Co-managing HIV, Hepatitis C, and Opioid Abuse

Naveed Saleh, MD, MS


January 23, 2018

Infection and Opioids

Effective antiretroviral treatments for HIV and hepatitis C exist and are widely available. In fact, treatment for hepatitis C is curative, which hardly seemed imaginable only a few short years ago. But despite there being effective treatments for these diseases, barriers exist that make their treatment difficult. Chief among these barriers is intravenous use of opioids.

The stark reality is that people with hepatitis C or HIV, or both diseases, are much more likely to die of drug overdose than of chronic illness itself. Furthermore, according to the Centers for Disease Control and Prevention, in 2014 death from drug overdose was more common than death caused by motor vehicle accidents or firearms. Of note, 80% of people who inject drugs and are HIV-positive also have hepatitis C.

At IDWeek 2017, managing infectious disease in opioid users was an important topic of coverage. In a lecture titled "Co-management of Opioid Treatment, HIV, and Hepatitis C Treatment," Brianna Norton, DO, MPH, an assistant professor of infectious disease and internal medicine at the Albert Einstein College of Medicine, discussed evidence-based approaches to treating opioid use disorder in patients with HIV and hepatitis C.[1]

The Austin, Indiana, Outbreak

In late 2014, an HIV outbreak was centered on a small rural town called Austin, in Scott County, Indiana. Austin is about 80 miles southeast of Indianapolis. Although Austin has a population of approximately 4200, by June 2015, 170 people had been diagnosed with HIV infection. To put this number in perspective, during the 10 years before the outbreak, only 5 people had been diagnosed with HIV in Scott County.[2]

In a 2016 article titled "HIV Transmission and Injection Drug Use: Lessons From the Indiana Outbreak," Diane M. Janowicz, MD,[2] attributed this HIV outbreak to injection drug use. "It is estimated that there were more than 500 syringe-sharing partners in Scott County. Injection practices were multigenerational and injection equipment was commonly shared. Individuals diagnosed with HIV infection during the outbreak had an average of nine high-risk syringe-sharing, sex, or social partners who needed to be tested for infection. The drug most commonly used was oxymorphone, in a reformulation available since 2012, which was crushed and injected. Oxymorphone produces a fixed but short-lived high, and individuals may inject the substance as many as 20 times per day."

According to Janowicz,[2] what happened in Austin serves as a "cautionary tale" illustrating the toll of the opioid epidemic.

"The patients whom we treat in the HIV clinic or our infectious disease clinics are going to be people who use drugs," says Dr Norton. "The core of the epidemic is people who inject drugs or people who use drugs.... These people who walk into your clinic—although you can treat them for HIV and cure them of hepatitis C, if we're not paying attention to their opioid disorder, they are going to die."

Evidence Basis for Opioid Substitution Therapy

The reality that opioid substitution therapy is the primary intervention to curb transmission of HIV and hepatitis C is well supported in the literature. With respect to hepatitis C transmission, in a 2017 Cochrane review, Platt and coauthors[3] suggest the following:

Opioid substitution therapy is associated with a reduction in the risk of HCV acquisition, which is strengthened in studies that assess the combination of opioid substitution therapy and needle syringe programs. There was greater heterogeneity between studies and weaker evidence for the impact of needle syringe programs on HCV acquisition. High needle syringe program coverage was associated with a reduction in the risk of HCV acquisition in studies in Europe.

As for HIV transmission, in a 2012 meta-analysis and systematic review published in the British Medical Journal, MacArthur and coauthors[4] conclude with the following:

Our study provides strong quantitative evidence of an association between opiate substitution treatment and reduced risk of HIV transmission among people who inject drugs. These data further support studies showing a range of benefits of opiate substitution treatment, and support calls for the global increase of harm reduction interventions to reduce the transmission of HIV between people who inject drugs and the wider community.

In addition to curbing transmission of HIV and hepatitis C, opioid substitution therapy greatly benefits the individual patient with opioid use disorder. According to Dr Norton, this intervention improves HIV outcomes; boosts HCV cure rates; and improves quality-of-life measures, including physical and mental health outcomes.

Approaching Opioid Substitution Therapy

The Drug Addiction Treatment Act of 2000 expanded access to medication-assisted treatment for opioid dependence. This legislation allowed qualifying physicians to provide office-based addiction treatment with buprenorphine, which is an opioid partial agonist.[5] Although infectious disease specialists and primary care physicians can prescribe buprenorphine, only a small minority of physicians have undertaken qualification to do so.

For HIV and hepatitis C to be managed effectively, Dr Norton encourages more providers to obtain the qualification to prescribe buprenorphine, which requires only 9 hours of training. "The best thing you can do as an HIV provider is offer [your patients] harm reduction," she says. "You can prescribe syringes, you can prescribe Narcan®, and you can discuss their risk for overdose death, which at that point is probably the biggest threat to their mortality."

Dr Norton continued, "After establishing a relationship over their HIV care, you can then start to discuss opioid substitution therapy [with your patients], and you can either refer them or start them on buprenorphine, which is what I do. Once you start them on buprenorphine, you can save them from overdose and skin and soft-tissue infections. Of note, by giving them harm reduction and opioid substitution therapy, you can reduce further transmission of HIV and hepatitis C in your community and reduce overall prevalence and incidence rates."

"[Finally], once they're undetectable for HIV, you can offer [your patients] a cure for hepatitis C," Dr Norton concluded. "You can truly save their lives. It's very rewarding to be able to offer someone all of these treatments in one setting and feel that you've made a life-changing difference in their outcomes."

On a final note, although Dr Norton does provide some counseling to patients and has case managers in her clinic, she stresses that psychotherapy shouldn't be an obstacle to the prescription of buprenorphine. "The more you can get someone counseling and psychiatric care, the better long-term health outcomes that person is liable to have," she said. "I think that the catch is not to make an unnecessary barrier to a prescription of buprenorphine, which may allow them to stop using heroin and reduce chaos in their lives and then enable them to see a psychiatrist."


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