February 5, 2001
Although there are experimental data suggesting that cocaine and heroin may have deleterious effects on the human immune system and may increase HIV-1 replication, there are no complementary prospective data in patients. If continuing hard drug use was indeed associated with evidence of accelerated disease progression -- the so-called "cofactor effect" -- this would have clear implications for HIV management.
This first prospective study of the association between hard drug use and its impact on surrogate markers of disease progression was carried out within the WITS (Women and Infant Transmission Study) cohort, which enrolled pregnant women from 1989 to 1995 who were interviewed about illicit drug use. In this study, "hard drugs" included cocaine, crack, heroin, or other opiates, including methadone, any reported injection drug use, or a positive urine toxicology screen for any of these substances. At baseline, the 1,148 women in this study were asked about hard drug use during pregnancy, and at follow-up they were asked about any such use in the 30 days prior to the interview. The concordance between self-reported drug use during pregnancy and urine toxicology was good, with a range of 87% concordance for crack or cocaine use to 98% for methadone for the 1,005 women for whom urine toxicology data were available. Forty percent reported drug use at study entry and had a mean CD4 % indistinguishable from those who did not use drugs, although drug users did have have higher mean viral loads (p <0.05), 3.87 log10 versus 3.67. However, longitudinal data failed to show a difference over time for either viral load or CD4 % between women who used drugs and those who did not. The impact of drug use on mortality was not assessed.
Because this study was based on data collected in the pre-HAART era, it is unclear whether outcomes would be the same now that effective combination therapy is available. What would be the impact of continuing drug use on adherence? Certainly the data do not support a cofactor hypothesis, and this is consonant with clinical experience. It should also be noted that since this is a seroprevalent cohort -- all participants were HIV-infected at entry -- the impact of duration of HIV infection cannot be assessed. Although there are many sound reasons for encouraging patients to stop using illicit drugs, it appears that a deleterious effect on HIV disease progression is not one of them.
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