Study finds that issues associated with drug use diminish survival among some people with HIV

The widespread availability of HIV treatment (antiretroviral therapy; ART) in Canada and other high-income countries has had a significant impact on the HIV pandemic. For people who take ART exactly as directed, HIV levels become suppressed. This allows the immune system to partially rebuild itself to the point where the risk of AIDS-related infections and complications is significantly reduced. This benefit of ART is so profound that researchers have found that many ART users will have a life expectancy similar to that of healthy people without HIV.

In addition, well-designed studies have found that people with HIV who achieve and maintain a suppressed viral load do not transmit the virus to their sexual partners.

These benefits of ART underscore the importance of HIV testing, access to care and treatment, and long-term engagement in care.

In British Columbia

A team of researchers in British Columbia has been monitoring the health of a group of people with HIV. The researchers recruited 644 adult participants who were taking ART and who, at least initially, were engaged in care. Recruitment took place between 2016 and 2018. Participants completed extensive surveys about their health and well-being.

Over the course of six years after recruitment, researchers found that 71 participants (11%) died.

Studies from other high-income countries have found that in the current era some ART users have diminished survival due to complications of cardiovascular disease (heart attack, stroke, heart failure, and so on) and cancers unrelated to HIV.

The B.C. researchers investigated the causes of death in their group of participants and found that “the most common reported underlying cause of death was drug use and overdose, followed by non-AIDS-related cancers.”

In addition, the researchers noted that about 24% of participants who died had an unknown cause of death, as it was still being investigated. They stated that “many of these deaths may also be due to overdoses, as overdose deaths often undergo investigation by the B.C. Coroner’s Office before being assigned a cause of death.”

Factors linked to reduced life expectancy

The B.C. researchers found that people with the following factors had reduced life expectancy in their study:

• experiencing recent homelessness
• recent engagement in substance use
• a history of incarceration
• low income
• having less than a high school education
• age 61 and older

The results of the B.C. study are troubling. According to the researchers, “these findings indicate that despite public health programming to increase access to healthcare amongst [people with HIV], structural inequalities continue to perpetuate health disparities, with [death] rates among this cohort appearing to increase over time.”

Focus on people experiencing homelessness

The B.C. researchers stated that previous studies have found that people with HIV who experience homelessness or incarceration had reduced life expectancy. They noted that in these studies people “experiencing homelessness are more likely to have challenges in […] being retained in care.”

In the current study, the B.C. researchers found that people with HIV who experienced homelessness “were twice as likely to die compared to those who did not experience homelessness.”

They noted that housing is very expensive in B.C. and may not be affordable for some people.

Connection is important

The B.C. researchers found that social support was an important factor in reducing the risk of death. Connection with other people was protective against death “despite experiences of substance use and incarceration […].”

Past research has found that social isolation can negatively influence a person’s mental health and decrease life expectancy.

Specific substances

The research team used peers of participants to help elicit information about participants’ health and any drugs they used. The team conducted statistical analysis and did not find any of the drugs listed by participants at the start of the study to be linked to an increased risk of death.

The researchers acknowledged that this finding was “unexpected,” and they suggested that factors such as older age, social isolation and the experience of homelessness have a greater impact on participants’ survival.

Also, the researchers collected substance use information when participants entered the study. But the substances used closer to their time of death may have been different than what was initially disclosed, and this could have affected their survival. Unfortunately, such information was not available.

What to do?

For nearly a decade a crisis has been underway in B.C. and other parts of Canada whereby the supply of street drugs has become poisoned, particularly with fentanyl, its analogues and other substances. This poisoning of the drug supply has led to increased deaths.

The research team suggests that a range of services and interventions could help turn the tide against the rise in deaths in this group of participants. The researchers stated that such interventions could include at least the following:

• access to affordable housing
• ongoing engagement in outreach so that people who experience homelessness do not fall out of care
• helping people build networks for social connection and support

Although not mentioned by the researchers, enhanced access to naloxone, opioid substitution therapy, drug-checking test strips and other harm-reduction measures may also be needed by people at risk from a contaminated drug supply.

Bear in mind

Since 1996, tremendous gains in life expectancy have been made among people with HIV thanks to effective treatment. However, in some populations, those gains risk being lost because of issues related to a poisoned supply of street drugs, lack of adequate housing and a loss of connection between people in the community. Studies are needed to design and test interventions to help make affected populations and communities more resilient, so that the survival benefits of ART are not lost.

By Sean R. Hosein

Resources

Harm Reduction Fundamentals: A toolkit for service providers – Self-directed learning 

What factors impact the likelihood of overdose among people who use drugs? – Research summary

How do social and structural factors increase risk of wounds and bacterial infections for people who inject drugs? – Research summary

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