EDITORIAL REVIEW

A review of barriers and facilitators of HIV treatment

among injection drug users
Evan Wooda,b, Thomas Kerra,b, Mark W. Tyndalla,b
and Julio S.G. Montanera,b

Globally, injection drug use continues to account for a substantial proportion of HIV
infections. There have not, however, been any evidence-based reviews of the barriers
and facilitators of HIV treatment among injection drug users. For this review, published
studies were extracted from nine academic databases, with no language or date
specified in the search criteria. Existing evidence demonstrates that, although injection
drug users often have worse outcomes from HIV treatment than non-injection drug
users, major antiretroviral-associated survival gains still have been observed among this
population. Inferior outcomes are explained by a range of barriers to antiretroviral
access and adherence, which often stem from the negative influences of illicit drug
policies, as well as issues within medical systems, including lack of physician education
about substance abuse. Evidence demonstrates that several under-utilized interventions
and novel antiretroviral delivery modalities have helped to greatly address these barriers
in several settings, and there is sufficient evidence to support immediate scale-up of
these programmes. These interventions include coupling antiretroviral therapy with
opioid substitution therapies as well as directly administered antiretroviral therapy
programmes. Of particular interest for future evaluation is the coupling of HIV treatment
programmes within comprehensive services, which also provide low-threshold (harm
reduction) HIV prevention programmes. Scale-up of evidence-based HIV treatment and
prevention to injection drug users, however, will require increasing political will among
both national policy-makers and international public health agencies.
2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

AIDS 2008, 22:12471256

Keywords: access, AIDS, antiretroviral therapy, HIV, injection drug use

Introduction been documented among persons receiving antiretroviral

Since the mid-1990s, there have been major advances in
the medical management of HIV disease [1]. In particular,
antiretroviral therapies have been shown to suppress plasma
HIV RNA to undetectable levels, and in turn substantial
reductions in HIV-related morbidity and mortality have
therapy [2,3]. Despite these survival benefits, the clinical
management of HIV disease presents major challenges.
High levels of adherence are required to durably suppress
the plasma HIV RNA [4], and incomplete adherence
has been associated with virological failure and the rapid
emergence of antiretroviral resistance [5].

From the aBritish Columbia Centre for Excellence in HIV/AIDS at St. Pauls Hospital, Providence Healthcare, Vancouver, and the
b
Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, Canada.
Correspondence to Evan Wood, MD, PhD, BC Centre for Excellence in HIV/AIDS, 6671081 Burrard Street, Vancouver,
BC V6Z 1Y6, Canada.
E-mail: uhri@cfenet.ubc.ca
Received: 10 December 2007; revised: 31 January 2008; accepted: 1 February 2008.

ISSN 0269-9370 Q 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 1247
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1248 AIDS 2008, Vol 22 No 11
During the past two decades, the HIV epidemic has
transitioned from primarily a sexually driven epidemic to
one in which syringe sharing among illicit injection drug
users (IDUs) contributes to a significant proportion of
new infections [6]. The Joint United Nations Program
on HIV/AIDS (UNAIDS) estimates that one-third of
new HIV infections outside sub-Saharan Africa are
attributable to injection drug use [7]. In North America,
injection drug use accounts for approximately one in four
cases of HIV [6], and in some areas where HIV is
spreading most rapidly, such as Eastern Europe and
Central Asia, more than 80% of all HIV cases occur
among IDUs [7]. In turn, as the HIV epidemic has
matured among this population, large and growing
numbers of HIV-infected injection drug users are in need
of highly active antiretroviral therapy (HAART) [810].
Frequently, HIV-positive IDUs first come to the attention
of the healthcare system as a result of harms related to the
use of injection drugs (e.g., endocarditis, cellulitis, drug
overdose, etc.) and are therefore identified early, while
other cases are identified at late stages of HIV disease and
subsequent to the development of life-threatening
opportunistic infections.
At present, the provision of optimal care to HIV-infected
IDUs is a major challenge [11]. In addition to the instability
resulting from compulsive drug-seeking behaviours [12],
challenges also stem from the fact that IDUs often exhibit
several characteristics, such as homelessness and psychiatric
illness, which severely complicate the challenges of
HAART delivery described above [1316]. Despite the
complexity and increasing frequency of this clinical
scenario, there has until now been no contemporary
evidence-based review of best practices for the treatment of
HIV among IDUs, and existing barriers to HAART and
potential solutions have remained poorly understood. We,
therefore, conducted the following narrative review to
summarize the latest evidence regarding barriers and
facilitators to HAART among IDUs and to describe the
best evidence for the optimal treatment of HIV infection
among this population.
Search strategy and selection criteria
For the present review, published studies were extracted
from nine academic databases (EMBASE, Cochrane
CENTRAL, MEDLINE (via PubMed), AIDSLINE,
AMED, CINAHL, TOXNET, Psych-info, and Web of
Science), with no language or date specified in the search
criteria. Key words used in the initial search included
HIV, AIDS, intravenous, injection, illicit, drug, anti-
retroviral, and treatment, and additional studies were
found by examining references from relevant articles. In
addition, abstracts presented at relevant international HIV
and infectious disease meetings during the past 2 years
were reviewed (extraction was from each databases
inception up to 1 November 2007).
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Existing challenges
Access to treatment
Myriad concerns have been identified with respect to the
management of HIV infection among IDUs. A primary
issue is access to HIV treatment, and a range of studies from
various international settings have demonstrated that, even
in settings where HAART is widely available, injection
drug users have lower uptake of antiretroviral therapy
than other HIV-infected populations [810,1719].
Although there is geographical variability with IDUs
presenting early for HIV treatment, several studies have
shown that IDUs commonly present for HAART late in
the course of HIV disease and often after AIDS-defining
illnesses have developed. This is of particular concern,
since research has consistently shown that initiation of
HAART during later-stage HIV infection presages a
worse survival outcome [20]. In addition, among IDUs
not on antiretroviral therapy, both gender and ethnicity
have been associated with differential access to anti-
retrovirals; as demonstrated in Fig. 1, female IDUs and
IDUs from ethnic minorities may be particularly affected
by issues of access to HIV/AIDS care [8,9,2123].
Studies have also shown that, because of these concerns,
HIV-infected IDUs are more likely to die without ever
having received HAART, even in settings where
antiretroviral therapy and other medical care is available
free of charge [24].
Several factors have been shown to explain poor access to
HAART among IDUs. A review of the literature
demonstrates that these factors can generally be grouped
into socio-structural, individual-level, and provider-
based concerns (Table 1). Socio-structural concerns have
primarily been explored with respect to HIV prevention
among this population [2529]. These studies have
consistently shown how national illicit drug strategies
which predominantly employ criminal sanctions and
create social marginalization of IDUs have served to
create a hidden population that is extremely difficult to
reach with HIV care and prevention services such as HIV
testing and needle exchange programmes [2529]. More
recently, studies have elucidated how these same socio-
structural influences may also create barriers to HIV
treatment among IDUs: public policies that seek to
reduce the prevalence of drug use by stigmatizing this
behaviour may create a social stigma in the social and
medical systems, which in turn may create tension with
care providers [3034].
Alternatively, individual-level concerns are issues inherent
in injection drug users themselves. A primary individual-
level issue which has been identified is the common
perception among IDUs that the side effects of HAART
will be intolerable [3537]. Similarly, low self-efficacy, or
doubt about ones ability to adhere to HAART, has also
been identified as a common barrier to initiating HAART
 HIV treatment in injection drug users Wood et al. 1249

