Opioid Use Disorders: Impact on HIV

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Presentation transcript:

Opioid Use Disorders: Impact on HIV Nora D. Volkow, MD Director, National Institute on Drug Abuse National Institutes of Health @NIDAnews

There are no conflicts of interest to declare

Globally HIV Appears to be Rising Among PWID Estimated HIV Prevalence Among People Who Inject Drugs (PWID) Globally HIV Appears to be Rising Among PWID Total Population PWID HIV Incidence (%) Lancet Glob Health. 2017.   Globally, 13M PWID and 1.7M are HIV+ Globally, 10% of HIV infections are from IDU WHO: https://www.who.int/hiv/topics/idu/en/ UNAIDS 2018 estimates

US Opioid Epidemic has Increased Overdose Deaths and Prevalence of PWID 1999 In 2017, 70,237 OD Deaths (9.6% higher than 2016) Prevalence of IDU in US has increased in past 15 years Heroin IDU in US (12 or older, past-month use) 2016 Year Β Coefficient: 0.1519 Ƿ Value for the trend: <0.0001 https://www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality/index.htm Han et al., SAMHSA (unpublished)

U.S. counties vulnerable to rapid spread of IDU-associated HIV HIV Can Spread Rapidly Among People Who Inject Drugs U.S. counties vulnerable to rapid spread of IDU-associated HIV 220 counties in 26 states Scott County, IN 215 HIV cases from IDU in 2014-2015 Cabell County WV, 55 HIV Cases from IDU in 2019 (588% increase from 2016) Lowell and Lawrence, MA, 129 HIV cases in IDU from 2015-2018 (2012-2014, entire Mass had 123 IDU cases). Multnomah County, OR. 42 HIV cases mostly IDU in 2018-2019. (200% increased from 2016-2017) Philadelphia, PA, 59 HIV Cases from IDU in 2018 (60% increase from 2016) King County, WA. 27 HIV cases from IDU in 2018. (286% from 2017) Van Handel et al., J Acquir Immune Defic Syndr. 2016 Northern KY, 280% increase in HIV cases from IDU in 2017 Estimates of HIV increases in IDU are from local newspapers (search Volkow et al., 2019)

Addiction is a Disease of the Brain Control Addicted Reduced Function of Frontal Cortex Healthy Controls Heroin Addicted Patients Low High Reduced Dopamine Signaling Volkow et al., PNAS 2011 Koob, GF and Volkow ND, Neuropsychopharmacology Reviews 2010

Addiction Can Be Treated Medications for Opioid Use Disorders (MOUD or MAT, OST) Impact of MOUD on HIV Transmission Log Dose Opioid Effect Full Agonist (Methadone: Daily) Partial Agonist (Buprenorphine: 3x/week, ER 1 month) Antagonist (Naltrexone: ER 1 month) DECREASES: Opioid use Opioid overdose deaths Criminal activity HIV and HCV transmission INCREASES Social functioning Retention in HIV treatment Improves HIV Outcomes MOUD reduced HIV infections by 54% MacArthur GJ et al. BMJ 2012

Effects of MOUD on Viral Suppression Treating Opioid Use Disorders in PLWH Effects of MOUD on Viral Suppression MOUD Improves uptake and retention in ART 69% increased recruitment to ART Two-fold increase in ART adherence 45% increase in odds of plasma viral suppression (VS) Lou et al., Clin Infect Dis. 2016

Medications for OUD are Highly Underutilized and Retention is Poor MOUD Coverage among PWID OUD Cascade of Care, USA Larney S et al., Lancet Global Health 2017 Williams et al. Health Affairs Blog, 2017

Implementing MOUD in Healthcare Settings Implementing MOUD in Jail/Prisons Springer SA et al., JAIDS 2018 XR-NTX given 1w prior to jail release with subsequent injections in community improved VS at 6m Post-release PLWH w OUD, are disproportionately incarcerated HIV prevalence is 3X that in community VS achieved during incarceration is lost from low linkage to HIV care, relapse and homelessness post-release Implementing MOUD in Healthcare Settings Primary Care: Low Threshold Office-Based Buprenorphine Treatment Unobserved induction, At most weekly visits, No psychosocial treatment Treatment retention at 38 weeks equivalent to specialized treatment. Bhatraju EP et al., Addict Sci Clin Pract. 2017

Extended Release (ER) Formulations Facilitate Use in Health Care & Justice Settings and Improve Compliance Mu Antagonist: NALTREXONE Mu Partial Agonist: BUPRENORPHINE Vivitrol® Once-month Injection SUBLOCADE™ (Buprenorphine ER), Once-Month Injectable FDA Approval 11.30.2017 CAM2038 Subcutaneous Buprenorphine ER: Once-Week Injection Once-Month Injection Median % Opioid-Negative Urines for 24 weeks Percent of Weekly Urine Tests 100% 80% 60% 40% 20% 0% PLACEBO ER-NTX PROBUPHINE® 6 months implant Placebo: N=124 ER-NTX: N=126 Krupitzky et al., Lancet 2011

Social Interaction Favored over Heroin Unless Social Interaction is Punished Resident self-administration chamber Partner chamber Social lever Drug lever Sliding door HEROIN James Nachtwey. TIME Special Report Venniro et al., Nature Neuroscience 2018

THANKS