1
|
Stone J, Fraser H, Walker JG, Mafirakureva N, Mundia B, Cleland C, Bartilol K, Musyoki H, Waruiru W, Ragi A, Bhattacharjee P, Chhun N, Lizcano J, Akiyama MJ, Cherutich P, Wisse E, Kurth A, Luhmann N, Vickerman P. Modelling the impact of HIV and hepatitis C virus prevention and treatment interventions among people who inject drugs in Kenya. AIDS 2022; 36:2191-2201. [PMID: 36111533 PMCID: PMC9671825 DOI: 10.1097/qad.0000000000003382] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES People who inject drugs (PWID) in Kenya have high HIV (range across settings: 14-26%) and hepatitis C virus (HCV; 11-36%) prevalence. We evaluated the impact of existing and scaled-up interventions on HIV and HCV incidence among PWID in Kenya. DESIGN HIV and HCV transmission model among PWID, calibrated to Nairobi and Kenya's Coastal region. METHODS For each setting, we projected the impact (percent of HIV/HCV infections averted in 2020) of existing coverages of antiretroviral therapy (ART; 63-79%), opioid agonist therapy (OAT; 8-13%) and needle and syringe programmes (NSP; 45-61%). We then projected the impact (reduction in HIV/HCV incidence over 2021-2030), of scaling-up harm reduction [Full harm reduction ('Full HR'): 50% OAT, 75% NSP] and/or HIV (UNAIDS 90-90-90) and HCV treatment (1000 PWID over 2021-2025) and reducing sexual risk (by 25/50/75%). We estimated HCV treatment levels needed to reduce HCV incidence by 90% by 2030. RESULTS In 2020, OAT and NSP averted 46.0-50.8% (range of medians) of HIV infections and 50.0-66.1% of HCV infections, mostly because of NSP. ART only averted 12.9-39.8% of HIV infections because of suboptimal viral suppression (28-48%). Full HR and ART could reduce HIV incidence by 51.5-64% and HCV incidence by 84.6-86.6% by 2030. Also halving sexual risk could reduce HIV incidence by 68.0-74.1%. Alongside full HR, treating 2244 PWID over 2021-2025 could reduce HCV incidence by 90% by 2030. CONCLUSION Existing interventions are having substantial impact on HIV and HCV transmission in Kenya. However, to eliminate HIV and HCV, further scale-up is needed with reductions in sexual risk and HCV treatment.
Collapse
Affiliation(s)
- Jack Stone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Josephine G. Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | | | | | | | | | | | - Wanjiru Waruiru
- Global Programs for Research and Training, Surveillance Department, University of California San Francisco, San Francisco, California, USA
| | | | | | - Nok Chhun
- Yale University School of Nursing, New Haven, Connecticut
| | - John Lizcano
- Yale University School of Nursing, New Haven, Connecticut
| | - Matthew J. Akiyama
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | - Ann Kurth
- Yale University School of Nursing, New Haven, Connecticut
| | - Niklas Luhmann
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
- NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, Bristol, UK
| |
Collapse
|
2
|
Fraser H, Stone J, Wisse E, Sambu V, Mfisi P, Duran IJ, Soriano MA, Walker JG, Makere N, Luhmann N, Kafura W, Nouvellet M, Ragi A, Mundia B, Vickerman P. Modelling the impact of HIV and HCV prevention and treatment interventions for people who inject drugs in Dar es Salaam, Tanzania. J Int AIDS Soc 2021; 24:e25817. [PMID: 34661964 PMCID: PMC8522890 DOI: 10.1002/jia2.25817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction People who inject drugs (PWID) in Dar es Salaam, Tanzania, have a high prevalence of HIV and hepatitis C virus (HCV). While needle and syringe programmes (NSP), opioid agonist therapy (OAT) and anti‐retroviral therapy (ART) are available in Tanzania, their coverage is sub‐optimal. We assess the impact of existing and scaled up harm reduction (HR) interventions on HIV and HCV transmission among PWID in Dar es Salaam. Methods An HIV and HCV transmission model among PWID in Tanzania was calibrated to data over 2006–2018 on HIV (∼30% and ∼67% prevalence in males and females in 2011) and HCV prevalence (∼16% in 2017), numbers on HR interventions (5254 ever on OAT in 2018, 766–1479 accessing NSP in 2017) and ART coverage (63.1% in 2015). We evaluated the impact of existing interventions in 2019 and impact by 2030 of scaling‐up the coverage of OAT (to 50% of PWID), NSP (75%, both combined termed “full HR”) and ART (81% with 