Research is scant regarding differential effects of specific types of recreational drugs use on antiretroviral therapy adherence among women, particularly to single-tablet regimens (STR). This is increasingly important in the context of marijuana legalization. We examined the effects of self-reported substance use on suboptimal (<95%) adherence in the Women’s Interagency HIV Study, 2003–2014. Among 1799 HIV-infected women, the most prevalent substance used was marijuana. In multivariable Poisson GEE regression, substance use overall was significantly associated with suboptimal adherence (adjusted prevalence ratio, aPR = 1.20, 95% CI 1.10–1.32), adjusting for STR use, socio-demographic, behavioral, and clinical factors. Among STR users, compared to no drug use, substance use overall remained detrimental to ART adherence (aPR = 1.61, 95% CI 1.24–2.09); specifically, both marijuana (aPR = 1.48, 95% CI: 1.11–1.97) and other drug use (aPR = 1.87, 95% CI 1.29–2.70) predicted suboptimal adherence. These findings highlight the need to intervene with drug-using women taking antiretroviral therapy to maintain effective adherence.
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Lima VD, Harrigan R, Bangsberg DR, Hogg RS, Gross R, Yip B, et al. The combined effect of modern highly active antiretroviral therapy regimens and adherence on mortality over time. J Acquir Immune Defic Syndr. 2009;50(5):529–36.
Paterson DL, Swindells S, Mohr J, Brester M, Vergis EN. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133:21–30.
Clay PG, Nag S, Graham CM, Narayanan S. Meta-analysis of studies comparing single and multi-tablet fixed dose combination HIV treatment regimens. Medicine (Baltimore). 2015;94(42):e1677.
Hanna DB, Hessol NA, Golub ET, Cocohoba JM, Cohen MH, Levine AM, et al. Increase in single-tablet regimen use and associated improvements in adherence-related outcomes in HIV-infected women. J Acquir Immune Defic Syndr. 2014;65(5):587–96.
Nachega JB, Parienti JJ, Uthman OA, Gross R, Dowdy DW, Sax PE, et al. Lower pill burden and once-daily antiretroviral treatment regimens for HIV infection: a meta-analysis of randomized controlled trials. Clin Infect Dis. 2014;58(9):1297–307.
Sax PE, Meyers JL, Mugavero M, Davis KL. Adherence to antiretroviral treatment and correlation with risk of hospitalization among commercially insured HIV patients in the United States. PLoS ONE. 2012;7(2):e31591.
Truong WR, Schafer JJ, Short WR. Once-daily, single-tablet regimens for the treatment of HIV-1 infection. Pharm Ther. 2015;40(1):44–55.
Hodder SL, Mounzer K, Dejesus E, Ebrahimi R, Grimm K, Esker S, et al. Patient-reported outcomes in virologically suppressed, HIV-1-infected subjects after switching to a simplified, single-tablet regimen of Efavirenz, Emtricitabine, and Tenofovir DF. AIDS Patient Care STDS. 2010;24(2):87–96.
Cohen CJ, Meyers JL, Davis KL. Association between daily antiretroviral pill burden and treatment adherence, hospitalisation risk, and other healthcare utilisation and costs in a US medicaid population with HIV. BMJ Open. 2013;3:e003028.
Bangsberg DR, Ragland K, Monk A, Deeks SG. A single tablet regimen is associated with higher adherence and viral suppression than multiple tablet regimens in HIV+ homeless and marginally housed people. AIDS. 2010;24(18):2835–40.
Gonzalez A, Mimiaga MJ, Israel J, Andres Bedoya C, Safren SA. Substance use predictors of poor medication adherence: the role of substance use coping among HIV-infected patients in opioid dependence treatment. AIDS Behav. 2013;17:168–73.
Cohn SE, Jiang H, McCutchan JA, Koletar SL, Murphy RL, Robertson KR, et al. Association of ongoing drug and alcohol use with non-adherence to antiretroviral therapy and higher risk of AIDS and death: results from ACTG 362. AIDS Care. 2011;23(6):775–85.
Hinkin CH, Barclay TR, Castellon SA, Levine AJ, Durvasula RS, Marion SS, et al. Drug use and medication adherence among HIV-1 infected individuals. AIDS Behav. 2007;11(2):185–94.
