HIV-infected drug users have increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. This includes an increased risk of viral hepatitis, tuberculosis (TB), bacterial infections, and mental illness. In a new paper in The Lancet Series on HIV in people who use drugs, Professor Frederick L Altice, Yale University, New Haven, CT, USA, and colleagues show that there are evidence based treatments for both HIV and these co-morbidities, and that antiretroviral treatment (ART) for HIV can improve not only the course of HIV infection but also these other conditions.
The authors say: "Evidence-based treatment for substance-use disorders improves the psychological and physiological disruptions that perpetuate the often unstable life of HIV-infected drug-dependent individuals. Treatment of HIV infection, substance-use disorders, and comorbidities in HIV-infected drug users is improved by comprehensive and multidisciplinary management of these disorders."
If appropriately dosed, medication-assisted therapies for opioid and alcohol dependence, such as methadone, buprenorphine and injectable naltrexone, enhance adherence to ART in patients with HIV, as well as treatment for the above mentioned co-morbidities. Furthermore, they improve retention in HIV care and decrease HIV risk behaviours.
The authors note that as and when ART becomes universally available to drug users with HIV, and their health status improves, so their other health problems will take on increased prominence, such as non-AIDS related comorbitities and TB, all of which will come with their own treatment priorities. HIV infected drug users with TB co-infection creates various clinical challenges since TB can be difficult to diagnose in HIV patients due to atypical chest radiographs, high-rates of TB in parts of the body outside the usual setting of the lungs, and the reduced sensitivity of skin tests used to diagnose TB in HIV patients. While people with latent TB but not HIV infection have a roughly 1 in 11 lifetime risk of having their TB develop into full blown disease, it becomes a 1 in 11 annual risk in patients with HIV co-infection. Concentration of people with HIV and substance use disorders behind bars facilitates transmission of TB, including multidrug resistant strains, due to overcrowding and increased numbers of people who are immunosuppressed. Despite available treatments for HIV and substance use disorders, little treatment is available within these settings.
Due to common routes of transmission, between 60% and 90% of HIV infected IDUs have hepatitis C, and few receive treatment for reasons including cost, physician reluctance, concern about poor treatment adherence, and misperception about potential harm of hepatitis C. Though effective treatments are available, treatment resources are limited due to expense and availability; if the person has hepatitis B, however, they can be treated with other oral antiviral agents that are also effective against HIV.
Mental illness and substance-use disorders are closely inter-related with HIV infection and concentrated especially among prison populations. If drug treatments such as antidepressants are warranted, then care must be taken in the selection of the medication. Some common antidepressants are associated with decreased metabolism of methadone in patients on OST, yet most are safe and effective.
"The concentration of HIV behind bars is a result of society's punitive rather than treatment-oriented approach to drug use," says Professor Altice*. "Despite society's failed policy of mass incarceration of drug users, many of whom are HIV-infected, these sites may be seminal places for the identification and treatment of HIV, but requires sufficient resources to continue care, not only for HIV but for the myriad of substance use disorders, mental illness and other complications, after release."
The authors conclude: "HIV-infected drug users have substantial HIV-related and non-HIV-related medical and psychiatric comorbidities. As a result, care is often complicated for the individual and for the health-care system. Several evidence-based interventions are available to improve treatment outcomes for this vulnerable population, but parity in treatment outcomes to reduce morbidity and mortality in HIV-infected drug users will be achieved only with further resources, expertise, political will, and commitment by the health-care establishment."
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