90% virally suppressed) from 2019, reducing sexual HIV transmission by 50%, and/or HCV‐treating 10% of PWID infected with HCV annually. Results The model projects HIV and HCV prevalence of 19.0% (95% credibility interval: 16.4–21.2%) and 41.0% (24.4–49.0%) in 2019, respectively. For HIV, 24.6% (13.6–32.6%) and 70.3% (59.3–77.1%) of incident infections among male and female PWID are sexually transmitted, respectively. Due to their low coverage (22.8% for OAT, 16.3% for NSP in 2019), OAT and NSP averted 20.4% (12.9–24.7%) of HIV infections and 21.7% (17.0–25.2%) of HCV infections in 2019. Existing ART (68.5% coverage by 2019) averted 48.1% (29.7–64.3%) of HIV infections in 2019. Scaling up to full HR will reduce HIV and HCV incidence by 62.6% (52.5–74.0%) and 81.4% (56.7–81.4%), respectively, over 2019–2030; scaled up ART alongside full HR will decrease HIV incidence by 66.8% (55.6–77.5%), increasing to 81.5% (73.7–87.5%) when sexual risk is also reduced. HCV‐treatment alongside full HR will decrease HCV incidence by 92.4% (80.7–95.8%) by 2030. Conclusions Combination interventions, including sexual risk reduction and HCV treatment, are needed to eliminate HCV and HIV among PWID in Tanzania.
Collapse
Affiliation(s)
- Hannah Fraser
- Population HealthSciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jack Stone
- Population HealthSciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Veryeh Sambu
- National AIDS Control Programmes, Dar es Salaam, Tanzania
| | - Peter Mfisi
- The Drug Control and Enforcement Authority, Prime Ministers Office, Dar es Salaam, Tanzania
| | | | | | - Josephine G Walker
- Population HealthSciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nobelrich Makere
- Tanzania Council for Social Development (TACOSODE), Dar es Salaam, Tanzania
| | | | - William Kafura
- Tanzania Commission for AIDS (TACAIDS), Dar es Salaam, Tanzania
| | | | - Allan Ragi
- Kenya AIDS NGO Consortium, Nairobi, Kenya
| | | | - Peter Vickerman
- Population HealthSciences, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
3
|
Mafirakureva N, Lim AG, Khalid GG, Aslam K, Campbell L, Zahid H, Van den Bergh R, Falq G, Fortas C, Wailly Y, Auat R, Donchuk D, Loarec A, Coast J, Vickerman P, Walker JG. Cost-effectiveness of screening and treatment using direct-acting antivirals for chronic Hepatitis C virus in a primary care setting in Karachi, Pakistan. J Viral Hepat 2021; 28:268-278. [PMID: 33051950 PMCID: PMC7821258 DOI: 10.1111/jvh.13422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 09/07/2020] [Accepted: 09/28/2020] [Indexed: 12/13/2022]
Abstract
Despite the availability of effective direct-acting antiviral (DAA) treatments for Hepatitis C virus (HCV) infection, many people remain undiagnosed and untreated. We assessed the cost-effectiveness of a Médecins Sans Frontières (MSF) HCV screening and treatment programme within a primary health clinic in Karachi, Pakistan. A health state transition Markov model was developed to estimate the cost-effectiveness of the MSF programme. Programme cost and outcome data were analysed retrospectively. The incremental cost-effectiveness ratio (ICER) was calculated in terms of incremental cost (2016 US$) per disability-adjusted life year (DALY) averted from the provider's perspective over a lifetime horizon. The robustness of the model was evaluated using deterministic and probabilistic sensitivity analyses (PSA). The ICER for implementing testing and treatment compared to no programme was US$450/DALY averted, with 100% of PSA runs falling below the per capita Gross Domestic Product threshold for cost-effective interventions for Pakistan (US$1,422). The ICER increased to US$532/DALY averted assuming national HCV seroprevalence (5.5% versus 33% observed in the intervention). If the cost of liver disease care was included (adapted from resource use data from Cambodia which has similar GDP to Pakistan), the ICER dropped to US$148/DALY, while it became cost-saving if a recently negotiated reduced drug cost of $75/treatment course was assumed (versus $282 in base-case) in addition to cost of liver disease care. In conclusion, screening and DAA treatment for HCV infection are expected to be highly cost-effective in Pakistan, supporting the expansion of similar screening and treatment programmes across Pakistan.