Cohen MH, Cook JA, Grey D, Young M, Hanau LH, Tien P, et al. Medically eligible women who do not use HAART: the importance of abuse, drug use, and race. Am J Public Health. 2004;94(7):1147–51.
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(3):251–9.
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(2):195–205.
Tucker JS, Orlando M, Burnam MA, Sherbourne CD, Kung F-Y, Gifford AL. Psychosocial mediators of antiretroviral nonadherence in HIV-positive adults with substance use and mental health problems. Health Psychol. 2004;23(4):363–70.
Arnsten JH, Demas PA, Grant RW, Gourevitch MN, Farzadegan H, Howard AA, et al. Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users. J Gen Intern Med. 2002;17(5):377–81.
O’Connor JL, Gardner EM, Mannheimer SB, Lifson AR, Esser S, Telzak EE, et al. Factors associated with adherence amongst 5295 people receiving antiretroviral therapy as part of an international trial. J Infect Dis. 2013;208(1):40–9.
Shuter J, Bernstein SL. Cigarette smoking is an independent predictor of nonadherence in HIV-infected individuals receiving highly active antiretroviral therapy. Nicotine Tob Res. 2008;10(4):731–6.
Lazo M, Gange SJ, Wilson TE, Anastos K, Ostrow DG, Witt MD, et al. Patterns and predictors of changes in adherence to highly active antiretroviral therapy: longitudinal study of men and women. Clin Infect Dis. 2007;45(10):1377–85.
Chander G, Lau B, Moore RD. Hazardous alcohol use: a risk factor for non-adherence and lack of suppression in HIV infection. J Acquir Immune Defic Syndr. 2006;43(4):411–7.
Simoni JM, Huh D, Wilson IB, Shen J, Goggin K, Reynolds N, et al. Racial/ethnic disparities in ART adherence in the United States: findings from the MACH14 study. J Acquir Immune Defic Syndr. 2012;60(5):466–72.
Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr. 2011;58(2):181–7.
State Marijuana Laws in 2017 Map. Governing magazine. http://www.governing.com/gov-data/state-marijuana-laws-map-medical-recreational.html. Accessed 14 May 2017.
Prentiss D, Power R, Balmas G, Tzuang G, Israelski DM. Patterns of marijuana use among patients with HIV/AIDS followed in a public health care setting. J Acquir Immune Defic Syndr. 2004;35(1):38–45.
D’Souza G, Matson P, Grady CD, Nahvi S, Merenstein D, Weber K, et al. Medical and recreational marijuana use among HIV-infected women in the Women’s Interagency HIV Cohort (WIHS), 1994–2010. J Acquir Immune Defic Syndr. 2012;61(5):618–26.
Slawson G, Milloy M-J, Balneaves L, Simo A, Guillemi S, Hogg R, et al. High-intensity cannabis use and adherence to antiretroviral therapy among people who use illicit drugs in a Canadian setting. AIDS Behav. 2014;19(1):120–7.
Verdejo-Garcia A, Benbrook A, Funderburk F, David P, Cadet JL, Bolla KI. The differential relationship between cocaine use and marijuana use on decision-making performance over repeat testing with the Iowa Gambling Task. Drug Alcohol Depend. 2007;90(1):2–11.
Puskas CM, Forrest JI, Parashar S, Salters KA, Cescon AM, Kaida A, et al. Women and vulnerability to HAART non-adherence: a literature review of treatment adherence by gender from 2000 to 2011. Curr HIV/AIDS Rep. 2011;8(4):277–87.
Ubbiali A, Donati D, Chiorri C, Bregani V, Cattaneo E, Maffei C, et al. Prediction of adherence to antiretroviral therapy: can patients’ gender play some role? An Italian pilot study. AIDS Care. 2008;20(5):571–5.
Kuyper LM, Wood E, Montaner JSG, Yip B, O’connell JM, Hogg RS. Gender differences in HIV-1 RNA rebound attributed to incomplete antiretroviral adherence among HIV-infected patients in a population-based cohort. J Acquir Immune Defic Syndr. 2004;37(4):1470–6.
