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CROI 2017: Will There Be a New Wave of HIV Among People Who Inject Drugs in the U.S.?

While there is little evidence yet for a crossover of HIV from gay men who inject drugs to heterosexuals, several studies presented at last month's Conference on Retroviruses and Opportunistic Infections in Seattle found that the conditions do exist for it to happen. And they find a new generation of heterosexual people who inject drugs (PWID) who are not connected to conventional drug services, are sharing needles, and are increasingly interested in methamphetamine.

[Produced in collaboration with aidsmap.com]

Meanwhile, studies among men who have sex with men (MSM) found that while injecting methamphetamine is in decline among the white MSM population, it is increasing among black MSM.

Ever since there was an outbreak of HIV among white, largely rural heroin users in Indiana in 2015, there have been concerns that the conditions exist in some parts of the U.S. for more outbreaks among heterosexual people who inject drugs.

Increasing Methamphetamine Injection Among Heterosexuals

Evidence from Seattle’s local authority, King County in Washington State, sends warning signs that conditions do exist for a crossover of HIV from MSM to heterosexuals due to a rise in heterosexuals injecting methamphetamine -- and evidence that a significant proportion are sharing needles with MSM.

Sara Glick from the University of Washington in Seattle said that at present HIV prevalence among MSM who inject drugs is very high at 35%-40%, but is only 3% among heterosexual drug injectors.

Two different behavioral surveillance programs of PWID -- the Seattle Area section of the National HIV Behavioral Surveillance (NHBS) of Injecting Drug Users, and the King County Syringe Exchange Program survey -- looked at the proportion of people injecting drugs in the last year who had injected methamphetamine. The survey included only those who had been sexually active in the past year.

Among MSM, methamphetamine was not unexpectedly the prominent drug of choice. In the NHBS survey the proportion of injecting MSM who used methamphetamine rose from 55% in 2005 to over 80% in 2009 and stayed at that level thereafter. In the King County survey, methamphetamine was used by over 80% of MSM who inject drugs from 2013 onwards.

In contrast, the use of methamphetamine by heterosexual PWID, who had previously mainly used opiates, has been sharply increasing. Among heterosexual PWID the proportion using methamphetamine rose from 24% in 2009 to 69% in 2015, and in the King County survey from 16% to 57%. Among women who inject drugs, meth usage rose similarly, from 26% to 65% in the NHBS survey and from 25% to 61% in the King County one.

The pattern of meth usage is somewhat different among heterosexuals. MSM are more likely to inject methamphetamine by itself, but heterosexuals were more likely to inject it alongside heroin in a so-called "goofball." By 2015, 47% of heterosexual males who inject drugs reported goofball injection while only 10% reported using methamphetamine alone. The proportions were similar for women (43% vs 17%).

However, goofball injection also became more popular among gay and bi men, reported by only 18% of MSM who inject drugs (24% of meth users) in 2009 but by 34% of MSM who inject drugs (41% of meth users) by 2015.

Of most concern is that sharing is occurring between gay and bi men and heterosexuals. Among MSM who admitted sharing injection equipment, their last sharing partner had been a woman in 31% of cases and a heterosexual man in 14%. Among women who inject drugs, their last sharing partner had been a man who has sex with a man in 15% of cases and a heterosexual men in 7% of cases.

Prescription Painkillers as a Gateway to Injecting

Dita Broz from the Centers for Disease Control and Prevention (CDC) provided some troubling evidence that since 2000 a massive increase in the number of people with addiction to orally administered opioid painkillers has led directly to a new generation of injectors.

Deaths from overdoses of opioid drugs have increased in the adult population from 3 per 100,000 in 2001 to 10.4 per 100,000 in 2015 (1 for every 9600 U.S. adults per year), and the steepest increase has been among users of non-conventional medical opioids such as fentanyl, with a 10-fold increase. Medically prescribed opioids, including methadone, are responsible for 4.7 overdose deaths per 100,000 per year.

In order to find out whether non-injected opioid painkiller use was a precursor to injecting opioids, the NHBS conducted a respondent-driven survey of people who had injected opioids during the last year in 16 cities and asked them: "Were you hooked on painkillers before you injected for the first time?"

