- People who use drugs are at heightened risk of overdose and death due to contamination of the drug supply
- B.C. researchers have been monitoring the long-term health of HIV-positive people who use drugs in a study
- Many HIV-positive people who use drugs have been dying of complications related to drug use and overdose
The widespread availability of potent combination HIV treatment (ART) has greatly reduced the risk of death from AIDS-related complications. The power of ART is so profound that researchers expect that many HIV-positive people will have near-normal life expectancy.
However, this rosy forecast may not apply to HIV-positive people who are struggling with chronic issues like complex mental health challenges, housing instability, poverty and dependence on drugs, alcohol, tobacco and other substances.
Opioid crisis—overdose and deaths
In the past decade, the supply of street drugs has become increasingly contaminated with very potent opioids, such as fentanyl, carfentanyl and their analogues. This has led to a massive increase in what researchers in British Columbia describe as “unintentional overdoses and drug-related deaths.” The opioid crisis has spread across Canada and the United States.
The LISA study
In 2007, researchers at the BC Centre for Excellence in HIV/AIDS in Vancouver began recruiting vulnerable populations of HIV-positive people—women, people who use drugs, and people coinfected with hepatitis C virus (HCV)—for a study called LISA. As part of the study, participants were monitored and factors linked to survival were assessed.
As time passed, data accumulated. Researchers with LISA have recently analyzed the data captured and found that 21% of participants had died with the leading causes of death as follows:
- drug-related complications or overdose
- HIV-related complications
- cancers unrelated to AIDS
The researchers stated that their findings suggest that “public health efforts to end the HIV epidemic and support the health and well-being of [HIV-positive people] are being thwarted by persistent health inequities and the enormous and persistent risks facing people who use drugs.” They assert that “low-barrier primary care is essential for supporting underserved [HIV-positive] people, and a safe drug supply is needed to support [HIV-positive] people who use drugs.”
Study details
Researchers recruited 1,000 people whom they described as “underserved populations often experiencing economic and social marginalization.”
The researchers accessed different databases, including those of B.C.’s Vital Statistics Agency, to develop a profile of each person and to determine whether or not they had died.
By June 30, 2017 (the end of the study), researchers had extensive data on 910 people, which formed the basis of their report.
Note that in British Columbia HIV care and treatment are provided at no cost to the patient.
Results
Over the course of the study, 21% of participants had died: 71% were men and 29% were women.
The major causes of death were as follows:
- drug-related complications or overdose – 27%
- HIV-related complications – 19%
- cancers unrelated to AIDS – 17%
- respiratory diseases and/or chronic obstructive pulmonary disease (COPD) – 8%
The researchers found that people who died tended to have one or more of the following factors when compared to people who remained alive:
- less likely to have an undetectable viral load prior to death
- more likely to have problematic alcohol use
- more likely to be using drugs prior to their death
- more likely to have unstable housing
- more likely to smoke tobacco
- more likely to experience periods of insufficient food
Comparisons with populations
Women
Among women who died, respiratory complications, including COPD, were the third leading cause of death—15% vs. 5% in men. Women were more likely than men to die from an overdose—33% vs. 25%. However, overall, the researchers did not find that women were at increased risk of death compared to men.
HIV-negative people
When researchers compared the data on deaths in LISA with deaths from HIV-negative people in B.C., they found that HIV-positive people in LISA were at a threefold increased risk of death.
Other points
According to the researchers, their results demonstrate “that the universal provision of HIV care and treatment alone does not adequately address the underlying structural and social inequalities driving mortality among underserved [HIV-positive] people.”
The researchers also stated that in the past decade, deaths among drug users have been “driven by a poisoned market and prohibition policies.”
HIV
Note that HIV-related causes were the second leading cause of death in the LISA study. In a province where care and treatment are provided at no cost to the patient and in an era where ART is generally well tolerated, there may be persistent barriers to care and treatment that are unique to people who use drugs.
For the future
The researchers offered the following broad prescriptions to help remedy the situation uncovered by the LISA study:
- Culturally appropriate, low-barrier, integrated primary care that addresses mental health and substance use is critical to supporting underserved communities and improving health outcomes overall. Evidence suggests that integrated care focused on HIV and substance use issues in community settings improves retention and adherence to ART.
- While B.C. has often been at the forefront of harm reduction strategies, these findings highlight the dire need for life-saving interventions, including increased safe supply options, that prioritize the needs of people who use drugs. This work underscores the need for a wide-ranging approach to tackling intersecting public health issues and for low-barrier, integrated care services with special focus on preventative healthcare, infectious diseases, mental health and addiction.
—Sean R. Hosein
Resources
BC Centre for Excellence in HIV/AIDS
Understanding Cirrhosis of the Liver: First steps for the newly diagnosed – CATIE, Canadian Association of Hepatology Nurses (CAHN)
What Works: What you need to know if you have HIV and use drugs – CATIE
Best Practice Recommendations for Canadian Harm Reduction Programs – Working Group on Best Practice for Harm Reduction Programs in Canada
Estimated number of people who inject drugs and coverage of harm reduction programs in Canada – CATIE News
Trends in liver cancer among HIV-positive people in North America – CATIE News
REFERENCES:
- Salters KA, Parent S, Nicholson V, et al. The opioid crisis is driving mortality among under-served people living with HIV in British Columbia, Canada. BMC Public Health. 2021 Apr 8;21(1):680.
- BC Centre for Excellence in HIV/AIDS. BC Centre for Excellence in HIV/AIDS to expand safer drug supply in the DTES with the support of Health Canada's Substance Use and Addictions Program (SUAP). Press release. 1 February 2021.