HIV Treatment-as-Prevention (TasP) for people who
use illicit drugs and implications for HCV TasP:
The North American experience
M-J MILLOY
Research scientist, British Columbia Centre for Excellence in HIV/AIDS;
Assistant professor, Division of AIDS, Department of Medicine, University of BC
8th International AIDS Society Conference on HIV pathogenesis, Treatment & Prevention
Vancouver, 22 July 2015
Page 1
I have no conflicts of interest to declare.
Page 2
Page 3
Page 4
Figure 1: Gains in life expectancy among ART-treated HIV+ in North America
Page 5
HIV+ people who use drugs have not
benefitted equally from HAART
– Lower rates of access to HAART
– Lower levels of adherence to HAART
– Higher rates of discontinuation
– Elevated rates of suboptimal HIV/AIDS
treatment outcomes
Page 6
Page 7
After IAS 2015:
Will people who use
drugs in North America
reap the full benefit
from TasP/90-90-90?
Page 8
450
400
350
300
250
200
150
100
50
0
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
Figure 1: New HIV diagnoses in Vancouver among PWID, 1985 to 1996
Page 9
HIV outbreak among PWID in
Vancouver’s Downtown Eastside (DTES)
• Proximate: Shift to cocaine injection
• “Deadly public policy”
– Housing policies
– Needle exchange restrictions
– Police enforcement and incarceration
– Changes in resource economy
Page 10
Scale-up of HIV/AIDS treatment for
people who use drugs
– 2005: Immediate initiation of PWID in
HIV/AIDS clinical guidelines
– 2010: STOP HIV/AIDS pilot project in DTES
•
Seek, Test, Treat and Retain (STTR)
– Ongoing: province-wide TasP-based effort
Page 11
AIDS Care Cohort to evaluate Exposure
to Survival Services (ACCESS)
– Open longitudinal prospective cohort
– HIV+ people who use illicit drugs
– Recruited from community settings in
Vancouver’s Downtown Eastside (DTES)
– Complementary cohort to VIDUS
– Ongoing since 2005
Page 12
ACCESS study: Baseline
– 817 participants; mean age = 43 (IQR: 37-48)
– 535 (66%) male; 466 (57%) Caucasian
– Homeless/marginally housed: 586 (73%)
– Live in the DTES: 528 (65%)
– Recently incarcerated: 188 (15%)
– Illicit drug use patterns:
• 136 (17%) ≥ daily heroin injectors
• 292 (36%) ≥ daily crack cocaine smokers
Page 13
Engagement in HIV care, ACCESS study, 2006 – 2012 (n = 805)
Page 14
12
8
+
+
+
4
+
+
+
+
0
Rates per 100 person-years ART treatment
16
Incidence of resistance, ACCESS study, 2006 - 2012
2006
2007
2008
2009
2010
2011
2012
Page 15
100%
Plasma HIV non-detectability, ACCESS, 2006 to 2013,
(n = 805 participants)
75%
50%
25%
0%
Proportion < 50 c/mL HIV RNA
Non-Aboriginal
Aboriginal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Interview period
Page 16
Page 17
Page 18
4
3
2
1
0
CD4 cell count per 100 cells/mL
5
CD4 cell count at treatment initiation, ACCESS, 2005 to 2013 (n = 357)
2005
2006
2007
2008
2009
2010
2011
2012
2013
Year
Page 19
Maximally-assisted therapy (MAT)
– “To improve access and adherence to ART by
minimizing barriers through a multidisciplinary
care approach”
– Directly-observed therapy; on-site MMT
– 15% ACCESS participants in MAT
– Among people with ≥ 1 day ART in last 180:
• 90% MAT participants achieved optimal adherence
• 63% non-MAT achieved optimal adherence
Page 20
HIV Cascade of Care among ACCESS
– Improvements in ART engagement, ART
adherence and viral suppression
– Relevant patient-level factors:
• Initiation of ART at higher CD4 cell counts;
• Adherence supports, including methadone codispensation;
• Decrease in pill burden
– Other factors?