100 Sex 100 Race

90 90
Probability of CD4 cell count

Probability of CD4 cell count

remaining unmonitored (%)

remaining unmonitored (%)

80 80

70 70

60 60

50 50

40 Women 40 Nonwhite

30 30

20 20
Men
White
10 10
Log-rank P = 0.03 Log-rank P = 0.009
0 0
0 3 6 9 12 15 18 0 3 6 9 12 15 18
Time (months) Time (months)
No. at risk No. at risk
Women 120 97 78 64 52 47 41 Nonwhite 106 92 76 55 43 40 34
Men 109 78 56 35 23 22 19 White 122 82 57 43 31 28 25

Fig. 1. KaplanMeier cumulative rate of first CD4 cell count monitoring among injection drug users stratified by sex and race.
Reprinted with permission from Wood et al. [21]. Copyright (2004) American Medical Association. All rights reserved.

among this population [37,38]. Other individual-level the problem of lower adherence is the fact that IDUs are
issues include psychiatric illness, addiction-related instabil- also significantly more likely to discontinue HAART
ity, limited social support, and homelessnessall of which outright after it has been started [32].
create barriers to readiness for the daily rigours of HIV
treatment [12,15,16,3944]. A range of barriers to HAART adherence has been
identified. These again can generally be grouped into
Finally, provider-based factors are those barriers to socio-structural, individual, and provider-based concerns
treatment that arise through physician reluctance rather (Table 1), and essentially operate through the same
than unwillingness on the part of the IDU patient [37,44 mechanisms as barriers to accessing therapy [34,53].
46]. A host of studies have demonstrated that physicians Socio-structural factors that are specifically relevant to
may be reluctant to prescribe HAART to IDUs even when adherence and antiretroviral discontinuation include
patients express an interest, because of the perception that incarceration, which is frequent among IDUs in most
IDUs may be less likely to adhere to HAART [37,4749]. settings and has been associated with worse virological
Other physician concerns include the belief that IDUs may suppression [54]. Individual barriers to adherence include
be more likely to develop and transmit antiretroviral- the instability caused by higher-intensity illicit drug use
resistant HIV [50], and the belief that the potential for HIV (which creates difficulties making appointments, etc.) [55]
risk behaviour may be increased after the initiation of and lower adherence self-efficacy. An additional individ-
HAART [51]. These issues obviously overlap with the ual-level concern, which has been reviewed in detail
issues of stigma raised above. elsewhere [56], is the common co-morbidity of hepatitis C
infection, which can increase side effects and limit
Adherence to treatment tolerability of HAART [57]. Finally, provider-based issues,
In addition to poorer access to HAART, studies have which have been identified as inhibiting HAARTuse after
consistently shown that, once therapy is initiated, IDUs it has been initiated, include lack of understanding of social
commonly have lower rates of adherence to HAART than issues facing IDUs and geographic distance between
non-IDUs [4,11,13,39,52]. Furthermore, compounding providers and IDUs residence [37,58].

Table 1. Barriers to HAART access and adherence grouped according to socio-structural, individual, or provider-based mechanism.

Socio-political barriers Individual barriers Provider-based barriers

1. Social marginalization [33,34] 1. Fear of side effects [35,36] 1. Physician perceptions [47,48]
2. Risk of criminal sanctions [33,34] 2. Low HAART self-efficacy [38,79] 2. Physician inexperience [80,100]
3. Incarceration [54] 3. Psychiatric illness [15] 3. Complicated appointments [58]
4. Financial barriers [58] 4. Addiction-related instability [12] 4. Travel to reach clinic [58]
5. Homelessness [46]
6. Hepatitis C co-infection [56]
7. Lack of health insurance [58]
8. Trust of healthcare system [111]

HAART, highly active antiretroviral therapy.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1250 AIDS 2008, Vol 22 No 11

Clinical outcomes a history of injection drug use was associated with a

The lower rates of access and adherence to HAART have 2.4-fold higher likelihood of mortality [3], an observation
generally translated into inferior clinical outcomes that has been demonstrated in individual settings [62,63].
among HAART-treated IDUs. For instance, IDUs have
been shown often to have lower rates of virological
suppression [52,59], although, as shown in Fig. 2, this
observation can be entirely explained by incomplete Addressing challenges to highly active
adherence among this population [13]. Blunted CD4 cell antiretroviral therapy delivery to injection
count responses to HAART among IDUs have similarly drug users
been reported [60], although this also appears to be
mediated through lower adherence [61]. Finally, these Together, in comparison to non-IDUs, the picture of
concerns, as well as competing causes of death due to reduced access and adherence and subsequent inferior
illicit drug overdoses and co-infections such as hepatitis virological response and elevated mortality [64,65] paints a
C, have translated into overall elevated mortality among grim picture of the current status of HIV infection among
IDUs. Recently, a collaboration among 13 international injection drug users [10]. While challenges certainly exist,
observational HIV treatment databases demonstrated that it is important to stress that, despite the above concerns, the

Overall cohort (n = 1442) Adherent patients (n = 816)

100 100
HIV risk category HIV risk category
Injection drug use Injection drug use
No injection drug use No injection drug use
90 90

80 80
Probability of remaining detectable (>500 copies/ml), %
Probability of remaining detectable (>500 copies/ml), %

70 70

60 60

50 Log-rank: 50
P < 0.001

40 40

30 30

20 20
Log-rank:
P = 0.12

10 10

0 0
0 6 12 18 24 0 6 12 18 24
Time from start of HAART (months) Time from start of HAART (months)

