GENEVA, Switzerland--A significant number of injection drug users in San Francisco who are HIV-positive do not receive protease inhibitors and may not even be aware of these medications--despite a commitment on the part of the city to make these drugs widely available.
"We found a lot of drug users were not taking the therapies, even though they were theoretically available to them. Many had not heard of the therapies, and some of them had heard of them but were still not taking them for whatever reasons," said Brian R. Edlin, MD, of the University of California San Francisco.
In a presentation here today (July 2) at the 12th World AIDS Conference, Edlin reported findings from a UCSF study on HIV therapy availability and adherence. Lead study investigator, he is a UCSF associate professor of health policy and community medicine and director of the UCSF Urban Health Study. Edlin noted that there is a bias against providing protease inhibitors, the powerful anti-HIV medications, to injection drug users because they are perceived as being poor adherers to treatment.
Nonetheless, the city has made it a policy to provide full access to these medications to all HIV-positive individuals. Federal guidelines also recommend that practitioners not discriminate in prescribing therapy on the basis of injection drug use, he said.
The UCSF research team set out to determine if, in fact, injection drug users were receiving the therapies.
Between October 1997 and March 1998, the research team interviewed 668 injection drug users in four San Francisco neighborhoods, testing them for HIV and questioning them about their knowledge of available HIV treatments. The researchers also conducted in-depth interviews with about a dozen individuals to help understand what factors might prevent or encourage those who were HIV-positive to adhere to combination therapy.
Sixty-three of the study participants (9.4 percent) were found to be HIV-positive. Of these, 13 individuals (21 percent) were not aware of their HIV status. Only 16 of the HIV-infected individuals (25 percent) had ever received protease inhibitors and only nine of them (14 percent) were still receiving the medications.
Most of the individuals who had not received the medications were not even aware of them, the researchers found. There were no significant differences among men and women or among blacks and whites as to who was more likely to receive the medications.
The in-depth interviews revealed that the most common obstacles to adhering to therapy were homelessness, which can make it difficult to store and keep track of multiple medications, concern about drug side-effects, fear and guilt, Edlin said. Participants said they would be more likely to comply with the regimen if they had clear information about the medications, had access to a clinic or field site, had a home and food, could store their pills in a portable, pocket-sized dispenser, were offered a cash incentive, and had a relationship with an accessible, caring physician.
"We need a concerted effort to address these issues and overcome them in order to allow drug users to receive the same benefits of therapy that other groups are able to have," Edlin said.
Based on the findings, he said the Urban Health Study has developed a model program for cities to help drug users take advantage of, and stick with, HIV therapy regimens. Under the model, cities could establish accessible field sites equipped with bathrooms and showers and a kitchen that would serve two meals a day. The sites would be staffed by health educators and other specialists who could provide peer education and counseling, virologic evaluation, social services, referrals to physicians and other services.
Edlin said San Francisco has provided funding for such a program, which is being implemented at the recommendation of the Mayor's Task Force on Adherence. The first field site is expected to open later this year in the city's Tenderloin district, with three more sites to follow in the spring of 1999, said Edlin, who was a task force member.
Edlin's colleagues in the study are research directors Jennifer Lorvick and Ricky N. Bluthenthal, statisticians Elizabeth A. Erringer and Alex H. Kral, and data manager Michael D. Ray, all of UCSF.