In this international trial:
- Researchers demonstrated the effectiveness of an integrated intervention designed to help people who inject drugs and have HIV overcome obstacles to health care.
- Participants who received the intervention engaged in HIV treatment, achieved viral suppression at higher rates, and died at half the rate of participants in a control group.
People who inject drugs and have HIV experience high mortality and face many obstacles in accessing care. To reduce the toll of the two conditions on the health and survival of this population, Dr. William Miller of Ohio State University and colleagues developed an intervention that integrates:
- Immediate referral to anti-HIV therapy
- Assignment of a systems navigator who helped participants start and stay in treatment for HIV and substance use
- Brief, flexible psychosocial counseling to help participants overcome their unique obstacles to starting and staying in treatment
Dr. Miller and an international team of researchers linked to the NIH-funded HIV Prevention Trials Network tested the intervention in three countries that have high rates of comorbid injection drug use and HIV. The researchers recruited a total of 502 men and women who injected drugs and were living with HIV in Indonesia, Ukraine, and Vietnam (see Figure 1). About one-quarter of the trial participants received the integrated intervention and the rest received the standard of care in their country.
After 1 year, 72 percent of those receiving the integrated intervention were on antiretroviral therapy for HIV, and 41 percent had no detectable HIV in their blood, compared with 43 percent and 24 percent, respectively, among standard-care participants (see Figure 2). Participants in the integrated intervention arm also were significantly more likely to be receiving medication-assisted therapy for their substance use disorders. In addition, 15 percent of standard-care recipients with HIV, but only 7 percent of those receiving the integrated intervention, had died—a 53 percent mortality differential.
At the start of the trial, the researchers asked each injection drug user with HIV to recruit an injection partner who did not have HIV. After a year, no new HIV infections had occurred among the 187 injection partners of intervention participants, whereas seven new infections occurred among the 619 injection partners of standard-care patients. Although the trial was too small to allow for statistical analysis of this finding, it suggests that the intervention can reduce recipients' risk of transmitting the virus to their uninfected injection partners.
Dr. Miller says, "Although this trial was conducted in three global sites, it has important lessons for the opioid crisis in the United States as well. Systems navigation and case management can help people get the care they need. Hopefully, this study will support that in the United States." (See Figure 3.)
Dr. Miller adds, "We have received funding from NIDA to conduct an implementation science trial in Vietnam. We hope to learn the best way to take the intervention to scale."
This study was supported by NIDA, the National Institute of Allergy and Infectious Diseases, and the National Institute of Mental Health.
- Text Description of Figure 2
The bar chart illustrates the treatment outcomes after 1 year for people who inject drugs and have HIV and who received either the standard of care in their country, indicated by the purple bars, or the integrated HPTN 074 intervention, indicated by the green bars. The vertical y-axis shows the proportion of participants meeting each outcome. The two bars on the left show the proportion of participants who were on antiretroviral therapy (ART) after 1 year. This proportion was 43 percent for the standard-care group and 72 percent for the intervention group. The two bars in the middle represent the proportion of participants showing viral suppression. This proportion was 24 percent for the standard-care group and 41 percent for the intervention group. The two bars on the right show the proportion of participants receiving medication-assisted therapy (MAT) for their injection drug use. This proportion was 25 percent for the standard-care group and 41 percent for the intervention group.
- Text Description of Figure 3
This figure illustrates the finding that an integrated therapy including three components results in improved outcomes for people who inject drugs and have HIV. The centers of the three smaller purple circles list the three components of the intervention—anti-HIV therapy, systems navigator, and psychosocial counseling. Plus signs between the smaller circles indicate that these components are administered together. The equal sign between the smaller circles and the larger circle indicates that the result of the addition of these three components is as indicated in the center of the larger circle, namely improved outcomes.
- Miller, W.C., Hoffman, I.F., Hanscom, B.S., et al. A scalable, integrated intervention to engage people who inject drugs in HIV care and medication-assisted treatment: A randomized, controlled vanguard trial (HPTN 074). Lancet, 392(10149):747–759, 2018.