Combating the Syndemic: Addressing Opioid Use Dysfunction and Reducing HIV Go Hand-in- Hand

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Since they started, the HIV and opioid epidemics have been inexorably entwined. Within the Eighties and Nineties, HIV was frequent amongst injection drug customers in inner-city minority populations. Immediately, the brand new era of people that inject medicine are usually younger and White and reside in rural or suburban settings.1

These individuals, in line with surveillance knowledge,2 are confronted with socioeconomic inequalities. The nonurban areas by which they dwell usually are not outfitted to handle the twin epidemics of opioid use and HIV. And so, in 2015, for the primary time in 2 a long time, the variety of HIV circumstances instantly attributed to injection drug use elevated.3

There is no such thing as a dearth of analysis into the respective HIV and opioid epidemics in america; for many years, investigators have been analyzing the hows and the whys underpinning every of those illnesses. However sadly for researchers counting on the prevailing years of proof supporting the connection between the charges of HIV an infection and opioid dependancy, the previous few a long time have drastically modified the panorama.

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The US HIV epidemic started, in line with Patrick S. Sullivan, PhD, professor of epidemiology on the Rollins College of Public Well being at Emory College, Atlanta, Georgia, and colleagues, as a “bicoastal epidemic centered in giant cities.” Through the previous 4 a long time, nevertheless, HIV epidemiology has modified.2 Utilizing publicly accessible HIV surveillance knowledge, Dr Sullivan and colleagues had been in a position to describe the prevalence of present and new HIV diagnoses by area, race, ethnicity, and age — knowledge that painted an image of a illness extremely geographically concentrated in Washington, DC, Puerto Rico, and 48 different so-called hotspot counties throughout the nation, situated disproportionately within the South.2

These counties signify 52% of all new HIV diagnoses made in 2018. Of the 5 metropolitan statistical areas represented by these knowledge, all had been in southern states and Washington, DC: Orlando and Miami, Florida; Atlanta, Georgia; Baton Rouge and New Orleans, Louisiana; Baltimore, Maryland; Jackson, Mississippi; and Memphis, Tennessee.2

The researchers proposed that these geographic disparities within the charges of HIV an infection are possible pushed by way of some mixture of inequitable entry to therapy providers, racial and ethnic composition, and the excessive burden of HIV an infection amongst Black individuals. Though African People signify solely 13% of the US inhabitants, they account for 41% of AIDS-related deaths.2 And though this burden is noticed in each women and men, 38% of all new HIV diagnoses amongst males who’ve intercourse with males (MSM) had been amongst Black people, and 63% of these males resided within the South.2

Charges of demise from opioid overdose even have steadily elevated through the previous decade, doubling within the years from 2013 to 2017.1 Just like the demographics of the HIV epidemic, the demographics of people that inject medicine even have modified. The present opioid epidemic primarily could be related to a “new era” of customers who’re White, younger, and dwell in nonurban areas which might be “poorly outfitted to leverage the sources wanted to handle the problem,” wrote Sally L. Hodder, MD, of the West Virginia Medical and Translational Science Institute at West Virginia College, West Virginia, and colleagues, in one other examine printed in The Lancet.1

Along with altering demographics, america has seen a gentle improve in opioid-related overdose deaths since 2000, largely attributable to using prescription painkillers and the doorway of fentanyl into the drug provide.1 The US Facilities for Illness Management and Prevention (CDC) estimates counsel that 18% of these aged 12 years and older in america both use illicit medicine or misuse prescription remedy, which interprets to upward of 70,000 drug-related deaths in 2017.1

“The city, inner-city heroin epidemics of the 80s and 90s had been overwhelmingly male and overwhelmingly minority, and that’s actually modified,” stated Chris Beyrer, MD, of the Desmond M. Tutu Professor of Public Well being and Human Rights on the Johns Hopkins Bloomberg College of Public Well being, Baltimore, Maryland, in an interview. “The present opioid disaster is whiter, it’s extra feminine, it’s extra rural and suburban — it’s a distinct demographic. And in these sorts of communities, “HIV is very stigmatized,” he added.

On February 5, 2019, the Trump Administration introduced plans to handle the HIV epidemic in america. In his State of the Union Deal with, then-President Trump pledged to lower the variety of new HIV infections by 75% in 5 years and by 90% in 10 years, successfully ending the epidemic by 2030.4 This proposal, a 4-pillar strategy developed by the US Division of Well being and Human Providers (HHS), was centered closely on HIV prognosis, therapy, prevention, and outbreak response.3 The instruments, researchers identified, are “already at hand” to perform this aim.4 The difficulty, then, lies with metropolis, state, and federal efforts to handle the injection opioid epidemic.

