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IAS 2015: Vancouver's HIV Treatment as Prevention Success Also Due to Harm Reduction

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"We talk a lot about the success of treatment as prevention in Vancouver, but we always need to make sure people understand that this requires an integration of various approaches," Evan Wood of the University of British Columbia said last week in a plenary presentation at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention.

[Produced in collaboration with Aidsmap.com]

HIV diagnoses among people who inject drugs in Vancouver have fallen by more than 90% since the peak of the epidemic in 1996. This success has been achieved, Wood said, through a combination of community empowerment, harm reduction, treatment for addiction, and universal access to HIV treatment and care. Nonetheless, the criminalization and marginalization of people who use drugs remained major obstacles.

"The success of treatment as prevention in injecting drug users in Vancouver has been phenomenal," Wood's colleague Julio Montaner said in another session. "The reason why it’s working so well is because there is a synergy between the needle exchange, the supervised injection site, the methadone program, and the treatment as prevention."

Montaner acknowledged that hew HIV infections have not fallen so far in men who have sex with men. For this group, there aren’t other highly effective interventions to provide together with treatment as prevention, he suggested.

The Treatment Cascade in People Who Inject Drugs

In many parts of the world, people who inject drugs have poor access to health services and have not fully benefited from HIV treatment. But MJ Milloy of the British Columbia Centre for Excellence in HIV/AIDS outlined improvements in the local care cascade for drug users in recent years. In 2006, 30% of those in care were on treatment and had an undetectable viral load. By 2012, the figure had risen to 71%.

Considerable efforts have been made to engage people who inject drugs with HIV and harm reduction services, which are always free of charge for those who need them.

The data come from the ACCESS cohort of people living with HIV who inject drugs in Vancouver. A series of analyses from this cohort presented at the conference shows the importance of opioid substitution therapy and social factors in making progress along the HIV treatment cascade.

This ongoing prospective observational cohort began in 1996 and currently has over 800 people in it. Two-thirds are men, the average age is 43, three-quarters are homeless or in unstable housing, two-thirds live in Vancouver’s Downtown Eastside (an area with many social problems), 15% have recently been incarcerated, 17% inject heroin daily, and 36% smoke crack daily.

One analysis examined how long it took members of the cohort to start antiretroviral treatment after being diagnosed with HIV, and the factors that delayed or facilitated this. Individuals who were taking methadone as opioid substitution therapy tended to start treatment promptly. People who generated income in "informal" ways (selling sex, dealing drugs, through crime, begging, etc.) had a slower uptake of HIV treatment, as did people who had been in prison. But there was no association between drug-using practices and slower uptake of treatment.

The next analysis looked at adherence to HIV treatment, specifically transitions from poor adherence to good adherence, or from good to poor adherence. Once again, methadone opioid substitution therapy promoted good outcomes. Continuing to inject drugs, recent incarceration, recent homelessness, sex work, and already having a low CD4 cell count made it harder to achieve good outcomes.

Just as social factors can be barriers to good treatment outcomes, the final analysis from the cohort suggested that treatment success is associated with subsequent social benefits. People who achieved optimal adherence to HIV treatment were more likely than others to cease to earn money in informal ways and were also more likely to transition out of homelessness. They also appeared to be more likely to start a romantic relationship, although this wasn’t quite statistically significant.

7/31/15

Reference

E Wood. How Drug Policy Should Respond to the HIV Epidemic? 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Presentation TUPL0103.

MJ Milloy. HIV TasP for PWID and implications for HCV TasP: the North American experience. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Presentation WESY0504.

B Joseph and MJ Milloy. Factors associated with initiation of antiretroviral therapy among HIV-infected people who use illicit drugs. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract TUAC0403.

B Joseph, T Kerr, C Piskas, et al. Factors linked to transitions in adherence to antiretroviral therapy among HIV-infected illicit drug users in a Canadian setting. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract TUPEC524.

L Richardson, T Kerr, B Hogg, et al. Social and socio-economic benefits of antiretroviral therapy adherence among HIV-infected people who use illicit drugs in Vancouver, Canada. Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015), Vancouver, Canada, abstract TUAC0405, 2015.