Despite Availability of Free Antiretroviral Treatment, HIV Infection Remains a Cause of Death Among People with Injection Drug Use

Injection drug use (IDU) remains a major risk factor for HIV acquisition, accounting for 30% of new infections globally. Combined antiretroviral treatment (c-ART) has revolutionized HIV care, but people with injection drug use are often less likely to receive it due to a number of barriers, including access to care, physician fear of non-adherence and subsequent development of antiretroviral resistance, and financial burdens. Investigators sought to determine the impact of HIV infection on mortality among 2283 people with injection drug use within a system of universal free healthcare.

• The participants were followed for a mean of 61 months; 27% were infected with HIV at study initiation and 8% sero-converted during the study period. Overall, 84% had hepatitis C (HCV), 67% were male, and the mean age was 37. HIV-infected participants were more likely to be older, enrolled in a methadone treatment program, have longer time since first injection, and be HCV co-infected.
• Over the study period, 491 (22%) of the participants died. AIDS-related deaths and accidental deaths declined, while non-AIDS-related deaths (from non-AIDS-related infections, non-AIDS-defining neoplasms, respiratory disease, cerebrovascular disease, and cardiovascular disease) increased substantially.
• Although all-cause mortality declined over time, HIV infection was associated with all-cause mortality (adjusted hazard ratio [aHR], 3.15). Among those with >95% cART adherence, the association remained (aHR, 2.17).

Comments:

Although there remains the possibility of unmeasured confounding and the implications may be impacted by generalizability, this study suggests that among people with injection drug use with access to free antiretroviral care, HIV infection still contributes to all-cause mortality, while causes of death have shifted away from AIDS-related etiologies.

Jeanette M. Tetrault, MD

Reference:

Lappalainen L, Hayashi K, Dong H, et al. Ongoing impact of HIV infection on mortality among persons who inject drugs despite free antiretroviral therapy. Addiction. 2014 [Epub ahead of print]. doi: 10.1111/add.12736.