Steffanie A. Strathdee, PhD, on Preventing HIV Among People Who Inject Drugs

In this podcast, Steffanie A. Strathdee, PhD, highlights her session at CROI 2020, including the lessons learned from the Vancouver HIV outbreak, the changing face of the HIV epidemic among people who inject drugs in the United States, the structural factors driving new outbreaks, and how this all plays into the "End the HIV Epidemic" goal.

Additional Resources:

• Strathdee SA. Preventing HIV among people who inject drugs: plus ça change, plus ça même chose. Presented at: Conference on Retroviruses and Opportunistic Infections 2020; March 8-11, 2020; Boston, MA. 
• Hyshka E, Strathdee S, Wood E, Kerr T. Needle exchange and the HIV epidemic in Vancouver: lessons learned from 15 years of research. Int J Drug Policy. 2012;23(4):261-270. https://doi.org/10.1016/j.drugpo.2012.03.006. 
• Conrad C, Bradley HM, Broz D, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone - Indiana, 2015. MMWR Morb Mortal Weekly Rep. 2015;64(16):443-444. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4584812/. 
• Strathdee SA, Patrick DM, Currie SL, et al. Needle exchange is not enough: lessons from the Vancouver injecting drug use study. AIDS. 1997;11(8):F59-65. https://doi.org/10.1097/00002030-199708000-00001. 
• Gonsalves GS, Crawford FW. Dynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15: a modelling study. Lancet HIV. 2018;5(10):e569-e577. https://doi.org/10.1016/s2352-3018(18)30176-0. 
• Goedel WC, King MRF, Lurie MN, et al. Implementation of syringe services programs to prevent rapid human immunodeficiency virus transmission in rural counties in the United States: a modeling study. Clin Infect Dis. 2020;70(6):1095-1102. https://doi.org/10.1093/cid/ciz321. 
• Alpren C, Dawson EL, John B, et al. Opioid use fueling HIV transmission in an urban setting: an outbreak of HIV infection among people who inject drugs—Massachusetts, 2015–2018. Am J Public Health. 2020;110(1):37-44. https://doi.org/10.2105/ajph.2019.305366. 
• Evans ME, Labuda SM, Hogan V, et al. Notes from the field: HIV infection investigation in a rural area—West Virginia, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(8):257-258. https://doi.org/10.15585/mmwr.mm6708a6. 
• Policy, financing, stigma, and workforce barriers stand in the way of addressing co-occurring opioid and infectious disease epidemics. News release. The National Academies of Sciences, Engineering, and Medicine; January 23, 2020. http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=25626&_ga=2.33770977.1923025633.1583527192-1143219002.1583527192.

Steffanie A. Strathdee, PhD, is associate dean of global health sciences, the Harold Simon Professor in the Department of Medicine, and codirector of the Center for Innovative Phage Applications and Therapeutics at the University of California, San Diego. She is also the author of The Perfect Predator: A Scientists’s Race to Save Her Husband From a Deadly Superbug.

TRANSCRIPT:

Amanda Balbi: Hello, everyone, and welcome to another installment of Podcasts360—your go‑to resource for medical news and clinical updates. I'm your moderator Amanda Balbi with Consultant360 Specialty Network.

One of the plenary sessions presented at the Conference on Retroviruses and Opportunistic Infections 2020 focused on preventing HIV among people who inject drugs.

Today, I'm joined by the speaker of that plenary session, Dr Steffanie Strathdee, who is associate dean of Global Health Sciences, the Harold Simon Professor in the Department of Medicine, and codirector of the Center for Innovative Phage Applications and Therapeutics at the University of California, San Diego.

She will be answering our questions about her session at CROI and shedding light on HIV infection among people who inject drugs.

Thank you so much for joining me today, Dr Strathdee.

Steffanie Strathdee: Thanks for having me.

Amanda Balbi: So, in your session, you talked about the public health base response to Vancouver's HIV outbreak among people who inject drugs, and how needle exchange programs are not enough to ameliorate this issue. What lessons were learned from this outbreak? How are these lessons translating to clinical practice?

