Association of opioid agonist therapy with the initiation of antiretroviral therapy - a systematic review

Characterizing opioid agonist therapy uptake and factors associated with treatment retention among people with HIV in British Columbia, Canada

Accidental overdoses are now the leading cause of death among people with HIV (PWH) in British Columbia (BC). We examined the utilization and retention of opioid agonist therapy (OAT). Adult PWH (≥19 years) with ≥ 1 OAT dispensation in BC between 2008 and 2020 were included (n = 1,515). OAT treatment episodes were formed based on specific criteria for slow-release oral morphine (SROM), methadone, injectable OAT (iOAT), and buprenorphine/naloxone. Retention in treatment was defined as any episode lasting ≥ 12 months. Logistic regression with generalized estimating equations modeled retention-associated factors. There was a 56.6% decline in OAT retention over time. Buprenorphine treatment exhibited significantly lower odds of retention (OR: 0.58; 95% CI: 0.36-0.92) compared to methadone. Conversely, no significant change in retention odds was observed for SROM (0.72; 0.33-1.54) and iOAT (0.81; 0.31-2.12). Factors associated with increased odds of retention included a 10-year increase in age (1.69; 1.46-1.95), previous retention history (1.96; 1.40-2.73), achieving OAT therapeutic dose (8.22; 6.67-10.14), and suppressed HIV viral load (1.35; 1.10-1.67). Individuals with a lifetime HCV diagnosis receiving iOAT were more likely to retain (3.61; 1.20-10.83). Each additional year on OAT during the study period was associated with a 4% increase in the odds of retention. A significant proportion of PWH had a history of OAT prescribing but experienced low retention rates. Retention outcomes were more positive for SROM and iOAT. The association between OAT medication type and retention odds may be particularly influenced by HCV diagnosis. Optimal management of opioid use disorder among PWH, with an emphasis on attaining the therapeutic dose is crucial.

Assessing the Temporality Between Transitions onto Opioid Agonist Therapy and Engagement with Antiretroviral Therapy in a Cohort of HIV-Positive People Who Use Opioids Daily

A robust evidence-base describes the beneficial association between opioid agonist therapy (OAT) and HIV-related outcomes among people living with HIV and opioid use disorder. While some evidence suggests the stabilizing effect of OAT on antiretroviral therapy (ART) treatment engagement, less is understood about the potential for an inverse relationship. We sought to examine the relationship between transitions in ART engagement and transitions onto OAT. We used data from a prospective cohort of people living with HIV who use drugs in Vancouver, Canada-a setting with no-cost access to ART and low or no-cost access to OAT among low-income residents. Restricting the sample to those who reported daily or greater opioid use, we used generalized linear mixed-effects models to estimate the relationships between our primary outcome of transitions onto OAT (methadone or buprenorphine/naloxone) and transitions (1) onto ART and (2) into ART adherence. Subsequent analyses assessed the temporal sequencing of transitions. Between 2005 and 2017, among 433 participants, 48.3% reported transitioning onto OAT at least once. In concurrent analyses, transitions onto ART were positively and significantly associated with transitions onto OAT. Temporal sequencing revealed that transitions into OAT were also positively and significantly associated with subsequent transitions onto ART. OAT's potential to facilitate the uptake of ART points to the continued need to scale-up low-threshold, client-centered substance use services integrated alongside HIV care.

Assessing HIV and overdose risks for people who use drugs exposed to compulsory drug abstinence programs (CDAP): A systematic review and meta-analysis

BACKGROUND

Evidence supports integrating drug use treatment, harm reduction, and HIV prevention services to address dual epidemics of drug use disorders and HIV. These dual epidemics have spurred a rise in legally-enforced compulsory drug abstinence programs (CDAP), despite limited evidence on its effectiveness. We conducted a systematic review and meta-analysis evaluating the association between CDAP exposure and HIV and overdose-related risk.

METHODS

We searched PubMed, EBSCOhost and Sociological Abstracts for studies that contained an individual-level association between CDAP exposure and related HIV or overdose risks, with no date restrictions. Meta-analyses were conducted on data abstracted from eligible studies, using pooled random-effects models and I-squared statistics. We assessed quality of the studies across 14 criteria for observational studies.

RESULTS

Out of 2,226 abstracts screened, we included 8 studies (5253 individuals/776 events) across China, Mexico, Thailand, Norway, and the United States. All but two were cross-sectional analyses, limiting strength of observed associations. In the two studies that reported association between CDAP and HIV seropositivity or receptive syringe sharing, findings were inconsistent and did not indicate that those with exposure to CDAP had increased odds of HIV or syringe sharing. However, we found the odds of experiencing non-fatal overdose in lifetime and in the last 6-12 months were 2.02 (95% CI 0.22 - 18.86, p = 0.16) to 3.67 times higher (95% CI 0.21 - 62.88, p = 0.39), respectively, among those with CDAP exposure than those without.

