Factors associated with mortality of HIV-positive clients receiving methadone maintenance treatment in China: Increasing daily methadone doses for Chinese injection drug users (IDUs) receiving methadone maintenance treatment reduces mortality in both HIV-infected and uninfected individuals, according to a study recently published in the Journal or Infectious Diseases. Enwu Liu and other researchers examined records of over 300,000 clients who received methadone maintenance treatment between March 2004 – when the Chinese government implemented a national Methadone Maintenance Treatment program — and April 2011, and calculated mortality rates for all clients, whether they received antiretroviral therapy or not. They found that the mortality rate for all clients was 11.8 per 1,000 person-years and 57.2 per 1,000 for HIV-infected clients. They also found that increasing average methadone doses to more than 75 mg per day reduces mortality by 24 percent, with a 47 percent reduction in mortality among people infected with HIV and on ART, and by 48 percent among people infected with HIV but not receiving ART. In addition researchers found that initiating ART at a CD4 T cell count of more than 300 is associated with decreased risk of death.
There are an estimated 780,000 people infected with HIV in China, with one third infected as a result of drug use and needle sharing. The report points out that internationally, studies show that opiate-dependent drug users enrolled in treatment have lower mortality than those who go without treatment, but those gains aren’t realized by HIV-infected individuals because of low coverage or adherence to ART. Among all patients enrolled in China’s National Free ART Program, injection drug users had the lowest ART coverage and highest mortality rate.
HIV prevention, treatment, and care for people who inject drugs: In this editorial written by Sarah Larney, Nickolas Zaller, and Josiah Rich, in the Journal of Infectious Diseases, the authors highlight the importance of providing better care and treatment for IDUs in light of the recent study on methadone maintenance treatment in China, summarized above. They point out that in 2010, the Reference Group to the United Nations on HIV and Injecting Drug Use reported that only four percent of HIV-infected IDUs receive ART. “Poor ART coverage among people who inject drugs has significant implications for broader efforts to control HIV, as epidemics among this population rapidly transition to self-sustaining generalized epidemics, particularly in developing countries. In this era of “treatment as prevention”, the urgent need for increased ART coverage and early initiation of treatment among people who inject drugs is clear,” they write.
They also highlight the importance of expanding opiate substitution treatment (OST), which acts as a conduit to ART initiation as people who inject drugs who are in OST enter ART more rapidly than their out-of-treatment peers, and show higher rates of ART adherence. OST also halves the risk of HIV infection for HIV-negative IDUs. Despite the evidence, OST coverage remains extremely low in many countries. There are only four OST clients for every 100 IDUs in East and South-east Asia, and less than one per 100 IDUs in Central Asia. Russia, despite having one of the world’s largest HIV epidemics among IDUs, doesn’t permit OST at all. The authors note many systematic and structural barriers to care for IDUs, and call on government leadership to address the gap. The authors write, “We have the tools to prevent and treat HIV among people who inject drugs. It is well past time we used them to their potential.”