Collapse
Affiliation(s)
| | - Aaron G. Lim
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | | | - Khawar Aslam
- Operational Center BrusselsMédecins Sans FrontièresIslamabadPakistan
| | - Linda Campbell
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Hassaan Zahid
- Operational Center BrusselsMédecins Sans FrontièresIslamabadPakistan
| | | | | | | | - Yves Wailly
- Operational Center BrusselsMédecins Sans FrontièresBrusselsBelgium
| | - Rosa Auat
- Operational Center BrusselsMédecins Sans FrontièresBrusselsBelgium
| | - Dmytro Donchuk
- Operational Center BrusselsMédecins Sans FrontièresBrusselsBelgium
| | | | - Joanna Coast
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Peter Vickerman
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK,NIHR Health Protection Research Unit in Behavioural Science and EvaluationUniversity of BristolBristolUK
| | - Josephine G. Walker
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| |
Collapse
|
4
|
Cepeda JA, Bórquez A, Magana C, Vo A, Rafful C, Rangel G, Medina‐Mora ME, Strathdee S, Martin NK. Modelling integrated antiretroviral treatment and harm reduction services on HIV and overdose among people who inject drugs in Tijuana, Mexico. J Int AIDS Soc 2020; 23 Suppl 1:e25493. [PMID: 32562375 PMCID: PMC7305416 DOI: 10.1002/jia2.25493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/02/2020] [Accepted: 03/31/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The HIV epidemic in Tijuana, Mexico is concentrated in key populations, including people who inject drugs (PWID). However, HIV interventions among PWID are minimal, and federal funding was provided for compulsory abstinence programmes associated with HIV and overdose. Alternatively, opioid agonist therapy reduces overdose, reincarceration, HIV, while improving antiretroviral therapy (ART) outcomes. We assessed potential impact and synergies of scaled-up integrated ART and opioid agonist therapy, compared to scale-up of each separately, and potential harms of compulsory abstinence programmes on HIV and fatal overdose among PWID in Tijuana. METHODS We developed a dynamic model of HIV transmission and overdose among PWID in Tijuana. We simulated scale-up of opioid agonist therapy from zero to 40% coverage among PWID. We evaluated synergistic benefits of an integrated harm reduction and ART scale-up strategy (40% opioid agonist therapy coverage and 10-fold ART recruitment), compared to scale-up of each intervention alone or no scale-up of low coverage ART and no harm reduction). We additionally simulated compulsory abstinence programmes (associated with 14% higher risk of receptive syringe sharing and 76% higher odds of overdose) among PWID. RESULTS Without intervention, HIV incidence among PWID could increase from 0.72 per 100 person-years (PY) in 2020 to 0.92 per 100 PY in 2030. Over ten years, opioid agonist therapy scale-up could avert 31% (95% uncertainty interval (UI): 18%, 46%) and 22% (95% UI: 10%, 28%) new HIV infections and fatal overdoses, respectively, with the majority of HIV impact from the direct effect on HIV transmission due to low ART coverage. Integrating opioid agonist therapy and ART scale-up provided synergistic benefits, with opioid agonist therapy effects on ART recruitment/retention averting 9% more new infections compared to ART scale-up alone. The intervention strategy could avert 48% (95% UI: 26%, 68%) of new HIV infections and one-fifth of fatal overdoses over ten years. Conversely, compulsory abstinence programmes could increase HIV and overdoses. CONCLUSIONS Integrating ART with opioid agonist therapy could provide synergistic benefits and prevent HIV and overdoses among PWID in Tijuana, whereas compulsory abstinence programmes could cause harm. Policymakers should consider the benefits of integrating harm reduction and HIV services for PWID.
