Do HIV Disease Progression and HAART Response Vary among Injecting Drug Users in Europe?

Impact of opioid substitution therapy on the HIV prevention benefit of antiretroviral therapy for people who inject drugs

OBJECTIVE

A recent meta-analysis suggested that opioid substitution therapy (OST) increased uptake of antiretroviral treatment (ART) and HIV viral suppression. We modelled whether OST could improve the HIV prevention benefit achieved by ART among people who inject drugs (PWID).

METHODS

We modelled how introducing OST could improve the coverage of ART across a PWID population for different baseline ART coverage levels. Using existing data on how yearly HIV-transmission risk is related to HIV plasma viral load, changes in the level of viral suppression across the population were used to project the relative reduction in yearly HIV-transmission risk achieved by ART, with or without OST, compared with if there was no ART - defined here as the prevention effectiveness of ART.

RESULTS

Owing to OST use increasing the chance of being on ART and achieving viral suppression if on ART, the prevention effectiveness of ART for PWID on OST (compared with PWID not on OST) increases by 44, 31, or 20% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively. Improvements in the population-level prevention effectiveness of ART are also achieved across all PWID, compared with if OST was not introduced. For instance, if OST is introduced at 40% coverage, the population-level prevention effectiveness of ART could increase by 27, 20, or 13% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively.

CONCLUSION

OST could improve the HIV prevention benefit of ART; supporting strategies that aim to concurrently scale-up OST with ART.

Social and structural factors associated with HIV disease progression among illicit drug users: a systematic review

OBJECTIVE

To systematically review factors associated with HIV disease progression among illicit drug users, focusing on exposures exogenous to individuals that likely shape access and adherence to HIV treatment.

DESIGN

A systematic review of peer-reviewed English-language studies among HIV-seropositive illicit drug users with at least one of these endpoint of interest: a diagnosis of AIDS; death; changes/differences in CD4 cell counts; or changes/differences in plasma HIV-1 RNA levels.

METHODS

Articles were included if they reported factors associated with an outcome of interest among a group of illicit drug users. Studies were identified, screened and selected using systematic methods.

RESULTS

Of 2668 studies matching the search criteria, 58 (2%) met the inclusion criteria, all but one from North America or western Europe. Overall, 41 (71%) studies contained significant individual-level clinical characteristics or behaviors (e.g. illicit drug use) associated with disease progression. Fifteen studies (26%) identified significant social, physical, economic or policy-level exposures, including incarceration, housing status or lack of legal income.

CONCLUSION

Although past studies demonstrate important environmental exposures that appear to shape access to care and subsequent disease progression, the limited literature to examine these factors demonstrates the need for future research to consider risk environment characteristics and the role they may play in shaping health outcomes from HIV infection among drug users through determining access and adherence to evidence-based care.

HIV infection and risk of overdose: a systematic review and meta-analysis

Drug overdose is a common cause of non-AIDS death among people with HIV and the leading cause of death for people who inject drugs. People with HIV are often exposed to opioid medications during their HIV care experience; others may continue to use illicit opioids despite their disease status. In either situation, there may be a heightened risk for nonfatal or fatal overdose. The potential mechanisms for this elevated risk remain controversial. We systematically reviewed the literature on the HIV-overdose association, meta-analyzed results, and investigated sources of heterogeneity, including study characteristics related to hypothesize biological, behavioral, and structural mechanisms of the association. Forty-six studies were reviewed, 24 of which measured HIV status serologically and provided data quantifying an association. Meta-analysis results showed that HIV seropositivity was associated with an increased risk of overdose mortality (pooled risk ratio 1.74, 95% confidence interval 1.45, 2.09), although the effect was heterogeneous (Q = 80.3, P < 0.01, I(2) = 71%). The wide variability in study designs and aims limited our ability to detect potentially important sources of heterogeneity. Causal mechanisms considered in the literature focused primarily on biological and behavioral factors, although evidence suggests structural or environmental factors may help explain the greater risk of overdose among HIV-infected drug users. Gaps in the literature for future research and prevention efforts as well as recommendations that follow from these findings are discussed.

Factors associated with improvement in disability-adjusted life years in patients with HIV/AIDS

BACKGROUND

The epidemic of HIV/AIDS and treatments that have emerged to alleviate, have brought about a shift in the burden of disease from death to quality of life/disability. The aim was to determine which factors are associated with improvements in the level of health of male and female patients with HIV/AIDS in Andalusia, in terms of disability-adjusted life years.

METHODS

Descriptive study based on a sample group of 8800 people on the Andalusian AIDS register between 1983 and 2004.

DEPENDENT VARIABLES

Life lost due to premature mortality (YLL), years lost due to disability (YLD) and disability-adjusted life years (DALY).

INDEPENDENT VARIABLES

vital state, sex, age at the time of diagnosis, age at the time of death, transmission category, province of residence, AIDS-indicator disease and the period of diagnosis. A bivariate analysis was carried out to find out if the health level variables changed in accordance with the independent variables. Using the independent variables which had a statistically significant link with the level of health variables, a multivariate linear regression model, disaggregated by gender, was constructed.

