Predictors of accessing antiretroviral therapy among HIV-positive drug users in China's National Methadone Maintenance Treatment Programme

Abstract

Aims: The objective of this study was to examine factors that predict antiretroviral therapy (ART) access among eligible, HIV-positive methadone maintenance treatment (MMT) clients. We also tested the hypothesis that sustained MMT participation increases the likelihood of accessing ART.

Design: A nation-wide cohort study conducted from 1 March 2004 to 31 December 2011.

Setting: MMT clients were followed from the time of their enrolment in China's national MMT programme until their death or the study end date.

Participants: Our cohort comprised 7111 ART-eligible, HIV-positive MMT clients, 49.2% of whom remained ART-naive and 50.8% of whom received ART.

Measurements: Demographic variables, drug use history, MMT programme participation and HIV-related clinical characteristics of study participants who remained naive to ART and those who accessed ART were compared by univariate and multivariable analysis.

Findings: Predictors of accessing ART among this cohort included being retained in MMT at the time of first meeting ART eligibility [adjusted odds ratio (AOR)=1.84, confidence interval (CI)=1.54-2.21, P<0.001] compared to meeting ART eligibility before entering MMT (AOR=0.98, CI=0.80-1.21, P=0.849) or previously entering MMT and dropping out before meeting ART eligibility. Additional predictors were CD4≤200 cells/μl when ART-eligibility requirement was first met (AOR=1.81, CI=1.61-2.05, P<0.001 compared to CD4=201-350 cells/μl), and being in a stable partner relationship (married/cohabitating: AOR=1.14, CI=1.01-1.28, P=0.030).

Conclusions: Retained participation in methadone maintenance treatment increases the likelihood that eligible clients will access antiretroviral therapy. These results highlight the potential benefit of colocalization of methadone maintenance treatment and antiretroviral therapy services in a 'one-stop-shop' model.

Keywords: Antiretroviral therapy; China; HIV/AIDS; drug user; heroin; methadone maintenance treatment.

Figure 1. Development of the study cohort

Figure 2. Cumulative annual enrollment of MMT and ART participants in China, 2004-2011

Figure 3. Duration of observed pathways between MMT entry, ART eligibility, and ART initiation

A, B, and C describes patients who received ART. (A: N=807; B: N=2806; C: N=3613). A describes patients who met ART eligibility criteria before entering MMT. A1 is the period from first meeting ART eligibility criteria to entering MMT (A1: Median=6.74 months, IQR: 2.20-16.59). A2 is the period from entering MMT to starting ART (A2: Median= 4.99 months, IQR: 1.31-13.08). B describes patients who met ART criteria after entering MMT. B1 is the period from entering MMT to first meeting ART eligibility criteria (B1: Median=13.70 months, IQR: 4.83-27.47). B2 is the period from first meeting ART criteria to starting ART (B2: Median=2.33 months, IQR: 0.72-9.56). C is the period from MMT initiation to the study endpoint for all ART-treated patients (N=3613, C: Median = 43.43 months, IQR: 27.56-56.94). Due to drop-outs and re-entries, actual median retention time in MMT was 34.8 months (IQR 13.2-51.6). D, E, and F describes ART-naïve patients (D: N=955; E N=2538; F N=3498). D describes patients who met ART eligibility criteria before entering MMT. D is the period between first meeting ART eligibility criteria to entering MMT (D: Median=10.12 months, IQR: 3.75-21.09. E describes patients who met ART criteria after entering MMT. E is the period between entering MMT to first meeting ART eligibility criteria.(E: Median=18.43 months, IQR: 6.74- 34.66). F is the period from MMT initiation to the study endpoint for all ART-naive patients (N=3498, F: Median= 33.64 months, IQR: 14.39-49.74), Due to drop-outs and re-entries, actual median retention time at MMT was 19.2 months (IQR: 6.0-42.0).