Fig. 2. Overall cumulative rates of plasma HIV RNA suppression among a Canadian cohort of HIV-infected patients and when
restricted to adherent patients. Adherence and plasma HIV RNA responses to highly active antiretroviral therapy among HIV-1
infected injection drug users Reprinted from Wood et al. [13] by permission of the publisher. 2003 Canadian Medical
Association.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Table 2. Strategies to improve access and adherence.
Socio-structural strategies Individual strategies
1. Low threshold programmes [74,75] 1. Addiction treatment [18,90,91]
2. Outreach services [68] 2. Psychiatric treatment [15,16]
3. Increased HIV testing [71,72] 3. Housing support [116]
4. Reduced financial barriers [8,58] 4. Improved self-efficacy [15,38]
5. Well resourced prisons [99]
advent of HAART has nevertheless been associated with
dramatic reductions in HIV-related mortality among IDUs
[3,63,66,67]. Although the majority of studies are
observational in nature, there is increasing evidence that
the above-described barriers to access and adherence to
HAART can be readily modified using well characterized
evidence-based interventions.
Not surprisingly, these strategies have generally targeted
the previously described socio-structural, individual, and
provider-based barriers to access and adherence (Table 2).
For instance, strategies aimed at addressing socio-
structural barriers include outreach programmes that
help to identify HIV-infected IDUs and refer them to
appropriate HIV prevention and care [6870]. These
programmes may be particularly important for case find-
ing, since accessing HIV testing has been associated with
uptake of HAART [71,72] and obviously testing and
counselling of IDUs unaware of their HIV status serve a
secondary public health benefit [73]. Similarly, meeting
IDUs on their own terms is important, and this may be
most effectively accomplished when HIV testing and
treatment services incorporate low-threshold HIV pre-
vention services (also known as harm reduction services),
such as needle exchange. Harm reduction services are
low-threshold in that they do not require abstinence from
illicit drug use. Several reports have demonstrated the
value of incorporating HIV testing and treatment into
low-threshold services for illicit drug users [71,74,75].
Strategies to address individual-based concerns largely
overlap with provider-based strategies that are discussed in
detail below. In brief, these strategies include efforts to
improve health insurance coverage and free access to
medical care [8,18,76,77]. Similarly, HAART self-efficacy
and willingness to initiate HAART have been shown
to increase through improved relationships with HIV-
experienced physicians [53,7780]. Finally, improvements
in stability from addiction treatment and housing support
may help to address physician reluctance to prescribe
HAART [44].
In terms of provider-related strategies, several clinic
characteristics have been associated with improved uptake
and adherence to HAART. Specifically, HAART delivery
models which tend to be highly flexible, comprehensive,
and interdisciplinary have been particularly helpful in this
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HIV treatment in injection drug users Wood et al. 1251
Provider-based strategies
1. Same day appointments [117]
2. On-site pharmacists [81]
3. Interdisciplinary clinics [14,86]
4. Adherence assistance [118]
5. Daily observed therapy [97]
6. Case management [83,87]
7. Greater HIV experience [77,80,100]
setting [14]. Several key features of such programmes
include on-site pharmacists, HIV specialist nurses, drop-
in services, less geographic distance between home and
HIV services, and services which offer case management
strategies [14,8187]. An additional key strategy is the
linking of the provision of addiction treatment with
antiretroviral therapy. Methadone maintenance therapy
has been most widely investigated and has been associated
with both improved uptake and adherence to HAART
[8891]. More recently, buprenorophine has shown
similar potential [92]. This may be of particular impor-
tance, given the known contribution of ongoing drug use
on reduced access and lower adherence to HAART, and
the evidence that patients infected with HIV through
injection drug use, but who stop using illicit drugs, may
have similar adherence to other risk groups [12]. An
additional clinical consideration when initiating antire-
trovirals is the co-administration of HAART with opioid
substitution therapy such as methadone. Since methadone
is metabolized by the cytochrome p-450 (CYP450)
enzymes, and since antiretroviral drugs can act as inhib-
itors or inducers of this process, some antiretrovirals may
lead to opioid withdrawal among persons on methadone
due to reduced methadone effect [93]. Conversely,
opioids may inhibit or induce metabolism of components
of a HAART regimen, since many antiretrovirals are
largely metabolized by enzymes of the CYP450 pathway
[93]. The optimal strategies for the co-administration of
methadone and antiretrovirals have been reviewed
elsewhere, and a knowledge of these patterns is required
for successful co-administration of these agents [93].
In addition, directly administered therapy programmes,
which provide daily supervision of antiretroviral therapy,
have also been associated with improved adherence
[9497]. While prison environments have traditionally
been associated with risk of HIV transmission and worse
HIV care [54,98], it has also been observed that prisons
with well resourced HIV care systems can create an
environment where HIV care is facilitated [99]. Finally,
management of co-morbid psychiatric conditions has been
associated with better HIV treatment outcomes [15,16].
In terms of provider-specific strategies, it has been
demonstrated that more experienced physicians may be
more likely to prescribe HAART to IDUs and to
promote higher levels of adherence among their patients
1252 AIDS 2008, Vol 22 No 11

[77,80,100]. In light of this evidence, it must be noted 24

23 HIV risk category
that increasing physician education in the area of 22 Injection drug use
evidence-based HIV and substance abuse treatment has 21 No injection drug use
significant potential to improve evidence-based HIV care 20
in this population [77,80,100]. One major concern is the 19
discordance between physician perceptions and empirical 18
17
evidence regarding potential harms of HAART use in

Probability of resistance (%)

