Steffanie Strathdee, PhD: Preventing HIV Among People Who Inject Drugs

On Friday, March 6^th, organizers of the Conference on Retroviruses and Opportunistic Infections (CROI 2020) announced the meeting would be held virtually as a result of the emerging COVID-19 situation in the United States and abroad.

In a plenary session on March 10^th, Steffanie Strathdee, PhD, discussed preventing HIV infections in people who inject drugs. Strathdee is the associate dean of Global Health Sciences and Harold Simon Professor of Medicine in the Department of Medicine at the University of California San Diego.

Contagion® spoke to Strathdee, who summarized her plenary presentation, via phone.

Strathdee: In 1997, I gave a plenary presentation at CROI in Vancouver. I presented on Vancouver's response to an HIV outbreak, which was to expand needle exchanges and expand HIV testing and methadone maintenance and then to also engage in some innovative approaches like population level treatment as prevention. They were the one of the first sites to do that, as well as the supervised injection facility, and they even piloted a heroin maintenance trial. And the US response was directly the opposite.

In fact, my paper was entered into the Congressional Record word for word. It was used as a political weapon to keep the congressional ban on federal funds for any needle exchange in place. And I was horrified, you know, because these 2 countries had told two totally different interpretations of what was happening. I thought it was useful to have that as a frame to say, "Okay, well, where are we now, with the US HIV epidemic?"

I've been living in the US since 1988 and clearly, we're in the throes of this major opioid crisis. It's driven not just by prescription drug use, but also heroin and fentanyl. In my presentation, I talked about why fentanyl is of special concern. Because it's used as a powder, people don't need to necessarily heat it to inject it and the heat is thought to deactivate and HIV and so we could start to see more HIV associated with fentanyl injection.

I walked through the epidemiology of where we are with the US HIV situation right now. We've seen a totally different pattern in the last few years. It used to be an epidemic among older, mostly African American, urban, drug injectors and now we're seeing mostly rural or suburban, white and younger people who are infected and so it's a very different pattern. We're also seeing about half of the new infections are among women, even though women are generally underrepresented among drug injectors as a population, they're overrepresented in terms of the HIV and I talk about some of the reasons for this. There are some gender inequities with women being second on the needles. If they are dependent on men to get their syringes or their drug supply or both, then they are often not an equal position to ensure that their syringes sterile. They may engage in sex work and have dependent children and those kinds of things may put them at higher risk for HIV infection.

I also highlight some of the behavioral surveillance data that was just released by the National HIV Behavioral Surveillance Program from the CDC. It shows that 6% of injectors across 23 cities are HIV positive. That sounds low, but then when you realize that one-third are using a syringe after somebody else is using it, just over half have been tested for HIV in the last 12 months and then needle sharing is more common among younger injectors, we start to see why the patterns that I've described are being perpetuated.

So, then I highlight 3 different outbreaks that have occurred.

The 1 that people are most familiar with is the oldest one in Scott County, Indiana. And yet, there's some new modeling work that came out over the last couple of years that showed that this epidemic could have largely been prevented if they had started harm reduction early when the epidemic was just taking off. There's another paper that is referenced in my presentation showing that incidence of HIV could have been blunted considerably if they if they had a proactive response to syringe service implementation, as opposed to a reactive response.

Then I go on to talk about viral hepatitis in West Virginia and how it was a really a harbinger of what we could expect to see with HIV. So the interventions were not put in place, and therefore, as you would predict, we have an HIV outbreak, not 1 but you know, a couple in West Virginia. It's very challenging in this setting, because West Virginia is entirely based in Appalachia, a very socially disadvantaged community, with multiple overlapping syndemics, which are co-occurring epidemics that have the same root causes. So here I'm talking about not just overdose deaths but acute hepatitis C, hepatitis B, neonatal opioid withdrawal syndrome. The adverse effects that are associated with a high performance in foster care was kind of keeps the cycle of addiction going. Unfortunately, the West Virginia lawmakers are doing the wrong thing by trying to ban statewide syringe exchange. There was a very successful, that small syringe exchange program going on in Charleston, they were pressured to close in March of 2018. They have not reopened.

Instead of expanding syringe access and methadone maintenance, West Virginia even has a moratorium on new methadone programs. So, it's kind of the recipe for an epidemic is how I would frame that.

