While HIV transmission has been significantly reduced over the past decades — especially among people who inject drugs, who now represent less than 10 percent of new HIV diagnoses per year — the recent national surge in opioid misuse threatens to reverse some of these gains.
In 2016, over 42,000 people died from overdose of an opioid, and Maryland had one of the highest per capita rates of overdose, at 36 per 100,000 residents. In addition, there have been notable outbreaks of HIV in small rural communities where HIV previously was scarce, such as Austin, Ind., and northern Kentucky.
Further, regions with previously well-controlled HIV epidemics, such as Massachusetts, may be seeing rises in new cases associated with injecting drug use.
Therefore, not only are deaths due to opioid overdose eclipsing the death rates at the peak of the HIV epidemic, injecting drug use has exacerbated the spread of HIV and other infections, including hepatitis C. It is critical that we utilize lessons learned from HIV to address this epidemic of opioid use disorder and in turn prevent further HIV outbreaks.
Let’s start with community engagement to change policy — we must focus on managing opioid use disorder as a medical illness rather than a crime. This means expanding access to evidence-based medical treatments, such as methadone and buprenorphine (suboxone), and supporting programs to divert individuals with substance use disorder from incarceration. At present, only 47 percent of counties have a physician who can prescribe buprenorphine, and the majority of publicly funded drug treatment programs do not prescribe medication assisted treatment.
In order to adequately manage all affected individuals, we must dramatically build capacity for this evidence-based treatment of opioid use disorder. This will require all members of the medical community to aid in management of this patient population, addressing addiction at all points of medical engagement.
A first step will be to operate models of care aimed at task-shifting addiction treatment with buprenorphine to non-specialist providers in community-based settings. This model was successfully employed in the Institute of Human Virology (IHV) at the University of Maryland School of Medicine ASCEND study to treat hepatitis C. It can also expand access to individuals in rural or underserved communities.
We must also engage specialist providers, such as infectious disease physicians, to take on aspects of addiction treatment care. If a patient is being seen for HIV or hepatitis C related to opioid use disorder, attempts to reduce harm associated with addiction and injecting drug use should be incorporated into the treatment plan.
The co-location of medication assisted treatment for opioid use disorder with HIV treatment has been proven to improve HIV related outcomes. Furthermore, we are currently studying the impact of co-location of buprenorphine with hepatitis C treatment in marginalized people who inject drugs in the IHV ANCHOR study. We propose a significant increase in such small clinic models that reach the targeted communities.
Finally, there are too few medications that can be effectively employed to treat opioid use disorder. Significant research funding is needed to stimulate the development of novel therapeutics to successfully manage this chronic illness. As HIV infection in the United States now threatens people with health disparities living in communities impacted by substance use disorder, we as a nation need to seek out innovative strategies to address opioid use disorder in conjunction with HIV care and prevention.
Only by utilizing lessons learned from the HIV epidemic, and by acknowledging the parallel and synergistic epidemics of opioid use disorder and HIV, can we prevent another generation of young people from being decimated by these diseases.
Dr. Robert C. Gallo is co-founder and director of the Institute of Human Virology (Twitter: @IHVmaryland) at the University of Maryland School of Medicine, where he is also the Homer and Martha Gudelsky Distinguished Professor in Medicine and co-founder and scientific director of the Global Virus Network. Shyam Kottilil is director of the Division of Clinical Care and Research within the Institute of Human Virology at the University of Maryland School of Medicine, where he is also a professor of medicine and member of the Global Virus Network.