16
marginalized populations [46,48,49,101]. For instance, 15
although IDUs are known to have lower levels of 14
adherence, studies have repeatedly demonstrated that 13
many IDUs can manage high adherence to antiretroviral 12
11
therapy (Fig. 2). Accordingly, ethical analyses have
10
specifically concluded that physicians should not indefi- 9
nitely withhold HAART from patients on the basis of the 8
presumption that they will be nonadherent, and this 7
argument is strengthened by the studies [41,102,103] that 6
5
have consistently demonstrated that providers are poor
4
judges of patients adherence. With respect to the 3
Log-rank
common concern of providers regarding potential for 2 P = 0.983
increased rates of antiretroviral resistance among IDUs 1
and potential for community transmission of antiretro- 0
0 6 12 18 24
viral resistance, this concern is not supported by evidence.
Time from start of ARVs (months)
On the contrary, monitoring studies have not shown n
IDU 335 308 290 263 226
elevated rates of antiretroviral resistance among the newly Non-IDU 856 772 726 675 590
HIV-infected IDU population [104107]. Similarly, the
studies, which have evaluated HIV risk behaviour among Fig. 3. Cumulative rates of protease inhibitor resistance
HAART-treated IDUs, have been generally inconsistent, among a Canadian cohort of patients stratified by history
and it is likely that any rise in HIV risk behaviour among of injection drug use. Reproduced with permission from
this population may be less than the rise in HIV risk Wood et al. [90]. ARVs, antiretroviral drugs; IDU, injection
behaviour seen in other populations, such as gay men drug user.
[51]. Finally, as shown in Fig. 3, data from one of the
few studies to compare rates of antiretroviral resistance and the limited availability of methadone in particular
between IDUs and other populations demonstrated regions in Eastern Europe and south-east Asia is of
similar rates of antiretroviral resistance to all classes of particular concern [112]. Finally, it is key to distinguish
antiretrovirals between IDUs and non-IDUs. The opiate (e.g., heroin)-dependent drug users from those
paradoxical finding of overall lower adherence but similar who are using stimulant-based compounds such as
resistance rates may be attributed to the fact that high but cocaine and methamphetamine. Unlike heroin, which
incomplete rates of adherence to HAART (i.e., 8090%) has a long half-life and so is generally injected only every
are required to rapidly select and maintain antiretroviral- few hours at most, the short half-life of certain stimulants
resistant mutations in plasma [108110]. such as cocaine allows for thirty or more injections per
day [113]. Stimulant addiction is also noteworthy in that
A limitation of many of the above studies is that they are there exists no gold standard substitution therapy in
based on observational data. Nevertheless, there are widespread use, as there is with heroin addiction. Both
several commonalities observed across international behavioural and pharmacologic strategies for the stabil-
settings, as well as several differences which likely reflect ization of HIV-infected stimulant users remain urgently
differing policies. For instance, in comparison to no needed.
HIV treatment, the survival benefits of HAART in IDUs
have been observed across settings [3,63,66,67], but IDUs
have also regularly been shown to have inferior clinical
outcomes to HAART in comparison to non-IDUs Conclusion
[3,62,63]. This observation is likely explained by universal
concerns that are more common among all IDU HIV treatment poses particular challenges for clinicians
populations, including compulsive drug-seeking beha- faced with the large and growing number of infections
viour and psychiatric illness, as well as higher rates of occurring among IDUs, since this population commonly
homelessness and social stigma [15,46,111]. Not surpris- exhibits several co-morbidities and social issues that
ingly, the beneficial effects of certain interventions, such complicate the delivery of HAART [6,7]. These concerns
as methadone maintenance therapy [18,88], are only are often exacerbated by illicit drug policies that entrench
observed in settings where methadone is in common use, stigma and marginalization among IDUs [3034] and