Bacon MC, von Wyl V, Alden C, Sharp G, Robison E, Hessol N, et al. The Women’s Interagency HIV Study: an observational cohort brings clinical sciences to the bench. Clin Diagn Lab Immunol. 2005;12(9):1013–9.
Barkan SE, Melnick SL, Preston-Martin S, Weber K, Kalish LA, Miotti P, et al. The Women’s Interagency HIV Study. Epidemiology. 1998;9(2):117–25.
Wilson TE, Barrón Y, Cohen M, Richardson J, Greenblatt R, Sacks HS, et al. Adherence to antiretroviral therapy and its association with sexual behavior in a national sample of women with human immunodeficiency virus. Clin Infect Dis. 2002;34(4):529–34.
Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.
Perdue T, Hagan H, Thiede H, Valleroy L. Depression and HIV risk behavior among Seattle-area injection drug users and young men who have sex with men. AIDS Educ Prev. 2003;15(1):81–92.
Johnson ME, Fisher DG, Fenaughty A, Theno S. Hepatitis C virus and depression in drug users. Am J Gastroenterol. 1998;93(5):785–9.
Weissman MM, Sholomskas D, Pottenger M, Prusoff B, Locke B. Assessing depressive symptoms in five psychiatric populations: a validation study. Am J Epidemiol. 1977;106(3):203–14.
Moyer VA. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(3):210–8.
Cummings P. Methods for estimating adjusted risk ratios. Stata J. 2009;9(2):175–96.
Hardin JW. Generalized estimating equations (GEE). Hoboken: Wiley; 2005.
Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986;42(1):121–30.
Cui J. QIC program and model selection in GEE analyses. Stata J. 2007;7(2):209–20.
Pan W. Akaike’s information criterion in generalized estimating equations. Biometrics. 2004;57(1):120–5.
StataCorp. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP; 2011.
Raffi F, Yazdanpanah Y, Fagnani F, Laurendeau C, Lafuma A, Gourmelen J. Persistence and adherence to single-tablet regimens in HIV treatment: a cohort study from the French national healthcare insurance database. J Antimicrob Chemother. 2015;70:2121–8.
Airoldi M, Zaccarelli M, Bisi L, Bini T, Antinori A, Mussini C, et al. One-pill once-a-day HAART: a simplification strategy that improves adherence and quality of life of HIV-infected subjects. Patient Prefer Adher. 2010;4:115–25.
Joseph B, Kerr T, Puskas CM, Montaner J, Wood E, Milloy M-J. Factors linked to transitions in adherence to antiretroviral therapy among HIV-infected illicit drug users in a Canadian setting. AIDS Care. 2015;27(9):1128–36.
Weber R, Huber M, Rickenbach M, Furrer H, Elzi L, Hirschel B, et al. Uptake of and virological response to antiretroviral therapy among HIV-infected former and current injecting drug users and persons in an opiate substitution treatment programme: the Swiss HIV cohort study. HIV Med. 2009;10(7):407–16.
Palepu A, Tyndall M, Yip B, O’Shaughnessy MV, Hogg RS, Montaner JSG. Impaired virologic response to highly active antiretroviral therapy associated with ongoing injection drug use. J Acquir Immune Defic Syndr. 2003;32(5):522–6.
Lucas GM, Gebo K, Chaisson RE, Moore RD. Longitudinal assessment of the effects of drug and alcohol abuse on HIV-1 treatment outcomes in an urban clinic. AIDS. 2002;16(5):767–74.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdoles-centGL.pdf. Accessed 14 May 2017.
Bonn-Miller MO, Oser ML, Bucossi MM, Trafton JA. Cannabis use and HIV antiretroviral therapy adherence and HIV-related symptoms. J Behav Med. 2014;37:1–10.
Bulgiba A, Mohammed UY, Chik Z, Lee C, Peramalah D. How well does self-reported adherence fare compared to therapeutic drug monitoring in HAART? Prev Med (Baltim). 2013;57(SUPPL):S34–6.
Thompson MA, Mugavero MJ, Amico KR, Cargill VA. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an international association of physicians in AIDS care panel. Ann Intern Med. 2012;156(11):817–33.
Buscher A, Hartman C, Kallen MA, Giordano TP. Validity of self-report measures in assessing antiretroviral adherence of newly diagnosed, HAART-Naïve. HIV patients. HIV Clin Trials. 2011;12(5):244–54.
