Opioid Use Has a Detrimental Effect on Uptake of Care for Uncontrolled HIV

Individuals who have been hospitalized with uncontrolled HIV infection and report problematic opioid use are more likely to report a lack of primary care for their HIV and to not be adherent to antiretroviral therapy (ART) compared with patients reporting that stimulants (eg, cocaine, ecstasy, or amphetamines) and/or alcohol are their primary drug of choice, according to results published in Addiction Science & Clinical Practice.

“The rise in problem opioid use combined with injection drug use is fueling an increase in infectious disease incidence, including HIV,” the study authors noted, with the CDC reporting that almost 10% of new HIV infections occur in persons who inject drugs. “It is imperative to better understand how those who report problem opioid use differ from those who report other drugs and/or alcohol in their engagement in HIV primary care.”

They conducted a secondary analysis of self-reported opioid use among 801 persons enrolled in the Hospital Visit as Opportunity for Prevention and Engagement for HIV-infected Drug Users (Project HOPE) study. All study participants were recruited between July 2012 and January 2014 from 11 hospitals in US cities reporting high rates of HIV infection, including Birmingham, Alabama; Miami, Florida; Baltimore, Maryland; and Philadelphia, Pennsylvania.

Sixty-seven percent were male, 75% were non-Hispanic black, the mean (SD) age was 44.2 (10.0) years, and only half were on HIV medication at their baseline visit—compared with the 82.9% who had previously been involved in HIV care at some point. They were also divided into 3 groups: patient navigation, patient navigation with financial incentives, and treatment as usual.

The primary goal was to get and keep patients in both HIV and drug/alcohol treatment in order for them to achieve viral suppression because they adhered to their ART regimen.

The authors report there was a greater likelihood that the 11.9% (n = 95) of study participants who reported primary opioid use did not participate in primary care compared with those who did not report any drug use (adjusted risk ratio [aRR], 0.84; 95% CI, 0.73-0.98), who used stimulants as their primary drug (aRR, 0.84; 95% CI, 0.74-0.95), or who used several drugs, but not alcohol (aRR, 0.79; 95% CI, 0.68-0.93). Overall, this group is 16% to 21% more likely to not have used primary care services.

This trend carried over into comparisons with alcohol, cannabis, and use of several drugs plus alcohol, but these results were not statistically significant.

Results also showed the opioid-use group had an older mean (SD) age of 48 (8.6) years compared with 44 (9.9) for the remaining study participants, as well as higher rates of the following:

• Previous drug/alcohol treatment: 71.6% vs 54.8%
• Unemployment: 37.9% vs 24.8%
• Less mean (SD) annual income: $7286 ($7760) vs $10,290 ($10,430)
• Time since HIV infection: 14 vs 12 years

Additional barriers to care that may prevent HIV-positive illicit opioid users from initiating and engaging in primary care include lack of treatment when in detention centers (eg, jails, prisons), unstable housing situations, and the stigma associated with illegal drug use and HIV-positive status.

“Lack of integrated care, however, is the most significant, tangible and well-documented structural barrier to both HIV care and drug and alcohol treatment,” the authors concluded. “These findings suggest that for hospitalized [persons with HIV] who use drugs and/or alcohol, tailored and expanded efforts are especially needed to link those who report problem opioid use to HIV primary care.”

One solution to break down these ongoing barriers to care for HIV-positive illicit opioid users includes expanding HIV care services to sites that primarily address drug issues, such as treatment centers, needle exchanges, and pain management clinics, the authors propose. Another is to initiate treatment with medications for opioid use disorder while someone is hospitalized for HIV or in primary care for the virus.

Reference

Critchley L, Carrico A, Gukasyan N, et al. Problem opioid use and HIV primary care engagement among hospitalized people who use drugs and/or alcohol. Addict Sci Clin Pract. Published online June 19, 2020. doi:10.1186/s13722-020-00192-9