Building bridges for action: Ending the HIV and opioid epidemic

Building bridges for action: Ending the HIV and opioid epidemic
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In his State of the union address, president Trump pledged to end the HIV epidemic in the United States in 10 years. It has been reported that the administration’s new budget proposal will include $250 million in new funding per year in the first year of this initiative for heavily impacted counties and some heavily impacted states, as well as Puerto Rico, with more increases slated for subsequent years over the coming decade. Several national HIV advocacy organizations have announced that they are “cautiously encouraged” by the president’s statement and this new commitment. As political appointees in the Obama White House who worked on HIV/AIDS and drug policy issues, we are also “cautiously encouraged”.

Nonetheless, many questions remain.

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To respond effectively to HIV anywhere, it is necessary to have a plan for responding everywhere. But, we endorse the administration’s emphasis on highly impacted counties and states. When half of new HIV diagnoses are in 48 out of more than 3,000 U.S. counties, this demands a focused response. And, when roughly 2  percent of the population (gay and bisexual men) comprises 7 in 10 new diagnoses, this also demands a tailored and intensive response.

 

We also heartily endorse the focus on scaling-up access to pre-exposure prophylaxis (PrEP), a relatively new technology that offers a safe and highly effective option for individuals not living with HIV to remain uninfected. Spreading the message that undetectable = untransmittable (U=U) and telling the broader public, as well as people living with HIV, that persons with HIV who are on antiretroviral therapy (ART) and maintain durable viral suppression cannot transmit HIV sexually, is incredibly important and powerful. There is no need to fear people with HIV and for those living with HIV, they can engage with sexual partners and be confident that they are not spreading HIV.

We write today with a plea to not squander the opportunity presented to leverage the "Ending the Epidemic" plan with the related challenge of preventing overdose deaths and promoting the health of people who use drugs.

The United States is facing an urgent crisis of problematic drug use, of which the opioid crisis is but one component. In October 2018, the president signed the SUPPORT for Patients and Communities Act that provides states and community-based organizations with additional tools to improve prevention, treatment and recovery initiatives.

The SUPPORT Act authorized $40 million per year to the CDC over a 5-year period to enhance state and local government surveillance capacity of opioid-use-related infectious diseases. This program also seeks to increase testing and linkage to care for HIV, Hepatitis C and other infectious diseases as part of substance use treatment. This is an important first step, but it remains insufficient as Congress must still act to appropriate these funds.

Better results will be realized if these HIV and opioid initiatives are coordinated and work together. The most recent data indicate that injection drug use was responsible for only 9  percent of new HIV diagnoses in 2017 (including 3 percent of diagnoses among men who have sex with men who also inject drugs). This is well below previous levels when roughly 1 in 4 diagnoses were attributed to injection drug use. This decline is due, in part, to the effectiveness and deployment of syringe services programs (SSPs) which offer people who use drugs access to sterile syringes and other services, including pathways to drug treatment.

Concern is increasing that our successes at preventing HIV, however, are threatened by increasing misuse of opioids and other drugs. CDC modeling indicates 220 U.S. counties have factors related to drug use patterns, Hepatitis C infections and other characteristics that place them at imminent risk for an HIV outbreak. And, these outbreaks are happening.

In 2017, CDC identified 52 clusters of active HIV and Hepatitis C transmission and provided technical assistance to 14 states to address them. Many of these outbreaks were associated with injection drug use. In 2014-2015, Scott County Indiana, experienced an outbreak associated with injection drug use that eventually resulted in 215 HIV infections.

A detailed transmission network analysis following this outbreak found that persons infected with HIV who were among the first individuals to become infected were more likely to engage in high-risk sexual behavior than to inject drugs. Therefore, researchers assert that the most plausible route by which HIV was first introduced into this network of people who use drugs was high-risk sexual behavior, emphasizing the overlapping nature of transmission risks and the need for access to PrEP and other sexual risk reduction interventions among people who use drugs.

How can the ending the epidemic initiative and the opioid response be maximized to greater effect?

Let’s develop effective models for underserved areas as envisioned in the HIV plan, bring these services to scale and quickly deploy them to additional parts of the country at high risk, which include both rural and urban America. There is significant overlap between the geographic areas of the HIV plan and parts of the country with high rates of overdose deaths associated with opioid misuse.

The evidence for effective HIV prevention and care services and responding to opioid misuse demand many of the same things: expanded access to medication assisted treatments (MAT), prioritizing health promotion and infectious disease control alongside overdose prevention and building cultural competency and sensitivity among health care and social services providers and law enforcement to better serve vulnerable members of their communities.

HIV programs can and must be enlisted to do more to respond to the opioid crisis. As of December 2015, 14 state AIDS Drug Assistance Programs (ADAPs) provided some form of MAT. ADAPs are the largest component of the Ryan White HIV/AIDS Program and provide ART and other prescription medication to people with HIV based on formularies established by each state or territory. More ADAPs need to provide the full array of MAT medications.

Finally, HIV and drug policy reformers can join in common cause and bolster public health leaders within the administration to recognize the scope of addiction in our nation, including how it threatens our HIV progress. We must develop new models for promoting drug user health.

Two decades ago, we fought for SSPs as a critical HIV prevention strategy, but faced opposition from people who believed they would promote drug use. A clear global consensus has developed over the benefits of SSPs, along with an acknowledgement that SSPs do not promote drug use. Even where SSPs exist in the U.S., however, they are rarely easily accessible or exist at the scale necessary to truly address the problem.

Now is the time to think big and think differently and embrace novel approaches that prevent overdose deaths while linking people to care. By expressing support and appropriating funding for all those affected by substance use and HIV, the administration can build bridges between the public health and public safety communities.

Much has been said about the president’s vision for ending the HIV epidemic and how it conflicts with the policies and rhetoric we have observed over the past two years. We see this, too. Nonetheless, we remain “cautiously encouraged” and see an opportunity to find common ground as we face these intertwined crises with the urgency they deserve.

Regina LaBelle and Jeffrey S. Crowley are distinguished scholars at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center. From 2009 to 2017, LaBelle served in the Office of National Drug Control Policy (ONDCP). From 2009-2011, Crowley served as the director of the White House Office of National AIDS Policy (ONAP) and senior advisor on disability Policy.