Tackling HIV, Hep C and Opioid abuse

There are considerable gaps in HIV and HCV prevention and care testing, linkage, and retention of patients with OUD.

For high-risk people, especially those with a history of IDU use, the CDC recommends routine HIV and HCV testing. Point-of-care fast testing for HIV and HCV was approved by the FDA in 2002 and 2010, respectively, and testing expenses are reimbursed under the Affordable Care Act. By identifying patients (possibly at an earlier disease stage) and facilitating earlier treatment commencement, testing addresses the first step in the HIV and HCV treatment care cascades (Yehia et al., 2014). Despite their heightened risk, HIV and HCV testing rates among U.S. opiate users have decreased in recent years (D' Aunno et al., 2014).

Testing for HIV and HCV is uncommon in substance abuse treatment settings, with an estimated 34-68 percent of people ignorant of their HCV and HIV status (Du et al., 2012; Ng et al., 2013). Poor HIV and HCV testing uptake has been attributed to structural constraints (e.g., availability, cost) (Kyle et al., 2015; Deblonde et al., 2010; Downing et al., 2001). Recent findings from our research group reveal that, particularly among people with OUD, considerable gaps remain in HIV and HCV testing, linkage and retention in HIV and HCV care, and accomplishment of prolonged virologic suppression. For example, 65.1 percent of people with OUD who were receiving addiction treatment (N=202) said they had not been tested for HCV in the previous year (Brown et al., 2017). 42.7 percent of those with a lifetime HCV testing history said they had been notified they had HCV (n=67/157), with 21.7 percent (n=14/67) saying they had chronic HCV and 10/14 saying they had received HCV therapy (Brown et al., 2017).

There is also evidence that some people with OUD will decline HCV and/or HIV testing if it is provided to them. While exact testing refusal rates for people in drug abuse treatment are unknown, one study in an outpatient clinic revealed that 34% of people declined HCV antibody testing (Grando-Lemaire et al., 2002). In addition, just 30% of people in a sample of five substance abuse clinics that offer free, on-site HIV fast testing were tested in the previous year (Kyle et al., 2015). Poor HCV and HIV testing uptake has been linked to both structural (e.g., availability, cost) and individual-level factors (e.g., testing knowledge, motivation) (Kyle et al., 2015; Deblonde et al., 2010). Three key testing barriers were identified in a systematic analysis of testing barriers among people who inject drugs: (a) a lack of routine testing services; (b) poor knowledge about testing and treatment; and (c) low perceived risk or low motivation for testing (Jones et al., 2014). Enhancing availability to free testing overcomes one key obstacle to testing uptake, but it does not address core individual-level hurdles like insufficient knowledge or poor enthusiasm for testing, as this review and other studies show. As a result, there is a need to create interventions to promote understanding and motivation for HCV and HIV testing among people with OUD, particularly among those with an IDU history.

According to the National HIV guidelines in the United States, 90 percent of all people should be diagnosed for HIV, 90 percent should receive HIV treatment, and 90 percent should be virologically suppressed using antiretroviral (ARV) drugs (Government, U.S., 2010). Only 79 percent of HIV-infected people in the United States are aware of their serostatus, according to one study, with 59 percent linked to care, 40 percent retained in care, 24 percent administered ARVs, and 19 percent virally suppressed (Gardner et al., 2011). While prolonged viral suppression is an effective method for reducing infectivity (Mugavero et al., 2012), linkage and retention in HIV and HCV care are frequently poor (Gardner et al., 2011; Mugavero et al., 2013), with reduced retention in care among those who use illegal drugs (Mugavero et al., 2013). Indeed, recent meta-analyses of HIV and HCV care cascades have found considerable gaps in the care continuums from first testing to confirmatory testing, linkage to care, medication initiation, and optimal virologic response, particularly among opiate users (Yehia et al., 2014; Mugavero et al., 2013).

Despite efforts to identify patients who are HIV-infected or at risk for HIV, people with OUD frequently have difficulty starting or continuing HIV and/or HCV treatment. Individuals who abuse opioids and/or engage in IDU may experience poorer HIV and HCV care linkage and retention following HIV/HCV testing and diagnosis (Yehia et al., 2015; Bamford, et al., 2010; Fleishman et al., 2012; Giordano et al., 2005). Efforts to link patients to HIV care after testing have had varying success rates (Rothman et al., 2012; Menon et al., 2016; Dombrowski, J. and R.G. Kinney, 2017). Existing interventions that link and/or keep people in substance abuse treatment and HIV/HCV preventive and care programs have largely been done in isolation, addressing only one point along the HIV or HCV care continuum. According to a recent assessment, interventions addressing the HIV care continuum have primarily concentrated on isolated sites along the care chain, with an emphasis on improving ARV adherence and a small number of treatments addressing linkage and retention in care (Risher et al., 2017). Furthermore, randomized controlled trials have been used in a small number of linkage-to-care strategies, emphasizing methodological flaws in the existing evidence (Risher et al., 2017). To increase HIV treatment linkage, retention, and re-engagement, patient navigation and case management approaches have been widely used (Udeagu et al., 2013). In New York City, for example, case managers used a stepwise approach (phone calls, letters, and home visits) to re-engage HIV-infected patients who had dropped out of HIV care (Udeagu et al., 2013). Antiretroviral Treatment and Access Study (ARTAS), a CDC-defined evidence-based intervention, also uses brief case management to empower and encourage self-efficacy, with proven success in linking HIV-infected patients to care (Craw et al., 2008). There have also been efforts to combine HIV and substance use treatment services, such as medication-assisted treatment (e.g., buprenorphine), in order to enhance HIV care outcomes among people with OUD (Altice et al., 2011; Sacks et al., 2011; Springer et al., 2012). While there is evidence that providing treatment services within the same healthcare system improves linkage to treatment (Yehia et al., 2015), there is a need for a more coordinated, multi-faceted approach to improving substance use, HIV, and HCV outcomes among people with OUD that can be more seamlessly integrated into clinical care.

To summarize, the opioid epidemic in the United States is a public health catastrophe that increases the risk of HIV and HCV acquisition and transmission. Individuals with OUD require comprehensive intervention techniques that target the entire HIV and HCV continuum of care. To proactively address inequities experienced by individuals with OUD accessing and getting HIV and HCV prevention and treatment services, novel public health initiatives that address the convergence of opioid use, injectable drug use, HIV, and HCV are urgently needed.