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IAS 2015: Opioid Substitution Therapy Combined with HIV Treatment Saves More Lives

Providing opioid substitution therapy (OST) along with antiretroviral therapy (ART) to people who inject drugs results in a significantly greater reduction in deaths compared to providing either intervention alone, according to a study by Bohdan Nosyk and colleagues from the University of British Columbia Centre of Excellence in HIV/AIDS at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention this week in Vancouver. Research from Ukraine, also presented at the conference, showed that people receiving opioid substitution therapy had better engagement with HIV care.

[Produced in collaboration with Aidsmap.com]

Opioid substitution therapy is recommended by the World Health Organization as a core element of the harm reduction and care package that should be provided for people who inject drugs after diagnosis with HIV infection. However, there are big variations worldwide in access to opioid substitution therapy for people living with HIV who inject drugs: a 21-country survey, published in 2013, found average coverage of just 3% for this population.

Opioid substitution is resisted in many countries because of the belief that heroin addiction can only be managed by abstinence. Methadone substitution is illegal in the Russian Federation, one of the countries with the most severe epidemic of HIV in people who inject drugs, and Russian attitudes towards methadone are so hardened that OST programs in Crimea were halted following Russian occupation of the region in 2014, Michel Kazatchkine, UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia, told a plenary session at the conference.

Nora Volkow, director of the U.S. National Institute on Drug Abuse, told an IAS 2015 press conference that opioid substitution therapy "is a win-win for prevention and a win-win for treatment, but there are too many places where it’s not happening...I don't know of any other area of medicine where despite the evidence that the intervention works, someone says 'we’re not going to do that because I think that that is not right'."

Opioid substitution therapy may be provided in the form of daily methadone or buprenorphine, and an extended-release buprenorphine implant is being tested with the aim of winning U.S. Food and Drug Administration approval.

OST has the potential to minimize drug-related harm by reducing the risk of drug overdose, reducing exposure to injection-related bacterial infections and hepatitis C, stabilizing drug users in order to address other health issues and allow comprehensive treatment of drug misuse. By reducing or eliminating dependency on heroin, OST reduces illicit drug consumption and has the potential to reduce the criminalization of drug users.

British Columbia

Nosyk and colleagues used data from the British Columbia HIV cohort database to examine the effects of opioid substitution therapy, antiretroviral therapy, or both on mortality in people who inject drugs receiving HIV care between 1996 and 2010 in the province.

The cohort comprised 1727 people who inject drugs, of whom 28.5% died during a median follow-up period of 5.1 years (9913 person-years of follow-up). In the majority of cases the cause of death was HIV-related (55%), but 18% died as a result of drug use, and the remainder of other causes.

The analysis found that although exposure to OST reduced the risk of HIV-related death by 80%, it did not significantly reduce the risk of death due to drug use in most statistical analyses.

In contrast, antiretroviral therapy independently reduced the risk of HIV-related death and death due to drug use, while receipt of both ART and opioid substitution had the greatest impact on mortality, reducing the risk of death by between 86% and 94%. People receiving both interventions were between one-half and one-third as likely to die as people receiving antiretroviral treatment alone.

OST in Ukraine

Research conducted in Ukraine shows that injection drug users who received OST were more likely to be engaged in HIV care, more likely to receive CD4 T-cell tests, and more likely to receive antiretroviral therapy.

The cross-sectional study, conducted in 9 HIV clinics in Ukraine in 2010, randomly sampled 296 HIV-positive people who were classified as opioid dependent. 65% were receiving opioid substitution therapy. Those receiving OST were significantly more likely to have hepatitis C. Those on OST had a significantly larger number of years of injection drug use (12.8 years vs 8.6 years) and had spent longer in prison, on average (4 years vs 1.5 years). However, the 2 groups had a similar average duration since HIV diagnosis (5 years).

Opioid substitution therapy was associated with fewer reports of injecting in the previous 30 days and a lower number of injections if injecting occurred, significantly lower use of stimulants or multiple drugs, and vastly lower expenditure on drugs in the previous month ($10 vs $397 for those who did not receive OST).

Opioid substitution was also associated with a significantly smaller number of visits to an emergency room in the previous 6 months, fewer HIV-related symptoms, better quality of life scores, and better self-evaluation of mental and physical health.

Among those receiving clinical care, receipt of OST was associated with more recent CD4 testing, more recent testing for tuberculosis, and higher uptake of ART (although this association was not statistically significant; p=0.08).

7/23/15

Reference

B Nosyk, JE Min, E Evans, et al. The effects of opioid substitution treatment and highly active antiretroviral therapy on the cause-specific risk of mortality among injection drug using people living with HIV/AIDS. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract MOPDD0102.

C Bachireddy, J Izenberg, S Soule, et al. The effect of opiate substitution therapy on healthcare utilization and engagement among HIV-infected people who inject drugs in Ukraine. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract MOPDD0101.