Background

1. Barriers to HIV care and Antiretroviral Treatment (ART) among HIV-infected Crack Users in the United States Christine Bell 1 Gabriel Cardenas 2 Tanisha Sullivan 1 Tamy Kuper 2 Lauren Gooden 2 Jessica Kaplan 1 Elizabeth Scharf 1 Allan Rodriguez 2 Carlos del Rio 1 Lisa Metsch 2 1 Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, and Emory CFAR and the Department of Epidemiology 2 University of Miami Miller School of Medicine, Department of Epidemiology and Public Health and Medicine and U. Miami D-CFAR.

2. Background About 1 in 4 persons living with HIV are not regularly attending HIV primary care HIV-infected drug users are less likely to utilize HIV primary care and receive HAART HIV-infected drug users also have higher rates of hospitalization and are more likely to leave the hospital against medical advice Use of crack cocaine continues to flourish in many inner-cities in the U.S.

3. Study objectives To describe barriers to HIV care and antiretroviral treatment among HIV infected crack users hospitalized in Grady Memorial Hospital (Atlanta) and Jackson Memorial Hospital (Miami). To assess factors associated with ever having had an HIV primary care provider To assess association with ever having received Antiretroviral Treatment (ART)

4. Methods • Structured interviews were conducted with HIV-infected crack users who were admitted to two inner city hospitals in the US between August 2006 – January 2008. • Interview eligibility criteria Hospitalized HIV patient at GMH or JMH were screened prior to interview to establish: 1) Sexual intercourse in the past 6 months 2) Crack-cocaine use in the past year • Data Analysis Logistic regression analyses were used to identify significant associations among the variables. • IRB approval was obtained from Emory IRB and Miami IRB and full informed consent was obtained from study participants before interview.

5. Demographic characteristics of study participants Atlanta: Grady Hospital • 141 study participants • 55% female, 45% male • 92% Black, 8% Other • Average age: 44 years old Miami: Jackson Hospital • 80 study participants • 48% female, 52% male • 86% Black, 14% Other • Average age: 43 years old Overall • < $5000 annual income: 70% • > 5 yrs since HIV diagnosis: 69% • Homeless: 49% Grady Memorial Hospital Jackson Memorial Hospital

6. History of HIV care and treatment No Yes No

7. *Variables forced into model **After adjusting for site, gender, age, and ethnicity

8. Variables not found to have a significant association with going to HIV care in our data* Education level ■ Attitude toward HIV care Provider responsiveness ■ Level of crack/alcohol consumption Putting off HIV care due to drugs/alcohol ■ Housing stability Unprotected sex in previous 6 months ■ Level of depression Referral to a case manager ■ Having children Social support History of incarceration Level of HIV knowledge *Variables not selected by backward stepwise at the 0.05 significance level to be associated in multivariate form with the dependent variable.

9. *Variables forced into model **After adjusting for site, gender, age, and ethnicity

10. Variables not found to have a significant association with taking HIV medications in our data* Education level ■Having children Income ■ Self-efficacy for taking HIV meds Putting off HIV care because of ■ Attitude for taking HIV meds drugs/alcohol ■ Level of depression Unprotected sex in previous 6 months Referral to a case manager upon diagnosis Social support Empowerment Level of crack/alcohol consumption Housing stability *Variables not selected by backward stepwise at the 0.05 significance level to be associated in multivariate form with the dependent variable.

11. Study Limitations Self report HIV, sexual, drug and social histories provided by study participants were assumed to be accurate Interview bias It is possible that participants provided answers that were most pleasing or acceptable to interviewer Other factors related to use of care and treatment There may be other factors related to utilization of HIV care and treatment among HIV crack users not covered in structured interviews. Interview data has not yet been corroborated with medical chart abstraction.

12. Implications for HIV public health policy In order to bring HIV infected crack users into primary HIV care, to keep them in care and to allow them to benefit from prevention and treatment interventions… Policy development: • A multifaceted intervention is needed that includes: • HIV care management • Substance abuse treatment and, • Strategies to improve socioeconomic stability • Project HOPE:Hospital Visit is an Opportunity for Prevention and Engagement with HIV-positive Crack Users

13. Acknowledgements Atlanta SiteFunding Carlos del Rio, MD, Co-PI NIH/NIDA (RO1 DA017612) Richard Rothenberg, M.D., Investigator NIH/NIAID (P30 AI050409) Tanisha Sullivan, Project Director Emory Center for AIDS Research (CFAR) Jessica Kaplan, Interviewer NIH/NIAID (1P30 AI023961) Elizabeth Scharf, Interviewer University of Miami Developmental Mary Yohannan, FacilitatorCenter for AIDS Research (DCFAR) Ossie Williams, Outreach Worker Miami Site Lisa Metsch PhD, PI Allan Rodriguez, MD, Co-PI Toye Brewer, MD, Co-I Margaret Pereyra, PhD, Co-I Shari Messinger, PhD, Biostat Lauren Gooden, MPH, Project Director Gabriel Cardenas, MPH, Data Manager Tamy Kuper, BA Project Director/ Interviewer Ginny Locascio, LPN, Facilitator Cheryl Riles, Interviewer Richard Walker, Outreach Worker