1. Receipt of medication-assisted treatment halves the risk of HIV-1 RNA viral load rebound for HIV-positive women who use illicit drugs
Joëlla W. Adams, MPH
Brown University
Principal Investigator: Professor M-J Milloy (BC Centre on Substance Use, Department of Medicine, University of British Columbia)

2. Disclosures Funding No conflict of interest to report
The ACCESS study is supported by the National Institutes of Health [U01-DA ]. This analysis was supported by the National Institutes of Health [F31-MH A1, R25-DA037190, U01-DA ]. M-J Milloy receives support from a Scholar award from the Michael Smith Foundation for Health Research, and a New Investigator from the Canadian Institutes of Health Research. The University of British Columbia received an unstructured gift from NG Biomed Ltd., a private firm seeking a license to produce medical cannabis, to support him. He is the Canopy Growth professor of cannabis science at the University of British Columbia, a position created using unstructured gifts to the university from Canopy Growth, a licensed producer of cannabis, and the Government of British Columbia’s Ministry of Mental Health and Addictions.

3. Women living with HIV may be particularly vulnerable to viral rebound
Studies in the U.S. and Canada often report low rates of ART adherence and high rates of viral rebound for women
Viral rebound can lead to drug-resistant virus, transmission to others, and HIV-related morbidity and mortality
Risk factors related to viral rebound may differ by gender but most studies aren’t powered to examine risk factors specifically for women
Study objective: evaluate the impact of sociodemographic, behavioral, and clinical factors on the hazard of viral rebound after achieving viral suppression over an eleven year period for a cohort of women living with HIV who use illicit drugs
For example, studies have suggested that
Increased rates of depression and/or mental illness
Intimate partner violence
Stigma related to sex work may put women at disproportionate risk of viral rebound

4. ACCESS Study, 2005-2017 Vancouver, Canada
185 women living with HIV with illicit drug use who achieved viral suppression with 2+ study interviews
46% are Indigenous, 5% are transgender women, and 25% self-identified as a sexual minority
Interviews ~6 months, systematic HIV viral load and CD4 monitoring
Methods
Kaplan-Meier survival curves for time to viral rebound
Extended Cox regression models with recurrent event framework, time-varying covariates, and frailty component
In Vancouver, there is universal, no-cost access to ART

5. OAT halves risk of viral rebound
Figure 1. Kaplan-Meier survival curve for time to first viral rebound following viral suppression by receipt of OAT (consistently on OAT, n=87 vs. never received OAT, n=50)
34% experienced at least one viral rebound over 11 years
68% had 1 viral rebound, 24% had two, and 8% had 3+ events
In adjusted analysis, the only factor protective against viral rebound was receipt of opioid agonist treatment in the past six months (AHR: 0.47, 95% CI: )
Adding time-varying ART adherence to the model attenuated effect of OAT (AHR: 0.60, 95% CI: ), suggesting that effect of OAT was mediated by ART adherence
OAT can improve HIV treatment outcomes for women
co-locate OAT and HIV treatment services
ensure low barrier to entering OAT services
importance of ART adherence support and counseling
Adjusted model included the following covariates: age, race/ethnicity, education level, sexual orientation, homelessness, incarceration, employment, exchange sex, injection drug use, binge alcohol use, binge drug use, overdose, ever sexual abuse, physical or sexual violence, year of earliest ART dispensation, CD4 count at baseline, viral load at baseline