In response to Dr Beyrer, there’s one main perpetrator answerable for the shift within the opioid epidemic from its demographics within the Eighties and Nineties to what it seems like at this time: OxyContin.

“The overprescribing of prescription opiates is basically on the coronary heart of this,” he defined. “Should you take a look at the quantity of ache prescriptions that had been being written, for instance, in West Virginia, it was greater than sufficient for each grownup in West Virginia to turn out to be opioid  dependent. It was extraordinary.”

The addition of ache as a fifth very important signal, coupled with lobbying efforts on the a part of the US pharmaceutical trade and OxyContin producer Perdue Pharma particularly, has considerably modified the ache therapy paradigm.

“Should you’ve been to a main care supplier for something within the final a number of years, you’ve gotten been requested, ‘Are you in ache at this time?’ And when you say ‘Sure, I’m in ache,’…and price your ache over a 4, [that is] reported to the doctor to begin therapy,” Dr Beyrer added.

By 2004, OxyContin had turn out to be a main drug of abuse in america.5 By 2009, 1.2 million emergency division visits had been being attributed to abuse or misuse of pharmaceutical ache drugs,6 reflecting a 5-year improve of 98%. Because the US Meals and Drug Administration (FDA) moved to answer hovering charges of dependancy and overdose deaths, entry to the opioid drugs on which so many individuals had turn out to be dependent emerged as a major problem.

A reformulated, abuse-deterrent OxyContin was launched in 2010; this tamper-resistant formulation included polyethylene oxide (PEO), an inactive polymer that rendered the tablets “more durable, extra crush-resistant, and tougher…to organize for injection,” in line with an FDA briefing doc.7 On the identical time, the company moved to handle how, precisely, OxyContin, Opana ER (oxymorphone hydrochloride, Endo Prescribed drugs), and different addictive opioid drugs had been being prescribed in medical observe. This, in line with Dr Beyrer, is what led to the artificial opioid disaster and the following hovering improve in heroin-involved overdose deaths.

“As we lastly understood what was taking place [with the opioid crisis] and at last began to have some sort of response and get management of prescribing, the individuals who had been already opioid-dependent and couldn’t come up with OxyContin converted to street-available medicine,” he stated. “By the best way? OxyContin at its peak on the black market was $50 a tablet. A bag of heroin in Baltimore Metropolis prices $15.”

Immediately, a line could be drawn instantly from the rise in opioid addiction-fueled, injection drug use to the rise in diagnoses of HIV attributed to injection drug use.3 However as a result of each drug dependancy and HIV stay extremely stigmatized, every situation — each individually and collectively — is tough to deal with.

“There are definitely interventions on the market, [but] the outcomes of these interventions are nonetheless fairly miserable,” stated Michael L. Barnett, MD, an assistant professor of well being coverage and administration on the Harvard T.H. Chan College of Public Well being in Boston, Massachusetts, in an interview. “This can be a dysfunction with very excessive charges of remission and relapse, so plenty of the main focus is on attempting to see what we will do to mitigate obstacles to accessing remedy for opioid use dysfunction [with] drugs [that] are fairly secure in contrast with the choice.”

There’s a sturdy physique of proof demonstrating the efficacy of medicines for opioid use dysfunction,8-10 however the obstacles to offering these drugs are excessive and embrace, however usually are not restricted to, doctor waivers to prescribe buprenorphine, the dearth of coaching in dependancy therapy providers provided in medical faculties and residency applications, and the thought, in line with Dr Barnett, that “dependancy drugs is one thing that different individuals do and one thing different individuals maintain.” And amongst injection drug customers, Dr Barnett added, the present adequacy of infectious illness screening is poor.

“These of us have to be screened for HIV, hepatitis C, and hepatitis B repeatedly,” he stated. “That’s one other high quality measure that I feel we ceaselessly fall quick on. Infectious illness physicians usually are not those doing this [treatment],” he added. “Many individuals with dependancy will finally get hepatitis C. How will we make it possible for we’re staying on high of that inhabitants?”