Collapse
Affiliation(s)
- Javier A Cepeda
- Division of Infectious Diseases and Global Public HealthUniversity of California San DiegoSan DiegoCAUSA
| | - Annick Bórquez
- Division of Infectious Diseases and Global Public HealthUniversity of California San DiegoSan DiegoCAUSA
| | - Christopher Magana
- Division of Infectious Diseases and Global Public HealthUniversity of California San DiegoSan DiegoCAUSA
| | - Anh Vo
- Division of Infectious Diseases and Global Public HealthUniversity of California San DiegoSan DiegoCAUSA
| | - Claudia Rafful
- Faculty of PsychologyUniversidad Nacional Autonoma de MexicoMexico CityMexico
- Center on Global Mental Health ResearchNational Institute on Psychiatry Ramón de la Fuente MuñizMexico CityMexico
- Centre on Drug Policy EvaluationSt. Michael’s HospitalTorontoCanada
| | - Gudelia Rangel
- Comisión de Salud Fronteriza México‐Estados UnidosTijuanaMexico
- El Colegio de la Frontera NorteTijuanaMexico
| | - María E Medina‐Mora
- Center on Global Mental Health ResearchNational Institute on Psychiatry Ramón de la Fuente MuñizMexico CityMexico
| | - Steffanie Strathdee
- Division of Infectious Diseases and Global Public HealthUniversity of California San DiegoSan DiegoCAUSA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public HealthUniversity of California San DiegoSan DiegoCAUSA
- Population Health SciencesUniversity of BristolBristolUnited Kingdom
| |
Collapse
|
5
|
Ickowicz S, Dong H, Ti L, Nolan S, Fairbairn N, Barrios R, Milloy MJ. Behavioural, social and structural-level risk factors for developing AIDS among HIV-positive people who use injection drugs in a Canadian setting, 1996-2017. AIDS Care 2020; 32:1262-1267. [PMID: 32476442 DOI: 10.1080/09540121.2020.1772955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
People who use injection drugs (PWID) experience high rates of HIV acquisition and, as a result of lower rates of optimal access and adherence to combination antiretroviral therapy (ART), experience worse HIV treatment outcomes than other key affected populations. However, the incidence and risk factors for the development of AIDS among HIV-positive PWID have not been completely described. We used data from a community-recruited prospective cohort of HIV-positive PWID in Vancouver, Canada, a setting with universal no-cost ART and a comprehensive clinical monitoring registry. We used multivariable extended Cox models to identify factors associated with time to AIDS. Between 1996 and 2017, 396 participants, including 140 (35.4%) women, were followed for a median of 39.0 months (interquartile range: 16.6-76.2), among whom 165 (41.7%) developed AIDS. In a multivariable model, homelessness (Adjusted Hazard Ratio [AHR] = 1.76 (1.18-2.61)) and injection drug use within the preceding six months (AHR = 1.74 (1.17-2.58)) were independently associated with a higher risk of developing AIDS. Despite widespread scale-up of programmes to improve ART utilization, significant risk factors for the development of AIDS remain among HIV-positive PWID in this setting.
