Essential features of directly administered antiretroviral therapy identified

NEW YORK (Reuters Health) - Directly administered antiretroviral therapy (DAART) has been proposed as a way to improve treatment compliance among certain HIV-infected patients, such as drug users. In a new study, researchers identify several factors that are important for a successful community-based DAART program.

The study, which is reported in the June 1st issue of Clinical Infectious Diseases, involved 72 HIV-infected drug users living in New Haven, Connecticut who were randomized to receive DAART or self-administered therapy. Seventy-eight percent of the patients were of a racial minority and 32% were women.

With DAART, subjects made regular visits to a mobile health clinic to receive their medications. In addition, they were given a pager to remind them of their next clinic visit and when to take their medications.

About a third of subjects were homeless and the majority of subjects reported a lack of interpersonal support, lead author Dr. Frederick L. Altice and colleagues, from Yale University in New Haven, note. Major depression and alcoholism were also common comorbidities.

At enrollment, the median CD4+ cell count and HIV-1 RNA load were 403 cells/mL and 146,333 copies/mL, respectively. Thirty-three percent of subjects reported missing at least one medical appointment in the preceding 6 months and 47% reported visiting an emergency department.

When surveyed before randomization, 67% of subjects noted a preference for self-administered therapy, but 76% said they would accept DAART if it was made compulsory. In terms of the preferred venue for DAART, a mobile syringe-exchange program was the most popular choice, while a methadone clinic was the least popular.

Among DAART subjects, adherence was higher when the medication administration was observed by a DAART specialist rather than unobserved (p < 0.0001). This supports the use of DAART programs with daily supervision of once-daily regimens, write the authors.

"This is the fist randomized, controlled trial among HIV-infected drug users comparing DAART with the usual standard of care in a community," the authors state. Based on the findings, "DAART should incorporate enhanced elements such as convenience, flexibility, confidentiality, cues and reminders, responsive pharmacy and medical services, and specialized training for staff," they add.

"It is important that, in the process of learning how to adapt observed therapy to the treatment of HIV infection, we develop cost-effective strategies," Dr. Jennifer Adelson Mitty and Dr. Timothy P. Flanigan, from The Miriam Hospital in Providence, Rhode Island, note in a related editorial. "This will allow modified directly observed therapy to be generalizable to all communities, including those in resource-poor environments."

Clin Infect Dis 2004;38:S373-S387.