Steffanie Strathdee: Well, I presented on the Vancouver outbreak before the CROI conference was even named CROI. It was in 1997, and at the time, this was an HIV outbreak that had an HIV incidence of 18 per hundred person years. That means 18 people out of 100 that were HIV negative were becoming infected every year within the injection‑drug‑using community, and so it was a very large concern.

This city had the largest needle exchange program in North America at the time, and what we really learned is that just handing out needles in exchange for dirty ones isn't really enough to ensure that an outbreak is prevented.

It needs to be one part of comprehensive prevention programs. Needle exchanges is absolutely critical. It brings in people from the community who are in need of other services like drug abuse treatment and HIV testing. But, in the absence of those other programs, needle exchange alone might not prevent an outbreak.

In Vancouver, we saw an epidemic that transitioned from primarily opiate‑using to stimulant‑using. People who inject stimulants inject a lot more frequently, they need more needles, and Vancouver was really overwhelmed with the demand.

In response to that, Vancouver ramped up its needle exchange program, expanded methadone maintenance, later incorporated supervised injection facilities—the first one in North America—also piloted a heroin maintenance trial, and expanded HIV testing and treatment in a treatment-as-prevention type of model.

It was able to bring HIV incidence down and to avert a more widespread epidemic, but the US interpretation of the Vancouver outbreak was exactly the opposite.

In the US, the response to the Vancouver HIV outbreak that occurred in the late 1990s was to really use this as evidence that needle exchange was a failure. My paper that was published later that year in 1997 was entered into the Congressional Record with the opposite interpretation. It was used as a weapon to keep the congressional ban on federal funds to support needle exchange in place.

That really is a sign of this larger war‑on‑drugs mentality that has been so pervasive in the United States and has been a major barrier to the implementation of harm reduction.

We really need to change the way we think about addiction and see it as a medical problem, rather than a moral failing. Because if we're going to withhold these services from injection drug users, we're going to see more HIV outbreaks and that these are going to spill over into other communities.

Amanda Balbi: How is the face of HIV epidemic changing among people who inject drugs in the United States?

Steffanie Strathdee: In the United States, we've seen a massive shift in the face of heroin use and injection drug use. Clearly, injection drug use involves injection of not just opiates but stimulants, as well.

In terms of HIV, we've seen that among people who inject drugs, it used to be mostly an urban, African American population that was at heightened risk. Now we're seeing that HIV outbreaks are occurring among rural populations and semi‑urban populations, younger people, and often many are Caucasian, and about half are female.

We're seeing changes in terms of the age distribution and the sex distribution, as well as the geographic dispersion, and it's made it challenging for HIV prevention and surveillance efforts.

Amanda Balbi: Absolutely. Also in your session, you talked about the areas—the locations—in the United States that were most vulnerable to HIV outbreaks and how that correlated with syringe exchange programs. Can you talk a little bit more about that?

Steffanie Strathdee: Yes, well, the Centers for Disease Control did an analysis based on data from 2015 after the Scott County, Indiana, HIV outbreak that occurred, and they wanted to anticipate which communities were most vulnerable to HIV and hepatitis C outbreaks.

They came up with 220 counties that they felt were vulnerable based on the data that they inputted into this model, and about half of them were in the Appalachian region. They've recently updated some of this model, and they have been working with various states to collect data to inform some of the public policies and programming.

We've seen that there is an expansion of these epidemics we're seeing, are moving from not just the injection‑drug‑using community but to their sexual partners. In some cases, mother to child transmission can occur if we're not early enough in providing antiretrovirals.

Your listeners may be aware of an HIV outbreak that occurred in rural Indiana and Scott County in 2014 to 2015. The lesson from there was that if harm-reduction interventions and HIV testing had been implemented and expanded early, we would have been able to avert 90% of those infections, and that was about 200 people. Unfortunately, the response was too late.

