Opioid Substitution Saves Lives of HIV-Positive Drug Users

The introduction of opioid agonist therapy — also known as methadone maintenance treatment — has led to a dramatic decrease in HIV- and drug-related mortality in HIV-positive injection drug users, researchers report.

“Our study adds to a growing body of evidence showing that access to opioid agonist therapy has positive downstream effects on HIV-related outcomes,” lead author Bohdan Nosyk, PhD, from the BC Centre for Excellence in HIV/AIDS in Vancouver, British Columbia, Canada, said in statement.

“These findings strongly suggest that opioid therapy is an essential component to improving HIV outcomes among people who inject drugs,” he added.

The study results were presented here at the 8th International AIDS Society (IAS) Conference.

Dr Nosyk and his team used a linked population-level administrative database to identify a cohort of injection drug users living with HIV in British Columbia from 1996 to 2010.

Study participants had a history of opioid substitution, indicated by methadone or buprenorphine dispensation records, or a history of injection drug use before HIV infection, indicated in the HIV testing database.

Of the 1727 people in the study cohort, 28.5% died during the median follow-up of 5.1 years — 18.7% from drug-related causes, 55.8% from HIV-related causes, and 25.6% from other causes.

Standardized mortality ratios were significantly lower when participants were receiving opioid agonist therapy than when they were not (12.2 vs 30.0).

Opioid agonist therapy reduced the risk for all-cause mortality (adjusted hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.23 - 0.49), as did highly active antiretroviral therapy (adjusted HR, 0.39; 95% CI, 0.31 - 0.48).

Together, opioid agonist therapy and antiretroviral therapy reduced all-cause mortality by 84%, Dr Nosyk reported.

Stabilizing the Lives of Drug Addicts

This study shows that these two interventions are helping stabilize the lives of injection drug users, said Julio Montaner, MD, from the BC Centre of Excellence for HIV/AIDS and the University of British Columbia in Vancouver.

“By stabilizing their addiction, you are really bringing order into their lives and allowing patients to benefit from HAART, which, these days, is completely doable,” Dr Montaner told Medscape Medical News.

“With many of the regimens now being given as one dose once a day — some even one pill once a day — and with much higher safety, efficacy, and tolerability profiles, we are able to achieve this very well,” he explained.

The Vancouver experience is a prime example of how the combination of harm-reduction strategies, addiction medicine strategies, and nonmedical supportive care can have a major impact on HIV transmission in injection drug users.

With these strategies, “we've been able to virtually eliminate HIV transmission in HIV-positive injection drug users — and a 95% reduction in HIV infection in this community is something to be celebrated,” Dr Montaner said.

People who use drugs are an important contributor to the HIV epidemic, said Nora Volkow, MD, from the US National Institute on Drug Abuse, who was the keynote speaker at the opening ceremony of IAS.

“Injection drug users can become a source of very rapid dissemination of HIV infection,” she told reporters attending a news conference.

For example, there has been a sharp increase in the number of people infected with HIV in Greece and other global “hotspots” because of an increase in injection drug use, Dr Volkow explained.

“This is tragic,” she added, because it has long been known that HIV infection can be prevented in injection drug users with needle exchange programs. Sadly, these programs are not being implemented in most places.

“Injection drug users are much less likely to be given treatment for HIV or substance use disorder because of the stigma of both,” said Dr Volkow. However, “not only is opioid agonist therapy useful in preventing HIV infection, treatment improves HIV-related outcomes because it improves adherence, so injection drug users are more likely to achieve viral suppression.”

At the heart of it all is a personal ideology that injection drug use is inherently wrong. “It's like saying to a patient who has an infection for which there is an antibiotic: 'I'm not going to give it to you because I don't think it's right',” she explained.

“Lives are being lost despite clear-cut evidence that our interventions work. If this stigmatization continues, it will interfere with our potential to use treatment as prevention for containing the HIV epidemic,” she said.

The BC Centre for Excellence in HIV/AIDS is supported by the National Institutes of Health, the National Institute for Drug Abuse, and the British Colombia Ministry of Health, which funded the Seek and Treat for Optimal Prevention of HIV/AIDS pilot project. Dr Nosyk, Dr Montaner, and Dr Volkow have disclosed no relevant financial relationships.

Pam Harrison reports.