Increasing HIV prevention and care for injecting drug users

Initiating HCV treatment with direct acting agents in opioid agonist treatment: When to start for people co-infected with HIV?

BACKGROUND

Direct acting antivirals (DAA) raise the possibility of eliminating Hepatitis C virus (HCV) among people who inject drugs (PWID). However, concerns regarding treatment retention and reinfection challenge implementation efforts. Opioid agonist treatment (OAT) provides an opportunity to engage HCV-positive PWID into DAA-based treatment. Our objective was to identify when OAT adherence sufficiently improved to inform DAA initiation in OAT settings, assuming continuous OAT retention for at least twelve weeks is necessary to complete the DAA treatment course.

METHODS

This was a retrospective cohort study of HCV/HIV co-infected PWID from a population-level linked administrative database of people diagnosed and living with HIV in British Columbia, Canada between 01/1996 and 12/2013. We used monthly follow-up data after initial OAT entry and considered the effects of demographics, disease severity, and HIV and OAT treatment characteristics over time on the probability of subsequent OAT retention of ≥12 weeks, and ≥8 weeks for sensitivity analysis. We fit a generalized linear mixed model to the overall study population, and on stratified samples of those continuously engaged on combination antiretroviral therapy (≥95% ART adherence). A set of monthly indicator variables (months 1, …, 7, >7) were included to fulfil the study objective.

RESULTS

Our study included 1427 HCV/HIV co-infected PWID (39.0% female, 68.8% OAT-naïve). The odds of subsequent twelve-week retention in OAT were statistically significantly greater in month 3 versus month 1 (adjusted odds ratio: 1.18; 95% confidence interval: 1.02, 1.37); and the odds of subsequent 8-week retention in OAT were statistically significantly greater in month 2 versus month 1 (1.15, 95% CI: 1.02, 1.31). Among continuously ART-adherent individuals, the odds of subsequent twelve-week retention were not statistically significantly greater than in month 1 (month 2: 1.12 (0.82, 1.51); month 3: 1.08 (0.79, 1.47); month 4: 1.24 (0.91, 1.71)).

CONCLUSION

We provide evidence that among HCV/HIV co-infected PWID, those retained in OAT for three or more months had higher odds of completing an additional twelve weeks of OAT, compared to no difference in those already receiving ART. These data may have implications for adherence to DAA therapy and further studies are needed to understand the optimal timing of DAA therapy in PWID receiving and not receiving OAT.

Public health strategies for prevention and control of HSV-2 in persons who use drugs in the United States

BACKGROUND

Herpes simplex virus type 2 (HSV-2) affects HIV acquisition, transmission, and disease progression. Effective medications for genital herpes and for HIV/AIDS exist. Parenteral transmission of HIV among persons who inject drugs is decreasing. Reducing sexual transmission of HIV and HSV-2 among persons who use drugs (PWUD; i.e., heroin, cocaine, "speedball", crack, methamphetamine through injection or non-injection) necessitates relevant services.

METHODS

We reviewed HSV-2 sero-epidemiology and HSV-2/HIV associations in U.S.-based studies with PWUD and the general literature on HSV-2 prevention and treatment published between 1995 and 2012. We used the 6-factor Kass framework to assess relevant HSV-2 public health strategies and services in terms of their goals and effectiveness; identification of, and minimization of burdens and concerns; fair implementation; and fair balancing of benefits, burdens, and concerns.

RESULTS

Eleven studies provided HSV-2 serologic test results. High HSV-2 sero-prevalence (range across studies 38-75%) and higher sero-prevalence in HIV-infected PWUD (97-100% in females; 61-74% in males) were reported. Public health strategies for HSV-2 prevention and control in PWUD can include screening or testing; knowledge of HSV-2 status and partner disclosure; education, counseling, and psychosocial risk-reduction interventions; treatment for genital herpes; and HIV antiretroviral medications for HSV-2/HIV co-infected PWUD.

CONCLUSIONS

HSV-2 sero-prevalence is high among PWUD, necessitating research on development and implementation of science-based public health interventions for HSV-2 infection and HSV-2/HIV co-infections, including research on effectiveness and cost-effectiveness of such interventions, to inform development and implementation of services for PWUD.

Translation of biomedical prevention strategies for HIV: prospects and pitfalls

Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother-to-child transmission. In recent years, antiretroviral drugs to reduce the risk of transmission (when the infected person takes the medicines; treatment as prevention) or reduce the risk of acquisition (when the seronegative person takes them; preexposure prophylaxis) have proven to be efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (ie, screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV-prevention strategies such as family planning for HIV-infected women who do not want more children and prevention of mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.

HIV infection among people who inject drugs: the challenge of racial/ethnic disparities

Racial/ethnic disparities in HIV infection, with minority groups typically having higher rates of infection, are a formidable public health challenge. In the United States, among both men and women who inject drugs, HIV infection rates are elevated among Hispanics and non-Hispanic Blacks. A meta-analysis of international research concluded that among persons who inject drugs, racial and ethnic minorities were twice as likely to acquire an HIV infection, though there was great variation across the individual studies. To examine strategies to reduce racial/ethnic disparities among persons who inject drugs, we reviewed studies on injection drug use and its role in HIV transmission. We identified four sets of evidence-based interventions that may reduce racial/ethnic disparities among persons who inject drugs: HIV counseling and testing, risk reduction services, access to antiretroviral therapy, and drug abuse treatment. Implementation of these services, however, is insufficient in many countries, including the United States. Persons who inject drugs appear to be changing drug use norms and rituals to reduce their risks. The challenges are to (a) develop a validated model of how racial/ethnic disparities in HIV infection arise, persist, and are reduced or eliminated over time and (b) implement evidence-based services on a sufficient scale to eliminate HIV transmission among all persons who inject drugs.

Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States

BACKGROUND

Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States.

METHOD

We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs.

RESULTS

SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data.

CONCLUSIONS

SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.