Aggressive intervention shows promise for injection users with HIV

A feasibility study that took place in three countries offers positive signs that aggressive outreach to HIV-infected individuals who inject drugs can increase their engagement in much-needed treatment.

Published in The Lancet, the study found that participants who received an aggressive intervention that included psychosocial counseling and help in navigating the healthcare system showed an increased use of medication treatment for both HIV and substance use, compared with individuals who received standard care. An official with the national institute that funded the study tells Addiction Professional that these findings should inspire conversations among professionals about how to launch integrated care initiatives for this hard-to-reach group.

“It does say that this can be done, but it is also important to emphasize that this was a fairly intense sort of effort to engage these individuals and keep them engaged,” says Sheryl Zwerski, DNP, director of the Prevention Services Program at the National Institute of Allergy and Infectious Diseases, which is part of the National Institutes of Health (NIH).

Study protocol

The study was conducted at a community health site in the Ukraine, two district health centers in Vietnam and a hospital site in Indonesia, with the sites selected partly on the basis of the presence of ongoing HIV epidemics in the community. The study involved both HIV-infected injection drug users and their uninfected injection partners, with a goal of determining how the studied intervention might help prevent transmission of the virus.

The HIV-infected drug users were divided into intervention and standard-of-care groups. The intervention group received a menu of services that included system navigation to encourage engagement and retention in HIV and substance use treatment, psychosocial counsling grounded in motivational interviewing and skill building techniques, and initiation of antiretroviral therapy (ART) regardless of the participant's CD4 cell count. The psychosocial counseling focused on adherence to ART and medication-assisted treatment (MAT) for opioid addiction. Standard-of-care participants received a package of services that mainly involved referral to HIV and MAT services.

Participants received 12 to 24 months of follow-up, with the primary aim of examining HIV infection outcomes and treatment retention rates. Outcomes were analyzed for a total of 502 HIV-infected injection drug users and 806 non-infected injection partners.

The researchers found that no injection partners in the intervention group became infected with HIV during follow-up, while seven partners in the standard-of-care group acquired HIV infection. Because of the very small number of new infections overall, it was determined that conducting a randomized controlled trial of this intervention is not feasible because of the large sample size that would be required in order to see a difference between the intervention and control groups, Zwerski explains.

The intervention group in this study showed superior outcomes compared with the standard-of-care group on other key variables:

• A total of 72% of intervention group participants reported ART use at week 52 of follow-up, compared with only 43% of standard-of-care participants.

• A total of 41% of intervention group participants were virally suppressed at week 52, compared with 24% of standard-of-care participants.

• Use of medication-assisted treatment was higher among intervention group participants and their injection partners than among the corresponding individuals in the standard-of-care group.

• Overall mortality rates were lower in the intervention group.

“Our study provides direct evidence of the feasibility of expediting linkage to care and treatment for HIV and substance use (assessed through MAT),” study authors wrote in their paper. This is particularly noteworthy given the many barriers to treatment that these individuals routinely face, from their personal behavior to provider attiudes to societal stigma.

Zwerski adds that it is important to note that the role of a system navigator can be assumed by non-medical professionals, such as peers or social workers, so this component does not have to become a big-ticket expense. “It wouldn't have to be a physician or a nurse,” she says, but simply someone who understands the workings of the local healthcare system.

Emphasis on integrated care

Zwerski says the results of this feasibility study highlight the potential benefits of integrated care that helps individuals navigate the complexities of the healthcare system and attends to their physical and psychological health needs.

For care providers, this means that “no matter where you are [in the system], providers should be keeping an eye to the bigger picture,” she says, “trying to coordinate care however possible.”