Clinic-Based Treatment of Opioid-Dependent HIV-Infected Patients Versus Referral to an Opioid Treatment Program

Abstract

Background Opioid dependence is common in HIV clinics. Buprenorphine/naloxone (BUP) is an effective treatment for opioid dependence that may be used in routine medical settings. Objective To compare clinic-based treatment with BUP (clinic-based BUP) with case-management and referral to an opioid treatment program (referred-treatment). Design Single-center, 12-month randomized trial. Participants and investigators were aware of treatment assignments. Setting HIV clinic in Baltimore, Maryland. Patients 93 HIV-infected, opioid-dependent subjects who were not receiving opioid agonist therapy and were not dependent on alcohol or benzodiazepines. Intervention The clinic-based BUP strategy included BUP induction and dose titration, urine drug test monitoring, and individual counseling; the referred-treatment arm included case management and referral to an opioid treatment program. Measurements Initiation and long-term receipt of opioid agonist therapy, urine drug test results, visit attendance with primary HIV providers, use of antiretroviral therapy, and changes in HIV RNA levels and CD4 cell counts. Results The average estimated participation in opioid agonist therapy was 74% (95% CI 61%–84%) in clinic-based BUP and 41% (29%–53%) in referred-treatment (p<0.001). Opioid and cocaine positive urine drug tests were significantly less frequent in clinic-based BUP than in referred-treatment, and study subjects in clinic-based BUP attended significantly more HIV primary care visits than study subjects in referred-treatment. Use of antiretroviral therapy and changes in HIV RNA levels and CD4 cell counts did not differ in the 2 arms of the study. Limitations This was a small single-center study, follow-up was only fair, and there was an imbalance in recent drug injection in the study arms at baseline. Conclusions This study suggests that management of HIV-infected, opioid-dependent patients with a clinic-based BUP strategy facilitates access to opioid agonist therapy and improves substance abuse treatment outcomes. Primary Funding Source Health Resources Services Administration, Special Projects of National Significance.

Substance Use: Impact on Adherence and HIV Medical Treatment

“…Recent work suggests that the context and delivery of OST may affect HIV treatment attendance and drug use cessation rates. For example, data from a randomized trial indicate that providing BUP and case management at HIV medical clinics may be more successful in reducing opioid use and increasing HIV primary care visits than referral to opioid treatment programs; however, this method of treatment may not have an effect on ART adherence or CD4 T-cell count and HIV viral load [68].…”

“…Opioid substitution therapy (OST), in particular methadone maintenance therapy (MMT) and buprenorphine-naloxone (BUP), has been shown to be effective in reducing opioid use, preventing relapse, and enhancing ART and HIV treatment adherence among people with HIV/AIDS [66][67][68]. Recent work suggests that the context and delivery of OST may affect HIV treatment attendance and drug use cessation rates.…”

Antiretroviral therapy for prevention of HIV transmission: Potential role for people who inject drugs in Central Asia

“…While expanding OST and ART coverage were the most effective for HIV prevention, averting 8300 infections as compared to no intervention, the most cost-effective intervention was use of OST. Additionally, the integration of OST programs in HIV care clinics has been associated with increased retention in care among HIVinfected persons who report substance use (Lucas et al, 2010). According to national monitoring and evaluation data, less than 47% of estimated PWID in Kazakhstan in 2011 and 52% of estimated PWID in Kyrgyzstan in 2012 were reached at least once every month with any type of HIV prevention interventions over a one year period (United Nations Office of Drug and Crime, 2008;Republican AIDS Center of Kazakhstan, 2012a,b;United Nations Development Programme, 2013).…”

Patient Perspectives of an Integrated Program of Medical Care and Substance Use Treatment

“…59 The integration of BPN/NLX treatment with primary care for opioid dependent-patients with HIV has been shown to be feasible in a multi-site demonstration project, 60 and to successfully improve engagement in HIV clinical care in a randomized clinical trial. 61 In the multi-site demonstration project, a clinical staff member, typically a nonphysician, such as nurse or counselor, who took ownership of the BPN/NLX program, was key to the success of the program. 62 In FAST PATH, the nurse and counselor case managers played this role with BPN/NLX.…”