A growing number of people with HIV in the US are dying from opioid
overdoses, according to a presentation at the Conference on Retroviruses and
Opportunistic Infections (CROI 2019) this month in Seattle.
While total mortality among HIV-positive people declined by 13% between
2011 and 2015, opioid overdose deaths in this population rose by 43%, Dr Karin
Bosh of the US Centers for Disease Control and Prevention (CDC) reported.
The ongoing opioid crisis in the US is a national public health
emergency, Bosh said. Since the start of the epidemic in 1999, approximately
400,000 people have died from prescription and illicit opioid overdoses, with
more than 80% of these being accidental. In 2017 there were more than 70,200
overdose deaths, two thirds of them due to opioids, according to the
CDC. A growing proportion of these deaths are attributable
to fentanyl, a synthetic opioid that is stronger than heroin.
People living with HIV often experience chronic pain, may receive higher
doses of opioids and have a high rate of substance use disorders and mental
illness, all of which could increase the risk of overdose, Bosh noted as
background.
The CDC researchers used National HIV
Surveillance System data through December 2017 to analyse opioid overdose
deaths between 2011 and 2015 (as reported through December 2017) among people
diagnosed with HIV in all 50 states and Washington, DC.
During this period, 1363 opioid overdose
deaths were reported. The opioid overdose death rate rose from 23 per 100,000
people with diagnosed HIV in 2011 to 33 per 100,000 in 2015, an increase of 43%.
Over the same period, the proportion of all deaths among HIV-positive people
that involved opioids increased from 1.2% to 2%.
Opioid overdose deaths rose in all
population subgroups, Bosh reported. In 2015, HIV-positive women were more
likely to die of opioid overdoses than men (about 35 versus 32 per 100,000).
The death rate rose by 47% among women and by 42% among men.
White people had the opioid overdose highest
death rate in 2015 (49 per 100,000), followed by Latinos (around 32 per
100,000) and African Americans (around 15 per 100,000). However, black
Americans saw the largest increase – a 73% rise, compared with 35% and 26%,
respectively, for whites and Latinos – reflecting the shifting demographics of
the US opioid epidemic.
By age, people aged 50-59 had the highest rates
(around 42 per 100,000), followed by those aged 40-49 (around 35 per 100,000), those
aged 30-39 and 60 or over (both around 25 per 100,000) and those aged 20-29
(around 20 per 100,000). Again, the groups with the lowest rates saw the largest
increases: 113% for the youngest group and a dramatic 202% for the oldest.
As expected, people in the injection drug
use HIV transmission category had a much higher likelihood of overdose death
(137 per 100,000) – as well as the largest increase, at 80% – than men who
have sex with men and heterosexuals (both around 15 per 100,000).
The highest opioid overdose death rate was
seen in the Northeast (around 60 per 100,000), followed by the Midwest (around
35 per 100,000), with lower rates in the South and West (both around 20 per
100,000). Deaths rose in all geographical regions except the West. Bosh
suggested this may be because the type of heroin widely available in the West
is harder to adulterate with fentanyl and other synthetics.
The
conference also included a symposium on substance use and HIV, featuring a
presentation on opiates and HIV. Dr Ricky
Bluthenthal of the University of Southern California in Los Angeles said that
the US opioid crisis has now reached all groups, regardless of demographic
characteristics, economic status or geography.
Bosh stressed the need for providers who
treat people living with HIV to engage in overdose prevention efforts, recommending
that these efforts target groups with the highest overdose death rates or
largest increases, in particular people who inject drugs.
One of the most reliable ways to prevent
opioid overdose deaths – which does not require waiting for broader
longer-term efforts to take effect – is providing people who use drugs with
ready access to naloxone (Narcan), a
medication that quickly reverses opioid overdoses.
Another approach is supervised
injection facilities or drug consumption rooms, which allow people to use drugs
under the watch of medical personnel or trained volunteers who can intervene in
case of overdose. There are currently around 120 such sites in 12 countries
worldwide, including Australia, Canada and several European countries, according
to the Drug Policy Alliance. There are current no supervised
injection sites in the UK or in the US, though several cities including New
York, Philadelphia, San Francisco, Seattle and Glasgow are attempting to open
them.