Page 21
Page 22
Page 23
Factors associated with plasma HIV RNA rebound (n = 277)
Page 24
HIV treatment
initiation among
PWID:
– Illicit drug use patterns
not associated with
treatment initiation
– Barriers to treatment
initiation:
• Illicit income generation
(drug dealing, sex
work, binning, etc.)
• Incarceration
Page 25
HIV Cascade of Care among ACCESS
– Improvements in ART engagement, ART
adherence and viral suppression
– Possible effect on HIV transmission patterns?
Page 26
90
80
70
60
50
40
30
20
10
0
96 97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
12
13
Figure 2: HIV seroconversion rate, 1996 to 2012, VIDUS
Page 27
80
60
40
Rate of HIV seroconversion in HIV-negative PWID (VIDUS)
20
0
0
20
40
60
80
100
Prevalence of viral load suppression (ACCESS)
Page 28
New HIV diagnoses in BC among injection drug users, 1985 – 2012
(BC Centre for Disease Control)
350
300
250
200
150
100
50
0
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12
Page 29
>96% decrease in rate of new HIV
infections in DTES associated with:
– Scale-up of HAART
– Scale-up of low-barrier methadone
– Needle exchange to needle distribution
– Opening supervised injection facility
– Heroin prescription trial
Page 30
TasP initiatives in North America:
– Province of British Columbia
– San Francisco, California
– New York State
Page 31
TasP initiatives in North America:
– Province of British Columbia
– San Francisco, California
– New York State
Limited commitments to scale up TasP
Limited data on HIV care cascade
Page 32
Figure 3: HIV care cascade, ALIVE study, Baltimore MD, 1998 - 2011
Page 33
Page 34
Page 35
Page 36
“If you would have asked me last year if I was
for a needle exchange program, I would have
said you’re nuts… I thought, just like a lot of
people do, that it’s enabling — that you’re just
giving needles out and assisting them in their
drug habit.”
Page 37
“If you would have asked me last year if I was
for a needle exchange program, I would have
said you’re nuts… I thought, just like a lot of
people do, that it’s enabling — that you’re just
giving needles out and assisting them in their
drug habit.” — Public health nurse, Indiana
Page 38
“If you would have asked me last year if I was
for a needle exchange program, I would have
said you’re nuts… I thought, just like a lot of
people do, that it’s enabling — that you’re just
giving needles out and assisting them in their
drug habit.” — Public health nurse, Indiana.
“But then I did the research on it, and
there’s 28 years of research to prove that it
actually works.”
Page 39
Despite decades of evidence…
– HIV outbreak driven by poor distribution to
sterile syringes ongoing in Indiana,
Saskatchewan
– Methadone remains sub-optimally delivered in
many settings
– Correctional settings remain key drivers of
poor access to HIV prevention and treatment
– 1 public Supervised Injection Facility
Page 40
TREATMENT-AS-PREVENTION
– Vancouver: TasP treatment scale-up associated
with improvements in HIV care cascade and
declines in new HIV infections
– Limited commitment to TasP scale-up in North
American settings; limited data on HIV care
cascade
– Repeating failures of HAART, PEP, PrEP, etc.?
Page 41
HIV PREVENTION IN NORTH AMERICA
– Ongoing preventable HIV outbreaks
– Criminalization limits optimal HIV/AIDS treatment
and prevention
– Further research not needed on effectiveness of
TasP, HAART, MMT, SIF, etc.
– Need to identify barriers to optimal delivery of all
HIV prevention tools for people who use drugs in
all settings
Page 42
“Reinstating the [US federal government] ban [on
needle exchange funding] is murderous. It's saying
that people who use drugs should contract fatal
and expensive diseases and die....this is a truly
shameful moment, when we go backward instead
of forward, and let a politics of ignorance, of
stigma, of hate, win out over compassion,
science and a desire for a healthy community.”
Laura Thomas, Drug Policy Alliance
Page 43
Acknowledgements
• ACCESS study participants for contributions to the research
• Current and past researchers and staff
• ACCESS supported by United States National Institutes of Health
(R01-DA021525)
• M-JSM supported in part by US NIH (R01-DA021525)
Page 44