
authors.forename: Silvia A
authors.initials: SA
authors.lastname: Guillemi
authors.forename: Julio S G
authors.initials: JS
authors.lastname: Montaner
authors.forename: Evan
authors.initials: E
authors.lastname: Wood
authors.forename: M-J S
authors.initials: MJ
authors.lastname: Milloy
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D002170:Canada; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D015497:HIV-1 / Q000302:isolation & purification*; D006801:Humans; D013287:Illicit Drugs; D008137:Longitudinal Studies; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010949:Plasma / Q000821:virology; D011446:Prospective Studies; D012367:RNA, Viral / Q000097:blood; D062487:Social Marginalization; D019966:Substance-Related Disorders / Q000150:complications* / Q000523:psychology; D019562:Viral Load
chemical_list: D044966:Anti-Retroviral Agents; D013287:Illicit Drugs; D012367:RNA, Viral