Injecting drug use is associated with a more rapid CD4 cell decline among treatment naive HIV-positive patients in Indonesia

Background: It remains unclear whether the natural course of human immunodeficiency virus (HIV) differs in subjects infected through injecting drug use (IDU) and no data have been published from low- or middle-income countries. We addressed this question in an urban cohort in Indonesia, which is experiencing a rapidly growing HIV epidemic strongly driven by IDU. Methods: All antiretroviral treatment (ART) nao¨ve HIV-positive patients who had at least two subsequent CD4 cell counts available before starting ART were included in this study.We examined the association between IDU and CD4 cell decline using a linear mixed model, with adjustment for possible confounders such as HIV viral load and hepatitis C antibodies. Results: Among 284 HIV-positive ART nao¨ve patients, the majority were male (56%) with a history of IDU (79% among men). People with a history of IDU had a statistically significant faster decline in CD4 cells (p B0.001). Based on our data, patients with a history of IDU would have an average 33% decline in CD4 cells after one year without ART, compared with a 22% decline among non-users. At two years, the decline would average 66 and 40%, respectively. No other factor was significantly associated with CD4 cell decline. Conclusions: We show that a history of IDU is associated with a more rapid CD4 cell natural decline among HIV-positive individuals in Indonesia.These findings have implications for monitoring ART nao¨ve patients with a history of IDU and for starting ART in this group.