Each Dr Barnett and Dr Beyrer highlighted the 2014 to 2015 HIV outbreak in Scott County, Indiana, underneath the management of then-Governor Mike Pence, as a main instance of an ideal, intersectional storm that illustrates what occurs when harm-reduction interventions resembling needle and syringe exchanges are criminalized.

“In Scott County…needle and syringe alternate, and distributing syringes and not using a prescription, was a felony with a 2-year sentence,” stated Dr Beyrer. “It was unlawful to offer providers wanted for primary public well being.”

“Mike Pence…lifted these restrictions for 1 month — simply 1 month — simply in Scott County. Finally, they needed to be lifted throughout the state as a result of it turned out that Scott County was not an remoted outbreak however actually simply 1 of the [outbreaks] that we had recognized.”

“There have been plenty of new HIV infections in Indiana as a result of there wasn’t actually a swift response to that downside,” Dr Barnett added. “There was a extra personal-responsibility, law-enforcement angle to the response, which we all know isn’t efficient.” 

Because of each advances in medical science and large-scale public well being campaigns, there’s a normal public consciousness and understanding of HIV. Current knowledge from giant medical research have confirmed the idea of “undetectable equals untransmittable,”3 which ought to have, in idea, contributed to a discount of the stigma related to HIV. In lots of communities, nevertheless, that isn’t precisely the case.

Within the White rural and suburban communities the place the present opioid disaster has taken maintain, HIV stays extremely stigmatized — much more so amongst ladies, a few of whom are moms dwelling on the intersection of drug use and HIV an infection.

“What we’re seeing is that each one of those intersecting challenges, starting with opioid use, usually tend to be taking place in households and have an intergenerational element,” famous Dr Beyrer. “Mother and father [are] utilizing with their grownup youngsters, adolescents [are] utilizing, women and men and {couples} [are] each utilizing and sharing.”

And for girls who inject medicine, there’s a further layer of stigma to deal with. “It’s very [stigmatizing] for girls to know how one can use; know how one can inject and how one can deal with tools,” Dr Beyrer defined. “It’s fairly often the person who makes use of first, then injects the girl, and that signifies that her chance of getting an unsterile injection is increased. There’s a gender dynamic to all of this [as well].”

No matter gender, entry to antiretroviral remedy (ART) for individuals who inject medicine is shrouded in controversy in a lot of the world. In lots of nations, governmental insurance policies require full abstinence from unlawful drug use earlier than offering ART. Reasonably than motivating individuals to hunt therapy, it deters individuals with HIV from searching for therapy.11 These insurance policies usually are not essentially mirrored in america, however there’s nonetheless a persistent, sustained disgrace related to those that are actively utilizing medicine inside the healthcare system.

“What you see is that individuals don’t need energetic drug customers of their observe,” Dr Beyrer stated. “[Physicians] refuse to deal with them or they arrange a coverage the place they are saying, ‘I’ll deal with your HIV so long as you’re clear, however when you begin utilizing once more, I gained’t.’ And in lots of of those settings, individuals don’t have plenty of choices.”

“The entire points with disparities in care throughout race, socioeconomic standing, and so forth are simply as a lot current in dependancy care, if no more so, than for different medical interventions,” Dr Barnett famous. “There’s a giant coverage concentrate on what will we do about entry to dependancy care in rural communities?”

Making certain that the accessible sources usually are not structurally organized round predominantly White communities, or round pathways predominantly utilized by White sufferers, is essential, in line with Dr Barnett. At Harvard, he identified, the dependancy clinic is situated at Brigham and Girls’s Hospital in Boston, Massachusetts, and is rife with marble columns, vivid excessive ceilings, and intimidating portraits of White males.

“It’s a spot that may appear intimidating for somebody who’s not used to being in these areas,” defined Dr Barnett, “somebody who works at evening as a janitor or somebody who doesn’t converse English. “The Brigham [and Women’s Hospital] can’t change itself, nevertheless it may attempt to spend money on dependancy therapy within the communities the place it’s wanted most.”

Taken collectively, the structural considerations, racial and socioeconomic points, and state- and federal-level coverage points can paint a grim image when attempting to handle these concurrent intersecting epidemics. Lowering injection drug use is paramount to lowering newly recognized circumstances of HIV, however the normal damaging angle towards drug customers, and injection drug customers particularly, renders these efforts daunting.

“On this specific inhabitants the place we all know that there are these associations [between] HIV and substance use, we’ve got an amazing quantity of information to indicate that when you implement the fundamentals of prevention, you’ll be able to just about deliver an finish to the epidemic of injection drug use,” Dr Beyrer stated.

