Suboptimal plasma HIV-1 RNA suppression and adherence among sex workers who use illicit drugs in a Canadian setting: an observational cohort study

Objective Studies have demonstrated the central function of plasma HIV-1 RNA viral load (pVL) levels on determining the risk of HIV disease progression and transmission. However, there is limited empirical research on virologic outcomes among sex workers who use illicit drugs (SW-DU). Methods Data were derived from the AIDS Care Cohort to evaluate Exposure to Survival Services, a cohort of HIV-positive illicit drug users. Using generalised estimating equations, we studied the longitudinal relationship between sex work and pVL suppression. We also tested whether adherence to antiretroviral therapy (ART) mediated the relationship between sex work and pVL suppression. Results Between May 1996 and May 2012, 587 ARTexposed participants (2224 person-years of observation) were included in the study, among whom 127 (21.6%) reported sex work. In a time-updated multivariate model adjusted for various demographic, socioeconomic and clinical confounders (eg, gender, incarceration, CD4 cell count), SW-DU had an independently reduced odds of pVL suppression compared to non-SW-DU (adjusted OR (AOR)= 0.66; 95% CI 0.45 to 0.96). However, adding ART adherence to the multivariate model eliminated this association (p> 0.05), suggesting adherence mediated the relationship between sex work and pVL suppression. Conclusions Evidence-based interventions to improve adherence to ART among SW-DU are urgently needed to help produce the maximum HIV treatment and prevention benefit of ART among this highly vulnerable population.