Simoni JM, Kurth AE, Pearson CR, Pantalone DW, Merrill JO, Frick PA. Self-report measures of antiretroviral therapy adherence: a review with recommendations for HIV research and clinical management. AIDS Behav. 2006;10(3):227–45.
Viswanathan S, Detels R, Mehta SH, Macatangay BJC, Kirk GD, Jacobson LP. Level of adherence and HIV RNA suppression in the current era of highly active antiretroviral therapy (HAART). AIDS Behav. 2015;19(4):601–11.
Johnston LD, O’Malley PM, Bachman JG, Schulenberg J. Monitoring the future national survey results on drug use, 1975–2008. Bethesda: National Institute on Drug Abuse; 2009.
Data in this manuscript were collected by the Women’s Interagency HIV Study (WIHS). The contents of this publication are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health (NIH). WIHS (Principal Investigators): UAB-MS WIHS (Michael Saag, Mirjam-Colette Kempf, and Deborah Konkle-Parker), U01-AI-103401; Atlanta WIHS (Ighovwerha Ofotokun and Gina Wingood), U01-AI-103408; Bronx WIHS (Kathryn Anastos), U01-AI-035004; Brooklyn WIHS (Howard Minkoff and Deborah Gustafson), U01-AI-031834; Chicago WIHS (Mardge Cohen and Audrey French), U01-AI-034993; Metropolitan Washington WIHS (Mary Young and Seble Kassaye), U01-AI-034994; Miami WIHS (Margaret Fischl and Lisa Metsch), U01-AI-103397; UNC WIHS (Adaora Adimora), U01-AI-103390; Connie Wofsy Women’s HIV Study, Northern California (Ruth Greenblatt, Bradley Aouizerat, and Phyllis Tien), U01-AI-034989; WIHS Data Management and Analysis Center (Stephen Gange and Elizabeth Golub), U01-AI-042590; Southern California WIHS (Joel Milam), U01-HD-032632 (WIHS I–WIHS IV). The WIHS is funded primarily by the National Institute of Allergy and Infectious Diseases (NIAID), with additional co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Cancer Institute (NCI), the National Institute on Drug Abuse (NIDA), and the National Institute on Mental Health (NIMH). Targeted supplemental funding for specific projects is also provided by the National Institute of Dental and Craniofacial Research (NIDCR), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Deafness and other Communication Disorders (NIDCD), and the NIH Office of Research on Women’s Health. WIHS data collection is also supported by UL1-TR000004 (UCSF CTSA) and UL1-TR000454 (Atlanta CTSA). The authors would like to thank Chiung-Yu Huang, PhD and Gayle Springer, MLA for statistical advice and data management support.
This study was funded primarily by the National Institute of Allergy and Infectious Diseases (NIAID), with additional co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Cancer Institute (NCI), the National Institute on Drug Abuse (NIDA), and the National Institute on Mental Health (NIMH). Targeted supplemental funding for specific projects is also provided by the National Institute of Dental and Craniofacial Research (NIDCR), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Deafness and other Communication Disorders (NIDCD), and the NIH Office of Research on Women’s Health. WIHS data collection is also supported by UL1-TR000004 (UCSF CTSA) and UL1-TR000454 (Atlanta CTSA).
Conflict of interest
Dr. Merenstein has been an expert witness on probiotic cases for General Mills, Nestle, Procter and Gamble and Bayer Health. All the other authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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Flowchart of the study visits, WIHS, 2003-2014. Semiannual study visits from 2003 to 2014 in the dashed box were included in the analysis. Calendar year was listed as last two digits (i.e. 1994: 94). Supplementary material 1 (TIFF 37 kb)
Study visit of exposure, covariate, and outcome data included in the analysis. Exposure and covariate data (i.e., from visit X) were paired with outcome data (i.e., from visit X + 1 in the analysis. Supplementary material 2 (TIFF 91 kb)
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Zhang, Y., Wilson, T.E., Adedimeji, A. et al. The Impact of Substance Use on Adherence to Antiretroviral Therapy Among HIV-Infected Women in the United States. AIDS Behav 22, 896–908 (2018). https://doi.org/10.1007/s10461-017-1808-4