Injecting drug use is associated with a more rapid CD4 cell decline among treatment naïve HIV-positive patients in Indonesia

Abstract

Background: It remains unclear whether the natural course of human immunodeficiency virus (HIV) differs in subjects infected through injecting drug use (IDU) and no data have been published from low- or middle-income countries. We addressed this question in an urban cohort in Indonesia, which is experiencing a rapidly growing HIV epidemic strongly driven by IDU.

Methods: All antiretroviral treatment (ART) naïve HIV-positive patients who had at least two subsequent CD4 cell counts available before starting ART were included in this study. We examined the association between IDU and CD4 cell decline using a linear mixed model, with adjustment for possible confounders such as HIV viral load and hepatitis C antibodies.

Results: Among 284 HIV-positive ART naïve patients, the majority were male (56%) with a history of IDU (79% among men). People with a history of IDU had a statistically significant faster decline in CD4 cells (p<0.001). Based on our data, patients with a history of IDU would have an average 33% decline in CD4 cells after one year without ART, compared with a 22% decline among non-users. At two years, the decline would average 66 and 40%, respectively. No other factor was significantly associated with CD4 cell decline.

Conclusions: We show that a history of IDU is associated with a more rapid CD4 cell natural decline among HIV-positive individuals in Indonesia. These findings have implications for monitoring ART naïve patients with a history of IDU and for starting ART in this group.

Keywords: CD4-positive T-Lymphocytes; Indonesia; cohort studies; human immunodeficiency virus; injecting drug use (IDU).

Figure 1

The predicted average decline in CD4 cells of HIV-positive ART naïve patients for people without (grey) and with (black) a history of injecting drug use (IDU). The 95% confidence intervals are given for people without (grey shaded area) and with (black dashed lines) a history of IDU. The CD4 cells were predicted with the following model: Log (CD4 cells)=0.0964+0.9623*log (CD4 cells baseline) – 0.0093*months – 0.0083*IDU – 0.0004 IDU*months² (Table 2).

Figure 2

Natural CD4 cell decline of HIV-positive ART naïve patients, with observed (grey) and fitted (black) values for people without (A) and with (B) a history of injecting drug use (IDU). All subjects with at least five CD4 cell counts are shown.