HIV treatment, injection drug use, and illicit drug policies

Periods of Homelessness Linked to Higher VACS Index Among HIV-Positive People Who Use Drugs

We sought to evaluate the impact of homelessness on HIV disease progression among people who use unregulated drugs (PWUD) living with HIV and test if this association was mediated by adherence to antiretroviral therapy (ART). We applied general linear mixed-effects modeling to estimate the longitudinal relationship between homelessness and the Veterans Aging Cohort Study (VACS) Index, a validated measure of HIV disease progression that predicts all-cause mortality, among a prospective cohort of PWUD. In a longitudinal model adjusted for ART adherence, homelessness was significantly associated with increased VACS Index scores and 16% of the association was mediated by ART adherence. These findings indicate that homelessness was a significant risk factor for HIV disease progression and this association was marginally mediated by ART adherence. Future studies are needed to quantify the other mechanisms (e.g., food insecurity, mental health) by which homelessness increases mortality risk among PWUD living with HIV.

Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions

BACKGROUND

People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). However, PrEP has been underutilized in this population, and PrEP adherence intervention needs are understudied.

METHODS

To inform PrEP intervention development, we reviewed evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID. Guided by a behavioral model of healthcare utilization and using the PICOS framework, we conducted a systematic review in four electronic databases to identify original research studies of ART adherence in HIV-infected PWID in the United States and Canada between Jan 1, 2006-Dec 31, 2016. We synthesized and interpreted findings related to developing recommendations for PrEP adherence interventions for PWID.

RESULTS

After excluding 618 duplicates and screening 1049 unique records, we retained 20 studies of PWID (mean n = 465) with adherence-related outcomes (via pharmacy records: n = 9; self-report: n = 8; biological markers: n = 5; electronic monitoring: n = 2). Predisposing factors (patient-level barriers to adherence) included younger age, female sex, and structural vulnerability (e.g., incarceration, homelessness). Enabling resources (i.e., facilitators) that could be leveraged or promoted by interventions included self-efficacy, substance use treatment, and high-quality patient-provider relationships. Competing needs that require specific intervention strategies or adaptations included markers of poor physical health, mental health comorbidities (e.g., depression), and engagement in transactional sex.

CONCLUSIONS

HIV treatment adherence research carries important lessons for efforts to optimize PrEP adherence among PWID. Despite limitations, this systematic review suggests that strategies are needed to engage highly vulnerable and marginalized sub-groups of this underserved population (e.g., younger PWID, women who inject drugs) in PrEP adherence-related research and programming.

Impact of Illicit Drug Use on Health-Related Quality of Life in Opioid-Dependent Patients Undergoing HIV Treatment

OBJECTIVE

To assess the impact of illicit drug use on health-related quality of life (health utility) among opioid-dependent HIV-infected patients.

DESIGN

Secondary analyses of data from the Buprenorphine-HIV Evaluation and Support cohort of HIV-infected patients with opioid dependence in 9 US HIV clinics between 2004 and 2009. Health status [short form-12 (SF-12)], combination antiretroviral treatment (ART) status, CD4 cell count, hepatitis C virus antibody status, current drug use, and demographics were assessed at the initial visit and quarterly follow-up visits until 1 year. The SF-6D health utility scores were derived from the SF-12. Multivariate mixed-effects regression models were used to assess the impact of illicit drug use on health utility controlling for demographic, clinical, and social characteristics.

RESULTS

Health utility was assessed among 307 participants, 67% male, with a median age of 46 years at 1089 quarterly assessments. In multivariate analyses, illicit opioid use, nonopioid illicit drug use, not being on ART, and being on ART with poor adherence were associated with lower health utility. The observed decrement in health utility associated with illicit opioid use was larger for those on ART with good adherence (beta = -0.067; P < 0.01) or poor adherence (-0.049; P < 0.01) than for those not on ART.

CONCLUSIONS

Illicit opioid and nonopioid drug use are negatively associated with health utility in patients with HIV; however, the relative effect of illicit opioid use is smaller than that of not being on ART. Postponing ART until initiation of opioid substitution therapy or abstinence may have limited benefits from the perspective of maximizing health utility.

Sexual behaviour of people living with HIV attending a tertiary care government hospital in Kathmandu, Nepal: a cross sectional study

Background

Clinical improvements that follow antiretroviral therapy (ART) may lead to increase or resumption of high risk activities that could unintentionally result in HIV transmission. The objective was to investigate whether treatment status is a significant predictor of sexual risk behaviour (unprotected sex).

