HIV care engagement among people with a history of injection drug use

Transcription

1 HIV care engagement among people with a history of injection drug use Ann N. Burchell, PhD Scientist, Dept of Family and Community Medicine and Li Ka Shing Knowledge Institute St. Michael s Hospital burchella@smh.ca Ontario Harm Reduction Conference October 26, 2015

2 Collaborators HIV Care Continuum Project Team Ann N. Burchell 2,3, Sandra Gardner 1,2, Beth Rachlis 1, Lucia Light 1, Tony Antoniou 3, Jean Bacon 1, Anita Benoit 2, Jeff Cohen 7, Tracy Conway 1, Curtis Cooper 5, Patrick Cupido 1, Tony DiPede 1, Claire Kendall 4, Mona Loutfy 2, Frank McGee 4, James Murray 4, Janet Raboud 2, Anita Rachlis 2, Wendy Wobeser 6, Sean B. Rourke 1 for the OHTN Cohort Study Team 1) Ontario HIV Treatment Network 2) University of Toronto 3) St. Michael's Hospital 4) AIDS Bureau, Ontario Ministry of Health and Long Term Care 5) University of Ottawa 6) Kingston Hotel Dieu Hospital 7) Windsor Regional Hospital

3 Continuum of HIV care ( Cascade ) In HIV Care HIV-Infected HIV- Diagnosed Linked to HIV care Engaged or Retained in HIV care On Antiretroviral Therapy Achieved Viral Suppression

4 What are the benefits of optimal HIV care engagement? Regular contact with HIV care promotes Starting antiretroviral treatment (ART) Better ART adherence Better primary care including early detection and management of coinfections and other co-morbidities Being on ART prevents HIV progression Positive prevention suppressed viral load prevents transmission to partner All of the above predicts better survival

5 Aims What are the patterns of HIV care engagement Among people attending specialty HIV clinics? Among people with HIV who have a history of IDU? Among people with HIV who continue to use substances?

6 OHTN Cohort Study (OCS) Ongoing follow-up study of persons in HIV care in Ontario Eligibility Criteria Data Positive HIV-antibody test or other laboratory evidence of HIV infection Patients at participating specialty HIV clinic Aged 16 years or older Capable of providing informed consent Medical charts, electronic medical records, face-to face interviews Data linkage with Public Health Ontario Laboratories 6,408 participants ever enrolled as of December 2013 Rourke et al. Cohort profile. Int J Epidemiol, 2013

7 Recruitment & follow-up at hospital-based specialty HIV clinics and primary care practices across Ontario

8 Characteristics of participants at their first interview (N=3,571) Mean age (SD) 45.9 (10.1) Born in Canada 68.5% Sex/Orientation MSM Heterosexual male Female Ethnicity White Aboriginal African/Black/Caribbean Other Median year of HIV diagnosis (IQR) 69.0% 13.6% 17.5% 62.9% 9.2% 16.4% 11.5% 1998 ( ) Income <$20,000 $20,000 to < $40,000 $40,000 to< $60,000 $60,000+ Employment status Employed Unemployed-seeking Not in the labour force Disability Education Some high school or less Completed high school Trade/Some college College/Some university University degrees 44.0% 21.2% 16.5% 18.3% 47.1% 6.2% 17.1% 29.7% 14.2% 17.5% 13.5% 27.4% 27.5%

9 History of drug use among participants Compare to all diagnosed with HIV in Ontario, of whom 11% report injection drug use as a risk factor Ever injected drugs Used substances in past 6 months (but did not inject) 3 Injected drugs in past 6 months Remis As reported at interviews in 2007/08 onwards

10 Recent drug use (past 6 months) among people with a history of IDU, by year of interview 100% Any substance use Injection drug use 80% 60% 40% 53% 45% 50% 41% 41% 38% 20% 23% 18% 24% 18% 24% 22% 0% Year of interview

11 Specific Drugs Reported by Drug Users 70 Percent

12 Continuum of HIV care ( Cascade ) In HIV Care HIV-Infected HIV- Diagnosed Linked to HIV care Engaged or Retained in HIV care On Antiretroviral Therapy Achieved Viral Suppression

13 Percent in continuous care among participants in annual HIV care, by IDU status % -3.8% IDU Non-IDU Continuous care defined as 2 HIV laboratory tests (viral load or CD4 cell count) at least 3 months apart

