This Week in HIV Research: Pain, Opioids, and Viral Suppression

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Just off of the primary highways of clinical HIV research -- away from your PARTNERs and your NA-ACCORDs -- a dizzying array of scientific avenues, side streets, and cul-de-sacs feature studies that may be comparatively small in scope, but are nonetheless vitally important in incrementally improving our ability to practice effective HIV prevention and treatment. We head down those slightly smaller streets for our featured studies this week, which include:

  • A reminder that not all opioid prescriptions are unwise -- such as, for instance, when used by people with chronic pain to improve HIV virologic suppression rates.
  • New data pointing toward a wide range of racial, gender, age, and risk group disparities in HIV care -- and suggesting that tailored interventions are the best solution.
  • Signs that prophylactic antibiotic use is on the rise among men who have sex with men (MSM) utilizing pre-exposure prophylaxis (PrEP) as a way to prevent non-HIV sexually transmitted infections.
  • Strategies to help care providers navigate ambiguous HIV test results among people taking PrEP.

Let's take a drive through town to examine each of these results in more detail. To beat HIV, you have to follow the roads of science!

Barbara Jungwirth is a freelance writer and translator based in New York. Follow Barbara on Twitter: @reliabletran.

Myles Helfand is the executive editor and general manager of TheBody.com and TheBodyPRO.com. Follow Myles on Twitter: @MylesatTheBody.


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Long-Term Opioid Treatment for Chronic Pain Associated With Less Virologic Failure

People living with HIV who suffer from chronic pain but are not on long-term opioid therapy (LTOT) are less likely to be virologically suppressed than those without such pain or those taking opioids for such pain, a study published in Journal of Acquired Immune Deficiency Syndrome found. Conversely, LTOT in those with chronic pain appeared to protect against virologic failure.

The 2,334 study participants attended a clinic at one of five university sites, the largest of which was the University of Alabama at Birmingham. Long-term opioid prescriptions ranged from 0% at the University of North Carolina (which enrolled 39 people) to 24.5% at the University of California at San Diego (which enrolled 711); the median prescription rate across all five sites was 15.3%. Researchers found a strong association between LTOT non-usage in people with chronic pain and a greater likelihood of virologic failure (adjusted odds ratio 1.97) or suboptimal clinic retention (adjusted odds ratio 1.46). They also found that LTOT usage among people with chronic pain appeared to confer protection against virologic failure (adjusted odds ratio 0.56).

Study authors speculated that the observed protective effect of LTOT on viral suppression may be due to LTOT adherence improving antiretroviral therapy adherence, or to health care providers only prescribing opioids to patients they consider reliable.

However, authors cautioned against drawing hasty conclusions about the value of opioid prescriptions in people with HIV, given the addictive potential of opioids. They called for longitudinal studies to investigate the relationship between chronic pain and virologic failure, as well as the role of opioid prescriptions.


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Tailored Interventions for Specific Subgroups Needed to Reduce Disparities in HIV Care

In the U.S. and Canada, rates of engagement in care and viral suppression differ not only by race and gender, but also by age and sexual HIV acquisition risk, a large cohort study published in Clinical Infectious Diseases found.

Researchers analyzed data on 19,521 people living with HIV, 59% of whom were men who have sex with men (MSM), 21.4% were women, and 19.6% were men who have sex with women (MSW). Study authors compared person-time spent in care, on antiretroviral therapy, and virally suppressed during the first five years after study entry among four age groups between 18 and 50+ years old, stratified by race/ethnicity, sex and heterosexual versus same-sex HIV acquisition.

Older African-American MSM, young white women and middle-aged African-American MSW, in particular, had worse care continuum outcomes -- especially viral suppression -- than other subgroups. Study authors called for clinical and public health interventions tailored to these subgroups.


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Antibiotics Used Prophylactically by Some on PrEP

Some MSM on PrEP are taking antibiotics -- often doxycycline -- to prevent sexually transmitted infections (STIs), a small survey published in The Lancet showed.

Forty-three percent of 107 MSM surveyed at a London sexual health clinic had had an STI during the prior six months, and 8% had taken antibiotics for STI prophylaxis. United Kingdom guidelines advise against this practice because of the risk of antibiotic resistance, but study participants reported that they obtained doxycycline and similar medications from sexual health clinics and general practitioners or purchased them online.

The British Association for Sexual Health and HIV has called for further studies to determine the potential impact of prophylactic antibiotics. Study authors noted that their results likely underestimate the prevalence of this practice since respondents may not want to disclose that they are taking drugs not approved by their health care provider.


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Three Strategies for Handling Ambiguous HIV Test Results While on PrEP

Ambiguous HIV test results in people taking PrEP are rare, and handling such cases is tricky, researchers noted in Open Forum Infectious Diseases.

After reviewing the literature, researchers compared three strategies that can be followed until further testing provides definitive results: continue PrEP, start antiretroviral treatment ART, or stop PrEP.

There are potential risks to each approach. If PrEP is continued, drug resistance may develop, the authors stated. In this scenario, rapid follow-up testing to minimize the time on PrEP while living with HIV is important. If antiretrovirals are started, the person may experience side effects and insurance may not cover the medications in the absence of an HIV diagnosis. Stopping PrEP would lead to a rapid increase in viral replication if the person is, in fact, living with HIV. This would make a reliable diagnosis easier to obtain, but has ramifications both for a confirmed positive (due to a lack of protective benefits from antiretroviral use during acute infection) and a false-positive (due to a period of time in which the person had less protection from HIV infection).

Study authors recommended that health care providers discuss these options with their patients and jointly decide on the best approach, given the patient's specific circumstances.