And then the third epidemic that I talked about is in Massachusetts. There was an outbreak in Lowell and Lawrence counties in the northeastern part of the state. This was just recently published on in a paper in American Journal of Public Health. Once again, the syringe exchange implementation was late. The epidemic started in 2015, it wasn't until 2017 that syringe exchange was implemented in Lawrence; in 2018 that it was implemented in Lowell. So, again, you know, we're seeing that we're behind the eight ball when the horse is already out of the barn.

Here is a different pattern of outbreak though, because in Scott County, we saw it was a point-source epidemic, where the epidemic was in 1 social network and it went through that network very quickly. Here we have a molecular epidemiology showing that there's multiple introductions of the virus and smaller networks. They also were able to look at what proportion of HIV-positive injectors were suppressed virally, because of antiretroviral use and adherence. You can see that for the entire duration of this outbreak, there's a high proportion that are not virally suppressed. So that's going to promote onward transmission.

When you think about ending the HIV epidemic and the goals that the federal government has set forth, they're very ambitious. It's not just prevention, it's treatment that we need to think about in the continuum of prevention to treatment, because if we don't engage highly stigmatized people such as drug injectors into care and support them then they're going to just, you know, have high viral loads and a single needle sharing event could lead to an infection.

So, I talk about this whole cascade of care. I present some data from Tijuana, from my own studies, and show how abysmal engagement and care is and that none of the drug injections are on ART, so not surprisingly, none are virally suppressed. And then when it comes to things like PrEP, we see that we've got a similar problem there. Drug injectors are maybe talking or thinking about PrEP, but they're not receiving it from their providers. That's another missed opportunity.

Then, the last cascade is the Drug Abuse Treatment Cascade, because we need to think about drug abuse treatment as HIV prevention, especially methadone and buprenorphine maintenance. Yet, there's a major treatment gap with only about 20% of people who inject drugs ever being on methadone maintenance at any given time. That means that people are going to continue injecting and potentially sharing needles and spreading the virus. The National Academies of Science, Engineering medicine just had a report. It was published in January, and many of the people who were attended CROI took part in the consultations. They identified a number of barriers to integrated services for addiction treatment and treatment for opioid addiction. Several of these are policies and programs. So, requiring prior authorization or same-day billing restrictions. If we could eliminate some of those barriers, we would go a lot farther to ensuring that people were having access to opioid treatment.

Finally, I talked about how it isn't just opioids, but there's a lot of concomitant substances such as alcohol and methamphetamine. Methamphetamine is really on the rise. That's a concern because people who inject methamphetamine tend to have more chaotic lifestyles, and they're much more at risk of failing to adhere to an antiretroviral regimen.

But we do have some good news on the horizon, there was a clinical trial that was published recently showing that mirtazapine, which is a treatment for depression, was associated with abstinence to methamphetamine. It was also associated with declines in unprotected sex among men who are having sex with men. What we need now is to ensure that treatments like methadone, buprenorphine and mirtazapine are scaled up, so that we can try to put a dent in the opioid epidemic, and therefore the HIV epidemic. I do highlight 1 paper which is an international multisite, randomized, control trial from the HIV Prevention Treatment Network that shows an integrated approach of having peer navigation and psychosocial counseling was able to improve engagement and drug abuse treatment and a higher uptake of antiretroviral treatment and more adherence, and therefore it halved mortality. That is a really terrific outcome and we need to learn those lessons in the US.

So, then I wrapped the whole thing up by saying that there are structural drivers that are impeding prevention and treatment among people who inject drugs. We need to address these underlying drivers, if we're going to end the epidemic, because we really know how to prevent these epidemics. It's not like the coronavirus right now, where we don't have a treatment available and we don't know what to do. We do know what to do and what we need is leadership and political will and advocacy. We need to remove these structural barriers to prevention and treatment programs and scale them up and have an evidence-based approach that looks at addiction as a medical problem, not as a moral problem.

If we don't do that, we're going to keep repeating history. So that's why I wanted to title this, plus ça change, plus ça même chose, the more some things change, the more they become the same. My last slide is really a call for an addiction subspecialty within infectious diseases. Because infectious disease providers are arguably the discipline that sees people who inject drugs the most and has a better understanding of their needs. Yet, there's very paltry training for addiction within medical school. If we are able to change that, I think that we'll have a future generation of leaders that will be able to address the concerns in this community.

The plenary, Preventing HIV among people who inject drugs: plus ça change, plus ça même chose, was presented on Tuesday, March 10, 2020, in a virtual session of CROI 2020.

Strathdee is the author of The Perfect Predator: A Scientist’s Race to Save Her Husband From a Deadly Superbug. Contagion®’s coverage of Strathdee’s story is available here.