Methods

A cross sectional study was conducted among 160 people living with HIV (PLHIV) (89 ART experienced and 71 ART naïve) attending Sukraraj Tropical and Infectious Disease Hospital in Kathmandu, Nepal. A structured questionnaire was used for data collection. Logistic regression with stepwise modeling was used to obtain adjusted odds ratios (OR) with 95 % CI.

Results

In this study, 92 % of sexually active respondents reported sex with a regular partner. ART experienced PLHIV were significantly more likely to report consistent condom use with their regular partners compared to ART naïve PLHIV (83 vs. 53 %; P = 0.006) during the past six months. In multivariate analysis, sex (OR = 4.59, 95 % CI: 1.15–18.39), treatment status (OR = 4.76, 95 % CI: 1.29–17.52) and alcohol consumption during last sex with regular partners (OR = 14.75, 95 % CI: 2.75–79.29) were significantly associated with unprotected sex.

Conclusion

ART naïve PLHIV were five times more likely to exhibit sexual risk behaviour (have unprotected sex) than ART experienced PLHIV. Thus the study provided no evidence to suggest that ART experienced PLHIV exhibit greater sexual risk behaviour compared to ART naïve PLHIV. Prevention programmes need to emphasize on counselling to PLHIV and their regular partners with focused interventions such as couple counselling and education programmes.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1559-0) contains supplementary material, which is available to authorized users.

Methadone maintenance therapy decreases the rate of antiretroviral therapy discontinuation among HIV-positive illicit drug users

We sought to examine whether methadone maintenance therapy (MMT) decreased rates of antiretroviral therapy (ART) discontinuation and was associated with plasma HIV RNA responses among a cohort of illicit drug users. Cumulative ART discontinuation rates were estimated using Kaplan-Meier methods and factors independently associated with ART discontinuation were identified using Cox proportional hazards regression. Engagement in MMT was negatively and independently associated with ART discontinuation [Adjusted Relative Hazard = 0.67 (95 % CI 0.54-0.83); p < 0.001]. Among participants receiving ART and MMT, 81.6 % of plasma HIV-1 RNA assessments were <500 copies/mL, while 65.81 % of HIV-1 RNA assessments among those prescribed ART without MMT were <500 copies/mL (p < 0.001). These results demonstrate that engagement in MMT conferred a protective benefit against ART discontinuation and was associated with a significant increase in plasma HIV RNA suppression among HIV-infected opioid-dependent drug users.

Incidence, risk factors and causes of death in an HIV care programme with a large proportion of injecting drug users

OBJECTIVES

To identify factors influencing mortality in an HIV programme providing care to large numbers of injecting drug users (IDUs) and patients co-infected with hepatitis C (HCV).

METHODS

A longitudinal analysis of monitoring data from HIV-infected adults who started antiretroviral therapy (ART) between 2003 and 2009 was performed. Mortality and programme attrition rates within 2 years of ART initiation were estimated. Associations with individual-level factors were assessed with multivariable Cox and piece-wise Cox regression.

RESULTS

A total of 1671 person-years of follow-up from 1014 individuals was analysed. Thirty-four percent of patients were women and 33% were current or ex-IDUs. 36.2% of patients (90.8% of IDUs) were co-infected with HCV. Two-year all-cause mortality rate was 5.4 per 100 person-years (95% CI, 4.4-6.7). Most HIV-related deaths occurred within 6 months of ART start (36, 67.9%), but only 5 (25.0%) non-HIV-related deaths were recorded during this period. Mortality was higher in older patients (HR = 2.50; 95% CI, 1.42-4.40 for ≥40 compared to 15-29 years), and in those with initial BMI < 18.5 kg/m(2) (HR = 3.38; 95% CI, 1.82-5.32), poor adherence to treatment (HR = 5.13; 95% CI, 2.47-10.65 during the second year of therapy), or low initial CD4 cell count (HR = 4.55; 95% CI, 1.54-13.41 for <100 compared to ≥100 cells/μl). Risk of death was not associated with IDU status (P = 0.38).

CONCLUSION

Increased mortality was associated with late presentation of patients. In this programme, death rates were similar regardless of injection drug exposure, supporting the notion that satisfactory treatment outcomes can be achieved when comprehensive care is provided to these patients.

