Dataset Information

The Effects of Opioid Substitution Treatment and Highly Active Antiretroviral Therapy on the Cause-Specific Risk of Mortality Among HIV-Positive People Who Inject Drugs.

ABSTRACT:

Background

Prior studies indicated opioid substitution treatment (OST) reduces mortality risk and improves the odds of accessing highly active antiretroviral therapy (HAART); however, the relative effects of these treatments for human immunodeficiency virus (HIV)-positive people who inject drugs (PWID) are unclear. We determine the independent and joint effects of OST and HAART on mortality, by cause, within a population of HIV-positive PWID initiating HAART.

Methods

Using a linked population-level database for British Columbia, Canada, we used time-to-event analytic methods, including competing risks models, proportional hazards models with time-varying covariates, and marginal structural models, to identify the independent and joint effects of OST and HAART on all-cause as well as drug- and HIV-related mortality, controlling for covariates.

Results

Among 1727 HIV-positive PWID, 493 (28.5%) died during a median 5.1 years (interquartile range, 2.1-9.1) of follow-up: 18.7% due to drug-related causes, 55.8% due to HIV-related causes, and 25.6% due to other causes. Standardized mortality ratios were 12.2 (95% confidence interval [CI], 9.8, 15.0) during OST and 30.0 (27.1, 33.1) during periods out of OST. Both OST (adjusted hazard, 0.34; 95% CI, .23, .49) and HAART (0.39 [0.31, 0.48]) decreased the hazard of all-cause mortality; however, individuals were at lowest risk of death when these medications were used jointly (0.16 [0.10, 0.26]). Both OST and HAART independently protected against HIV-related death, drug-related death and death due to other causes.

Conclusions

While both OST and HAART are life-saving treatments, joint administration is urgently needed to protect against both drug- and HIV-related mortality.

SUBMITTER: Nosyk B

PROVIDER: S-EPMC4560909 | biostudies-literature | 2015 Oct

REPOSITORIES: biostudies-literature

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Publications

The Effects of Opioid Substitution Treatment and Highly Active Antiretroviral Therapy on the Cause-Specific Risk of Mortality Among HIV-Positive People Who Inject Drugs.

Nosyk Bohdan B Min Jeong E JE Evans Elizabeth E Li Libo L Liu Lei L Lima Viviane D VD Wood Evan E Montaner Julio S G JS

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 20150625 7

<h4>Background</h4>Prior studies indicated opioid substitution treatment (OST) reduces mortality risk and improves the odds of accessing highly active antiretroviral therapy (HAART); however, the relative effects of these treatments for human immunodeficiency virus (HIV)-positive people who inject drugs (PWID) are unclear. We determine the independent and joint effects of OST and HAART on mortality, by cause, within a population of HIV-positive PWID initiating HAART.<h4>Methods</h4>Using a linke ...[more]

PMID: 26113656

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Project description:BackgroundProvision of Anti-Retroviral Therapy (ART) and Opioid Substitution Therapy (OST) are important components of the targeted intervention (TI) programme for people who inject drugs (PWID). Homeless HIV positive PWIDs in Delhi is a key population experiencing gaps in uptake of these services, especially the ART uptake which is reportedly far from 90%, UNAIDS' 90-90-90 target to end the AIDS epidemic.ObjectiveTo assess the gaps and barriers in accessing the ART and OST services uptake among HIV positive homeless PWID in Delhi and to explore experiences and perspectives of the PWIDs and service providers.MethodologyWe used a convergent parallel mixed methods design which included a cross-sectional quantitative survey and a qualitative study. Two hundred thirty five homeless HIV positive PWID were interviewed and in-depth interviews were conducted with five PWIDs and nine health providers.ResultsWhile only 12% of PWIDs were on ART, 80% were availing OST services. The top individual, health system related and structural barriers for ART service access were insufficient and incorrect knowledge (63%), long waiting time (86%) and lack of family support (44%) respectively. Inconvenient timings, stringent registration requirements and negative attitude of health providers were expressed as major barriers of accessing ART services during the interviews while these were not a concern in OST services. Homelessness, poverty, stigma were common barriers for both services. Integrated, 'single window' service and provision of additional support like nutrition and shelter were suggested as measures to improve access by both health providers and the PWIDs themselves.ConclusionThere is an urgent need for structural and health systems changes to improve access to ART and OST services. These include integrated service delivery, flexibility in timing of the centers, accelerated ART initiation, simplification of bureaucratic procedures, nutritional and social support to all homeless HIV positive PWIDs.

