FREDERICK L. ALTICE, M.D., MA

Professor Of Medicine,

Epidemiology and Public Health

Yale University

Special Populations

Special Populations

All PLWHA are “special populations”.

Treatment of a stigmatized and complex medical and social conditions associated with poor outcomes is challenging even in the best of circumstances.

The additional challenges of incarceration, poverty, food and housing instability, and psychiatric and substance use disorders further complicate adherence and often require specialized interventions to optimize treatment outcomes.

Special Populations

Pregnant women

Children and adolescents

Substance use disorders (SUDs)

Mental health disorders (MHDs)

Incarcerated populations

Homeless and marginally housed populations

Special Populations and Syndemics

Pregnant

Women

Children &

Adolescents

Substance

Use Disorders

Mental Health

Disorders

Incarceration Unstable

Housing

Sex

Workers

Migrants

Pregnant Women

More than 50% of HIV+ women are of child-bearing age

Most current data are from resource-poor countries and

address short-term PMTCT and not treatment adherence

throughout and after pregnancy

Targeted PMTCT treatment (including HIV testing and

serostatus awareness) improves adherence to ART for

PMTCT and is recommended over untargeted approaches

(treatment without HIV testing) in high HIV prevalence

settings (IIIB).

Pregnant Women

Zambian RCT of universal SD NVP vs targeted HIV

testing & treatment demonstrated higher NVP uptake in

universal group, but adherence was lower among women

who were illiterate and unaware of their HIV status.

Labor ward-based PMTCT adherence services are

recommended for women who are not ART before labor

(IIB).

Cluster RCT in 12 Zambian delivery centers found that

VCT + ART training in the labor ward was feasible and

improved SD NVP coverage and adherence.

Pregnant Women – Future Research

Investigation of specific ART adherence

barriers related to pregnancy status

Well-controlled studies to understand

adherence barriers for pregnant women

and to improve ART adherence

antenatally and post-partum

Children and Adolescents

PLWHA between birth and 24 are developmentally

diverse, including perinatally and behaviorally infected.

Perinatal infection: adherence mostly related to caregivers

and medication-associated problems include problems

swallowing, “bad” taste and timing around meals or other

activities.

Transition from childhood to adolescence then adulthood is

challenging, resulting in deteriorations in adherence, loss of

comprehensive services and health insurance.

Adolescents and young adults transition to poor retention,

lower ART prescription and poor outcomes.

Children and Adolescents

Intensive youth-focused case management is recommended

for adolescents and young adults living with HIV to improve

entry into and retention in care (IVB).

Two observational studies showed (1) 174 HIV+ youth had

increased appointment attendance after self-efficacy

focused CM introduced and (2) 61HIV+ newly diagnosed

or intermittently engaged gay youth improved clinic

attendance and increased intensive CM intervention was

associated with increased likelihood of ART prescription.

Children and Adolescents

Pediatric- and adolescent-focused therapeutic support

interventions using problem-solving approaches and

addressing psychosocial context are recommended (IIIB).

Two RCTs, one cohort and two pilot studies showed

supportive, yet either mixed or non-significant findings with

regard to short-term adherence and VL outcomes.

Pill-swallowing training is recommended and may be helpful

for younger patients (IVB).

Adherence improved in 23 patients with swallowing

difficulties after change from liquid to pills.

Children and Adolescents

DAART improves short-term outcomes and may be

considered (IVC).

Three cohort studies of DAART showed CD4 improvements;

CD4 gains were sustained in 2 of the 3 studies after

DAART discontinuation. In the Cambodian study, the cost

was $60 per child/year.

Research gaps: better understanding and appropriate

intervention development for heterogeneous groups of

children and adolescents; interventions that focus on the

transition from child to adolescent to adult; and use of

mobile technologies.

Substance Use Disorders

SUDs are associated with reduced linkage, retention,

prescription of ART, ART adherence and virologic failure.

Offering buprenorphine or methadone for HIV+ patients

with opioid dependence is recommended (IIA).

One RCT and 4 cohort studies support increased ART

prescription, increased retention in care and immunological

improvements. ART adherence and VL outcomes variable,

but generally favor improvements.

DAART is recommended for those with SUDs (IB), confirmed

by 4 RCTs and 3 cohort studies; 1 RCT suggests non-

durable treatment outcomes.

Substance Use Disorders

Integration of DAART into methadone maintenance

programs for individuals with opioid dependence is

recommended (IIB).

One RCT and 3 longitudinal studies suggest improved

adherence and higher levels of viral suppression.

Future Research: Interventions with ART-naïve patients and

transitional interventions that sustain persistence from

current EBIs. Inclusion of individuals with SUDs into trials of

existing EBIs beneficial for non-drug users, peer-driven,

contingency management, family support and electronic

device interventions are needed.

THPE606: Rose, RCT of SBIRT

associated with reductions in drug

use and increased VS.

Mental Health Disorders

A meta-analysis of 95 studies in resource rich and poor

countries correlated depression with ART non-adherence.

Screening, management and treatment for depression and

other mental illnesses in combination with adherence

counseling is recommended (IIA).

Several RCTs, including among MSM and women, show CBT

+ ART adherence counseling improves depressive

symptoms and ART adherence. One RCT of stress

management w/o ART adherence did not improve

adherence. Pharmacological treatment for depression

improves ART adherence & outcomes.

Mental Health – Future Research

Interventions for other psychiatric disorders, including PTSD

and bipolar and personality disorders.

Examination of relationship of MHDs to ART adherence

and development of interventions in LMICs are needed.

Investigations of systematic MH screening and mechanisms

through which MHDs negatively influence, including

symptoms, influence ART adherence and treatment

outcomes.

WEPDD0102: Reif, Pilot study of

40 HIV+s with serious mental

illness received home-based MH

services showed MH improvements

and reductions in missed doses.

Incarceration

Compared to the general population, HIV is several-fold

greater among the incarcerated globally, including LMICs.

Incarceration negatively impacts continuity of HIV care

and adherence and post-release outcomes remain dismal.

DAART is recommended during incarceration (IIIB) and may

be considered upon release to the community (IIC).

Within prison, one comparative and one small RCT

confirmed higher adherence and viral suppression.

After release, one RCT of 154 HIV+ prisoners showed

higher adherence and viral suppression among those

receiving DAART.

Incarceration

ART distribution and adherence strategies and outcomes in

LMICs are needed.

Better studies needed to determine if DAART is the optimal

strategy within prisons and duration needed post-release.

Studies examining if treatment for underlying SUDs, MHDs

and/or provision of housing on improvements in post-

release outcomes.

Studies of medication-assisted therapies post-release.

Structural interventions on reducing incarceration itself and

police harassment on detention are needed.

WEPE330: Springer, Retention on BPN

increased adherence and MVS among

released HIV+ prisoners after 6 months.

WEPE617: Kang-Dufour, 2-month

outcomes of Peer Navigation after jail

release showed decreased drug use.

Homeless and Marginally Housed

Often experience multiple overlapping medical,

psychiatric and social co-morbidities.

Homelessness often disrupts daily routines, including taking

medications, and can make medication storage difficult.

Case management is recommended to mitigate multiple

adherence barriers (IIIB), based on 1observational study.

Pillbox organizers are recommended (IIA), based on one

large observational study associated with improved

adherence and viral suppression among homeless people

with multiple adherence barriers.

Homeless and Marginally Housed

Future Research

Better strategies to assess adherence and detect

lapses to individually tailor support to functional

adherence challenges.

Studies on the effectiveness of DAART, adherence

tools, ICM and medical outreach for the homeless

and marginally housed.