Injection drug users' access to a supervised injection facility in Vancouver, Canada: the influence of operating policies and local drug culture

North America's first supervised injection facility (SIF) was established in Vancouver, Canada, in 2003. Although evaluation research has documented reductions in risk behavior among SIF users, there has been limited examination of the influence of operational features on injection drug users' access to these facilities. We conducted an ethnographic study that included observational research within the SIF, 50 in-depth individual interviews with SIF users, and analysis of the regulatory frameworks governing the SIF. The government-granted exemption allowing the facility to operate legally imposes key operating regulations, as well as a cap on capacity, which results in significant wait times to enter the injecting room. Regulations that prohibit practices that are common in the local drug culture also negatively affect SIF utilization. Restructuring policies that shape the operation of the SIF could enhance access to the facility and permit SIF services to better accommodate local drug use practices.

Developing Canada's research base for harm reduction and health equity approaches to HIV prevention and treatment

In the area of infectious disease control, Canadian research efforts to address the HIV epidemic in Vancouver's Downtown East Side neighbourhood have fueled the development of harm reduction and health equity perspectives worldwide. These research efforts have, in turn, reshaped the field of public health approaches to HIV prevention and control. As a result of the intensive and sustained research initiatives led by Canadian scientists Drs. Thomas Kerr and Evan Wood, the 'HIV problem' and public health responses to it have been radically reconceptualized - shifting from an exclusive focus on individual choice towards asking fundamental questions about our society and the structural features that put people at risk for contracting HIV. Their research on harm reduction and health equity related to HIV vulnerability and outcomes has informed and shaped: (1) the establishment of North America's first supervised injection facility, Insite, located in Vancouver's Downtown East Side neighbourhood; (2) dramatic changes to Vancouver's needle exchange policies; (3) HIV treatment approaches among injection drug using populations (IDU). By drawing attention to the ways in which Canadian health care policies and programs can be restructured to better support the health of vulnerable populations, the work of Drs. Kerr and Wood represents a uniquely Canadian public health milestone.

Difficulty accessing syringes and syringe borrowing among injection drug users in Bangkok, Thailand

INTRODUCTION AND AIMS

Thailand's longstanding HIV epidemic among injection drug users (IDU) has been attributed, in part, to the Thai government's unwillingness to implement evidence-based HIV prevention interventions. This study was undertaken to examine risk factors for syringe borrowing among a community-recruited sample of Thai IDU.

DESIGN AND METHODS

We examined the prevalence of syringe borrowing among 238 IDU participating in the Mit Sampan Community Research Project, Bangkok. Multivariate logistic regression was used to identify independent predictors of syringe borrowing in the past 6 months.

RESULTS

A total of 238 IDU participated in this study; 66 (26.2%) were female, and the median age was 36.5 years. In total, 72 (30.3%) participants reported borrowing a used syringe in the past 6 months, with 47 (65.3%) of these individuals reporting multiple borrowing events. In multivariate analyses, syringe borrowing was positively associated with difficulty accessing syringes [adjusted odds ratio (AOR) = 2.46; 95% confidence interval (CI): 1.08-5.60] and injecting with other people on a frequent basis (AOR = 3.17; 95% CI: 1.73-5.83). Primary reasons offered for experiencing difficulty accessing syringes included being too far from syringe outlets (34.1%), pharmacies being closed (13.6%) and being refused syringes at pharmacies (9.1%).

DISCUSSION AND CONCLUSIONS

We observed an alarmingly high rate of syringe borrowing among a community-recruited sample of Thai IDU. Various lines of evidence indicate that poor access to sterile syringes is driving the high rate of syringe borrowing observed in this study. Immediate action should be taken to increase access to sterile syringes among Thai IDU.

Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis

BACKGROUND

High plasma HIV-1 RNA concentrations are associated with increased risk of HIV-1 transmission. Initiation of antiretroviral therapy (ART) reduces plasma HIV-1 concentrations. We aimed to assess the effect of ART use by patients infected with HIV-1 on risk of transmission to their uninfected partners.

METHODS

Participants in our prospective cohort analysis were from a randomised placebo-controlled trial that enrolled heterosexual African adults who were seropositive for both HIV-1 and herpes simplex virus type 2, and their HIV-1 seronegative partners. At enrolment, HIV-1 infected participants had CD4 counts of 250 cells per microL or greater and did not meet national guidelines for ART initiation; during 24 months of follow-up, CD4 counts were measured every 6 months and ART was initiated in accordance with national guidelines. Uninfected partners were tested for HIV-1 every 3 months. The primary outcome was genetically-linked HIV-1 transmission within the study partnership. We assessed rates of HIV-1 transmission by ART status of infected participants.