RESULTS

Amongst the women, we found a model which explained the level of health of 64.9%: a link was found between a higher level of health (lower DALYs) and not intravenous drug use, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis. Amongst the men, we found a model which explained the level of health of 64.4%: a link was found between a higher level of health (lower DALYs) and intravenous drug use, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis.

CONCLUSION

A higher level of health (lower DALY) amongst both men and women was found to be linked to not be intravenous drug user, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis.

Risk of hepatitis-related mortality increased among hepatitis C virus/HIV-coinfected drug users compared with drug users infected only with hepatitis C virus: a 20-year prospective study

BACKGROUND

Progression of liver-related disease is accelerated in individuals coinfected with HIV and hepatitis C virus (HCV). Because the life expectancy of HIV-infected drug users (DUs) improved after the widespread use of highly active antiretroviral therapy (HAART), HCV-related death is likely to become more important. To disentangle the effects of HCV and HIV, we compared the overall and cause-specific mortality between HCV/HIV-infected DUs and HCV-infected DUs and DUs without HCV or HIV, followed up between 1985 and 2006.

METHODS

A total of 1295 participants in the Amsterdam Cohort Study were included. Cause-specific hazard ratios (CHRs) were estimated for the eras before (<1997) and since HAART (> or =1997) within and among serologic groups.

RESULTS

The risk of dying decreased for most causes of death > or =1997; this decrease was not the same for the different serologic groups. Among HCV/HIV-coinfected DUs, the risk of hepatitis/liver-related death did not substantially change over time (CHR = 0.87, 95% confidence interval [CI]: 0.21 to 3.58), whereas the risk of AIDS-related mortality decreased. Compared with DUs solely infected with HCV, HCV/HIV-coinfected DUs were at increased risk of dying from hepatitis/liver-related disease (CHR = 7.15, 95% CI: 1.98 to 25.8), other natural causes (CHR = 3.09, 95% CI: 1.41 to 6.79), and nonnatural causes (CHR = 2.30, 95% CI: 1.07 to 4.95) in the HAART era.

CONCLUSIONS

HCV/HIV-coinfected DUs remain at increased risk of dying from hepatitis/liver-related death in the HAART era compared with HCV-monoinfected DUs. This risk did not change in HCV/HIV-coinfected DUs after HAART was introduced, suggesting that in the HAART era, HIV continues to accelerate HCV disease progression. Efforts should be made to establish effective treatment for HCV infection in HCV/HIV-coinfected individuals.

Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview

AIDS-related mortality and the rate of progression to AIDS have dramatically decreased since the advent of highly active antiretroviral treatment (HAART). The overall benefit from antiretroviral HIV treatment has, however, been lesser in HIV-infected injecting drug users (IDUs) than in other patient groups (e.g. men who have sex with men). Poorer outcomes in HIV-infected IDUs are related to a variety of factors, including increased rates of non-HIV-related deaths, hepatitis C, delayed access to effective treatment, lower adherence to care and treatment regimens, continuation of illicit drug use, depression and negative life events. The available evidence strongly suggests the need for the large-scale implementation of comprehensive treatment and care strategies for IDUs that include both treatment of drug dependence and HAART.

When to start antiretroviral therapy

The current literature is controversial in providing evidence to determine the optimal time to initiate therapy among patients with HIV. However, there is evidence that initiating early treatment might provide benefits by treating primary HIV infection, preserving normal immune function, suppressing HIV viral replication, deferring clinical progression, and reducing HIV transmission. The biggest challenges in initiating treatment early are issues related with long-term management, including toxicities, adherence, and drug resistance. However, the availability of superior new antiretroviral drugs and simplified regimens, the development of effective treatment strategy, and further improvement of adherence through directly observed treatment are addressing the issues and changing the balance towards earlier treatment.

Disclosure of HIV status and sexual orientation independently predicts increased absolute CD4 cell counts over time for psychiatric patients

OBJECTIVE

The objective of this study was to replicate the relationship between disclosure of sexual orientation and immune functioning in HIV-positive persons and to extend those findings to a different type of disclosure (HIV status) and a different population (psychiatric outpatients in a publicly funded HIV/AIDS clinic).

METHODS

A sample of psychiatric outpatients (N = 373) from a large, urban HIV clinic was assessed for level of sexual orientation and HIV status disclosure as well as absolute CD4 cell counts over time. Mixed-effects random regression analysis was used to build a predictor model that included biobehavioral covariates.

RESULTS

Consistent disclosure of both sexual orientation and HIV status independently predicted increased CD4 cell counts over time controlling for important biobehavioral covariates. The only other significant effects in the model were baseline CD4 cell count and number of days between assessment of disclosure and assessment of CD4 cell count.

CONCLUSIONS

Relieving potential psychological distress by disclosing sexual orientation and HIV status has a positive impact on CD4 cell counts over time even among outpatients stressed by psychiatric illness and economic disadvantage. Additional research is needed to understand whether and under what conditions disclosure should be part of HIV disease management.