Collapse
Affiliation(s)
- S Ickowicz
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada
| | - H Dong
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada
| | - L Ti
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| | - S Nolan
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| | - N Fairbairn
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| | - R Barrios
- BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada.,Faculty of Medicine, School of Population and Public Health, Vancouver, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| |
Collapse
|
6
|
Lum N, Wai KT, Thar AMC, Show KL, Harries AD, Wann NMA, Hone S, Oo HN. HIV testing and ART initiation in people who inject drugs and are placed on methadone in Kachin State, Myanmar. Public Health Action 2020; 10:27-32. [PMID: 32368521 DOI: 10.5588/pha.19.0063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/07/2020] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- N Lum
- National AIDS Programme, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - K T Wai
- Department of Medical Research, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - A M C Thar
- Expanded Programme on Immunization, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - K L Show
- Department of Medical Research, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France.,London School of Hygiene & Tropical Medicine, London, UK
| | - N M A Wann
- Department of Medical Services, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - S Hone
- National AIDS Programme, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - H N Oo
- National AIDS Programme, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| |
Collapse
|
7
|
Using Contact Patterns to Inform HIV Interventions in Persons Who Inject Drugs in Northern Vietnam. J Acquir Immune Defic Syndr 2019; 78:1-8. [PMID: 29389769 DOI: 10.1097/qai.0000000000001632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Population mixing patterns can greatly inform allocation of HIV prevention interventions such as treatment as prevention or preexposure prophylaxis. Characterizing contact patterns among subgroups can help identify the specific combinations of contact expected to result in the greatest number of new infections. SETTING Baseline data from an intervention to reduce HIV-related risk behaviors in male persons who inject drugs (PWID) in the Northern Vietnamese province of Thai Nguyen were used for the analysis. METHODS Egocentric network data were provided by PWID who reported any drug-injection equipment sharing in the previous 3 months. Age-dependent mixing was assessed to explore its epidemiological implications on risk of HIV transmission risk (among those HIV-infected) and HIV acquisition risk (among those not infected) in PWID. RESULTS A total of 1139 PWID collectively reported 2070 equipment-sharing partnerships in the previous 3 months. Mixing by age identified the 30-34 and 35-39 years age groups as the groups from whom the largest number of new infections was transmitted, making them primary targets for treatment as prevention. Among the uninfected, 25-29, 30-35, and 35-39 years age groups had the highest HIV acquisition rate, making them the primary targets for preexposure prophylaxis. CONCLUSIONS Collection and analysis of contact patterns in PWID is feasible and can greatly inform infectious disease dynamics and targeting of appropriate interventions. Results presented also provide much needed empirical data on mixing to improve mathematical models of disease transmission in this population.
Collapse
|
8
|
Depressive Symptoms at HIV Testing and Two-Year All-Cause Mortality Among Men Who Inject Drugs in Vietnam. AIDS Behav 2019; 23:609-616. [PMID: 30357641 DOI: 10.1007/s10461-018-2318-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
People who inject drugs (PWID) with HIV experience an elevated risk of death. A potentially important determinant of survival is the high burden of depression. This study examined the relationship of depressive symptoms at HIV testing with 2-year all-cause mortality among newly diagnosed HIV-positive PWID in Vietnam. At HIV testing, 141 PWID (42%) experienced severe depressive symptoms, and over the 2 years following diagnosis, 82 PWID (24%) died. Controlling for potential confounders, the 2-year risk of death among those with depressive symptoms was 9.7% (95% CI - 1.2, 20.6%) higher than the risk among those without depressive symptoms. This increased risk of mortality for PWID with depressive symptoms was relatively consistent throughout the 2-year period: at 6, 12, and 18 months, the risk difference was 12.6% (5.5-19.7%), 13.9% (4.6-23.2%), and 11.0% (0.9-21.1%), respectively. HIV diagnosis may provide an important opportunity for depression screening and treatment, subsequently improving survival in this key population.Trial registry: ClinicalTrials.gov NCT01689545.