CONCLUSION

Research assessing HIV risk associated with CDAP is scant and inconclusive, while evidence of robust associations between CDAP and overdose risk continues to mount. More rigorous, longitudinal studies are needed to evaluate the causal relationships between CDAP and these health outcomes. Aside from the growing evidence base on collateral harms, ethical considerations dictate that voluntary, evidence-based drug treatment should be prioritized to address the drivers of excess morbidity and mortality among people who use drugs.

Human Immunodeficiency Virus Prevention for People Who Use Drugs: Overview of Reviews and the ICOS of PICOS

BACKGROUND

This article summarizes the results from systematic reviews of human immunodeficiency virus (HIV) prevention interventions for people who use drugs (PWUD). We performed an overview of reviews, meta-analysis, meta-epidemiology, and PROSPERO Registration CRD42017070117.

METHODS

We conducted a comprehensive systematic literature search using the Centers for Disease Control and Prevention HIV/AIDS Prevention Research Synthesis Project database to identify quantitative systematic reviews of HIV public heath interventions with PWUD published during 2002-2017. We recombined results of US studies across reviews to quantify effects on HIV infections, continuum of HIV care, sexual risk, and 5 drug-related outcomes (sharing injection equipment, injection frequency, opioid use, general drug use, and participation in drug treatment). We conducted summary meta-analyses separately for reviews of randomized controlled trials (RCTs) and quasi-experiments. We stratified effects by 5 intervention types: behavioral-psychosocial (BPS), syringe service programs (SSP), opioid agonist therapy (OAT), financial and scheduling incentives (FSI), and case management (CM).

RESULTS

We identified 16 eligible reviews including >140 US studies with >55 000 participants. Summary effects among US studies were significant and favorable for 4 of 5 outcomes measured under RCT (eg, reduced opioid use; odds ratio [OR] = 0.70, confidence interval [CI] = 0.56-0.89) and all 6 outcomes under quasi-experiments (eg, reduced HIV infection [OR = 0.42, CI = 0.27-0.63]; favorable continuum of HIV care [OR = 0.68, CI = 0.53-0.88]). Each intervention type showed effectiveness on 1-6 outcomes. Heterogeneity was moderate to none for RCT but moderate to high for quasi-experiments.

CONCLUSIONS

Behavioral-psychosocial, SSP, OAT, FSI, and CM interventions are effective in reducing risk of HIV and sequelae of injection and other drug use, and they have a continuing role in addressing the opioid crisis and Ending the HIV Epidemic.

Treatment trajectories and barriers in opioid agonist therapy for people who inject drugs in rural Puerto Rico

BACKGROUND

Research has shown medication for opioid use disorder (MOUD) to have positive effects, including reducing HIV and HCV transmission, but important barriers to access remain among people who inject drugs (PWID). Barriers include lack of social and familial support, bureaucracy, distance to treatment, poverty, and homelessness. However, we know little about how these barriers interact with each other to shape PWID's drug treatment access and retention.

METHODS

We used qualitative methods with a dataset from a study conducted during 2019 with 31 active PWID residing in rural Puerto Rico. The study gathered ethnographic data and narratives about treatment trajectories to document the lived experiences of PWID as they moved in and out of treatment.

RESULTS

Participants were at least 18 years old; 87.7% were male, the mean age was 44.1 years, and the mean age at first injection was 22 years. Participants identified homelessness, lack of proper ID or other identifying documents, and previous negative experiences with MOUD as the main barriers to treatment entry and retention. In addition, PWID's belief that MOUD simply substitutes an illegal drug for a legal one, while furthering drug dependence by chronically subjecting patients to treatment, constitutes an additional barrier to entry. Findings from this study demonstrate that MOUD barriers to access and retention compound and are severely affected by poverty and other forms of vulnerability among PWID in rural Puerto Rico.

CONCLUSION

Policies to increase access and retention should consider barriers not in isolation but as an assemblage of many factors.

