A New Piece of the Harm Reduction Puzzle? Directly Observed Antiretroviral Therapy for HIV-infected Opioid-Dependent Individuals

Antiretroviral therapy adherence improves treatment outcomes and reduces antiretroviral drug resistance in patients with HIV, however, illicit drug use threatens antiretroviral adherence. The impact of measures to promote antiretroviral adherence in HIV-infected patients with opioid dependence who receive methadone maintenance treatment (MMT), but who continue to use illicit drugs, has not been systematically assessed. This 24-week randomized clinical trial compared directly observed antiretroviral therapy (DOT) with treatment as usual among 77 HIV-infected opioid-dependent patients receiving MMT.

• Median duration of MMT was 10 years, and the median dose was 125 mg. Active drug use was common throughout the trial, with 74% of participants using cocaine, 67% using opioids, and 42% using both cocaine and opioids.

• Among participants randomized to treatment as usual, adherence was compromised in those engaged in active opioid use compared with no drug use (63% versus 75%, p=0.04) and in those engaged in polysubstance use compared with no drug use (60% versus 73%, p=0.01).

• Adherence (ranging from 82–85%) was not affected in participants randomized to DOT, regardless of active drug use.

Comments:

Despite the small sample size and the site having been limited to a single methadone clinic, these findings suggest that DOT attenuates the adverse effects of active drug use on antiretroviral adherence in HIV-infected patients with opioid dependence. Thus, DOT could be considered a component of harm reduction for this population.

Jeanette M. Tetrault, MD

Reference:

Nahvi S, Litwin AH, Heo M, et al. Directly observed antiretroviral therapy eliminates adverse effects of active drug use on adherence. Drug Alcohol Depend. 2012;120(1-3):174–180.