Michel Kazatchkine, UN Secretary-General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia talks with Eduard Karamov, Ivanovsky Institute of Virology, Russian Federation. Photo ©Marcus Rose/IAS

Providing opioid substitution therapy (OST) alongside antiretroviral therapy to people who inject drugs results in a significantly greater reduction in deaths compared to providing either intervention alone, a study of the Canadian province of British Columbia has shown.

The findings were presented by Dr Bohdan Nosyk and colleagues from the University of British Columbia Centre for Excellence in HIV/AIDS at the Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015) in Vancouver.

Research from Ukraine, also presented at the conference, showed that people receiving opioid substitution therapy had better engagement with HIV care.

Opioid substitution therapy is recommended by the World Health Organization as a core element of the harm reduction and care package that should be provided for people who inject drugs after diagnosis with HIV. There are big variations worldwide in access to opioid substitution therapy for people living with HIV who inject drugs: a 21-country survey published in 2013 found average coverage of just 3% for this population.

Opioid substitution is resisted in many countries because of the belief that heroin addiction can only be treated by abstinence. Methadone substitution is illegal in the Russian Federation, one of the countries with the most severe epidemic of HIV in people who inject drugs. Russian attitudes towards methadone are so hardened that opioid substitution therapy programmes in Crimea were halted following Russian occupation of the region in 2014, Professor Michel Kazatchkine, UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia, told a plenary session at the conference.

Dr Nora Volkow, director of the United States National Institute on Drug Abuse told a press conference that opioid substitution therapy “is a win-win for prevention and a win-win for treatment, but there are too many places where it’s not happening… I don’t know of any other area of medicine where despite the evidence that the intervention works, someone says ‘we’re not going to do that because I think that that is not right’.”

Opioid substitution therapy may be provided in the form of daily methadone or buprenorphine, and an extended-release buprenorphine implant is being tested with the aim of winning US Food and Drug Administration (FDA) approval.

Opioid substitution therapy has the potential to minimise drug-related harm by reducing the risk of drug overdose, reducing exposure to injecting-related bacterial infections and hepatitis C, stabilising drug users in order to address other health issues and allow comprehensive treatment of drug misuse. By reducing or eliminating dependency on heroin, OST reduces illicit drug consumption and has the potential to reduce the criminalisation of drug users.

View other major presentations on injecting drug use and HIV at IAS 2015 using the links below.

Christopher Pilcher at IAS 2015. Photo by Liz Highleyman, hivandhepatitis.com

Studies have convincingly shown that early antiretroviral treatment improves the health and survival of individuals living with HIV and has the added public health benefit of reducing HIV transmission. But getting people into care can be challenging and some are lost at each stage of the HIV care cascade.

A programme at San Francisco General Hospital that offers antiretroviral therapy on the same day as HIV diagnosis led to a high rate of treatment uptake and more rapid viral load suppression compared to standard practices, according to late-breaking study findings presented at the conference.

People newly diagnosed with HIV and clinic providers both expressed enthusiasm about the RAPID programme, which is now being implemented more widely as part of the city's 'Getting to Zero' initiative.

Participants in the RAPID programme achieved viral suppression in a median of 56 days, compared with 119 days for those in the universal antiretroviral therapy standard-of-care group and 283 days in CD4-guided treatment group. After three months on antiretroviral therapy, 75% of RAPID participants achieved viral suppression, compared with 38% in the two standard-of-care groups. After six months the corresponding response rates were 95% vs 70%.

Image from presentation by Galant au Chan at IAS 2015

HIV has had a severe generational effect on urban gay and bisexual men in North America, Europe and Australia who were sexually active during the 1980s.

An innovative analysis of HIV trends in the Seattle area has found that gay men who were born in the early 1960s (and are now in their fifties) have the highest lifetime risk of becoming HIV positive.

By the age of 30, one-in-five white gay men have acquired HIV. By the age of 50, two-in-five have done so. There are also severe racial inequalities. Three-in-five black gay men of this generation have acquired HIV by the age of 50.

However, the situation has considerably improved for more recent generations, both black and white.

Presenting the findings to the conference, Galant au Chan of the University of Washington said that the results are probably not generalisable across the United States.

Seattle has high-quality services and a well-informed population. Dr Chan is planning to conduct similar analyses of the epidemic in other parts of the country to compare results.

Image from presentation by Julie Pannetier at IAS 2015.

Until recently, it had generally been assumed that African migrants who were diagnosed with HIV while living in European countries had acquired HIV before migration. Most come from countries where the prevalence of HIV is very high.

If transmission mostly occurs before migration to Europe, the priority for European health services is testing and diagnosis. However, if transmission occurs while living in Europe, a broader prevention response is appropriate.

In France, migrants from sub-Saharan Africa are disproportionately affected by HIV, making up a quarter of all people living with HIV in the country.

However, research presented to the conference suggests that between a third and a half of African people living with HIV in France probably acquired HIV after they left Africa.

The study of 1031 African migrants receiving HIV care in France used CD4 cell count data and life histories to calculate dates of seroconversion. Researchers concluded that between 35% and 49% acquired HIV after arriving in France. Men, younger people and those who had lived in France for longer were more likely to have acquired their infection after migration.

Similar findings have been reported in the United Kingdom, where epidemiologists have calculated that around a third of African people diagnosed with HIV in the UK seroconverted after migration.

Dr José Gatell at IAS 2015. Photo by Liz Highleyman, hivandhepatitis.com

A new NNRTI, doravirine, was found to be as effective as efavirenz at suppressing HIV replication. Additionally, half as many study participants taking doravirine experienced drug-related side-effects and they were less likely to stop treatment prematurely.

Drugs in the non-nucleoside reverse transcriptase inhibitor (NNRTI) class of antiretrovirals are generally effective and easy to use.

Efavirenz (Sustiva or Stocrin, also part of the combination pill Atripla) has been widely used, but often causes central nervous system (CNS) side-effects, such as dizziness and abnormal dreams. As a result, it is no longer recommended in US or European treatment guidelines for use by people starting HIV treatment for the first time.

Dr José Gatell from the University of Barcelona reported the latest results from an ongoing study comparing doravirine with efavirenz, for people starting HIV treatment. Overall treatment response rates were comparable in the two groups, but participants taking doravirine were less than half as likely as participants taking efavirenz to discontinue treatment. The difference was mainly driven by a higher drop-out rate due to side-effects from efavirenz.