Time-space constraints to HIV treatment engagement among women who use heroin in Dar es Salaam, Tanzania: A time geography perspective

Timely initiation and sustained adherence to antiretroviral therapy (ART) are essential to improving the health outcomes of people living with HIV and preventing onward HIV transmission. However, women who use heroin often face challenges to initiating and adhering to ART. In this paper we identify spatial, temporal, and social factors that affect HIV treatment engagement among women who use heroin, drawing from a time geography framework. We conducted in-depth interviews with 30 heroin-using women living with HIV in Dar es Salaam, Tanzania between January and March 2019. We found that unstable housing, high mobility, HIV-related stigma, and unpredictable daily paths due to heroin use and involvement in sex work spatially and temporally constrained women who use heroin from incorporating HIV treatment behaviors into daily routines. Some women, however, were able to overcome these time-space constraints to HIV treatment engagement through social support and social role performance. Time geography, including concepts of time-space constraints and daily paths, is a useful framework for identifying barriers to ART engagement. Structural, relational, and individual interventions aimed at eliminating time-space constraints hold the potential to improve HIV treatment engagement among particularly vulnerable and mobile populations.

Optimizing HIV prevention and treatment outcomes for persons with substance use in Central Asia: what will it take?

Purpose of review

To summarize the status of HIV and substance use in Central Asia and discuss potential ways to move forward to effective epidemic control among people who inject drugs (PWID) in the region and beyond.

Recent findings

PWID and their partners remain the population most affected by HIV in Central Asia. Lack of effective substance use prevention and treatment options and limited involvement of PWID-led community-based organizations in HIV programs, combined with the requirement for official registration, stigma and discrimination of PWID, and criminalization of drug use remain key barriers to effective HIV prevention and treatment.

Summary

Sustainable HIV epidemic control among PWID will not be feasible without decriminalization of drug use, addressing stigma and discrimination and policy changes to enhance uptake of HIV-related prevention, treatment and support services by PWID. It is also critical to ensure adoption of innovations, particularly those that combine evidence-based biomedical, behavioral and structural interventions tailored to the needs of the PWID.

HIV testing and ART initiation in people who inject drugs and are placed on methadone in Kachin State, Myanmar

Setting

People who inject drugs (PWID) enrolled for methadone maintenance therapy (MMT) and never previously tested for human immunodeficiency virus (HIV) in Myitkyina Drug Dependency Treatment Hospital, Myitkyina, Kachin State, Myanmar.

Objectives

To compare before (2016) and after (2018) adoption of 'Test and Treat' guidelines for antiretroviral therapy (ART): 1) the demographic profile of PWID, 2) HIV testing uptake and ART initiation in those diagnosed HIV-positive, and 3) time taken for events.

Design

This was a cohort study using secondary programme data.

Results

In 2016 and 2018, there were respectively 141 and 146 PWID: all were male except for one female and age distribution between the 2 years was similar. In 2018, significantly more PWID were HIV-tested than in 2016 (85% vs. 45%; P ≤ 0.001). Among those tested, the proportions who were HIV-positive were similar (37% in 2016 and 38% in 2018). In 2018, significantly fewer HIV-positive PWID were started on ART than in 2016 (19% vs. 48%; P = 0.01). Median times between enrolment on MMT and HIV testing (2 vs. 1 day) and between being diagnosed HIV-positive and started on ART (31 vs. 17 days) for 2016 and 2018 were not significantly different.

Conclusion

ART uptake decreased in 2018 compared with 2016, and ways to rectify this are urgently needed.

Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study

Introduction

The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours.

Methods

In a nationally representative cross-sectional study, soon-to-be released prisoners in Kyrgyzstan (N=368) and Azerbaijan (N=510) completed standardized health assessment surveys. After identifying correlated variables through bivariate testing, we built multi-group path models with pre-incarceration official and unofficial detention as exogenous variables and pre-incarceration composite HIV risk as an endogenous variable, controlling for potential confounders and estimating indirect effects.

Results

Overall, 463 (51%) prisoners reported at least one detention in the year before incarceration with an average of 1.3 detentions in that period. Unofficial detentions (13%) were less common than official detentions (41%). Optimal model fit was achieved (X²=5.83, p=0.44; Goodness of Fit Index (GFI) GFI=0.99; Comparative Fit Index (CFI) CFI=1.00; Root Mean Square Error of Approximation (RMSEA) RMSEA=0.00; PCLOSE=0.98) when unofficial detention had an indirect effect on HIV risk, mediated by drug addiction severity, with more detentions associated with higher addiction severity, which in turn correlated with increased HIV risk. The final model explained 35% of the variance in the outcome. The effect was maintained for both countries, but stronger for Kyrgyzstan. The model also holds for Kyrgyzstan using unique data on within-prison drug injection as the outcome, which was frequent in prisoners there.

Conclusions

Detention by police is a strong correlate of addiction severity, which mediates its effect on HIV risk behaviour. This pattern suggests that police may target drug users and that such harassment may result in an increase in HIV risk-taking behaviours, primarily because of the continued drug use within prisons. These findings highlight the important negative role that police play in the HIV epidemic response and point to the urgent need for interventions to reduce police harassment, in parallel with interventions to reduce HIV transmission within and outside of prison.