Collapse
|
9
|
Fraser H, Mukandavire C, Martin NK, Goldberg D, Palmateer N, Munro A, Taylor A, Hickman M, Hutchinson S, Vickerman P. Modelling the impact of a national scale-up of interventions on hepatitis C virus transmission among people who inject drugs in Scotland. Addiction 2018; 113:2118-2131. [PMID: 29781207 PMCID: PMC6250951 DOI: 10.1111/add.14267] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/02/2017] [Accepted: 05/04/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS To reduce hepatitis C virus (HCV) transmission among people who inject drugs (PWID), Scottish Government-funded national strategies, launched in 2008, promoted scaling-up opioid substitution therapy (OST) and needle and syringe provision (NSP), with some increases in HCV treatment. We test whether observed decreases in HCV incidence post-2008 can be attributed to this intervention scale-up. DESIGN A dynamic HCV transmission model among PWID incorporating intervention scale-up and observed decreases in behavioural risk, calibrated to Scottish HCV prevalence and incidence data for 2008/09. SETTING Scotland, UK. PARTICIPANTS PWID. MEASUREMENTS Model projections from 2008 to 2015 were compared with data to test whether they were consistent with observed decreases in HCV incidence among PWID while incorporating the observed intervention scale-up, and to determine the impact of scaling-up interventions on incidence. FINDINGS Without fitting to epidemiological data post-2008/09, the model incorporating observed intervention scale-up agreed with observed decreases in HCV incidence among PWID between 2008 and 2015, suggesting that HCV incidence decreased by 61.3% [95% credibility interval (CrI) = 45.1-75.3%] from 14.2/100 person-years (py) (9.0-20.7) to 5.5/100 py (2.9-9.2). On average, each model fit lay within 84% (10.1/12) of the confidence bounds for the 12 incidence data points against which the model was compared. We estimate that scale-up of interventions (OST + NSP + HCV treatment) and decreases in high-risk behaviour from 2008 to 2015 resulted in a 33.9% (23.8-44.6%) decrease in incidence, with the remainder [27.4% (17.6-37.0%)] explained by historical changes in OST + NSP coverage and risk pre-2008. Projections suggest that scaling-up of all interventions post-2008 averted 1492 (657-2646) infections over 7 years, with 1016 (308-1996), 404 (150-836) and 72 (27-137) due to scale-up of OST + NSP, decreases in high-risk behaviour and HCV treatment, respectively. CONCLUSIONS Most of the decline in hepatitis C virus (HCV) incidence in Scotland between 2008 and 2015 appears to be attributable to intervention scale-up (opioid substitution therapy and needle and syringe provision) due to government strategies on HCV and drugs.
Collapse
Affiliation(s)
- H Fraser
- University of Bristol, Bristol, UK
| | | | - NK Martin
- University of Bristol, Bristol, UK,University of California, San Diego, USA
| | | | | | - A Munro
- University of the West of Scotland, Paisley, UK
| | - A Taylor
- University of the West of Scotland, Paisley, UK
| | | | - S Hutchinson
- Glasgow Caledonian University, Glasgow, UK,Health Protection Scotland, Glasgow, UK
| | | |
Collapse
|
10
|
Hickman M, Steer C, Tilling K, Lim AG, Marsden J, Millar T, Strang J, Telfer M, Vickerman P, Macleod J. The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom. Addiction 2018; 113:1461-1476. [PMID: 29672985 PMCID: PMC6282737 DOI: 10.1111/add.14188] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/28/2017] [Accepted: 02/05/2018] [Indexed: 01/18/2023]
Abstract
AIMS To estimate whether opioid substitution treatment (OST) with buprenorphine or methadone is associated with a greater reduction in the risk of all-cause mortality (ACM) and opioid drug-related poisoning (DRP) mortality. DESIGN Cohort study with linkage between clinical records from Clinical Practice Research Datalink and mortality register. SETTING UK primary care. PARTICIPANTS A total of 11 033 opioid-dependent patients who received OST from 1998 to 2014, followed-up for 30 410 person-years. MEASUREMENTS Exposure to methadone (17 373, 61%) OST episodes or buprenorphine (9173, 39%) OST episodes. ACM was available for all patients; information on cause of death and DRP was available for 5935 patients (54%) followed-up for 16 363 person-years. Poisson regression modelled mortality by treatment period with an interaction between OST type and treatment period (first 4 weeks on OST, rest of time off OST, first 4 weeks off OST, rest of time out of OST censored at 12 months) to test whether ACM or DRP differed between methadone and buprenorphine. Inverse probability weights were included to adjust for confounding and balance characteristics of patients prescribed methadone or buprenorphine. FINDINGS ACM and DRP rates were 1.93 and 0.53 per 100 person-years, respectively. DRP was elevated during the first 4 weeks of OST [incidence rate ratio (IRR) = 1.93 95% confidence interval (CI) = 0.97-3.82], the first 4 weeks off OST (IRR = 8.15, 95% CI = 5.45-12.19) and the rest of time out of OST (IRR = 2.13, 95% CI = 1.47-3.09) compared with mortality risk from 4 weeks to end of treatment. Patients on buprenorphine compared with methadone had lower ACM rates in each treatment period. After adjustment, there was evidence of a lower DRP risk for patients on buprenorphine compared with methadone at treatment initiation (IRR = 0.08, 95% CI = 0.01-0.48) and rest of time on treatment (IRR = 0.37, 95% CI = 0.17-0.79). Treatment duration (mean and median) was shorter on buprenorphine than methadone (173 and 40 versus 363 and 111, respectively). Model estimates suggest that there was a low probability that methadone or buprenorphine reduced the number of DRP in the population: 28 and 21%, respectively. CONCLUSIONS In UK general medical practice, opioid substitution treatment with buprenorphine is associated with a lower risk of all-cause and drug-related poisoning mortality than methadone. In the population, buprenorphine is unlikely to give greater overall protection because of the relatively shorter duration of treatment.