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

have resulted in lower access and adherence to HAART
and inferior clinical outcomes among this population [8
10,1719]. Specifically, worse clinical outcomes among
IDUs are explained by a range of barriers to HAART
access and adherence that fall broadly into the categories
of socio-structural, individual-level, and provider-based
barriers. It is critical that these issues be addressed, given
the known cost-effectiveness of HAART and the fact that
engaging injection drug users in medical care may have
significant potential to avert new infections [114,115].
Finally, it must be stressed that major antiretroviral-
associated survival gains have been observed among this
population [3,63], and the preponderance of evidence
demonstrates that several under-utilized interventions and
novel HAART delivery modalities have significantly
addressed the barriers to access and adherence. These
interventions and modalities include strategies that directly
address known barriers to HAART by closing the gap
between IDUs and the public health and medical systems
[8,18,44,6872,7477]. The outcome of HIV-infected
IDUs in the era of HAART is strictly dependent on the
scaling-up and rigorous evaluation of these strategies. To
this end, significant physician education is also urgently
required to improve awareness of evidence-based care
delivery and to address discordance between perceptions
about IDUs inferior responses to HAART and observed
clinical outcomes.
Acknowledgements
We thank Deborah Graham, Peter Vann and Kelly Hsu
for their administrative assistance. Particular thanks goes
to Daniel Werb for his assistance with the literature
review. This work was also supported by grants from the
US National Institutes of Health, the Canadian Institutes
of Health Research, and the Canadian Foundation for
AIDS Research. T.K. is supported by a Canadian
Institutes of Health Research New Investigator Award
and a Michael Smith Foundation for Health Research
Scholar Award. M.W.T. is supported by a Michael
Smith Foundation for Health Research Senior Scholar
Award.
There are no conflicts of interest for E.W. and T.K.
M.W.T. reports having served on advisory boards of
Abbott, GlaxoSmithKline, Boehringer Ingelheim, and
Bristol-Meyers Squibb, and has received research support
from Merck Frosst Canada. J.S.G.M. has received
educational grants from, served as an ad hoc adviser to
or spoken at various events sponsored by Abbott
Laboratories, Agouron Pharmaceuticals Inc., Boehrin-
ger Ingelheim Pharmaceuticals Inc., Borean Pharma AS,
BristolMyers Squibb, DuPont Pharma, Gilead
Sciences, GlaxoSmithKline, HoffmannLa Roche,
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
HIV treatment in injection drug users Wood et al. 1253
Immune Response Corporation, Incyte, JanssenOrtho
Inc., Kucera Pharmaceutical Company, Merck Frosst
Laboratories, Pfizer Canada Inc., Sanofi Pasteur, Shire
Biochem Inc., Tibotec Pharmaceuticals Ltd. and
Trimeris Inc.
References
1. Hammer SM, Katzenstein DA, Hughes MD, Gundacker H,
Schooley RT, Haubrich RH, et al. A trial comparing nucleoside
monotherapy with combination therapy in HIV-infected
adults with CD4 cell counts from 200 to 500 per cubic
millimeter. AIDS Clinical Trials Group Study 175 Study Team.
N Engl J Med 1996; 335:10811090.
2. Hogg RS, Yip B, Chan KJ, Wood E, Craib KJ, OShaughnessy
MV, et al. Rates of disease progression by baseline CD4 cell
count and viral load after initiating triple-drug therapy. JAMA
2001; 286:25682577.
3. Egger M, May M, Chene G, Phillips AN, Ledergerber B, Dabis
F, et al. Prognosis of HIV-1-infected patients starting highly
active antiretroviral therapy: a collaborative analysis of pro-
spective studies. Lancet 2002; 360:119129.
4. Paterson DL, Swindells S, Mohr J, Brester M, Vergis EN, Squier
C, et al. Adherence to protease inhibitor therapy and out-
comes in patients with HIV infection. Ann Intern Med 2000;
133:2130.
5. Deeks SG. Treatment of antiretroviral-drug-resistant HIV-1
infection. Lancet 2003; 362:20022011.
6. Karon JM, Fleming PL, Steketee RW, De Cock KM. HIV in the
United States at the turn of the century: an epidemic in
transition. Am J Public Health 2001; 91:10601068.
7. UNAIDS. 2006 report on the global AIDS epidemic. Available
online: http://www.unaids.org/en/HIV_data/2006GlobalRe-
port/default.asp [Accessed 15 September 2006].
8. Cunningham WE, Markson LE, Andersen RM, Crystal SH,
Fleishman JA, Golin C, et al. Prevalence and predictors of
highly active antiretroviral therapy use in patients with HIV
infection in the United States. HCSUS Consortium. HIV Cost
and Services Utilization. J Acquir Immune Defic Syndr 2000;
25:115123.
9. Gebo KA, Fleishman JA, Conviser R, Reilly ED, Korthuis PT,
Moore RD, et al. Racial and gender disparities in receipt of
highly active antiretroviral therapy persist in a multistate
sample of HIV patients in 2001. J Acquir Immune Defic Syndr
2005; 38:96103.
10. Wood E, Schechter MT, Tyndall MW, Montaner JS, OShaugh-
nessy MV, Hogg RS. Antiretroviral medication use among
injection drug users: two potential futures. AIDS 2000;
14:12291235.
11. Vlahov D, Celentano DD. Access to highly active antiretro-
viral therapy for injection drug users: adherence, resistance,
and death. Cad Saude Publica 2006; 22:705718.
12. Lucas GM, Cheever LW, Chaisson RE, Moore RD. Detrimental
effects of continued illicit drug use on the treatment of HIV-1
infection. J Acquir Immune Defic Syndr 2001; 27:251259.
13. Wood E, Montaner JS, Yip B, Tyndall MW, Schechter MT,
OShaughnessy MV, et al. Adherence and plasma HIV RNA
responses to highly active antiretroviral therapy among HIV-1
infected injection drug users. CMAJ 2003; 169:656661.
14. Conanan B, London K, Martinez L, Modersbach D, OConnell
J, OSullivan M, et al. Adapting your practice: Treatment and
recommendations for homeless patients with HIV/AIDS. Nash-
ville: Healthcare for the Homeless Clinicians Network, Na-
tional Healthcare for the Homeless Council, Inc. 2003.
Available online: http://www.nhchc.org/Publications/HIVgui-
de52703.pdf [Accessed 1 April 1 2008].
15. Treisman GJ, Angelino AF, Hutton HE. Psychiatric issues in the
management of patients with HIV infection. JAMA 2001;
286:28572864.
16. Angelino AF, Treisman GJ. Management of psychiatric disor-
ders in patients infected with human immunodeficiency virus.
Clin Infect Dis 2001; 33:847856.
1254 AIDS 2008, Vol 22 No 11
17. Molitor F, Walsh RM, Leigh JP. Determinants of longer time
from HIV result to enrollment in publicly funded care and
treatment in California by race/ethnicity and behavioral risk.
AIDS Patient Care STDS 2002; 16:555565.
18. Celentano DD, Galai N, Sethi AK, Shah NG, Strathdee SA,
Vlahov D, et al. Time to initiating highly active antiretroviral
therapy among HIV-infected injection drug users. AIDS 2001;
15:17071715.
19. Celentano DD, Vlahov D, Cohn S, Shadle VM, Obasanjo O,
Moore RD. Self-reported antiretroviral therapy in injection
drug users. JAMA 1998; 280:544546.
20. Wood E, Hogg RS, Harrigan PR, Montaner JS. When to initiate
antiretroviral therapy in HIV-1-infected adults: a review for
clinicians and patients. Lancet Infect Dis 2005; 5:407414.
21. Wood E, Hogg RS, Bonner S, Kerr T, Li K, Palepu A, et al.
Staging for antiretroviral therapy among HIV-infected drug
users. JAMA 2004; 292:11751177.
22. Shapiro MF, Morton SC, McCaffrey DF, Senterfitt JW, Fleishman
