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HAART REDUCES DEATH AMONG HOMELESS
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"Sustained Use of Antiretroviral Therapy Reduces Mortality among HIV-infected Homeless and Marginally Housed Individuals Living in San Francisco"
Mortality has declined in most HIV-infected populations with access to antiretroviral (ARV) therapy. However, few studies have examined the impact of HAART on populations with severe barriers to access, particularly the homeless for whom mortality has been disproportionately high. We
sought to determine predictors of death, including sustained time on ARV, among a group of HIV-infected homeless and marginally housed persons in San
Francisco, during the first 4 years after HAART became available.
Between 1996-2000 a representative sample of 330 HIV-positive adults was recruited from free meal programs, homeless shelters, and low-income hotels. Quarterly interviews and blood draws were conducted. Hazards of death were compared by ARV use, drug use, sex, age, and housing-related variables. ARV use was defined as the number of months out of the prior 6 that an individual had taken any ARV. This variable was calculated for each month of follow-up. Hazard ratios (HR) were estimated using extended Cox models, which allow for time dependent variables.
The population was 16% female, 57% nonwhite, and the median age was 41 yrs. A history of mental health hospitalization was reported by 25% of participants, 64% had an IDU history, and 36% reported spending most nights sleeping on the street. At baseline, the median CD4 cell count was 384, 56% of participants had prior ARV experience, and 29% had prior HAART experience. Among participants, 246 (75%) received ARV during the study period and all but 3 received HAART. Median follow-up time was 39.7 months per person, during which 57 individuals died (5.2 per 100 person-years).
Thirty-six (36) died from AIDS or possible AIDS (63% of all deaths). Controlling for CD4 cell count and pre-HAART ARV experience, and using 6 out of the prior 6 months (mos) on therapy as the reference group, individuals on ARV therapy for 3-5 mos had almost 3 times the risk of death (HR = 2.9, p=0.011); while individuals on ARV therapy for 0-2 months had over 3 times the risk (HR = 3.5, p < 0.001). Changes in hazard ratios were negligible when deaths were restricted to AIDS/possible AIDS.
The authors concluded that among San Francisco's HIV-infected homeless and marginally housed, 74% received HAART. Even in a cohort with a history of 65%
adherence, we found that sustained treatment substantially reduced mortality. While adherence remains an issue, HAART has had a significant effect on mortality in this population.
Abst. 43. 2003 Retrovirus Conference, Feb 10-14, Boston, MA. E. D. Riley*1, D. R. Bangsberg1, D. Guzman1, S. Perry2, A. Moss1. 1Univ of California at San Francisco and 2Stanford Univ, Palo Alto, CA
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