Prescription drug "diversion" -- the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace -- has been a topic of widespread commentary since the latter part of the 1990s, and a number of recent studies have addressed patterns of narcotic analgesic abuse and diversion. The scientific literature, however, has been virtually silent regarding the diversion of antiretroviral medications (ARV) for HIV. Nevertheless, pilot work conducted by the investigators of this application suggests that ARV diversion is a growing problem among drug-involved individuals in Miami, and is likely occurring in other large urban centers where rates of HIV infection are high. The ramifications of this diversion are potentially significant. Importantly, those prescribed ARV medications may not be consistently adhering to their treatment regimens, resulting in a deterioration of their own health and increasing the potential for the emergence of medication-resistant strains of HIV. From a public health perspective, the widespread transmission of drug-resistant HIV could leave newly-infected individuals with few viable treatments. Within this context, the overall goals of the proposed 4-year project are to examine the patterns and predictors of ARV diversion among drug-involved HIV-positive individuals in Miami (Dade County), Florida, and to describe the dynamics of ARV medication diversion to local street markets. The study will utilize a theory-driven, mixed method approach to achieve these goals.
The specific aims of the qualitative component of the proposed research are to: 1) Describe the key individual, provider, and environmental factors that influence ARV diversion through formative qualitative research;and, 2) Adapt and refine the Andersen model of health services utilization to include the key dimensions of ARV diversion identified in the formative qualitative research phase.
Aims 1 and 2 will be accomplished by: 1) Conducting baseline and follow-up in-depth interviews with 90 drug-involved, indigent, HIV positive ARV diverters and non-diverters to examine motivations for diversion and non-diversion over time;2) Conducting baseline and follow-up in-depth interviews with 30 "pill brokers" to document their ARV diversion activities over time;and, 3) Conducting in-depth baseline and follow-up interviews with 45 HIV positive buyers of illicit ARVs to examine motivations for illicit ARV purchases over time. The primary specific aim of the quantitative component of the research is to: 3) Compare the key differences between ARV diverters and non-diverters on individual, provider, and environmental level factors described by the modified Andersen Model of health services utilization, and examine their effects on patterns of ARV medication diversion.
Aim 3 will be accomplished by: 1) Recruiting a sample of 500 indigent, HIV positive individuals who are current drug users [250 of whom divert ARV medications and 250 who do not];and, 2) assessing the constellation of individual, provider and environmental factors hypothesized to predict ARV diversion.
A comprehensive understanding of the nature, motivations for, and mechanisms of ARV medication diversion is critical for funding and regulatory agencies, industry, public health organizations, and health care providers as they attempt to develop appropriate prevention, risk management, treatment, and policy initiatives. Most importantly, this study will inform interventions targeting the significant health consequences of ARV diversion and non-adherence by highly vulnerable populations.
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