JA, Perlman JF, et al. Variations in the care of HIV-infected
adults in the United States: results from the HIV Cost and
Services Utilization Study. JAMA 1999; 281:23052315.
23. Giordano TP, Visnegarwala F, White AC Jr, Troisi CL,
Frankowski RF, Hartman CM, et al. Patients referred to an
urban HIV clinic frequently fail to establish care: factors
predicting failure. AIDS Care 2005; 17:773783.
24. Wood E, Montaner JS, Schechter MT, Tyndall MW, OShaugh-
nessy MV, Hogg RS. Prevalence and correlates of untreated
HIV-1 infection in the era of modern antiretroviral therapy.
J Infect Dis 2003; 188:11641170.
25. Rhodes T, Mikhailova L, Sarang A, Lowndes CM, Rylkov A,
Khutorskoy M, et al. Situational factors influencing drug
injecting, risk reduction and syringe exchange in Togliatti
City, Russian Federation: a qualitative study of micro risk
environment. Soc Sci Med 2003; 57:3954.
26. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA.
The social structural production of HIV risk among injecting
drug users. Soc Sci Med 2005; 61:10261044.
27. Wood E, Kerr T, Small W, Jones J, Schechter MT, Tyndall MW.
The Impact of police presence on access to needle exchange
programs. J Acquir Immune Defic Syndr 2003; 34:116
118.
28. Davis CS, Burris S, Kraut-Becher J, Lynch KG, Metzger D.
Effects of an intensive street-level police intervention on
syringe exchange program use in Philadelphia, PA. Am J Public
Health 2005; 95:233236.
29. Bluthenthal RN, Kral AH, Lorvick J, Watters JK. Impact of law
enforcement on syringe exchange programs: a look at Oakland
and San Francisco. Med Anthropol 1997; 18:6183.
30. Wood E, Kerr T, Montaner JS. HIV treatment, injection drug
use, and illicit drug policies. Lancet 2007; 370:810.
31. Cohen OJ. Antiretroviral therapy: time to think strategically.
Ann Intern Med 2000; 132:320322; [Editorial comment].
32. Wood E, Montaner JS, Braitstein P, Yip B, Schechter MT,
OShaughnessy MV, et al. Elevated rates of antiretroviral
treatment discontinuation among HIV-infected injection drug
users: implications for drug policy and public health. Int J
Drug Pol 2003; 15:133138.
33. Open Society Institute. Delivering HIV care and treatment for
persons who use drugs: lessons from research and practice.
Available online: www.soros.org [Accessed 15 September
2006].
34. Open Society Institute. Breaking Down Barriers: lessons on
providing HIV treatment to injection drug users; 2004. Avail-
able online: http://www.soros.org/initiatives/health/focus/
ihrd/articles_publications/publications/arv_idus_20040715
[Accessed 15 September 2006].
35. Shannon K, Bright V, Duddy J, Tyndall MW. Access and
utilization of HIV treatment and services among women
sex workers in Vancouvers Downtown Eastside. J Urban
Health 2005; 82:488497.
36. Kerr T, Palepu A, Barness G, Walsh J, Hogg R, Montaner J, et al.
Psychosocial determinants of adherence to highly active
antiretroviral therapy among injection drug users in Vancou-
ver. Antivir Ther 2004; 9:407414.
37. Bassetti S, Battegay M, Furrer H, Rickenbach M, Flepp M,
Kaiser L, et al. Why is highly active antiretroviral therapy
(HAART) not prescribed or discontinued? Swiss HIV Cohort
Study. J Acquir Immune Defic Syndr 1999; 21:114119.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
38. Kerr T, Marshall A, Walsh J, Palepu A, Tyndall M, Montaner J,
et al. Determinants of HAART discontinuation among injec-
tion drug users. AIDS Care 2005; 17:539549.
39. Chander G, Himelhoch S, Moore RD. Substance abuse and
psychiatric disorders in HIV-positive patients: epidemiology
and impact on antiretroviral therapy. Drugs 2006; 66:769789.
40. Weiser SD, Wolfe WR, Bangsberg DR. The HIV epidemic
among individuals with mental illness in the United States.
Curr HIV/AIDS Rep 2004; 1:186192.
41. Bangsberg D, Tulsky JP, Hecht FM, Moss AR. Protease inhi-
bitors in the homeless. JAMA 1997; 278:6365.
42. Gebo KA, Keruly J, Moore RD. Association of social stress,
illicit drug use, and health beliefs with nonadherence to
antiretroviral therapy. J Gen Intern Med 2003; 18:104111.
43. Knowlton A, Arnsten J, Eldred L, Wilkinson J, Gourevitch M,
Shade S, et al. Individual, interpersonal, and structural corre-
lates of effective HAART use among urban active injection
drug users. J Acquir Immune Defic Syndr 2006; 41:486492.
44. Maisels L, Steinberg J, Tobias C. An investigation of why
eligible patients do not receive HAART. AIDS Patient Care
STDS 2001; 15:185191.
45. Bogart LM, Kelly JA, Catz SL, Sosman JM. Impact of medical
and nonmedical factors on physician decision making for
HIV/AIDS antiretroviral treatment. J Acquir Immune Defic
Syndr 2000; 23:396404.
46. Loughlin A, Metsch L, Gardner L, Anderson-Mahoney P,
Barrigan M, Strathdee S. Provider barriers to prescribing
HAART to medically-eligible HIV-infected drug users. AIDS
Care 2004; 16:485500.
47. Ding L, Landon BE, Wilson IB, Wong MD, Shapiro MF, Cleary
PD. Predictors and consequences of negative physician atti-
tudes toward HIV-infected injection drug users. Arch Intern
Med 2005; 165:618623.
48. Escaffre N, Morin M, Bouhnik AD, Fuzibet JG, Gastaut JA,
Obadia Y, et al. Injecting drug users adherence to HIV anti-
retroviral treatments: physicians beliefs. AIDS Care 2000;
12:723730.
49. Gross R, Bilker WB, Friedman HM, Coyne JC, Strom BL.
Provider inaccuracy in assessing adherence and outcomes
with newly initiated antiretroviral therapy. AIDS 2002;
16:18351837.
50. Wainberg MA, Friedland G. Public health implications of
antiretroviral therapy and HIV drug resistance. JAMA 1998;
279:19771983.
51. Battegay M, Bucher HC, Vernazza P. Sexual risk behavior in
HIV-infected injection drug users. Clin Infect Dis 2004;
38:11751177.
52. Wood E, Hogg RS, Yip B, Harrigan PR, OShaughnessy MV,
Montaner JS. Effect of medication adherence on survival of
HIV-infected adults who start highly active antiretroviral
therapy when the CD4R cell count is 0.200 to 0.350 T
109 cells/l. Ann Intern Med 2003; 139:810816.
53. Murri R, Fantoni M, Del Borgo C, Izzi I, Visona R, Suter F, et al.
Intravenous drug use, relationship with providers, and stage
of HIV disease influence the prescription rates of protease
inhibitors. J Acquir Immune Defic Syndr 1999; 22:461466.
54. Palepu A, Tyndall MW, Li K, Yip B, OShaughnessy MV, Schech-
ter MT, et al. Alcohol use and incarceration adversely affect
HIV-1 RNA suppression among injection drug users starting
antiretroviral therapy. J Urban Health 2003; 80:667675.
55. Stein MD, Rich JD, Maksad J, Chen MH, Hu P, Sobota M, et al.
Adherence to antiretroviral therapy among HIV-infected
methadone patients: effect of ongoing illicit drug use. Am J
Drug Alcohol Abuse 2000; 26:195205.
56. Rockstroh JK, Spengler U. HIV and hepatitis C virus co-infec-
tion. Lancet Infect Dis 2004; 4:437444.
57. Greub G, Ledergerber B, Battegay M, Grob P, Perrin L, Furrer
H, et al. Clinical progression, survival, and immune recovery
during antiretroviral therapy in patients with HIV-1 and
hepatitis C virus coinfection: the Swiss HIV Cohort Study.
Lancet 2000; 356:18001805.
58. McKinney MM, Marconi KM. Delivering HIV services to vul-
nerable populations: a review of CARE Act-funded research.
Public Health Rep 2002; 117:99113.
59. Palepu A, Tyndall M, Yip B, OShaughnessy MV, Hogg RS,
Montaner JS. Impaired virologic response to highly active
antiretroviral therapy associated with ongoing injection drug
use. J Acquir Immune Defic Syndr 2003; 32:522526.

