Improvements in HIV treatment outcomes among indigenous and non-indigenous people who use illicit drugs in a Canadian setting.
BACKGROUND
In many settings worldwide, members of indigenous groups experience a disproportionate burden of HIV. In Canada, there is an urgent need to improve HIV treatment outcomes for indigenous people living with HIV (IPLWH), to not only reduce HIV/AIDS-associated morbidity and mortality but also curb elevated rates of viral transmission. Thus, by comparing indigenous and non-indigenous participants in an ongoing longitudinal cohort of HIV-positive people who use illicit drugs, we sought to investigate longitudinal changes in three HIV treatment indicators for IPLWH who use illicit drugs during a community-wide treatment-as-prevention (TasP) initiative in British Columbia, Canada.


METHODS
We used data from the ACCESS study, an ongoing observational prospective cohort of HIV-positive illicit drug users recruited from community settings in Vancouver, British Columbia. Cohort data are linked to comprehensive retrospective and prospective clinical records in a setting of no-cost HIV/AIDS treatment and care. We used multivariable generalized estimating equations (GEE) to evaluate longitudinal changes in the proportion of participants with exposure to antiretroviral therapy (ART) in the previous 180 days, optimal adherence to ART (i.e. ≥ 95% vs. < 95%) and non-detectable HIV-1 RNA viral load (VL <50 copies/mL plasma).


RESULTS
Between 2005 and 2014, 845 individuals were recruited, including 326 (39%) self-reporting any indigenous ancestry, and contributed 6732 interviews and 13,495 VL measurements. Among indigenous participants, the proportion with recent ART increased from 51 to 94% and non-detectable VL from 23 to 65%. In multivariable models, later interview period was positively associated with recent ART (adjusted odds ratio (AOR) = 1.16 per interview period, 95% confidence interval (CI): 1.11 to 1.20) and non-detectable VL (AOR = 1.07, 95% CI: 1.04 to 1.10). In adjusted models comparing indigenous and non-indigenous participants, we did not observe differences between the two groups (all p>0.1).


CONCLUSIONS
In this large and long-term study involving community-recruited HIV-positive illicit drug users, we observed a substantial and increasing proportion of indigenous participants reach several important thresholds in HIV care at rates indistinguishable from non-indigenous participants. The current findings highlight the important role of TasP on vulnerable populations in this setting and contribute to the evidence base supporting the immediate scale-up of ART to address HIV/AIDS-associated morbidity, mortality and viral transmission.
British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.|Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; uhri-mjsm@cfenet.ubc.ca.
M-J
MJ
Milloy
Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.|Canadian Institutes of Health Research HIV Trials Network, Vancouver, BC, Canada.
Alexandra
A
King
British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.|Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
Thomas
T
Kerr
First Nations Health Authority, West Vancouver, BC, Canada.|School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
Evan
E
Adams
British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.
Hasina
H
Samji
British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.
Silvia
S
Guillemi
British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.|Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
Evan
E
Wood
British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.|Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
Julio
J
Montaner
D000328:Adult; D001955:British Columbia; D055030:Drug Users; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D013287:Illicit Drugs / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D019966:Substance-Related Disorders / Q000150:complications*; D016896:Treatment Outcome
D013287:Illicit Drugs
AIDS; HAART; HIV; highly active antiretroviral therapy; indigenous; plasma HIV-1 RNA viral load; treatment-as-prevention