ART Adherence Unit (AAU) - A therapeutic community facility that aims to improve HIV treatment outcomes for people who inject drugs in Pakistan.

Tariq Zafar, Salman ul Hasan Qureshi, Joost Breeksema, Nick Veldwijk

With a weighted national HIV prevalence of around 38%, people who inject drugs (PWID) are the single largest group of people living with HIV (PLHIV) in Pakistan. In order to be initiated into HIV treatment, PWID are obliged undergo detoxification. In the absence of opioid substitution treatment (OST), Nai Zindagi has piloted a novel residential rehabilitation facility for HIV positive PWID who have initiated antiretroviral therapy (ART). This ART Adherence Unit (AAU) combines treatment for opioid dependence with HIV treatment adherence support. A cross-sectional study assessed the impact of completing a full, eight weeks residency at the AAU on ART adherence and drug relapse rates.

The evaluation study found a statistically significant impact on ART adherence for clients who completed AAU treatment (77,4%) compared to those had not attended the AAU (51%). While relapse into drug use does negatively influence adherence, it did not always lead to discontinuation of ART. Of the 77% who were still adherent, 41% were still clean, while 36% had relapsed. Of those who had discontinued ART, almost all had also relapsed into heroin use. The most commonly cited reasons for non-adherence were side effects (47%) and relapse into drug use (37%).

The study shows that a combined approach to treating opioid dependence and supporting HIV treatment can help boost adherence outcomes, despite relapses into drug use. Given the requirement for PWID to undergo detoxification prior to ART initiation, and the absence of OST for the foreseeable future, the AAU model plays an important role in improving ART adherence for PWID. The Global Fund has already acknowledged the effectiveness by doubling capacity of the AAU. Since relapse is part of the cycle of opioid dependence, the AAU also poses an important alternative for other countries where few options exist for PLHIV who use drugs.