FINDINGS

3381 couples were eligible for analysis. 349 (10%) participants with HIV-1 initiated ART during the study, at a median CD4 cell count of 198 (IQR 161-265) cells per microL. Only one of 103 genetically-linked HIV-1 transmissions was from an infected participant who had started ART, corresponding to transmission rates of 0.37 (95% CI 0.09-2.04) per 100 person-years in those who had initiated treatment and 2.24 (1.84-2.72) per 100 person-years in those who had not-a 92% reduction (adjusted incidence rate ratio 0.08, 95% CI 0.00-0.57, p=0.004). In participants not on ART, the highest HIV-1 transmission rate (8.79 per 100 person-years) was from those with CD4 cell counts lower than 200 cells per microL. In couples in whom the untreated HIV-1 infected partner had a CD4 cell count greater than 200 cells per microL, 66 (70%) of 94 transmissions occurred when plasma HIV-1 concentrations exceeded 50 000 copies per mL.

INTERPRETATION

Low CD4 cell counts and high plasma HIV-1 concentrations might guide use of ART to achieve an HIV-1 prevention benefit. Provision of ART to HIV-1 infected patients could be an effective strategy to achieve population-level reductions in HIV-1 transmission.

FUNDING

Bill & Melinda Gates Foundation; US National Institutes of Health.

Factors related to injection drug use among female prisoners

Female inmates (N = 655) of a large prison facility in the southeastern United States were surveyed about their substance use, social histories, and demographics. Multinomial logistic regression was used to identify predictors of injection drug use. The sample was primarily young (M = 34 +/- 9 years), and evenly split on race (45.3% White and 44.6% Black). Four predictors were identified as significant risk factors for injection drug use: being White, having a prior history of substance user treatment, having a prior drug-related charge, and being a problem drinker. Implications, limitations, and future directions are discussed.

The impact of incarceration upon adherence to HIV treatment among HIV-positive injection drug users: a qualitative study

INTRODUCTION

HIV-positive injection drug users (IDU) often do not derive the full benefits of highly active antiretroviral therapy (HAART). Among IDU, recent incarceration has been associated with discontinuation of HAART for non-clinical reasons. We sought to qualitatively evaluate experiences with HAART among HIV-positive IDU who had been recently incarcerated within provincial prisons in British Columbia in order to identify factors influencing adherence to treatment.

METHODS

Twelve in-depth qualitative interviews were conducted with males recruited from a cohort study (ACCESS) involving over 450 HIV-positive IDU. All participants had been incarcerated after initiating HAART. Audio-recorded interviews were conducted to examine experiences of taking HAART in prison, with particular attention to adherence and experiences of treatment discontinuation.

FINDINGS

Participant accounts described situations where adherence to HIV treatment was compromised in custody. A small number of participants reported treatment interruptions that lasted over a week when they were unable to obtain HIV medications through institutional healthcare. Short-term interruptions in treatment were said to be common during intake into the correctional system and at the point of release from custody. High levels of HIV discrimination motivate prisoners to hide the fact that they are HIV-positive by making efforts to take medications discreetly, which may result in missed doses.

CONCLUSIONS

The current study identified contextual factors within correctional environments that hinder individuals' ability to adhere to HAART. These findings also indicate that improved health services and coordination with community care providers are needed to enhance the quality of HIV treatment within correctional environments.

A review of barriers and facilitators of HIV treatment among injection drug users

Globally, injection drug use continues to account for a substantial proportion of HIV infections. There have not, however, been any evidence-based reviews of the barriers and facilitators of HIV treatment among injection drug users. For this review, published studies were extracted from nine academic databases, with no language or date specified in the search criteria. Existing evidence demonstrates that, although injection drug users often have worse outcomes from HIV treatment than non-injection drug users, major antiretroviral-associated survival gains still have been observed among this population. Inferior outcomes are explained by a range of barriers to antiretroviral access and adherence, which often stem from the negative influences of illicit drug policies, as well as issues within medical systems, including lack of physician education about substance abuse. Evidence demonstrates that several under-utilized interventions and novel antiretroviral delivery modalities have helped to greatly address these barriers in several settings, and there is sufficient evidence to support immediate scale-up of these programmes. These interventions include coupling antiretroviral therapy with opioid substitution therapies as well as directly administered antiretroviral therapy programmes. Of particular interest for future evaluation is the coupling of HIV treatment programmes within comprehensive services, which also provide low-threshold (harm reduction) HIV prevention programmes. Scale-up of evidence-based HIV treatment and prevention to injection drug users, however, will require increasing political will among both national policy-makers and international public health agencies.