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Since its widespread clinical use in 1996, highly active antiretroviral therapy (HAART) has become the standard of care for patients with advanced HIV infection. HAART has extended AIDS-free survival time. The gains in survival are not as great among women or intravenous drug users (IDUs), but they do not differ by race, according to a study supported in part by the Agency for Healthcare Research and Quality (HS07809).
Researchers from the Johns Hopkins University School of Hygiene and Public Health compared time to AIDS development and time to death among HIV-infected patients in an urban HIV clinical practice during the era of monotherapy and combination therapy (era 1, 1990-1995) versus the HAART era (era 2, 1996-1999). In era 2, women who were less ill (CD4 cell counts greater than 200 at baseline) increased their median disease-free survival time by 14 percent and women who were sicker (CD4 cell counts of 200 or less) by 34 percent compared with era 1. For men, survival increased much more, by 43 and 100 percent, respectively. In fact, women were 34 percent more likely to progress to AIDS than men in era 2 (relative hazard or RH 1.34; 1 is equal hazard) compared with era 1.
Disease-free survival time increased by 16 percent for less ill IDUs and 34 percent for more ill IDUs in era 2 compared with era 1, whereas for non-IDUs disease-free survival time increased by 65 and 135 percent, respectively. IDUs were 39 percent more likely than non-IDUs (RH 1.39) to progress to AIDS in era 2 compared with era 1. There were no significant differences between the two eras by race or other HIV transmission risk group.
Women and IDUs were less likely to be on any form of antiretroviral therapy than men and non-IDUs. In fact, after adjustment for receipt of HAART and for achieving an undetectable HIV-1-RNA level, there were no significant differences between men and women or between IDUs and non-IDUs. IDUs have been shown to not use HIV therapy in previous studies, and doctors may not prescribe it for them because of their unstable living conditions and their greater tendency to miss appointments than non-IDUs. Optimal results of HAART require adherence to complex dosing regimens that may overwhelm many patients, especially those using intravenous drugs and women who lack social support.
See "Differences in HIV disease progression by injection drug use and by sex in the era of highly active antiretroviral therapy," by Katharine E. Poundstone, Richard R. Chaisson, M.D., and Richard D. Moore, M.D., in the June 2001 issue of AIDS 15(9), pp. 1115-1123.
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