Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women

Abstract

Background: Longitudinal associations between patterns of crack cocaine use and progression of HIV-1 disease are poorly understood, especially among women. This study explores relationships between crack use and HIV-1 disease outcomes in a multicenter cohort of infected women.

Methods: Subjects were 1686 HIV-seropositive women enrolled at six US research centers in the Women's Interagency HIV Study. Approximately 80% were non-white and 29% used crack during the study period. Cox survival and random regression analysis examined biannual observations made April 1996 through September 2004. Outcome measures included death due to AIDS-related causes, CD4 cell count, HIV-1 RNA level, and newly acquired AIDS-defining illnesses.

Results: Persistent crack users were over three times as likely as non-users to die from AIDS-related causes, controlling for use of HAART self-reported at 95% or higher adherence, problem drinking, age, race, income, education, illness duration, study site, and baseline virologic and immunologic indicators. Persistent crack users and intermittent users in active and abstinent phases showed greater CD4 cell loss and higher HIV-1 RNA levels controlling for the same covariates. Persistent and intermittent crack users were more likely than non-users to develop new AIDS-defining illnesses controlling for identical confounds. These results persisted when controlling for heroin use, tobacco smoking, depressive symptoms, hepatitis C virus coinfection, and injection drug use.

Conclusion: Use of crack cocaine independently predicts AIDS-related mortality, immunologic and virologic markers of HIV-1 disease progression, and development of AIDS-defining illnesses among women.

Figure 1

Survival by patterns of crack use in a cohort of HIV-1 infected women. Compared with nonusers (dashed line), and intermittent users (dotted line), days to death for persistent crack users (solid line) was significantly shorter and survival rates significantly lower (p<.05).

Figure 2

Time to newly acquired AIDS-defining illness by patterns of crack use in a cohort of HIV-1 infected women. Compared with nonusers (dashed line), days to illness for intermittent users (dotted line) and persistent crack users (solid line) were significantly shorter and hazard rates significantly higher (p<.001).

Figure 3

Unadjusted proportions of women with CD4 lymphocyte count <200 copies/mm3 over 18 semi-annual study visits. Nonusers (dashed line) had generally lower proportions, while persistent users (solid line) typically had the highest proportions, with intermittent users (dotted line) falling in between.

Figure 4

Unadjusted proportions of women with HIV-1 RNA viral load >100,000 copies over 18 semi-annual study visits. Nonusers (dashed line) had consistently lower proportions, while persistent users (solid line) generally had the highest proportions, with intermittent users (dotted line) falling in between.