As this is a respondent-driven sample, there’s no denominator; we can’t tell if respondents were typical of PWID in their area. But there was a large increase in prior prescription opioid use in the last 25 years. Among people who first injected opioids before 1995, 12% said they had been hooked on painkillers before they started to inject. Among people who had started injecting any year after 2005, that proportion had increased to 50%. The median time between becoming addicted to prescription painkillers and injecting was 4 years.

Nearly 1 in 3 PWID (30.5%) said they had obtained the painkillers directly from prescriptions by doctors. Another 40% had got them from a friend or family; half of these had been bought, half given. 1 in 16 people (6.7%) had stolen them.

Prior prescription painkiller dependence was 2.9 times more likely among people who had first started to inject after 2000 than among people who had started before that. Also associated with prior painkiller addiction were younger age (under-30s were 70% more likely to have had prior painkiller dependence), being white rather than of other race/ethnicity (also 70% more likely), and, to some extent, being homeless (20% more likely) and female (10% more likely).

People who had started injecting after 2000 were less likely to have HIV (2% vs 6%), however.

Changing Patterns of Meth Use Among Gay Men

Two surveys looked at trends in methamphetamine use, both injected and non-injected, among MSM in the U.S. Both found that trends in drug use among gay men in general had stayed flat, but that who was using them had changed: use by black and poorer men had increased at almost exactly the same rate as it had decreased among white men.

Brooke Hoots of the CDC said that non-medical prescription opioid use had been reported by about 7.7% of MSM in 2008, 2011, and 2014, and almost the same proportion reported using methamphetamine (8% in 2014). A higher proportion of MSM reported using cocaine, but again with little variation (18.6% in 2008 and 19% in 2014).

More white than black MSM reported prescription opioid use, but while use among white men has been slightly, though not significantly, decreasing (from 10.2% in 2008 to 9.5% in 2014), it has risen significantly, from 4.2% to 5.9%, among black MSM.

There was a similar change related to income: prescription opioid use among MSM earning under $20,000 a year rose from 6.7% to 9.3%, while it fell among MSM earning over $75,000 a year, from 8.5% to 6.4%.

Similar trends were reported specifically from Washington DC, where Irene Kuo of George Washington University found complementary trends in meth use in white and black MSM. Among white MSM, the proportion in the city who reported using meth in the last year had gone down from 9.5% to 4.7% between 2008 and 2014. Among black MSM, however, it had gone up from 4.4% to 9.9%.

There were encouraging signs among white MSM that young men were not taking to meth: men over 30 were 2.5 times more likely to use meth than those under 30. On the other hand, as the national survey found, it is increasingly becoming a drug of the poor rather than the rich: white MSM earning under $20,000 a year were no less than 8.45 times more likely to use meth than men earning over $50,000 a year.

HIV-positive MSM were 10.6 times more likely to use meth if they were white and 4.2 times more likely if they were black but here, as ever, the question is whether their meth use increased their risk of HIV or their having HIV made them more likely to use meth. Interestingly, there was no significant association between condom use and meth use.

Finally, an interesting study from San Diego looked at what might be called the tertiary effects of opiate substitution therapy (OST), or medication-assisted therapy as it is often known in the U.S. People receiving OST not only suffer from fewer injection-related ills (primary benefit) and share needles less and pass on fewer infections to others (secondary effect), but they also initiate fewer people into injecting (tertiary benefit).

A group of PWID were asked: "Have you ever helped someone inject who had never injected before?" People in OST programs were 38% less likely to report that they had.

3/8/17

Sources

SN Glick, R Burt, K Kummer, et al. Increasing methamphetamine use among non-MSM who inject drugs in King County, WA. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13-16, 2017. Abstract 873.

D Broz, M Zlotorzynska, M Spiller, et al. "Hooked on painkillers" prior to first injection among PWID in 16 US cities. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13-16, 2017. Abstract 869.

B Hoots, D Broz, L Nerlander, et al. Changes in prescription opioid, meth, and cocaine use among MSM in 20 US cities. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13-16, 2017. Abstract 871.

I Kuo, R Patrick, J Opoku, et al. Changing patterns of crystal meth use in black & white MSM, Washington DC, 2008-2014. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13-16, 2017. Abstract 872.

