- Delivering HIV medication and methadone together was linked to greater adherence
- Engaging patients facilitated HIV drug adherence rates above 95%
- Researchers called for decentralized delivery of ART and methadone together
The widespread availability of HIV testing and treatment has generally led to significantly reduced rates of AIDS-related illness and death in Canada and other high-income countries. The benefits of HIV treatment (ART) are so profound that scientists increasingly expect that many ART users will have a near-normal life expectancy. However, some populations—such as those with chaotic lives and/or competing priorities caused by trauma, addiction, untreated or poorly managed mental health conditions, or homelessness— may not be able to take ART exactly as prescribed and directed.
A key part of a larger strategy of helping people who use street drugs such as heroin and other opioids is the prescription of methadone. Prescribed methadone can help stabilize the lives of people who use street drugs and serve as an entryway to other services. As sharing unsterile equipment for street drug use can lead to a range of infections, including HIV and hepatitis C virus (HCV), people who are receiving methadone or other opioid substitution also need to be offered screening and treatment for these germs.
In Vancouver, a team of scientists who work with people who use street drugs have noted that there are sites—community clinics, doctors’ offices, pharmacies—where both ART and methadone are provided. In such places, pharmacists or nurses observe patients taking their dose of methadone. The scientists, based at the B.C. Centre on Substance Use, the University of British Columbia and the B.C. Centre for Excellence in HIV/AIDS, conducted a study to assess the long-term impact of dispensing both ART and methadone in once place. They found that the likelihood of HIV-positive people achieving high adherence (95% or greater) to ART was significantly enhanced when both ART and methadone were dispensed in the same location as opposed to in different locations.
The B.C. scientists stated that their findings “highlight the need to consider a simple integrated approach with medication dispensation [of ART and methadone] at the same facility in low-threshold settings.”
The scientists accessed information from several databases, principally the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS). Since 2005, this database has enrolled HIV-positive people who use street drugs from the following places listed by the scientists:
- open drug markets
- harm reduction sites
- low-barrier social service organizations
Participants in ACCESS answered surveys and had blood drawn on a regular basis for analysis.
For the present study, scientists focused on information collected from 345 participants, distributed as follows:
- 121 people who were taking ART and methadone, both dispensed in the same facility
- 224 people who were taking ART and methadone dispensed in different facilities
A brief profile of participants upon entry to the study is as follows:
- age – 46 years
- 57% men, 43% women
- 93% were co-infected with HCV
- substances used included: alcohol, cocaine, crack and heroin
- the average dose of methadone used was 90 mg/day
The scientists focused on the period between June 2012 and December 2017.
The scientists found that participants who received methadone and ART in the same setting were significantly more likely to achieve what the researchers called “optimal adherence to ART” (adherence rates of at least 95%) than participants whose drugs were dispensed in different locations.
Why the difference?
The scientists noted that “daily ingestion of [methadone] provides an opportunity to supervise the…consumption of ART” in places where methadone is dispensed.
The B.C. scientists stated that their findings can be used to “assist government officials, policy makers and service providers to make decisions on designing [services] for the provision of [methadone] and ART for HIV-positive people who use drugs.”
The scientists called for a decentralized approach to providing the delivery of ART and methadone; this would include “accessible community-based distribution settings and the potential engagement of nonmedical staff to mitigate the effects of stigma and discrimination often experienced by people who use drugs.” They also stated that “pharmacy-delegated methadone administration may better meet the needs of people who use drugs, potentially leading to improved treatment outcomes” for both opioid use disorder and HIV infection.
The present study did not randomly assign participants to different clinics/locations for receiving ART and methadone. Therefore, its findings may not be applicable outside of ACCESS. Also, the scientists noted that their findings may not apply to “stabilized…patients who receive take-home doses [of methadone].”
Nevertheless, the study’s findings document an important aspect of care that may be needed by some HIV-positive people who use street drugs—the dispensation of both ART and methadone in the same facility. The high rate of adherence found in such facilities shows the potential for keeping some, perhaps even many, HIV-positive people who use methadone retained in HIV treatment. This latter point is important if cities, regions and countries are to help more people achieve and maintain the benefits of ART.
—Sean R. Hosein
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