Why Patients with HIV & HCV Are More Likely to Die from Overdose than Disease

Outcomes for patients with HIV and Hepatitis C (HCV) virus have improved dramatically, but many physicians fail to treat their patients’ leading cause of mortality — opioid overdose.

Physicians must consider the treatment of opioid use disorder (OUD) a necessary component of HIV and HCV treatment, especially as an opioid epidemic overwhelms the nation, according to Brianna Norton, DO, MPH, Assistant Professor at Albert Einstein College of Medicine, Montefiore Medical Center, New York.

In a presentation at ID Week 2017 in San Diego, CA, Norton said that 60% of existing HCV prevalence is among people who use drugs (PWUD), and 80% of the incidence of HCV is in PWUD, yet many of these people are often denied treatment.

“We have thought for a long time that this predominantly affected the baby boomer cohort, but we now know that this is no longer true because of the opioid epidemic,” Norton said.

The majority of new HCV infections between 2007 and 2012 were in young PWUD. During that time, the US saw a more than 50% increase in HCV infections, with certain states suffering a more than 200% increase.

New HIV infections followed a similar trend. 10% of new HIV infections were among people who inject drugs [PWID]. 80% of patients with HIV who inject drugs are co-infected with HCV, and suffer poorer outcomes because of co-infection.

“The people who come into your clinics are going to be people who have HIV and who have Hep C. They are going to be people who are using drugs, and they are going to be sick,” Norton said. “When these people walk into your clinic, you can treat them for their HIV and cure them of their HCV, but if we’re not paying attention to their OUD, there are going to be other reasons that they die.”

Norton outlined several key points for physicians looking to improve outcomes and reduce mortality for patients with HIV, HCV and OUD:

• Take buprenorphine training online (8 hour commitment)
• Get a nurse at your clinic to invest in the training
• Do not withhold HIV or HCV treatment for PWUD
• Write prescriptions for syringes or narcan to reduce harmful behavior
• Discuss harm reduction with your patients
• Treat patients concurrently with their sexual or drug using partners

There are benefits to treating OUD that go beyond reducing individual mortality, Norton said — this type of treatment also reduces incidence and transmission of HIV and HCV within communities.

To support that statement, Norton cited real-world results of the April 2017 controlled, randomized PREVAIL study. In the study, patients were randomized into 3 arms to either self-administer HCV medications, take observed oral doses by nursing staff at the same time as receiving methadone or buprenorphine and weekly directly administered IFN injections if applicable, or attend a weekly treatment group and weekly directly administered IFN injections if applicable.

“No matter what group you were in, SVR12 [sustained virologic response at 12 weeks] rates for Hep C were wonderful within this opioid therapy program,” Norton said. “It shows that in real life, integrating opioid opioid substitution therapy [OST] and Hep C treatment can be good, and people can do well with it.”

The results are especially notable, Norton said, because many of the patients in the study were from difficult-to-treat populations. 90% were on Medicaid, more than half were PWUD, with half of PWUD using buprenorphine, and about 25% had HIV.

“It’s very rewarding to be able to offer someone treatment for HIV, HCV and OUD in one setting. You feel that you have made a life changing different in their outcomes. You can truly save their lives,” Norton said. “You can save them from overdosing, skin and soft tissue infections, and most importantly, by giving them harm reduction and OST you can reduce further transmission of HIV and Hep C in your community.”