Intensive efforts to reach people who inject drugs who have
acquired HIV in a recent transmission outbreak in the city have resulted in
high levels of antiretroviral treatment and viral suppression in a
predominantly homeless population, clinicians and nurse specialists from
Glasgow’s Brownlee Centre for Infectious Diseases reported in a poster discussion session dedicated to
the city’s response to the outbreak at the International Congress on Drug Therapy in HIV Infection (HIV Glasgow 2018) last week.
An HIV
outbreak among people who inject drugs in Glasgow was detected in 2015.
Virus sequencing by a team at the University of Edinburgh has established that
119 people diagnosed with HIV in Scotland were infected with a subtype C strain
of HIV that had two mutations conferring resistance to non-nucleoside reverse
transcriptase inhibitors. This viral strain was first detected in a person
diagnosed with HIV in 2005. Transmission began to accelerate in 2014 and in
2016; around 100 very closely related viruses were identified in
recently diagnosed drug users, indicating very rapid transmission.
Professor Andrew Leigh-Brown of the University of Edinburgh
said that the outbreak was one of the largest of recent years among people who
inject drugs. The Glasgow outbreak was on a similar scale to those in the US state
of Indiana and in Athens, but unlike those outbreaks, it occurred in the face
of intensive harm reduction activity in the city.
After the outbreak was detected, engaging people in care and
encouraging them to start antiretroviral therapy (ART) was a priority. Healthcare
workers in Glasgow faced several challenges: many of the drug users diagnosed
with HIV were homeless and spent their time in the east end of Glasgow, far from
the city’s main HIV clinic at Gartnavel Hospital on the western outskirts of
the city. A new model of care was needed, Erica Peters of the Brownlee Centre
told the symposium.
Instead of offering hospital-based appointments and
antiretroviral dispensing, consultants and clinical nurse specialists went out
to provide clinical services at homeless healthcare facilities in the city. Nurses
have also gone to areas known as public injecting sites, as well as homeless
shelters and areas known for rough sleeping, to follow up patients. As a
result, two-thirds of people who inject drugs diagnosed with HIV have attended
a consultant-led bloodborne viruses clinic in a health facility for the
homeless.
Antiretroviral drug dispensing was carried out through
community pharmacies. Seventy-two people received antiretrovirals in this
way, dispensed alongside opioid substitution therapy and by July 2018, 43
people were still receiving antiretrovirals through a community pharmacy.
Overall, 102 people who inject drugs diagnosed since 2014 have ever received
antiretrovirals, reported Rebecca Metcalfe of the Brownlee Centre. Ninety-five
per cent are currently on treatment and 86.5% of all those diagnosed have an
undetectable viral load.
As well as being critical for individual health, rapid ART
initiation also has the potential to reduce HIV transmission. In September 2015 guidance on treatment initiation changed, to recommend treatment regardless of CD4 cell count. A comparison of
the speed of ART initiation between men who have sex with men (MSM) and people who
inject drugs diagnosed with HIV in Glasgow with CD4 counts over 350 cells/mm3 at diagnosis showed that it took five times as long
for drug users to start treatment compared to MSM after September 2015.
Prior to September 2015, it took MSM 154 days to start
treatment, whereas it took a median of 385 days for people who inject drugs to
start treatment.
After September 2015 the interval between diagnosis and
treatment initiation in MSM fell to 22 days, an 86% reduction. In people who
inject drugs the median interval fell from 385 days to 111 days, a 71%
reduction.
The outreach clinic has also provided direct-acting
antiviral treatment for people with hepatitis C co-infection through community
pharmacies, in the same way as for antiretroviral drugs. Seventy-six people were
diagnosed with chronic hepatitis C virus (HCV) infection. Of these, 26 have already begun treatment
and 50 await treatment. Of the 18 people who have completed treatment, 17 had
an undetectable HCV RNA at the end of treatment and in one case, treated
failed. One person has subsequently been reinfected with HCV.