The opioid crisis is driving mortality among under-served people living with HIV in British Columbia, Canada

Abstract

Introduction Universal provision of effective antiretroviral medication has been essential to reduce mortality, increase longevity, and reduce onward transmission of HIV. This study aims to illuminate persistent threats to the health and longevity of under-served PLWH in British Columbia (BC), Canada. Methods Between 2007 and 2010, 1000 PLWH across BC were enrolled in the Longitudinal Investigation into Supportive and Ancillary health services (LISA) study and completed a cross-sectional survey on their HIV-care experiences and healthcare engagement. The sample generally reflects an under-served population of PLWH. A linkage to the provincial Vital Statistics registry is used in this analysis in order to examine overall mortality and cause-specific mortality trends; probability of death was modeled using logistic regression for participants with ongoing clinical monitoring (n = 910). Results By June 2017, 208 (20.8%) participants had died. The majority of deaths 57 (27.4%) were attributed to drug-related complications or overdoses, 39 (18.8%) were attributed to HIV-related complications, and 36 (17.3%) to non-AIDS-defining malignancies. We observed elevated odds of death among PLWH who smoked tobacco (aOR: 2.11, 95% CI: 1.38, 3.23), were older (aOR: 1.06 per one-year increase, 95% CI: 1.04, 1.08), indicated heavy alcohol consumption (aOR: 1.57, 95% CI: 1.11, 2.22), and reported unstable housing (aOR: 1.96, 95% CI: 1.37, 2.80); while higher CD4 cell count was protective (aOR: 0.87 per 100-unit increase, 95% CI: 0.79, 0.94) as was male gender), though non-significant (aOR: 0.73, 95% CI: 0.49, 1.07). Conclusions Overdose is - the leading cause of mortality among a cohort of under-served PLWH in BC, Canada. Public health efforts to end the HIV epidemic and support the health and well-being of PLWH are being thwarted by persistent health inequities and the enormous and persistent risks facing people who use drugs. Integrated low-barrier primary care is essential for supporting under-served PLWH, and safe drug supply is needed to support PLWH who use drugs.

Prevalence, correlates, and quality-of-life outcomes of major or persistent pain among women living with HIV in Metro Vancouver, Canada

“…The high proportion of participants managing pain with criminalized drugs in our study is concerning as there is an drug toxicity crisis in British Columbia characterized by contamination of the criminalized drug supply. Unintentional overdose now represents the major driver of mortality in PLWH in the province [ 66 ]. While we did not observe an association between pain and overdose, our data are limited to before 2019, after which the annual rate of drug toxicity deaths in British Columbia increased from 19.4 to 42.7 per 100,000 in 2022 [ 8 ].…”

HIV Vulnerability Among Survival Sex Workers Through Sexual Violence and Drug Taking in a Qualitative Study From Victoria, Canada, With Additional Implications for Pre-exposure Prophylaxis for Sex Workers

“…One possible origin of this HIV “death sentence” discourse could be from participants’ previous and ongoing social immersion with persons living with HIV on the more vulnerable end of the social and economic spectra, persons experiencing difficulties with antiretroviral adherence (for instance, because of street entrenchment) such that participants would infer and conclude that HIV treatment prognoses remained poorer. For added perspective, one recent HIV cohort study found that the leading cause of death of persons living with HIV in the province of BC was drug overdose ( Salters et al, 2021 ).…”

“…The present opioid epidemic, a “mass poisoning” event on account of an unsafe drug supply ( Tyndall, 2020 ), has been especially harmful for vulnerable populations in BC ( Salters et al, 2021 ), and antagonistic policing practices have been demonstrated to undermine lifesaving overdose prevention services—and exacerbate the risks of overdoses for vulnerable women ( Goldenberg et al, 2020 ). Unsafe occupational environments are powerful factors driving HIV infection risks among sex workers ( Benoit and Millar 2001 ; Shannon et al, 2008 ; Krüsi et al, 2016 ).…”

Characterizing opioid agonist therapy uptake and factors associated with treatment retention among people with HIV in British Columbia, Canada

“…In BC, the illicit drug toxicity has reduced survival gains achieved by combination antiretroviral therapy (ART) among PWH ( St-Jean et al, 2021 ). Recent evidence indicates a shift in mortality patterns among PWH, with non-HIV causes, particularly accidental overdoses, becoming the leading cause of death from 2010 onwards ( Yazdani et al, 2022 , Salters et al, 2021 ).…”

“…Despite the promising outlook in HIV treatment, healthcare inequities among PWH with complex co-occurring comorbidities – such as OUD – are jeopardizing improved HIV outcomes ( Salters et al, 2021 ). Studies have found that among people who inject drugs and have HIV, OAT independently influenced the HIV cascade of care and the odds of receiving ART were higher among lifetime recipients of OAT compared to non-OAT recipients ( Mazhnaya et al, 2018 , Mlunde et al, 2016 ).…”