Collapse
Affiliation(s)
- Matthew Hickman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Colin Steer
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Aaron G. Lim
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - John Marsden
- Addictions Department, Institute of Psychiatry, Psychiatry and NeuroscienceKing's College LondonLondonUK
| | - Tim Millar
- Centre for Mental Health and Safety, School of Health SciencesThe University of ManchesterManchesterUK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychiatry and NeuroscienceKing's College LondonLondonUK
| | | | - Peter Vickerman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - John Macleod
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| |
Collapse
|
11
|
Hoang T, Nguyen H, Shiraishi RW, Nguyen M, Bingham T, Nguyen D, Nguyen T, Duong H, Lyss S, Tran H. Factors associated with concurrent heroin use among patients on methadone maintenance treatment in Vietnam: A 24-month retrospective analysis of a nationally representative sample. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 55:113-120. [PMID: 29550740 DOI: 10.1016/j.drugpo.2018.02.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 02/02/2018] [Accepted: 02/16/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Methadone maintenance treatment (MMT) is highly effective for reducing heroin use and HIV transmission among people who inject opioids. We sought to measure and understand factors associated with continued heroin use, a critical factor affecting treatment outcome among MMT patients in Vietnam. METHOD We collected data from medical charts of a nationally representative sample of patients who were on MMT from May 2008 to December 2013. We selected 10 MMT clinics using probability proportional to size and 50 patients/clinic by systematic random sampling. Concurrent heroin use was defined by self-report/positive urine test recorded in patient charts during month 3, 6, 12, and 24 after MMT initiation. We used multivariable logistic regression to identify factors associated with concurrent heroin use over the first 24 months in treatment. FINDINGS All clients used heroin at baseline; concurrent heroin use was 55% at month 3; 19%, 14.6% and 15.2% at month 6, 12, and 24, respectively. Having no family emotional/financial support at baseline versus having this support (AOR = 2.03; 95% confidence interval [CI] = 1.17-3.53); using heroin for <15 years versus ≥15 years at baseline (AOR = 1.55; 95% CI = 1.01-2.38); being HIV-infected/not on antiretroviral treatment (ART; AOR = 1.79; 95% CI = 1.07-2.98) or being HIV infected/on ART (AOR = 2.39; 95% CI = 1.61-3.55), versus not being HIV infected; baseline methamphetamine use versus non-use (AOR = 2.68; 95% CI = 1.08-6.65), were associated with increased odds of concurrent heroin use among patients. CONCLUSION The association between concurrent heroin use among MMT patients and lack of family emotional/financial support, highlights the critical importance of these types of support for successful treatment. Association with shorter heroin use history suggests motivational enhancement may reduce concurrent heroin use. Living with HIV, whether on ART or not, is associated with increased concurrent heroin use and suggests safe injection commodities and education, and drug-drug interaction management, are needed for this subgroup. Though few MMT clients reported baseline methamphetamine use, its association with later heroin use suggests the need for effective methamphetamine use interventions.