14 Percent on antiretroviral treatment among participants in annual HIV care, by IDU status -1.5% % IDU Non-IDU Initiated ART before or during the year with no evidence of having stopped in that year

15 Continuum of HIV care ( Cascade ) In HIV Care HIV-Infected HIV- Diagnosed Linked to HIV care Engaged or Retained in HIV care On Antiretroviral Therapy Achieved Viral Suppression

16 Percent with suppressed viral load (<200 copies/ml) among participants on antiretroviral treatment, by IDU status -6.1% % IDU Non-IDU

17 Adherence among participants on ART, by IDU status 100% 80% Have you missed any of your doses of ART medications over the past 4 days? 75% 89% 86% 60% 40% 20% 25% 11% 14% 0% Yes No Current IDU (n=12) Past IDU (n=54) Non-IDU (n=904)

18 Source: Sandra Gardner Ongoing substance use & suppressed viral load Tobacco p< Binge drinking p= Substance use p< Pattern held even after accounting for smoking, drinking, 70 income, housing & mental health concerns 60 50

19 Engagement in care among people with a history of IDU ever enrolled in OCS, On ART increased from 56% to 73% Undetectable VL increased from 34% to 65% In care Continuous care On ART Undetectable VL

20 Engagement in care among all people ever enrolled in OCS, On ART increased from 67% to 77% Undetectable VL increased from 42% to 73% In care Continuous care On ART Undetectable VL

21 Interpretation Since early 2000s, dramatic gains in viral suppression Why? ART regimen improvements (tolerability, dosing) Guidelines (earlier initiation, no treatment interruption) Patients with history of IDU generally had lower HIV care engagement Driven by ongoing substance use Not explained by differences in income, housing, employment, ethnicity, nor a host of other factors

22 Interpretation Better access to high quality harm reduction, addictions treatment, mental health care may have far reaching benefits Better HIV care engagement, adherence Lower viral load, less disease progression, less transmission Longer lives

23 OCS Acknowledgments We thank all participants and the interviewers, data collectors, research associates and coordinators, nurses and physicians who provide support for data collection and extraction OCS Study Team Sean B Rourke (PI), Ann N Burchell, Ahmed M Bayoumi, John Cairney, Jeffrey Cohen, Curtis Cooper, Fred Crouzat, Sandra Gardner, Kevin Gough, Don Kilby, Mona Loutfy, Nicole Mittmann, Janet Raboud, Anita Rachlis, Edward Ralph, Sergio Rueda, Irving E Salit, Roger Sandre, Marek Smieja, Wendy Wobeser OCS Governance Committee Patrick Cupido (Chair), Adrian Betts, Anita Benoit, Les Bowman, Tracey Conway, Tony Di Pede, Michael Hamilton, Brian Huskins, Clemon George, Troy Grennan, Claire Kendall, Nathan Lachowsky, Joanne Lindsay, John MacTavish, Shari Margolese, Colleen Price, Rosie Thein OCS Scientific Steering Committee Leighton McDonald, Ann N Burchell, Curtis Cooper, Sergio Rueda, Barry Adam, Tony Antoniou, Adrian Betts, John Cairney, Tracey Conway, Sandra Gardner, Trevor Hart, Mona Loutfy, Peggy Millson, Kelly O Brien, Janet Raboud, Anita Rachlis, Sean Rourke, Sergio Rueda, Wendy Wobeser OHTN Staff Jason Globerman, Madison Giles, Robert Hudder, Lucia Light, Veronika Moravan, Nahid Qureshi Funding AIDS Bureau, Ontario Ministry of Health and Long Term Care CIHR New Investigator Salary Award to ANB Data Linkage Public Health Ontario Laboratories

24 OCS likely best case scenario Compare with all patients undergoing viral load testing in Ontario in % had 2+ viral loads (vs 86% in OCS) 77% had viral load <500 copies/ml (vs 89% in OCS) Participants successfully navigated HIV diagnosis & linked to care at specialty HIV clinics, enrolled in study Participants tend to be healthier than other patients at these clinics 2 1. Remis et al. Trends in HIV viral load testing in Ontario, Available: 2. Raboud et al. BMC Med Res Methodol 2013.