The impact of access and adherence on mortality from HIV disease in the era of modern antiretroviral therapy.

摘要

Objectives. To identify the proportion of HIV-related deaths that occur among persons who have never accessed antiretroviral therapy; model the potential public health impact of improved access to antiretroviral therapy; determine the role of socio-economic status on access and as a predictor of HIV disease progression; evaluate the impact of adherence to HAART on survival rates; and to determine rates of therapy discontinuation and virological response among HIV-infected injection drug users.; Methods. British Columbia's HIV/AIDS Drug Treatment Program provides antiretroviral therapy to all eligible HIV positive persons in British Columbia free of charge. Data from the Centre as well as mortality data from Vital Statistics, socio-economic data from Statistics Canada, and prescription refill data from pharmacies were used to evaluate and model mortality patterns and antiretroviral therapy use among HIV-infected individuals.; Results. Overall, 32.7% of persons who have died of HIV/AIDS during the period 1995–2001 died without accessing antiretroviral therapy. Several markers of socio-economic status were associated with non-receipt of therapy, and socio-economic status was associated with the receipt of sub-optimal therapy among those who initiated treatment. Models developed also indicate that improved uptake of antiretroviral therapy among injection drug users could have a substantial impact on life expectancy and mortality in this setting. Among patients who initiated triple therapy, rates of sub-optimal adherence are common, and are associated with markedly higher rates of mortality. In particular, patients with a history of injection drug use may be at risk of treatment cessation and poor virologic response.; Conclusions. Limited access to antiretroviral therapy, particularly among certain sub-populations, has contributed on to ongoing AIDS mortality. Among persons who initiate therapy, the problem of limited access has been compounded by sub-optimal adherence and prescription patterns, as well as high rates of treatment discontinuation. These data suggest that novel strategies are required to improve access and adherence to antiretroviral therapy despite a universal healthcare system that provides antiretrovirals and HIV/AIDS care free of charge.