Women and Drug Users With HIV Receive Inadequate Care

Marcia Frellick

October 29, 2015

BARCELONA, Spain — Despite increasing access to HIV treatment in Europe, in a significant proportion of countries, one in six people who need treatment don't receive it, according to a recent report from the European Centre for Disease Prevention and Control.

In more than one-third of the countries that provided data for the report, coverage of people known to need antiretroviral therapy is below 85%. And in one in 10 of the countries — most of which are outside the European Union and European Economic Area — coverage is below 50%.

Extending that coverage will mean reaching out to groups of patients who typically present late, with lower CD4 counts, such as women and intravenous drug users, said Deniz Gökengin, MD, from the Ege University School of Medicine in Izmir, Turkey, speaking here at the 15th European AIDS Conference.

Many women in Turkey and in other parts of Europe depend on their spouses or families to access healthcare, and many are unaware that they have the virus, she said.

"They have a single partner and they think they are safe but, in fact, they are infected by their partners," Dr Gökengin told Medscape Medical News. "They don't have economic freedom, usually, and are underserved."

Fear of stigma is also a big factor, as demonstrated in a study of barriers to access to care for women in 27 countries (AIDS Care. 2015;27:1220-1230).

Fear of Stigma

"Globally and by region, community HIV/AIDS stigma was the most prevalent barrier, identified by almost 78% of women in the global population, regardless of severity," Dr Gökengin said.

There have been significant gains overall. Since 1995, antiretroviral therapy has averted 30 million new infections and 7.8 million deaths, Dr Gökengin reported, and the use of therapy increased from less than 10% in 2000 to more than 40% in 2014.

In many low- and middle-income Eastern European countries, there has been a substantial expansion in access to antiretroviral therapy. But that has not kept pace with the number of new infections that come largely from injection drug users, men who have sex with men, and sex workers, said Dr Gökengin.

People who inject drugs are disproportionately less likely than others with HIV infection to receive antiretroviral therapy, even in countries where injection drug users account for the largest proportion of those infected with HIV, according to one study (Lancet. 2010;376:355-366).

In Russia, for instance, 83% of HIV-infected people are injection drug users, but only 20% to 30% of them are on antiretroviral therapy.

And in Ukraine, which has one of the largest HIV/AIDS epidemics in Europe, primarily driven by injection drug use, the main barrier to antiretroviral therapy has been described as "harassment and discrimination by police." Police know who the drug users are, said Dr Gökengin, and they often don't want to go for treatment and be seen.

Women Underrepresented in HIV Trials

The benefits of antiretroviral therapy for all HIV-infected people, regardless of CD4 count, seen in the START trial led to the recommendation that all 34 million people living with the virus receive treatment, as reported by Medscape Medical News.

"If you have good clinical care, the majority of patients can reach undetectable viral loads," said José Arribas, from La Paz-Carlos III University Hospital in Madrid.

However, more studies are needed to determine which treatments are most effective, he said, especially for women, who are grossly under-represented in HIV clinical trials — making up only about 10% to 15%.

The Women's Antiretroviral Efficacy and Safety Study (WAVES), presented last month at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), is an exception.

It is first phase 3 HIV study to enroll only women, Dr Arribas reported. It showed that outcomes were better in people taking the single-pill integrase inhibitor elvitegravir than in people taking a multipill regimen that consisted of ritonavir-boosted atazanavir plus the combination of emtricitabine and tenofovir disoproxil fumarate (Truvada).

More studies of advanced patients are needed because too many present late to clinics, he pointed out.

In a 2011 EuroSIDA study of more than 16,000 adults being treated in a network of 103 hospitals in 33 European countries plus Israel and Argentina, the median CD4 cell count at diagnosis was 300 to 400 cells/mm³, he said.

Dr Gökengin reports receiving honoraria from Gilead, AbbVie, Janssen, and GlaxoSmithKline. Dr Arribas reports receiving advisory fees, speaker fees, and grant support from ViiV, Janssen, AbbVie, BMS, Gilead, and MSD.

15th European AIDS Conference. Presented October 24, 2015.


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