Engagement in methadone maintenance therapy associated with less time with plasma HIV-1 RNA viral load above 1500 copies/mL among a cohort of HIV-positive people who use drugs in Vancouver, Canada Presentation prepared for the 22nd International AIDS Conference in Amsterdam, Netherlands July 25th 2018 Brittany Barker, MPP PhD Candidate, UBC Research Associate, BC Centre on Substance Use Brittany.barker@bccsu.ubc.ca

I have no conflicts of interest to declare Acknowledgement of xʷməθkwəy̓əm (Musqueam), Skwxwú7mesh (Squamish), and Səl̓ílwətaʔ/Selilwitulh (Tsleil-Waututh) Nations land where my work takes place.

Outline Background Study rationale The ACCESS study Methods Study sample Results Discussion

Background Elevated plasma HIV-1 RNA viral load (VL): HIV disease progression Risk of onward viral transmission Heightened HIV transmission risk threshold: VL >1500 copies/ml People who inject drugs (PWID) >25% of new HIV infections in North America >80% in some Eastern European and Central Asian countries where HIV outbreaks are occurring

Study Rationale People who inject drugs (PWID) Individual, social and structural barriers to HIV care Methadone maintenance therapy (MMT) Reduces incidence of HIV among PWID Promotes ART initiation and adherence Does MMT curb onward viral transmission?

Objective Examine relationship between engagement in low-threshold MMT and amount of person time with VL>1500 copies/ml among a cohort of people who use drugs and living with HIV in Vancouver, Canada

AIDS Care Cohort to Evaluate Access to Survival Services (ACCESS) Study design: Community-recruited cohort of people living with HIV/AIDS who use illicit drugs (ongoing since 2005) Data collection: Interviewer administered questionnaire and blood sample for serologic analysis at baseline and semi-annually Data linkages: Complete HIV clinical profile (e.g., VL, CD4 cell count, ART dispensation) from central provincial treatment provider (BCCfE Drug Treatment Program) Setting: Universal no-cost HIV/AIDS care including medications

Methods Sample restricted to all ART-exposed participants with two VL observations Outcome variable: proportion of time VL>1500 copies/ml (clinical data) Based on pairs of VL measurements every six months and estimated proportion of time between to recreate VL history1 Explanatory variable: engagement in MMT (self-report) Generalized estimating questions (GEE) 1Method originally described by Marks et al. AIDS 2015

Study sample 5 Dec 2005 – 29 Nov 2017 n=867 PWUD living with HIV Proportion with VL>1500c/ml 5 Dec 2005 – 29 Nov 2017 n=867 PWUD living with HIV 9062 observations (4532 person-years) 522 (60.2%) engaged in MMT over study period

Results

Discussion On average, 19% of observation time VL >1500c/ml Key role of access to evidence-based addiction care Halting disease progression among PWID Optimizing ART treatment for comorbid opioid dependence Lower risk of onward viral transmission in community Barriers to treatment still persist globally (e.g., US, Russia) Urgent scale-up of access and integrated evidence-based addiction and HIV treatment and care

Acknowledgements Co-authors: Kit Fairgrieve, Keith Ahamad, Thomas Kerr, Jean Shoveller, Julio Montaner, Evan Wood, and M-J Milloy ACCESS study participants Co-investigators and the research team at the BC-CSU BC-CSU Staff, and Administrative Support: Elaine Fernandes, Peter Vann, Tricia Collingham, Jenny Mathews, Steve Kain, Ana Prado, and the entire study team Funders: US National Institutes of Health (R01- DA021525), Michael Smith Foundation for Health Research (M-JSM), Canadian Research Chairs Program (EW), Canadian Institutes of Health Research (BB & M-JSM), NIDA/NIH (JM)