ML Mittal, D Vashishtha, X Sun,et al. Opioid substitution therapy and initiation into injection drug use in San Diego, CA. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13-16, 2017. Abstract 870.

CROI 2017: Science, Community, and Political Will Can End HIV Epidemic, Says New York Commissioner

New York City’s strategy to end the HIV/AIDS epidemic is firmly rooted in science, was developed in conjunction with community activists, and has support from top-level political leaders, Demetre Daskalakis told a plenary audience at the Conference on Retroviruses and Opportunistic Infections last week in Seattle. "When you combine political will, biological interventions, and harm reduction, you can get to zero," he said.

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CROI 2017: Several New Candidates in HIV Drug Pipeline Discussed at Conference

This year's Conference on Retroviruses and Opportunistic Infections (CROI), held last month in Seattle, included presentations on several new investigational antiretroviral drugs in development, reflecting a more robust pipeline than we have seen in recent years.

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CROI 2017: Efavirenz/ Tenofovir/Emtricitabine Less Likely to Cause Adverse Birth Outcomes

Infants exposed to an antiretroviral regimen of tenofovir, emtricitabine, and efavirenz (Atripla) from conception experienced fewer adverse birth outcomes compared to those exposed to other 3-drug regimens, according to a study of births in Botswana presented at the 2017 Conference on Retroviruses and Opportunistic Infections (CROI) last week in Seattle.

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CROI 2017: Timothy Brown, the Berlin Patient, Celebrates a Decade Cured of HIV

Participants at a Community HIV Cure Research Workshop on February 12, in advance of the Conference on Retroviruses and Opportunistic Infections in Seattle, held a "birthday" party for Timothy Ray Brown -- formerly known as the Berlin Patient -- to celebrate 10 years since the bone marrow transplant that would lead to the only known cure for HIV.

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CROI 2017: Unique Case of PrEP Failure Without Drug Resistance Reported in Amsterdam

HIV pre-exposure prophylaxis (PrEP) appears to be nearly 100% effective if taken consistently. However, among tens of thousands of cases of PrEP preventing HIV, there have been a few reports of people who acquired HIV despite high adherence to PrEP and adequate drug levels, including one reported in a poster at the Conference on Retroviruses and Opportunistic Infections (CROI 2017) last week in Seattle.

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CROI 2017: Bone Marrow Transplant Patient Off ART for 288 Days Without HIV Rebound

A HIV-positive bone marrow transplant recipient at the Mayo Clinic experienced prolonged viral remission lasting nearly 10 months -- longer than the so-called Boston patients -- after interrupting antiretroviral therapy (ART), according to a report at the Conference on Retroviruses and Opportunistic Infections this month in Seattle. Although his viral load eventually rebounded, his HIV reservoirs appeared to be reduced.

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CROI 2017: New NNRTI Doravirine Shows Good Efficacy in Phase 3 Study

Doravirine, an investigational next-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) from Merck, reduced HIV viral load as well as boosted darunavir in a Phase 3 clinical trial of people starting antiretroviral therapy (ART) for the first time, but it had a better lipid profile, according to a late-breaking presentation at the Conference on Retroviruses and Opportunistic Infections last week in Seattle.

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CROI 2017: Time with Transmissible HIV Viral Load Has Fallen By Three-Quarters Since 2000

A study by the Centers for Disease Control and Prevention (CDC) presented at the recent Conference on Retroviruses and Opportunistic Infections in Seattle found that the proportion of time people with HIV in the U.S. spend in care but not virally suppressed has fallen from 40% to 10% in the last 15 years. The study also found that young people, black people, and people with public rather than private health coverage spent less time with viral load below 1500 copies/mL, the World Health Organization (WHO) threshold for HIV transmission.

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CROI 2017: Spanish HIV Vaccine Induces Control Off ART in Nearly 40% of Recipients

A so-called "HIV Conserv" vaccine has, for the first time, produced significant prolonged viral control in a large minority of recipients once they were taken off antiretroviral therapy (ART). So far, 1 participant has stayed off ART for 7 months without having to resume it, according to a report at the Conference on Retroviruses and Opportunistic Infections last week in Seattle.

