Integrated Intervention Improves Care of HIV-Infected People Who Inject Drugs

By Will Boggs MD

NEW YORK (Reuters Health) - An intervention focusing on systems navigation, psychosocial counseling and antiretroviral therapy (ART) at any CD4 count improves outcomes among HIV-infected people who inject drugs (PWID), according to a feasibility and efficacy study.

"I think it shows a combination of effects, really," Dr. William C. Miller from The Ohio State University, in Columbus, told Reuters Health by email. "First, the impact of getting people started on ART, which can have a dramatic effect on HIV-related mortality. But I think it also reflects the beneficial life effects from engaging and supporting PWID. Perhaps the most surprising result is the reduction of mortality among the HIV-uninfected PWID partners."

PWID have low rates of HIV testing, insufficient access to and use of HIV prevention services and HIV care, poor access to treatment for substance misuse and harm-reduction services, and persistent social barriers.

Dr. Miller's and colleagues in the HIV Prevention Trials Network 074 study assessed the feasibility and effects of a flexible, integrated intervention to facilitate the initiation of ART and medication-assisted treatment (MAT) with the ultimate goal of reducing HIV transmission from HIV-infected PWID to their injection partners who are not infected.

The randomized, controlled trial enrolled 504 HIV-infected PWID and included 806 of their partners in the analysis. At baseline, 80% of PWID were ART naive and 22% reported current MAT use.

Most participants in the intervention group completed their initial meeting (123/126, 98%), their first psychosocial counseling session (99%) and at least two more counseling sessions within 60 days of enrollment (83%).

At week 52, 72% of the intervention group reported ART use (versus 43% of the standard of care group, a significant difference) and 41% of the intervention group reported MAT use (versus 25% of the standard of care group, also a significant difference).

Injection partners also reported higher MAT use (34% of intervention partners versus 26% of standard of care partners), though this finding was only borderline significant.

Significantly more intervention participants (41%) than standard of care participants (24%) were virally suppressed at week 52.

No injection partners in the intervention group acquired HIV infection, compared to seven partners in the standard of care group (1.0 case per 100 person-years), the researchers report in the September 1 issue of The Lancet.

Mortality was 53% lower in the intervention group (5.6 deaths per 100 person-years) than in the standard of care group (12.1 deaths per 100 person-years), a significant difference. Moreover, mortality was significantly lower among injection partners in the intervention group (0.46 deaths per 100 person-years) than among partners in the standard of care group (2.6 deaths per 100 person-years).

"This study is most directly relevant to places with a significant PWID-related HIV epidemic," Dr. Miller said. "That would primarily be Central Asia, Southeast Asia and Eastern Europe. That being said, I think the study is instructive for the U.S. and Europe as well. PWID need help. Give them that help and they can often do better."

"The intervention in this study does not require anyone with a physician-level of education and training," he said. "It's the people around the physicians that are really important for this intervention. Can you give the PWID an opportunity to engage with you? Can you facilitate their care? They will take their medications if they understand why it is important. Support them, give them an opportunity (repeatedly if necessary), and you give them a lifeline."

As for feasibility, the researchers note, "Retention was acceptable at week 52, exceeding 80% in the surviving index participants and partners. Thus, following up a large cohort of PWID is feasible, but in our study HIV incidence was too low for an efficient HIV prevention trial among injection partners."

Dr. Mary Ellen Mackesy-Amiti from the University of Illinois at Chicago, who has also studied risk behaviors among PWID, told Reuters Health by email, "It's not enough to give someone who has been diagnosed with HIV a clinic referral; people often need a little more help to overcome barriers to engagement and retention in care. This is especially true for people with substance use disorders."

"I think (the intervention) is most likely to benefit systems that serve low-income/low-resource populations, whether urban or rural," said Dr. Mackesy-Amiti, who was not involved in the new study.

SOURCE: https://bit.ly/2CnNVRA

Lancet 2018.

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