Currently, we have a number of HIV outbreaks that are occurring among people who inject drugs, and these are in largely rural and semi‑urban areas of the US. There is an ongoing HIV outbreak in West Virginia, in Cabell County in particular.

There was an outbreak of HIV infection in Massachusetts that has largely been dealt with, in Lowell and Lawrence Counties, which are in the North‑Eastern parts of Massachusetts. A swift response from the local health departments, in conjunction with the Centers for Disease Control, dealt with this outbreak.

As opposed to the Scott County outbreak, this is thought to be multiple introductions of HIV as opposed to a point source, which is what we've seen in Scott County.

In Massachusetts, now we also have a new cluster of HIV that was just identified and reported to the CDC in January, 7 new cases in Boston. That might sound small, but you really need to put these within the context of what that region was seeing previously.

In Scott County, the outbreak started when the physician noticed that they, all of a sudden, had 2 new cases of HIV. This is a region where that whole county had only seen 4 cases over the previous couple of years.

It really behooves your listeners that, if they're infectious disease physicians, to keep your eye out, and if you see something that looks unusual to call it to the authorities’ attention because a very swift response is needed in order to thwart these epidemics right from the beginning.

Amanda Balbi: You also made a point in your presentation to mention the Ending the HIV Epidemic goal. In your opinion, what has to be done in order to meet this goal and keep patients with HIV in the care continuum?

Steffanie Strathdee: In order to end the HIV epidemic among the injection‑drug‑using community, there needs to be both an emphasis on prevention and treatment, and we have gaps along the way. Certainly, on the prevention side, needle exchange, although it is now permitted to be supported with federal dollars, it's still left up to individual states to whether or not they want to support it.

Some states are more permissive than others. In West Virginia, for example, we're seeing that there's an effort underway to make needle exchange illegal. Certainly, that's the only state where it's fully in Appalachia, and it's at extremely high risk, and it's experienced an outbreak right now. So, that's the wrong thing to do.

In terms of treatments, there's not just treatment for antiretrovirals that is required to treat HIV infection. There's also a need to expand drug-abuse treatment because drug-abuse treatment is HIV prevention. Here we're talking about specifically methadone maintenance and buprenorphine maintenance.

In my presentation, I also covered a new drug, mirtazapine, that has been shown to be efficacious in reducing risk behaviors among people who inject drugs and men who have sex with men. This is for methamphetamine users in particular. This is a drug that's already available over the counter to treat depression.

It's wise that we turn to it because many opiate users are also coadministering stimulants like methamphetamine, and methamphetamine is a major barrier to adherence and uptake of antiretroviral treatment in this population.

Amanda Balbi: Absolutely. What would you say is the overall key take‑home message(s) or messages for our listeners today?

Steffanie Strathdee: There was an important document that was published by the National Academy of Science, Engineering, and Medicine, that was published in January of 2020. They identified several barriers to integrated services for injection‑drug‑using communities. This includes things like requiring prior authorization to prescribe methadone maintenance, and payment and financing limitations, and problems with the workforce and training.

They really made a call for integrated services, because this is a very vulnerable community of injection drug users, and if they have to go 10 different places to meet their needs, we're not going to be able to reduce both the opiate‑use and the HIV and hepatitis C risks.

One of the other important factors is that there are structural impediments to dealing with this population that are thwarting both HIV prevention and treatment. When I talk about structural factors, I mean things like homelessness, unemployment, and a lack of education.

We need to stop looking at individuals in silos and blaming them for their behaviors when it's sometimes our own policies and our way of approaching a problem that is creating the factors that are putting them at risk for HIV in the first place.

And also the fragmented nature of the services that we're offering people, both in terms of HIV prevention and treatment, is a barrier to their uptake of antiretrovirals and their adherence. There's a real call for an understanding of these structural factors, both that shape individual-level risks and that are driving the policies that are trying to deliver services.

Amanda Balbi: Thank you for joining us today on this podcast and telling us about your session.

Steffanie Strathdee: It's been a pleasure. Thanks for having me.