Project description:BackgroundThe French Addictovigilance network has observed the existence of the intravenous use of oral morphine capsules among people suffering from opioid use disorders. According to persons who inject morphine, these capsules are easy to dissolve and then inject, giving them the image of an "injectable" opioid substitution treatment (OST). In France, validated OSTs are only available orally, so dissolving morphine capsules represents the only alternative for patients who are not sufficiently relieved by oral forms. This practice presents risks related to the potential persistence of particles of the oral galenic in the injectable solution, despite its filtration, but also risks-notably of overdose-related to the pharmacological effects of opioids and to variations of the quantities of morphine extracted during the dissolution of the capsules. We conducted an online survey among the people concerned to collect data on their needs and expectations regarding a possible injectable substitution.MethodAn anonymous online survey including all voluntary respondents residing in France and using oral morphine intravenously was conducted in partnership with the Psychoactif harm reduction organization, from 23/03/2020 to 01/04/2021.ResultsThe analysis of the 157 exploitable questionnaires showed that 41% of the respondents obtained their drugs only from illegal markets. The others received, regularly or occasionally, medical prescriptions, reimbursed in 84% of cases. For 78% of the respondents, injection was the most frequent route of morphine administration, with 3.8 ± 2 injections per day. 56% of the respondents were receiving an OST, on prescription (79%), monthly (86%), in addition to morphine. Skenan® capsules were the most frequently used (81%) and 47.2% of the respondents had already experienced injection-related complications. 95% of the respondents were in favor of experimenting with an injectable morphine substitution. Those who never received medical prescriptions were the youngest (< 25 years) respondents, they reported only occasional use of morphine, and always intravenously.ConclusionOral morphine capsules dissolved and injected intravenously are not a safe and sustainable injectable substitution. Respondents wish to be able to benefit from an injectable substitution with a formulation adapted to the intravenous route. The availability of an injectable substitution would facilitate harm reduction and entry into care for the people concerned, particularly the youngest who have never received morphine prescriptions.

Project description:AimsTo estimate the effects of needle and syringe programmes (NSP) and opioid substitution therapy (OST), alone or in combination, for preventing acquisition of hepatitis C virus (HCV) in people who inject drugs (PWID).MethodsSystematic review and meta-analysis. Bibliographic databases were searched for studies measuring concurrent exposure to current OST (within the last 6 months) and/or NSP and HCV incidence among PWID. High NSP coverage was defined as regular NSP attendance or ≥ 100% coverage (receiving sufficient or greater number of needles and syringes per reported injecting frequency). Studies were assessed using the Cochrane risk of bias in non-randomized studies tool. Random-effects models were used in meta-analysis.ResultsWe identified 28 studies (n = 6279) in North America (13), United Kingdom (five), Europe (four), Australia (five) and China (one). Studies were at moderate (two), serious (17) critical (seven) and non-assessable risk of bias (two). Current OST is associated with 50% [risk ratio (RR) =0.50, 95% confidence interval (CI) = 0.40-0.63] reduction in HCV acquisition risk, consistent across region and with low heterogeneity (I2 = 0, P = 0.889). Weaker evidence was found for high NSP coverage (RR = 0.79, 95% CI = 0.39-1.61) with high heterogeneity (I2 = 77%, P = 0.002). After stratifying by region, high NSP coverage in Europe was associated with a 56% reduction in HCV acquisition risk (RR = 0.44, 95% CI = 0.24-0.80) with low heterogeneity (I2 = 12.3%, P = 0.337), but not in North America (RR = 1.58, I2 = 89.5%, P = < 0.001). Combined OST/NSP is associated with a 74% reduction in HCV acquisition risk (RR = 0.26, 95% CI = 0.07-0.89, I2 = 80% P = 0.007). According to Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria, the evidence on OST and combined OST/NSP is low quality, while NSP is very low.ConclusionsOpioid substitution therapy reduces risk of hepatitis C acquisition and is strengthened in combination with needle and syringe programmes (NSP). There is weaker evidence for the impact of needle syringe programmes alone, although stronger evidence that high coverage is associated with reduced risk in Europe.

Project description:ObjectiveTo quantify the effect of opiate substitution treatment in relation to HIV transmission among people who inject drugs.DesignSystematic review and meta-analysis of prospective published and unpublished observational studies.Data sourcesSearch of Medline, Embase, PsychINFO, and the Cochrane Library from the earliest year to 2011 without language restriction.Review methodsWe selected studies that directly assessed the impact of opiate substitution treatment in relation to incidence of HIV and studies that assessed incidence of HIV in people who inject drugs and that might have collected data regarding exposure to opiate substitution treatment but not have reported it. Authors of these studies were contacted. Data were extracted by two reviewers and pooled in a meta-analysis with a random effects model.ResultsTwelve published studies that examined the impact of opiate substitution treatment on HIV transmission met criteria for inclusion, and unpublished data were obtained from three additional studies. All included studies examined methadone maintenance treatment. Data from nine of these studies could be pooled, including 819 incident HIV infections over 23,608 person years of follow-up. Opiate substitution treatment was associated with a 54% reduction in risk of HIV infection among people who inject drugs (rate ratio 0.46, 95% confidence interval 0.32 to 0.67; P<0.001). There was evidence of heterogeneity between studies (I(2)=60%, χ(2)=20.12, P=0.010), which could not be explained by geographical region, site of recruitment, or the provision of incentives. There was weak evidence for greater benefit associated with longer duration of exposure to opiate substitution treatment.ConclusionOpiate substitution treatment provided as maintenance therapy is associated with a reduction in the risk of HIV infection among people who inject drugs. These findings, however, could reflect comparatively high levels of motivation to change behaviour and reduce injecting risk behaviour among people who inject drugs who are receiving opiate substitution treatment.

Dataset Information

The Effects of Opioid Substitution Treatment and Highly Active Antiretroviral Therapy on the Cause-Specific Risk of Mortality Among HIV-Positive People Who Inject Drugs.

Background

Methods

Results

Conclusions

Publications

The Effects of Opioid Substitution Treatment and Highly Active Antiretroviral Therapy on the Cause-Specific Risk of Mortality Among HIV-Positive People Who Inject Drugs.

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