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HIV Treatment-as-Prevention (TasP) for people who use illicit drugs and implications for HCV TasP: The North American experience

M-J MILLOYResearch scientist, British Columbia Centre for Excellence in HIV/AIDS; Assistant professor, Division of AIDS, Department of Medicine, University of BC

8th International AIDS Society Conference on HIV pathogenesis, Treatment & PreventionVancouver, 22 July 2015

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I have no conflicts of interest to declare.

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Figure 1: Gains in life expectancy among ART-treated HIV+ in North America

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HIV+ people who use drugs have not benefitted equally from HAART

– Lower rates of access to HAART– Lower levels of adherence to HAART– Higher rates of discontinuation– Elevated rates of suboptimal HIV/AIDS

treatment outcomes

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After IAS 2015: Will people who use drugs in North America reap the full benefit from TasP/90-90-90?

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1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 19960

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Figure 1: New HIV diagnoses in Vancouver among PWID, 1985 to 1996

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HIV outbreak among PWID in Vancouver’s Downtown Eastside (DTES)• Proximate: Shift to cocaine injection• “Deadly public policy”

– Housing policies– Needle exchange restrictions– Police enforcement and incarceration– Changes in resource economy

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Scale-up of HIV/AIDS treatment for people who use drugs

– 2005: Immediate initiation of PWID in HIV/AIDS clinical guidelines

– 2010: STOP HIV/AIDS pilot project in DTES• Seek, Test, Treat and Retain (STTR)

– Ongoing: province-wide TasP-based effort

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AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS)

– Open longitudinal prospective cohort – HIV+ people who use illicit drugs– Recruited from community settings in

Vancouver’s Downtown Eastside (DTES)– Complementary cohort to VIDUS– Ongoing since 2005

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ACCESS study: Baseline– 817 participants; mean age = 43 (IQR: 37-48)– 535 (66%) male; 466 (57%) Caucasian– Homeless/marginally housed: 586 (73%)– Live in the DTES: 528 (65%)– Recently incarcerated: 188 (15%)– Illicit drug use patterns:

• 136 (17%) ≥ daily heroin injectors• 292 (36%) ≥ daily crack cocaine smokers

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Engagement in HIV care, ACCESS study, 2006 – 2012 (n = 805)

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Incidence of resistance, ACCESS study, 2006 - 2012

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Plasma HIV non-detectability, ACCESS, 2006 to 2013, (n = 805 participants)

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CD4 cell count at treatment initiation, ACCESS, 2005 to 2013 (n = 357)

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Maximally-assisted therapy (MAT)– “To improve access and adherence to ART by

minimizing barriers through a multidisciplinary care approach”

– Directly-observed therapy; on-site MMT– 15% ACCESS participants in MAT– Among people with ≥ 1 day ART in last 180:

• 90% MAT participants achieved optimal adherence• 63% non-MAT achieved optimal adherence

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HIV Cascade of Care among ACCESS– Improvements in ART engagement, ART

adherence and viral suppression– Relevant patient-level factors:

• Initiation of ART at higher CD4 cell counts;• Adherence supports, including methadone co-

dispensation;• Decrease in pill burden

– Other factors?

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Factors associated with plasma HIV RNA rebound (n = 277)

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HIV treatment initiation among PWID:

– Illicit drug use patterns not associated with treatment initiation

– Barriers to treatment initiation:

• Illicit income generation (drug dealing, sex work, binning, etc.)

• Incarceration

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HIV Cascade of Care among ACCESS– Improvements in ART engagement, ART

adherence and viral suppression– Possible effect on HIV transmission patterns?

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Figure 2: HIV seroconversion rate, 1996 to 2012, VIDUS

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85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 120

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New HIV diagnoses in BC among injection drug users, 1985 – 2012 (BC Centre for Disease Control)

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>96% decrease in rate of new HIV infections in DTES associated with:

– Scale-up of HAART– Scale-up of low-barrier methadone– Needle exchange to needle distribution– Opening supervised injection facility– Heroin prescription trial

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TasP initiatives in North America:– Province of British Columbia– San Francisco, California– New York State

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TasP initiatives in North America:– Province of British Columbia– San Francisco, California– New York State

Limited commitments to scale up TasP

Limited data on HIV care cascade

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Figure 3: HIV care cascade, ALIVE study, Baltimore MD, 1998 - 2011

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“If you would have asked me last year if I was for a needle exchange program, I would have said you’re nuts… I thought, just like a lot of people do, that it’s enabling — that you’re just giving needles out and assisting them in their drug habit.”

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“If you would have asked me last year if I was for a needle exchange program, I would have said you’re nuts… I thought, just like a lot of people do, that it’s enabling — that you’re just giving needles out and assisting them in their drug habit.” — Public health nurse, Indiana

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“If you would have asked me last year if I was for a needle exchange program, I would have said you’re nuts… I thought, just like a lot of people do, that it’s enabling — that you’re just giving needles out and assisting them in their drug habit.” — Public health nurse, Indiana.“But then I did the research on it, and there’s 28 years of research to prove that it actually works.”

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Despite decades of evidence…– HIV outbreak driven by poor distribution to

sterile syringes ongoing in Indiana, Saskatchewan

– Methadone remains sub-optimally delivered in many settings

– Correctional settings remain key drivers of poor access to HIV prevention and treatment

– 1 public Supervised Injection Facility

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TREATMENT-AS-PREVENTION– Vancouver: TasP treatment scale-up associated

with improvements in HIV care cascade and declines in new HIV infections

– Limited commitment to TasP scale-up in North American settings; limited data on HIV care cascade

– Repeating failures of HAART, PEP, PrEP, etc.?

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HIV PREVENTION IN NORTH AMERICA– Ongoing preventable HIV outbreaks– Criminalization limits optimal HIV/AIDS treatment

and prevention– Further research not needed on effectiveness of

TasP, HAART, MMT, SIF, etc.– Need to identify barriers to optimal delivery of all

HIV prevention tools for people who use drugs in all settings

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“Reinstating the [US federal government] ban [on needle exchange funding] is murderous. It's saying that people who use drugs should contract fatal and expensive diseases and die....this is a truly shameful moment, when we go backward instead of forward, and let a politics of ignorance, of stigma, of hate, win out over compassion, science and a desire for a healthy community.”

Laura Thomas, Drug Policy Alliance

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Acknowledgements• ACCESS study participants for contributions to the research• Current and past researchers and staff• ACCESS supported by United States National Institutes of Health

(R01-DA021525)• M-JSM supported in part by US NIH (R01-DA021525)