Comparative Effectiveness of Alcohol and Drug Treatment in HIV Infected Veterans Kevin L. Kraemer, MD, MSc Professor of Medicine and Clinical & Translational Science Chief, Section of Treatment, Research, and Education in Addiction Medicine (STREAM) University of Pittsburgh

CER Funding/Team Funding: Supported by R01 AA022886 “Comparative Effectiveness of Alcohol and Drug Treatment in HIV-Infected Veterans” (PI – Kraemer), through April 2019 Team: Kathleen McGinnis, David Fiellin, Melissa Skanderson, Adam Gordon, Susan Zickmund, Todd Korthuis, Rory McCarthy Resident/Fellow Collaborators: Jonathan Robbins (Pitt  OHSU), Benjamin Oldfield (Yale)

Specific Aims of the Comparative Effectiveness Project Aim 1. Compare the effectiveness of initiation, engagement, and retention in different types of alcohol and drug treatment on quality of HIV care and virologic suppression Aim 2. Identify predictors of initiation, engagement, and retention in alcohol and drug treatment in HIV-infected Veterans Aim 3. Assess effects of ACA insurance expansion on access and barriers to alcohol and drug treatment and HIV treatment for HIV-infected Veterans

The First Thing We Did Compare the frequency of initiation, engagement, and retention in substance use disorder (SUD) treatment among HIV-infected and uninfected patients with SUDs

Definition of Index SUD Episode An outpatient visit or inpatient/residential admission with associated primary or secondary substance use ICD-9 codes (series 291, 292, 303, 304, 305) following a “break in care” (5 months without SUD-related service or pharmacotherapy)

Index SUD Episodes among Total Sample (Virtual Cohort) HIV-infected (n=43,116) HIV-uninfected (n=94,253) % Any Index SUD Episode* 37.6 34.4 Index Alcohol Episode* 27.1 28.1 Index Illicit Drug Episode* 30.9 24.4 *P-value < .001

Initiation/Engagement/Retention in SUD Treatment Settings after Index Episode HIV-infected (n=16,171) HIV-uninfected (n=32,339) Initiated (1 service in 14d), % 16.2 15.8 Engaged (2+ services in 30d), %* 19.9 19.0 Retained in SUD Treatment at: 3 months (7+ services)* 6 months (13+ services)* 12 months (25+ services) 17.3 14.5 10.1 16.5 13.8 9.7 If initiated, mean # SUD visits 23.0 21.2 * p < .05 ** p < .01

Trends in Methadone Use following Index Episode for Opioid Use Disorder *Test for trend is statistically significant for uninfected (p<.001), but not for HIV-infected

Trends in Buprenorphine Use following Index Episode for Opioid Use Disorder % *Test for trend is statistically significant for both HIV-infected and uninfected (both p<.001)

Trends in Oral Naltrexone Use following Index Episode for Alcohol Use Disorder % P=.03 *Test for trend is statistically significant for both HIV-infected and uninfected (p=.006 and p<.001)

Conclusions HIV-infected Veterans were more likely to have an index SUD episode than uninfected controls Initiation, engagement, and retention in SUD treatment and use of pharmacotherapy was low for both HIV-infected and uninfected Veterans Buprenorphine and naltrexone treatment has slowly increased in both HIV-infected and uninfected

Aim 2 Work: Predictors of Initiating and Engaging in Opioid Agonist Therapy (OAT) Lead Investigator: Jonathan Robbins, MD (work done as Pitt IM resident; now at OHSU) Aims: Measure the incidence of OAT initiation after an opioid use disorder (OUD) has been diagnosed Model the predictors of OAT initiation Compare OAT initiation between HIV-infected and uninfected Veterans

Adjusted1 Predictors of OAT Initiation within 14 days, Accounting for Multiple OUD Index Episodes (Mixed Effects Model) Methadone Buprenorphine Combined OAT OR (95% CI) Age (ref = < 40 years old) 40-49 1.05 (0.82 – 1.34) 0.65 (0.47– 0.91)2 0.95 (0.75 – 1.19) > 49 1.13 (0.88 – 1.46) 0.59 (0.42 – 0.83) 1.00 (0.79 – 1.26) Ethnicity (ref = white) Black 1.70 (1.49 – 1.96) 0.85 (0.71 – 1.02) 1.49 (1.32 – 1.68) Latino 1.22 (0.97 – 1.54) 0.87 (0.63 – 1.20) 1.16 (0.95 – 1.42) Other/unknown 1.87 (0.998 – 3.50) 0.90 (0.40 – 2.00) 1.53 (0.87 – 2.70) HIV-infection 0.93 (0.84 – 1.04) 0.91 (0.78 – 1.07) 0.93 (0.84 – 1.02) Year of diagnosis (ref = 2000-2004) 2005-2008 0.98 (0.88 – 1.09) 2.88 (2.33 – 3.56) 1.11 (1.00-1.22) 2008-2012 0.59 (0.52 – 0.67) 3.45 (2.78 – 4.30) 0.84 (0.75 – 0.95) Rural location (ref = urban) 0.55 (0.45 – 0.66) 1.39 (1.14 – 1.68) 0.66 (0.57 – 0.77) Alcohol use disorder 1.63 (1.45 – 1.83) 1.61 (1.32 – 1.96) 1.63 (1.46 – 1.81) Polysubstance use3 0.88 (0.79 – 0.98) 1.46 (1.21 – 1.75) 0.96 (0.87 – 1.06)

Aim 2 Work: Predictors of Initiation/Engagement/Retention in Alcohol Pharmacotherapy Lead Investigator: Benjamin Oldfield, MD; National Clinical Research Scholar, Yale Univ. Aims -- To identify: patient-level and facility-level characteristics that predict initiation of, engagement with, and retention in AUD pharmacotherapy among HIV infected and uninfected Veterans in the VACS virtual cohort the interaction effect of HIV status on patient- and facility-level factor Status: Writing Group being assembled

Qualitative phone interviews of: Aim 3: Assess effects of ACA insurance expansion on access and barriers to SUD treatment and HIV treatment for HIV-infected Veterans Qualitative phone interviews of: 108 VACS patients (HIV/HCV co-infected, + SUD episode in past 12 months) 16 providers (1 ID and 1 SUD/Mental Health at each VACS site) 6 key informants (national leaders in HIV or SUD) To date: 26 patients, 12 providers, 3 key informants Plans for 2nd round of interviews in 2018

Aim 1: Compare the effectiveness of initiation, engagement, and retention in different types of SUD treatment on quality of HIV care and virologic suppression

Aim 1: Approach Design: Quasi-experimental Sample: VACS Virtual Cohort; HIV-infected with index SUD episode SUD Treatment: defined by SUD inpatient and outpatient stop codes and pharmacotherapy data Analyses: propensity score adjusted, difference-in-differences analyses of outcomes for the 12 months before and after treatment Alcohol/Drug Treatment Episode Outcomes: Quality of HIV Care; Virologic Suppression Difference-in-Differences

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