Collapse
Affiliation(s)
- Thai Hoang
- Centers for Diseases Control and Prevention, Division of Global HIV and TB, Atlanta, USA.
| | - Hong Nguyen
- Centers for Diseases Control and Prevention, Division of Global HIV and TB, Atlanta, USA
| | - Ray W Shiraishi
- Centers for Diseases Control and Prevention, Division of Global HIV and TB, USA
| | - Mai Nguyen
- Vietnam Administration of HIV/AIDS Control, Viet Nam
| | - Trista Bingham
- Centers for Diseases Control and Prevention, Division of Global HIV and TB, USA
| | - Diep Nguyen
- Vietnam Administration of HIV/AIDS Control, Viet Nam
| | - Tam Nguyen
- Vietnam Administration of HIV/AIDS Control, Viet Nam
| | - Hao Duong
- Centers for Diseases Control and Prevention, Division of Global HIV and TB, Atlanta, USA; The Partnership for Health Advancement in Vietnam (HAIVN), Viet Nam
| | - Sheryl Lyss
- Centers for Diseases Control and Prevention, Division of Global HIV and TB, Atlanta, USA
| | - Hien Tran
- Vietnam Administration of HIV/AIDS Control, Viet Nam
| |
Collapse
|
12
|
Kumi Smith M, Jewell BL, Hallett TB, Cohen MS. Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1075:125-162. [PMID: 30030792 DOI: 10.1007/978-981-13-0484-2_6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.
Collapse
Affiliation(s)
- M Kumi Smith
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | | | | | - Myron S Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
13
|
Nosyk B, Zang X, Min JE, Krebs E, Lima VD, Milloy MJ, Shoveller J, Barrios R, Harrigan PR, Kerr T, Wood E, Montaner JSG. Relative effects of antiretroviral therapy and harm reduction initiatives on HIV incidence in British Columbia, Canada, 1996-2013: a modelling study. Lancet HIV 2017; 4:e303-e310. [PMID: 28366707 PMCID: PMC5494273 DOI: 10.1016/s2352-3018(17)30045-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 01/16/2017] [Accepted: 01/20/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) and harm reduction services have been cited as key contributors to control of HIV epidemics; however, the specific contribution of ART has been questioned due to uncertainty of its true efficacy on HIV transmission through needle sharing. We aimed to isolate the independent effects of harm reduction services (opioid agonist treatment uptake and needle distribution volumes) and ART on HIV transmission via needle sharing in British Columbia, Canada, from 1996 to 2013. METHODS We used comprehensive linked individual health administrative and registry data for the population of diagnosed people living with HIV in British Columbia to populate a dynamic, compartmental transmission model to simulate the HIV/AIDS epidemic in British Columbia from 1996 to 2013. We estimated HIV incidence, mortality, and quality-adjusted life-years (QALYs). We also estimated scenarios designed to isolate the independent effects of harm reduction services and ART, assuming 50% (10-90%) efficacy, in reducing HIV incidence through needle sharing, and we investigated structural and parameter uncertainty. FINDINGS We estimate that 3204 (upper bound-lower bound 2402-4589) incident HIV cases were averted between 1996 and 2013 as a result of the combined effect of the expansion of harm reduction services and ART coverage on HIV transmission via needle sharing. In a hypothetical scenario assuming ART had zero effect on transmission through needle sharing, we estimated harm reduction services alone would have accounted for 77% (upper bound-lower bound 62-95%) of averted HIV incidence. In a separate hypothetical scenario where harm reduction services remained at 1996 levels, we estimated ART alone would have accounted for 44% (10-67%) of averted HIV incidence. As a result of high distribution volumes, needle distribution predominantly accounted for incidence reductions attributable to harm reduction but opioid agonist treatment provided substantially greater QALY gains. INTERPRETATION If the true efficacy of ART in preventing HIV transmission through needle sharing is closer to its efficacy in sexual transmission, ART's effect on incident cases averted could be greater than that of harm reduction. Nonetheless, harm reduction services had a vital role in reducing HIV incidence in British Columbia, and should be viewed as essential and cost-effective tools in combination implementation strategies to reduce the public health and economic burden of HIV/AIDS. FUNDING BC Ministry of Health; National Institutes of Health (R01DA041747); Genome Canada (142HIV).
Collapse
Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
| | - Xiao Zang
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
| | - Viviane D Lima
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - M-J Milloy
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jean Shoveller
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Rolando Barrios
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - P Richard Harrigan
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kerr
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Evan Wood
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|