This Week in HIV Research: Removing Barriers to Better Care
In a fascinating number of ways, humanity is a species of walls. We build them physically, mentally, and emotionally -- sometimes without even noticing. Many of the most challenging aspects of fighting the HIV pandemic are, be it directly or indirectly, because of these walls we erect. A fair amount of the scientific work that takes place in HIV today is aimed at assessing whether those walls cause more harm than good -- or at trying to remove the walls we've unwisely built.
This week, we highlight some recently published HIV-relevant studies that confront or examine some of these walls, including:
- Evidence that a person's use of injection drugs should not be a barrier to their receipt of direct-acting antivirals for hepatitis C (HCV).
- A thought-provoking exploration of medical pain treatment among people living with HIV (PLWH) -- specifically marijuana and opioid use in an era of shifting legal status and ongoing public health crises.
- Experts' takes on where training is most needed to remove the barriers to more effective HIV care.
- Mixed findings on whether a switch from Atripla to Complera can put a stop to neurological impairment.
We, of course, will put up no walls between you and further information about each of these studies. To beat HIV, you have to follow the science!
Injection Drug Use Isn't a Barrier to HCV Cure
Sustained virologic response (SVR) rates on direct-acting antivirals -- a key measure of HCV treatment success -- are similar between people who inject drugs (PWID) and those who do not, a meta-analysis published in Clinical Infectious Diseases showed.
The analysis covered 23 studies that cumulatively examined 1,702 people on opioid substitution therapy, 538 people who inject drugs, and 19,723 controls. Overall, 90% of participants achieved SVR, as did 90% of those on OST and 88% of PWID.
Most "treatment failures" were study drop-outs, with 43% of discontinuations occurring between the end of treatment and the 12-week follow-up visit. "These patients may in fact have been cured," study authors suggested.
Based on the findings, the authors recommended HCV treatment independent of current injection drug use. A recent U.S. study reached the same conclusion after finding little change in drug use patterns and a decline in injection equipment sharing after people were cured of HCV.
Unfortunately, in the U.S., some states' Medicaid programs will not cover DAAs for PWID, a related commentary by Brianna L. Norton, D.O., of Montefiore Medical Center and Alain H. Litwin, M.D., of the University of South Carolina School of Medicine noted. "Given the irrefutable evidence that PWID can be successfully cured, and that rapid treatment scale-up of this key population is the only approach to reduce transmission and incident infection, payor polices must immediately allow for treatment of PWID," they demanded.
No Tie Between Marijuana and Opioid Misuse in PLWH With Chronic Pain
A small study among PLWH found no association between prescription opioid misuse or pain levels and the concurrent use of marijuana. However, the herb was linked to three-fold greater odds of a detectable viral load compared to participants not using it. The findings were published in the Journal of Acquired Immune Deficiency Syndromes.
The study was conducted at two safety-net hospitals in Boston, Massachusetts, and Atlanta, Georgia, between July 2015 and December 2016. It involved 166 PLWH (65% men; 72% black) who had been prescribed opioids for chronic pain.
While 85% of participants reported marijuana use at some point, 57% of those who used marijuana said they hadn't done so in the past 12 months. The remainder were split across several usage frequencies, the most common being 14% who used marijuana "a few times" in the past 12 months and 6% reporting daily use.
As the study authors noted, prior research is both sparse and mixed regarding the relative benefits and dangers of concurrent use of marijuana and opioids, despite their common usage among PLWH with chronic pain. The current study provides new data points, but without additional clarity: It found that marijuana use had neither a beneficial nor harmful effect on opioid use, and also that it had no significant relationship with a person's level of reported pain severity.
It also found, in a post-hoc analysis, an average odds ratio (OR) of 3.03 (P = .03) for detectable viral load among people who reported marijuana use within the past year. "It is possible that PLWH who have chronic pain and are on [chronic opioid therapy] already face significant health and quality of life challenges, and adding marijuana to this affected their adherence to [antiretroviral treatment] or retention in care," study authors hypothesized. The OR spread was wide for this relationship: 95% OR was 1.11 to 8.31.
Since only 5% of participants had a medical marijuana card, most self-reported use was likely illicit at the time, study authors noted. Laws regarding marijuana usage have eased in both Massachusetts and Georgia since the study took place. Study authors called for prospective studies on the impact of marijuana on pain, opioid use, and HIV outcomes.
Most Pressing Workforce Training Topic Is Mental Health and HIV, Experts Say
HIV experts in the eastern U.S. considered mental health to be the most urgent topic on which they would like to see health care provider training, researchers reported in AIDS.
Based on the Delphi method, three rounds of surveys, each of which built on the previous one, were completed by 34, 38, and 32 panel members, respectively, for a total of 116 participants. The first questionnaire asked for a list of five to 10 HIV topics that were important to address in trainings; the second asked panelists to rate the urgency of each topic on a consolidated list that was based on round one; and in the third round participants ranked the topics deemed most urgent in round two by their importance.
Participants were located in New York, New Jersey, Puerto Rico, or the U.S. Virgin Islands.
In order, the top 10 topics in the final round of most urgent training needs were:
#1: Mental health.
#2: Care coordination and planning (including case management).
#3: Black men who have sex with men.
#4: Medication adherence.
#5: Care retention.
#6: Viral suppression.
#7: Pre-exposure prophylaxis (PrEP).
#8: Linkage to care.
#9: HIV testing implementation/integration.
#10: HIV stigma.
Results show that HIV professionals view behavioral health problems as important to HIV care, but lack the confidence to address them, study authors concluded, adding: "We cannot improve access to mental health care for PLWH without a workforce and health care system with the capacity to provide that care."
No Neurocognitive Improvement After Switch From Efavirenz to Rilpivirine
Switching from tenofovir disoproxil fumarate/emtricitabine/efavirenz (Atripla) to the newer tenofovir disoproxil fumarate/emtricitabine/rilpivirine (Complera) did not affect neurocognitive performance, an open-label trial among 74 people that was published in AIDS found. Gilead Sciences, the maker of both drugs, funded the study.
Participants recruited were on a stable efavirenz regimen but had one of the following two characteristics:
- An altered neurocognitive assessment.
- Depression, anxiety. or low sleep quality.
- They were randomized 1:1 to switch to rilpivirine immediately or after 24 weeks.
At 24 weeks, neurocognition had improved overall, mainly because of the practice effect from repeated testing, study authors wrote. Test scores did not differ between the study arms, but participants in the immediate switch arm reported improvements in sleep quality and self-perceived cognition compared to the delayed switch group.
Study authors offered two possible interpretations of the results:
- Efavirenz may not affect neurocognitive performance as it was measured within the study.
- The neurological damage inflicted by long-term use of efavirenz takes more than 24 weeks to be reversed.
In any case, results show that switching from efavirenz may offer symptomatic relief of self-perceived cognition problems, they concluded.