This Week in HIV Research: Better Serving the Underserved

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It's heartening to see a growing amount of research exploring some of our most marginalized communities -- the same communities that tend to be disproportionately affected by HIV, alongside a host of other challenges. Our latest selection of recently published HIV-related studies features an array of findings that further our understanding of how HIV affects some of these groups -- and how specific interventions can potentially ameliorate that effect.

This week, we learn that:

  • Although HIV care retention is poorer among transgender women, viral suppression rates are not.
  • A simple heating method may help curb HIV transmission within clustered areas of opioid use.
  • Harm reduction and treatment access programs may not be enough to manage HIV outbreaks among people who are homeless.
  • When it comes to improving viral suppression among people who use substances, it's not as black-or-white as "abstinence or bust."

And now, a bit more information on each of these findings. To beat HIV, you have to follow the science!

Trans Women and HIV Care: Lower Engagement, Similar Viral Suppression Rates

Transgender women living with HIV are less likely to be retained in care than cisgender women and men, but once in care, they have similar rates of viral suppression, a U.S. study published in Clinical Infectious Diseases showed.

The authors included data on 396 trans women, 14,094 cis women, and 101,667 cis men who are part of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Data spanned a wide time period, ranging from 2001 to 2015. Overall, the prevalence of retention in care was found to be lower for trans women than cisgender people -- and it did not improve during the course of the study. Counter to the researchers' initial hypothesis, however, viral suppression was just as likely among trans women as it was among cisgender people after adjusting for age, race, HIV risk group, and cohort.

Fear of revealing their gender identity or experience with poor treatment by medical providers may keep trans folk from accessing HIV treatment, explaining the retention difference, the authors surmised. They also noted that other research has shown improvement in viral suppression rates when the same clinician provides both gender-affirming and HIV care; the NA-ACCORD sites provide both types of care, which may explain why adjusted analyses showed no difference in viral suppression, despite lower retention in care, study authors noted.

Given the diverse demographics found within the transgender cohort, the authors recommended that efforts to engage young people of color in HIV care include transgender concerns, such as potential interactions between HIV medications and hormone therapy, to help engage this population in HIV care.

Bastiaan Slabbers via iStock

"Heat Your Wash" Approach May Reduce HIV Transmission Amidst Opioid Use

Briefly heating the commonly re-used solution ("wash") of controlled-release hydromorphone, an opioid, destroys HIV in the solution, researchers reported in Journal of Acquired Immune Deficiency Syndrome.

The research was driven by a spike in new HIV diagnoses in London, a Canadian city in Ontario province with a well-established syringe exchange program and high rates of opioid substitution therapy. Researchers interviewed people using intravenous drugs, then replicated what they had learned in the laboratory.

While most people did not share needles or syringes, the "cooker" and filter used in the process were often reused because significant amounts of the drug remain in that equipment. Researchers confirmed that 45% of the drug remains after dissolution and filtering. They also found that one of the excipients in long-acting hydromorphone, microcrystalline cellulose, appears to stabilize HIV, but that heating the mixture to boiling destabilized the virus. Briefly boiling twice brought HIV down below detectable levels.

Study authors called on the pharmaceutical industry to look for a different excipient. Meanwhile, a "cook your wash" public health campaign has been introduced, which has (alongside other interventions) helped lead to a large drop in new seroconversions, Michael Silverman, M.D., one of the study authors, noted in a related press release.

oakie via Unsplash

Seattle Area Responds to HIV Outbreak Among Homeless

Despite the prevalence of local syringe exchange and HIV treatment programs, HIV diagnoses have increased significantly among people who inject drugs in King County, Wash. -- including an outbreak analyzed in a recent Morbidity and Mortality Weekly Report. Seattle is located in King County.

This analysis included data on 14 related seroconversions diagnosed in 2018 that were linked to nine previously diagnosed people. All 23 people in the cluster were living homeless, and the recent seroconversions occurred within a 3-square-mile area. The outbreak included 11 cisgender women, nine of whom exchanged sex for money or goods. Only two of the 14 newly diagnosed people reported no injection drug use.

Study authors identified three key factors contributing to the outbreak:

  • Limited syringe services in that particular area.
  • Rising homelessness county-wide.
  • The opioid epidemic

Since 2007, King County homelessness has grown by 47% (as of 2017), and opioid overdose deaths by 264% (as of 2018).

In response to the outbreak, local health authorities have expanded HIV testing, condom distribution, and syringe services among people who live homeless in the area; asked local emergency departments to increase HIV screening; and pushed the local jail to provide opt-out HIV testing. Study authors called on other health departments to similarly investigate potential outbreaks in their areas.

LexScope via Unsplash

Viral Suppression Can Improve Without Substance Use Abstinence

A reduction in substance use is often associated with viral suppression in people living with HIV, even if abstinence is not achieved, an observational study published in Clinical Infectious Diseases showed.

Data came from more than 12,000 people who attended HIV clinics at different U.S. sites and was supplemented by several additional studies, two of which focused on people involved in the criminal justice system.Drugs were classified in four categories: unprescribed opioids/heroin, methamphetamines/crystal meth, cocaine/crack, and marijuana. Some participants took more than one type of drug.

In all categories, abstinence from the drug was associated with greater likelihood of viral suppression and lower relative viral load. However, taking opioids or methamphetamine less frequently was also associated with viral suppression (in the case of opioids, the association appeared to be even stronger for reduction than for abstinence), as was reducing the number of different substance types used.

Although the study authors cautioned against drawing a causal relationship between substance use frequency and viral suppression, they did write that the findings highlight "the potential benefits of harm-reduction substance use interventions that are able to successfully reduce use even when abstinence is not achieved."