Dr Hodder and colleagues (which incorporates Dr Beyrer) prompt quite a lot of really helpful methods to handle the HIV and opioid epidemics.1 First, they wrote, it’s important to decrease stigma for each individuals dwelling with HIV and other people with opioid use dysfunction. Neighborhood-based interventions are important, as is the dedication of devoted thought  leaders, for guaranteeing that individuals who inject medicine can “obtain high quality providers in a nonjudgmental setting.”

One other technique is to offer common healthcare for all individuals who inject medicine. Solely 18% of the estimated 22 million individuals with substance use problems had been in a position to obtain dependancy therapy previous to Medicaid enlargement.1 Following the enlargement, uninsured hospitalizations related to substance use problems decreased from 22% to 14% in the middle of 1 yr.

A renewed concentrate on evidence-based approaches, together with the discontinuation of the conflict on medicine and its related carceral paradigm that emphasizes imprisonment over dependancy therapy, the inclusion of main care clinics as touchpoints for sufferers that may present remedies resembling HIV pre-exposure prophylaxis (PrEP), methadone, and buprenorphine, and a renewed concentrate on analysis to develop each higher remedies for opioid use dysfunction and differentiated care fashions can even go a great distance towards facilitating a twin discount in HIV diagnoses and opioid use.

“The excellent news is that we’ve got a toolkit that’s actually efficient at stopping HIV and viral hepatitis unfold amongst individuals who inject medicine,” stated Dr Beyrer. “This isn’t rocket science; it’s the fundamentals of public well being prevention. It really works, it’s efficient, it’s low cost, and it’s an alternative choice to mass incarceration.”

“It truly is the duty of all people who supplies healthcare to get educated about this and to turn out to be not only a supplier, but additionally an advocate, for insurance policies that work and are evidence-based. That’s what we’re purported to be doing,” he added. “We’re purported to be scientists.”


1. Hodder SL, Feinberg J, Strathdee SA, et al. The opioid disaster and HIV within the USA: lethal synergies. Lancet. 2021;397(10279):1139-1150. doi:10.1016/S0140-6736(21)00391-3

2. Sullivan PS, Johnson AS, Pembleton ES, et al. Epidemiology of HIV within the USA: epidemic burden, inequities, contexts, and responses. Lancet. 2021;397(10279):1095-1106. doi:10.1016/S0140-6736(21)00395-0

3. Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV epidemic: a plan for america. JAMA. 2019;321(9):844-845. doi:10.1001/jama.2019.1343

4. Lerner AM, Fauci AS. Opioid injection in rural areas of america: a possible impediment to ending the HIV epidemic. JAMA. 2019;322(11):1041-1042. doi:10.1001/jama.2019.10657

5. Van Zee A. The promotion and advertising and marketing of oxycontin: industrial triumph, public well being tragedy. Am J Public Well being. 2009;99(2):221-227. doi:10.2105/AJPH.2007.131714

6. US Meals and Drug Administration. Timeline of chosen FDA actions and vital occasions addressing opioid misuse and abuse. Up to date March 30, 2021. Accessed June 15, 2021.

7. FDA Advisory Committee Assembly. September 10-11, 2021 joint assembly of the drug security and threat administration advisory committee and the anesthetic and analgesic drug merchandise advisory committee assembly announcement. OxyContin® (oxycodone hydrochloride) extended-release tablets. NDA 022272. Postmarketing requirement briefing doc. Revealed September 10-11, 2020. Accessed June 15, 2021.

8. Bell J, Strang J. Remedy therapy of opioid use dysfunction. Biol Psychiatry. 2020;87(1):82-88. doi:10.1016/j.biopsych.2019.06.020

9. Haight BR, Discovered SM, Laffont CM, et al; RB-US-13-0001 Examine Investigators. Efficacy and security of a month-to-month buprenorphine depot injection for opioid use dysfunction: a multicenter, randomized, double-blind, placebo-controlled, part 3 trial. Lancet. 2019;393(10173):778-790. doi:10.1016/S0140-6736(18)32259-1

10. Koehl JL, Zimmerman DE, Bridgeman PJ. Drugs for administration of opioid use dysfunction. Am J Well being Syst Pharm. 2019;76(15):1097-1103. doi:10.1093/ajhp/zxz105

11. Individuals who inject medicine, HIV and AIDS. Up to date October 10, 2019. Accessed June 15, 2021.

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