60. Dragsted UB, Mocroft A, Vella S, Viard JP, Hansen AB, Panos
G, et al. Predictors of immunological failure after initial
response to highly active antiretroviral therapy in HIV-1-
infected adults: a EuroSIDA study. J Infect Dis 2004; 190:
148155.
61. Wood E, Montaner JS, Yip B, Tyndall MW, Schechter MT,
OShaughnessy MV, Hogg RS. Adherence to antiretroviral
therapy and CD4 T-cell count responses among HIV-infected
injection drug users. Antivir Ther 2004; 9:229235.
62. Lieb S, Brooks RG, Hopkins RS, Thompson D, Crockett LK,
Liberti T, et al. Predicting death from HIV/AIDS: a case-
control study from Florida public HIV/AIDS clinics. J Acquir
Immune Defic Syndr 2002; 30:351358.
63. Poundstone KE, Chaisson RE, Moore RD. Differences in HIV
disease progression by injection drug use and by sex in the era
of highly active antiretroviral therapy. AIDS 2001; 15:1115
1123.
64. van Sighem A, Danner S, Ghani AC, Gras L, Anderson RM, de
Wolf F. Mortality in patients with successful initial response to
highly active antiretroviral therapy is still higher than in non-
HIV-infected individuals. J Acquir Immune Defic Syndr 2005;
40:212218.
65. Mocroft A, Gatell J, Reiss P, Ledergerber B, Kirk O, Vella S,
et al. Causes of death in HIV infection: the key determinant to
define the clinical response to anti-HIV therapy. AIDS 2004;
18:23332337.
66. Mocroft A, Madge S, Johnson AM, Lazzarin A, Clumeck N,
Goebel FD, et al. A comparison of exposure groups in the
EuroSIDA study: starting highly active antiretroviral therapy
(HAART), response to HAART, and survival. J Acquir Immune
Defic Syndr 1999; 22:369378.
67. Sterne JA, Hernan MA, Ledergerber B, Tilling K, Weber R,
Sendi P, et al. Long-term effectiveness of potent antiretroviral
therapy in preventing AIDS and death: a prospective cohort
study. Lancet 2005; 366:378384.
68. Molitor F, Kuenneth C, Waltermeyer J, Mendoza M, Aguirre A,
Brockmann K, et al. Linking HIV-infected persons of color and
injection drug users to HIV medical and other services: the
California Bridge Project. AIDS Patient Care STDS 2005;
19:406412.
69. Molitor F, Waltermeyer J, Mendoza M, Kuenneth C, Aguirre A,
Brockmann K, et al. Locating and linking to medical care HIV-
positive persons without a history of care: findings from the
California Bridge Project. AIDS Care 2006; 18:456459.
70. Martinez J, Bell D, Dodds S, Shaw K, Siciliano C, Walker LE, et al.
Transitioning youths into care: linking identified HIV-infected
youth at outreach sites in the community to hospital-based
clinics and or community-based health centers. J Adolesc
Health 2003; 33:2330.
71. Wood E, Kerr T, Hogg RS, Palepu A, Zhang R, Strathdee SA,
et al. Impact of HIV testing on uptake of HIV therapy among
antiretroviral naive HIV-infected injection drug users.
Drug Alcohol Rev 2006; 25:451454.
72. Centers for Disease Control and Prevention. Revised guidelines
for HIV counseling, testing, and referral and revised recom-
mendations for HIV screening of pregnant women. MMWR
2001; 50 (No. RR-19).
73. Frieden TR, Das-Douglas M, Kellerman SE, Henning KJ. Apply-
ing public health principles to the HIV epidemic. N Engl J Med
2005; 353:23972402.
74. Altice FL, Springer S, Buitrago M, Hunt DP, Friedland GH. Pilot
study to enhance HIV care using needle exchange-based
health services for out-of-treatment injecting drug users.
J Urban Health 2003; 80:416427.
75. Bamberger JD, Unick J, Klein P, Fraser M, Chesney M, Katz
MH. Helping the urban poor stay with antiretroviral HIV drug
therapy. Am J Public Health 2000; 90:699701.
76. Cook JA, Cohen MH, Grey D, Kirstein L, Burke J, Anastos K,
et al. Use of highly active antiretroviral therapy in a cohort of
HIV-seropositive women. Am J Public Health 2002; 92:8287.
77. Gardner LI, Holmberg SD, Moore J, Arnsten JH, Mayer KH,
Rompalo A, et al. Use of highly active antiretroviral therapy in
HIV-infected women: impact of HIV specialist care. J Acquir
Immune Defic Syndr 2002; 29:6975.
78. Burke JK, Cook JA, Cohen MH, Wilson T, Anastos K, Young M,
et al. Dissatisfaction with medical care among women with
HIV: dimensions and associated factors. AIDS Care 2003;
15:451462.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
HIV treatment in injection drug users Wood et al. 1255
79. Johnson MO, Chesney MA, Goldstein RB, Remien RH, Catz S,
Gore-Felton C, et al. Positive provider interactions, adherence
self-efficacy, and adherence to antiretroviral medications
among HIV-infected adults: A mediation model. AIDS Patient
Care STDS 2006; 20:258268.
80. Strathdee SA, Palepu A, Cornelisse PG, Yip B, OShaughnessy
MV, Montaner JS, et al. Barriers to use of free antiretroviral
therapy in injection drug users. JAMA 1998; 280:547549.
81. Sorensen JL, Mascovich A, Wall TL, DePhilippis D, Batki SL,
Chesney M. Medication adherence strategies for drug abusers
with HIV/AIDS. AIDS Care 1998; 10:297312.
82. Malta M, Carneiro-da-Cunha C, Kerrigan D, Strathdee SA, Mon-
teiro M, Bastos FI. Case management of human immunodefi-
ciency virus-infected injection drug users: a case study in Rio de
Janeiro, Brazil. Clin Infect Dis 2003; 37 (Suppl 5):S386S391.
83. Katz MH, Cunningham WE, Fleishman JA, AndersenRM, Kellogg
T, Bozzette SA, et al. Effect of case management on unmet needs
and utilization of medical care and medications among HIV-
infected persons. Ann Intern Med 2001; 135:557565.
84. Andersen MD, Smereck GA, Hockman EM, Ross DJ, Ground
KJ. Nurses decrease barriers to healthcare by hyperlinking
multiple-diagnosed women living with HIV/AIDS into care.
J Assoc Nurses AIDS Care 1999; 10:5565.
85. Rompalo AM, Shah N, Mayer K, Schuman P, Klein RS, Smith
DK, et al. Influence of injection drug use behavior on reported
antiretroviral therapy use among women in the HIV Epide-
miology Research study: on-site versus referral care. J Acquir
Immune Defic Syndr 2001; 28:2834.
86. Sherer R, Stieglitz K, Narra J, Jasek J, Green L, Moore B, et al.
HIV multidisciplinary teams work: support services improve
access to and retention in HIV primary care. AIDS Care 2002;
14:S31S44.
87. Kushel MB, Colfax G, Ragland K, Heineman A, Palacio H,
Bangsberg DR. Case management is associated with improved
antiretroviral adherence and CD4R cell counts in homeless and
marginally housed individuals with HIV infection. Clin Infect
Dis 2006; 43:234242.
88. Clarke S, Delamere S, McCullough L, Hopkins S, Bergin C,
