Despite the central role of substance use in the acquired immunodeficiency syndrome (AIDS) epidemic, the role of individual substances on human immunodeficiency virus (HIV) disease progression has been a complicated puzzle. Cook and colleagues studied the impact of crack cocaine use among 1686 HIV-seropositive women in the Women’s Interagency Cohort Study between 1996 and 2004, the era of highly active antiretroviral therapy (HAART). Outcomes examined included death, AIDS-defining illness, CD4 count, and HIV viral load.
To identify the impact of crack cocaine specifically, researchers controlled for known potential confounders in multivariable analyses, including age, race/ethnicity, education, income, baseline HIV viral load and CD4 cell count, year of HIV diagnosis, study site, HAART adherence, and problem drinking. Analyses were based on patterns of use: 1203 women (71.4%) were nonusers of crack cocaine, 429 (25.4%) were intermittent users, and 54 (3.2%) were persistent users.
* Persistent use was significantly associated with increased death, AIDS-defining illness, and HIV viral load and with a decrease in CD4 count compared with nonusers.
* Intermittent users had an increase in AIDS-defining illnesses compared with nonusers and had intermediate CD4 counts and HIV viral loads.
This study provides the most definitive evidence to date that crack cocaine use adversely impacts HIV disease progression clinically and immunologically in women. Although the authors are careful to note minor methodological deficiencies, from a pragmatic perspective, the HIV clinical progression puzzle as it relates to crack cocaine use in women has been notably elucidated.
Jeffrey H. Samet, MD, MA, MPH
Cook JA, Burke-Miller JK, Cohen MH, et al. Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women. AIDS. 2008;22(11):1355–1363.