Expanding access to HIV antiretroviral therapy among marginalized populations in the developed world

Evan Wood, Julio S.G. Montaner, David R. Bangsberg, Mark W. Tyndall, Steffanie A. Strathdee, Michael V. O'Shaughnessy, Robert S. Hogg

Research output: Contribution to journalReview articlepeer-review

68 Scopus citations


We now have a great deal of evidence demonstrating that lower income populations, women, ethnic minorities, and illicit drug users are at risk of poor access to antiretroviral therapy and higher rates of treatment discontinuation. Although the majority of these studies have been conducted among living cohorts, data is emerging to suggest that limited access is contributing to the ongoing HIV/AIDS mortality rates in the developed world. Fears regarding the potential for community-wide transmission of antiretroviral resistant HIV among the homeless, mentally ill, and injection drug users have thus far largely been unfounded [58,64, 66,100]. Although this concern deserves continued monitoring, in many instances it is likely that resistance is not observed because a proportion of these patients will cease antiretroviral therapy outright or will be insufficiently adherent for resistance to develop [66]. The above issues have several implications. First, interventions to improve retention among those who initiate therapy are urgently required, and efforts are needed to ameliorate barriers to treatment retention and adherence. Second, among individuals who have not accessed therapy, strategies to improve contact with HIV care providers are needed. When contact is made, guidelines for physicians must be based on available evidence [69-71]. This evidence suggests that physicians should seek to address modifiable barriers to adherence and retention in HIV treatment prior to the start of therapy among patients not requiring immediate treatment [58,68]. In addition, no patient should be denied the opportunity to initiate HAART regardless of perceived or real barriers to optimal adherence including continued illicit drug use. Given that the extent of the HIV/ AIDS public health crisis, and since the full benefits of HAART are not compromised when patients are successfully retained in treatment, regardless of ethnicity, gender, and history of injection drug use [55,101], efforts to address social, cultural, and medical barriers are an urgent priority.

Original languageEnglish (US)
Pages (from-to)2419-2427
Number of pages9
Issue number17
StatePublished - Nov 21 2003
Externally publishedYes


  • AIDS
  • Access
  • Adherence
  • Antiretrovirals
  • Gender
  • Injection drug use
  • Race

ASJC Scopus subject areas

  • Immunology and Allergy
  • Immunology
  • Infectious Diseases


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