This Week in HIV Research: Connecting the Dots

Among PLWH with substance use disorder, opioid antagonist treatment (OAT) improves a person’s engagement at nearly every step in the HIV care cascade, a Canadian study published in AIDS found.

Data came from 639 PLWH recruited through community-based referrals who regularly use opioids in Vancouver, B.C., Canada. At baseline, 70% of participants were on OAT.

For people who have already received an HIV diagnosis, the HIV care cascade is generally understood to involve four stages: initial linkage to and engagement in HIV care; commencement of antiretroviral therapy (ART); consistent access to and usage of antiretroviral therapy; and maintenance of viral suppression. In this study, PLWH on OAT showed a nonsignificant trend toward greater linkage to care—followed by a statistically significant increase across all subsequent stages.

The study authors suggested that the progressively sharper difference in care cascade success may be partly due to clinicians being more likely to prescribe ART to PLWH who are on OAT than PLWH who are not being treated for their substance use. (They noted that other studies have found that treatment against opioid use improves ART adherence, which in turn results in higher rates of viral suppression.)

The finding that OAT has a limited effect on linkage to HIV care may be due to low statistical power for this subgroup, or instability from cycling in and out of substance use treatment, which may impact HIV care engagement, the authors wrote. Integration of treatment for substance use and HIV may help counteract such instability.

In line with general population trends in British Columbia, engagement in opioid use treatment during the study was significantly higher than in the U.S. This may be due to better OAT availability and differences between the two countries in prescribing and delivery practices, the authors suggested.

Limitations included the study recruitment method, the fact that all participants had already been diagnosed with HIV, and self-reported data on OAT engagement. “While these findings are encouraging, they highlight the need to reach populations off OAT to maximize the clinical and community-level benefits of ART,” study authors concluded.

“[Prioritizing] the promotion of mental health among MSM is a public health strategy that could help to end the global HIV epidemic,” researchers from the U.S., Kenya, and the Philippines wrote in The Lancet HIV.

The statement is based on the authors’ review of evidence on the synergistic epidemics of HIV and mental health among MSM around the world. These epidemics are driven by structural factors and other determinants. Study authors used a variety of conceptual frameworks and approaches that align with the socioecological systems model to analyze the results of their scoping review. Most included studies are from North America and Western Europe, with some from Asia and Latin America. (Evidence from sub-Saharan Africa is just beginning to emerge, they stated.)

Mental health programs for MSM have included interventions aimed at preventing seroconversion by addressing the needs of older men, dealing with trauma from childhood abuse, and increasing condom use and HIV knowledge in men struggling with alcohol use, the authors reported. Some interventions have been culturally adapted to various locales, such as China or Romania. Other programs help MSM living with HIV who use substances and address intersectional issues stemming from people’s experiences with, e.g., both sexual stigma and racial discrimination.

Study authors proposed several strategies to more effectively integrate mental health services with care efforts targeting MSM, including:

• Coupling mental health services with HIV prevention and treatment.
• Affirming indigenous local mental health approaches.
• Developing mental health providers – including laypersons – who are skilled in addressing the unique challenges faced by MSM.
• Using local approaches for promoting health equity.

HIV testing in the emergency department (ED) increased 20-fold after universal screening was adopted at the University of California—Davis ED in November 2018, a study published in AIDS found. Positive HIV tests increased five-fold during that time, likely due to higher screening rates.

Study authors conducted an interrupted time series of ED visits in the year before and after introduction of the screening program. The program consisted of an alert in the electronic medical health record (EMR) for adult ED visitors between the ages of 18 and 64 who had blood drawn for laboratory tests and did not have a documented HIV test within the prior year, or who were being tested for gonorrhea, chlamydia, or syphilis. Participants could opt out of the HIV test.

Before the intervention, 1% of patients among 61,172 ED encounters received an HIV test in the ED. After the intervention, 24% of patients in 59,073 encounters received such a test. The greatest increase was soon after implementation of the alert, with a 6% drop in HIV testing by the end of the study, likely due to health care workers’ alert fatigue, study authors suggested.

In addition to new HIV diagnoses, the intervention also found 41 PLWH who were out of care, 37 of whom were linked back to care.

Study authors noted that HIV rates among older adults are rising and suggested that future interventions should increase the age limit for opt-out HIV screening.

Among PLWH who previously had hepatitis C (HCV), the two factors most strongly associated with HCV recurrence are being a man who has sex with men or very recently clearing a prior HCV infection, a systematic review and meta-analysis published in The Lancet HIV showed.

In 41 studies (most of which were conducted in Europe) with a combined total of 9,024 participants, overall HCV reinfection incidence was 3.76 per 100 person-years of follow-up (PYFU). Among MSM, this rate jumped to 6.01/100 PYFU. Among people who reported receiving treatment for a recent acute HCV infection, reinfection incidence was 8.16/100 PYFU; by contrast, among people who reported receiving treatment for chronic HCV infection, reinfection incidence was 2.89/100 PYFU.

Among people who reported recent injection drug use, reinfection incidence was 5.49/100 PYFU; notably, however, this rate dropped to 3.29/100 PYFU among people who reported any lifetime history of drug use, suggesting successful risk reduction efforts among this population. Among MSM, there was little difference between those who had a history of injecting drugs and those who did not.

Reinfection rates did not differ significantly by hepatitis C treatment (i.e., interferon-based or direct-acting antivirals).

Study authors called for expanded enactment of strategies that allow people to have sex and inject drugs safely, including harm reduction approaches. Continuing to screen PLWH who have completed hepatitis C treatment for reinfection helps treat those reinfections early, they noted; together with broad access to DAAs, early treatment could prevent onward transmission of HCV.

Study limitations included participant demographics (mostly men in high-income countries); selection bias toward PLWH engaged in care; and heterogeneous reinfection results across studies, which was partly due to differences in access to harm reduction services or in population-level HCV incidence.