IAS 2015: HIV Treatment Scale-up Linked to Reduced Mortality Among Vancouver Drug Injectors

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HIV-related and all-cause death decreased significantly among people who inject drugs -- with similar declines for both women and men -- since the introduction of expanded access to antiretroviral therapy (ART) as part of a "treatment as prevention" initiative in Vancouver, researchers reported last month at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. These findings support recommendations to treat everyone with HIV, both to benefit their own health and to reduce transmission.

Early HIV treatment and biomedical prevention were key themes of the IAS conference. Data from the START trial showed that starting ART immediately after HIV diagnosis, rather than waiting for the CD4 T-cell count to drop, was associated with a 57% lower risk of AIDs-related and non-AIDS illness and death. Final results from HPTN 052 showed no evidence of transmission from HIV-positive people on ART with full viral suppression to their partners -- a concept dubbed treatment-as-prevention, or TasP.

Kanna Hayashi from the British Columbia Centre for Excellence in HIV/AIDS reported findings from an analysis of rates and predictors of death among HIV-positive people who inject drugs in Vancouver since the advent of effective combination ART in the late 1990s.

In 2010 the city began an initiative to increase access and improve adherence to ART in an effort to stem the ongoing epidemic among drug injectors. HIV/AIDS remains a major cause of death among people who inject drugs, but it is not clear how efforts to expand treatment access have affected mortality in this population, the researchers noted as background.

The study team looked at longitudinal data from ACCESS (AIDS Care Cohort to Evaluate Exposure to Survival Services), a prospective cohort study of nearly 1000 HIV-positive injection drug users. Every 6 months participants completed a questionnaire about drug use and other risk factors and were tested for HIV and hepatitis C virus (HCV). These data were confidentially linked to a province-wide ART dispensing database and the British Columbia vital statistics database to determine mortality rates and causes of death between May 1996 and May 2013.

The analysis included 961 participants, of whom 353 (37%) were women. About half were white and the median age was 35 for women and 31 for men. Most participants -- 94% of men and 89% of women -- were coinfected with HCV.

Participants had been injecting drugs for a median of about 15 years; 39% of women and 19% of men reported daily heroin injection, while 35% and 27%, respectively, reported daily cocaine injection. More than 70% had unstable housing, about a quarter of both men and women had been incarcerated, and half the women and 8% of the men reported sex work. 30% were enrolled in methadone maintenance therapy and nearly 40% were enrolled in other types of addiction treatment.

Most participants had recently started combination ART. 16% had started treatment with a CD4 T-cell count >200 cells/mm3 and had at least 95% adherence, while two-thirds had either started with a lower CD4 count or had poorer adherence, and 16% had never accessed ART.

Results

"In this 18-year cohort study of community-recruited HIV-positive people who inject drugs, mortality rates were similar between male and female participants," the researchers concluded. "HIV-related mortality rates have significantly declined since the beginning of efforts to expand access and adherence to ART, suggesting that treatment-as-prevention-based efforts to scale-up ART among people who inject drugs have been associated with sharp declines in HIV/AIDS-related mortality among this population."

However, they added, "High-intensity prescription opioid use independently predicted mortality among men, indicating a need to identify factors shaping harms from illicit prescription opioid use among this population."

8/19/15

Reference

K Hayashi, T Kerr, H Dong, et al. Reductions in mortality rates among HIV-positive people who inject drugs in Vancouver, Canada, during a treatment-as-prevention-based HAART scale up initiative: a gender-based analysis. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract MOPEB156.