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CROI 2017: Treatment-as-Prevention Study Sees Substantial Drug Resistance, but No Impact on HIV Therapy

A study of the prevalence of transmitted drug resistance among participants in the ANRS 12249 trial of treatment as prevention, has found that a substantial minority of participants had HIV with drug resistance mutations. However, there was no evidence that pre-existing drug resistance had any impact on the success of treatment, according to a report at the Conference on Retroviruses and Opportunistic Infections this month in Seattle.

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CROI 2017: Stopping Smoking Cuts Risk of Some Cancers Quickly in People with HIV

Smoking probably contributes far more to the risk of cardiovascular disease in people with HIV than antiretroviral drug choice, viral load, or any factor linked to the virus, but stopping smoking leads to a rapid reduction in the risk of some cancers, according to results from a cluster of studies presented at the 2017 Conference on Retroviruses and Opportunistic Infections last week in Seattle.

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CROI 2017: How Should HIV Self-Testing Be Provided?

At a session on HIV self-testing at the Conference on Retroviruses and Opportunistic Infections this month in Seattle, researchers presented findings from studies looking at some of the unanswered questions about self-testing and how best to implement it, with examples from Malawi and the United States.

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CROI 2017: Changes In Viral Suppression Over Time Reveal Disparities in HIV Care

Sustained viral suppression over the course of a year may be a better measure than the most recent viral load test result when it comes to understanding access to and engagement in HIV care, according a study by Centers for Disease Control and Prevention (CDC) researchers presented at the 2017 Conference on Retroviruses and Opportunistic Infections this week in Seattle.

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CROI 2017: New HIV Capsid Inhibitors Show High Potency and Prolonged Activity in Early Studies

A novel type of antiretroviral drug that interferes with the assembly and disassembly of the HIV capsid, which encloses the genetic blueprint of the virus, may offer a new potent and long-acting treatment option if it continues to look promising in larger studies, according to a presentation at the Conference on Retroviruses and Opportunistic Infections this month in Seattle.

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CROI 2017: New HIV Infections Fall in the U.S. but Disparities Remain

The number of annual new HIV infections in the U.S. fell by 18% overall since 2008, offering evidence that prevention and treatment efforts are having an impact, according to data from the Centers for Disease Control and Prevention (CDC) released to coincidence with presentations at the 2017 Conference on Retroviruses and Opportunistic Infections this week in Seattle. A closer look at the data, however, shows some notable differences across demographic groups and geographic regions.

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CROI 2017: STI Rates Among PrEP Users Are High, But Evidence that PrEP Increases Them Is Inconclusive

A study of pre-exposure prophylaxis (PrEP) users presented at the Conference on Retroviruses and Opportunistic Infections this month in Seattle showed that they had very high rates of sexually transmitted infection (STI) diagnosis -- on the order of 20 times higher than among HIV-negative gay men in the general population. However, it is unclear whether STIs increased further after people went on PrEP.

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CROI 2017: STI Prophylaxis in PrEP Users Reduces Syphilis and Chlamydia, but Not Gonorrhea

Use of the antibiotic doxycycline as on-demand post-exposure prophylaxis by men who have sex with men taking part in the Ipergay HIV PrEP trial produced a 70% drop in chlamydia infections and a 73% drop in syphilis, but no reduction in gonorrhea, according to a late-breaking report at the 2017 Conference on Retroviruses and Opportunistic Infections (CROI) this week in Seattle.

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CROI 2017: Monoclonal Antibodies Show Promise for HIV+ People with Few Treatment Options

A pair of long-acting monoclonal antibodies that prevent HIV from entering human cells -- ibalizumab and PRO 140 -- may offer new treatment options for people with highly resistant virus and limited treatment options, researchers reported at the Conference on Retroviruses and Opportunistic Infections (CROI) last week in Seattle.

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CROI 2017: Infants Treated Within Days of Birth Can Clear HIV Reservoir Rapidly

HIV viral load and viral DNA fall rapidly in infants who begin antiretroviral therapy (ART) within days of birth, a pair of South African studies have found, showing the potential for clearing the reservoir of HIV-infected cells -- but infants with such a dramatic response to treatment may be a minority. The findings were presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2017) this week in Seattle.

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