Mulcahy F. Assessing limiting factors to the acceptance of
antiretroviral therapy in a large cohort of injecting drug users.
HIV Med 2003; 4:3337.
89. Sambamoorthi U, Warner LA, Crystal S, Walkup J. Drug abuse,
methadone treatment, and health services use among injection
drug users with AIDS. Drug Alcohol Depend 2000; 60:7789.
90. Wood E, Hogg RS, Kerr T, Palepu A, Zhang R, Montaner JS.
Impact of accessing methadone on the time to initiating HIV
treatment among antiretroviral-naive HIV-infected injection
drug users. AIDS 2005; 19:837839.
91. Palepu A, Tyndall MW, Joy R, Kerr T, Wood E, Press N, et al.
Antiretroviral adherence and HIV treatment outcomes among
HIV/HCV co-infected injection drug users: the role of metha-
done maintenance therapy. Drug Alcohol Depend 2006;
84:188194.
92. Moatti JP, Carrieri MP, Spire B, Gastaut JA, Cassuto JP, Moreau
J. Adherence to HAART in French HIV-infected injecting drug
users: the contribution of buprenorphine drug maintenance
treatment. The Manif 2000 study group. AIDS 2000; 14:151
155.
93. Maas B, Kerr T, Fairbairn N, Montaner J, Wood E. Pharmaco-
kinetic interactions between HIV antiretroviral therapy and
drugs used to treat opioid dependence. Expert Opin Drug
Metab Toxicol 2006; 2:533543.
94. Clarke S, Keenan E, Ryan M, Barry M, Mulcahy F. Directly
observed antiretroviral therapy for injection drug users with
HIV infection. AIDS Read 2002; 12:305307; 312316.
95. Mitty JA, Stone VE, Sands M, Macalino G, Flanigan T. Directly
observed therapy for the treatment of people with human
immunodeficiency virus infection: a work in progress.
Clin Infect Dis 2002; 34:984990.
96. Lucas GM, Weidle PJ, Hader S, Moore RD. Directly adminis-
tered antiretroviral therapy in an urban methadone mainte-
nance clinic: a nonrandomized comparative study. Clin Infect
Dis 2004; 38 (Suppl 5):S409S413.
97. Altice FL, Mezger JA, Hodges J, Bruce RD, Marinovich A,
Walton M, et al. Developing a directly administered antire-
troviral therapy intervention for HIV-infected drug users:
implications for program replication. Clin Infect Dis 2004;
38 (Suppl 5):S376S387.
1256 AIDS 2008, Vol 22 No 11
98. Dolan K, Kite B, Black E, Aceijas C, Stimson GV. HIV in prison
in low-income and middle-income countries. Lancet Infect Dis
2007; 7:3241.
99. Springer SA, Pesanti E, Hodges J, Macura T, Doros G, Altice FL.
Effectiveness of antiretroviral therapy among HIV-infected
prisoners: reincarceration and the lack of sustained benefit
after release to the community. Clin Infect Dis 2004; 38:1754
1760.
100. Delgado J, Heath KV, Yip B, Marion S, Alfonso V, Montaner JS,
et al. Highly active antiretroviral therapy: physician experience
and enhanced adherence to prescription refill. Antivir Ther
2003; 8:471478.
101. Wong MD, Cunningham WE, Shapiro MF, Andersen RM,
Cleary PD, Duan N, et al. Disparities in HIV treatment and
physician attitudes about delaying protease inhibitors for
nonadherent patients. J Gen Intern Med 2004; 19:366374.
102. Bangsberg DR, Hecht FM, Clague H, Charlebois ED, Ciccar-
one D, Chesney M, et al. Provider assessment of adherence to
HIV antiretroviral therapy. J Acquir Immune Defic Syndr
2001; 26:435442.
103. Bangsberg DR, Moss A. When should we delay highly active
antiretroviral therapy? J Gen Intern Med 1999; 14:446448.
104. Yerly S, Jost S, Telenti A, Flepp M, Kaiser L, Chave JP, et al.
Infrequent transmission of HIV-1 drug-resistant variants.
Antivir Ther 2004; 9:375384.
105. Yerly S, Vora S, Rizzardi P, Chave JP, Vernazza PL, Flepp M,
et al. Acute HIV infection: impact on the spread of HIV and
transmission of drug resistance. AIDS 2001; 15:22872292.
106. Little SJ, Holte S, Routy JP, Daar ES, Markowitz M, Collier AC,
et al. Antiretroviral-drug resistance among patients recently
infected with HIV. N Engl J Med 2002; 347:385394.
107. Richman DD, Morton SC, Wrin T, Hellmann N, Berry S,
Shapiro MF, et al. The prevalence of antiretroviral drug
resistance in the United States. AIDS 2004; 18:13931401.
108. Harrigan PR, Hogg RS, Dong WW, Yip B, Wynhoven B,
Woodward J, et al. Predictors of HIV drug-resistance muta-
tions in a large antiretroviral-naive cohort initiating triple
antiretroviral therapy. J Infect Dis 2005; 191:339347; [Epub
ahead of print 2004, December 2022].
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
109. Bangsberg DR, Hecht FM, Charlebois ED, Zolopa AR,
Holodniy M, Sheiner L, et al. Adherence to protease inhibi-
tors, HIV-1 viral load, and development of drug resistance in
an indigent population. AIDS 2000; 14:357366.
110. Bangsberg DR, Porco TC, Kagay C, Charlebois ED, Deeks SG,
Guzman D, et al. Modeling the HIV protease inhibitor
adherence-resistance curve by use of empirically derived
estimates. J Infect Dis 2004; 190:162165 [Epub ahead of
print 2004, June 2009].
111. Altice FL, Mostashari F, Friedland GH. Trust and the accep-
tance of and adherence to antiretroviral therapy. J Acquir
Immune Defic Syndr 2001; 28:4758.
112. Kerr T, Wodak A, Elliott R, Montaner JS, Wood E. Opioid
substitution and HIV/AIDS treatment and prevention. Lancet
2004; 364:19181919.
113. Tyndall MW, Currie S, Spittal P, Li K, Wood E, OShaughnessy
MV, et al. Intensive injection cocaine use as the primary risk
factor in the Vancouver HIV-1 epidemic. AIDS 2003; 17:887
893.
114. Long EF, Brandeau ML, Galvin CM, Vinichenko T, Tole SP,
Schwartz A, et al. Effectiveness and cost-effectiveness of
strategies to expand antiretroviral therapy in St. Petersburg,
Russia. AIDS 2006; 20:22072215.
115. Montaner JS, Hogg R, Wood E, Kerr T, Tyndall M, Levy AR,
et al. The case for expanding access to highly active antire-
troviral therapy to curb the growth of the HIV epidemic.
Lancet 2006; 368:531536.
116. Bouhnik AD, Chesney M, Carrieri P, Gallais H, Moreau J,
Moatti JP, et al. Nonadherence among HIV-infected injecting
drug users: the impact of social instability. J Acquir Immune
Defic Syndr 2002; 31 (Suppl 3):S149S153.
117. Andersen R, Bozzette S, Shapiro M, St Clair P, Morton S,
Crystal S, et al. Access of vulnerable groups to antiretroviral
therapy among persons in care for HIV disease in the United
States. HCSUS Consortium. HIV Cost and Services Utilization
Study. Health Serv Res 2000; 35:389416.
118. Stone VE. Strategies for optimizing adherence to highly active
antiretroviral therapy: lessons from research and clinical
practice. Clin Infect Dis 2001; 33:865872.