BC-CfE 2017 Spring HIV/Antiretroviral Update: Overdose epidemic will worsen, continuing hope for expanded HCV treatment and coverage

July 5, 2017

The 2017 Spring HIV/Antiretroviral update featured a diverse roster of leading health professionals to discuss the latest numbers from the front lines of the opioid epidemic, advances in Hepatitis C screening and progress in meeting 90-90-90 HIV/AIDS targets around the world.

ADDICTION

Dr. Patricia Daly characterized the current state of the opioid crisis in Vancouver as one of the most challenging public health emergencies of her career.

Vancouver is on track to exceed the number of opioid related deaths in 2016, with most of this year’s fatalities occurring as a direct result of fentanyl or carfentanil contamination. Over 80 percent of people presenting with overdose are male, and while status First Nations people form only 2 percent of the population, 18 percent of overdoses seen in Vancouver’s emergency departments from 2012-2016 were among this group.

While the crisis continues and harm reduction remains a priority, Dr. Daly highlighted the importance of early intervention, reaching out to Indigenous communities, supporting early childhood development, and addressing the needs of vulnerable youth.

Dr. Nadia Fairbairn followed Dr. Daly with a warning that Vancouver’s current opioid epidemic resembles another public health crisis from Vancouver’s past.

“The opioid crisis has been rivalled in modern history only by the peak of the AIDS epidemic in the 1990’s,” she said. “Although these epidemics differ in nature, the large scale, highly coordinated response to HIV and AIDS that had such a huge impact on changing its course, may be instructive today in combating the opioid epidemic.”

Dr. Fairbairn discussed loss of tolerance to opioids through detox, incarceration and hospitalization and the resulting increased risk of overdose post-release and increased risk of HIV morbidity and mortality. Fairbairn spoke to an alternative - initiating a “slow taper” using methadone or buprenorphine/nalaxone in an outpatient setting - combined with counseling about overdose risk and take-home naloxone training.

SYPHILIS

Dr. Peter Phillips began his syphilis update with the question - is the epidemic under control? The short answer is no. While syphilis rates improved around 2010, they increased fivefold by 2015 in BC, and are projected to further increase in 2016.

Over 86 percent of men diagnosed with syphilis were men who have sex with men (MSM). Forty percent of newly diagnosed cases were also among HIV positive populations.

Phillips suggested new paradigms in treatment and treatment options as well as information about the impact of having HIV on treatment options – need to be explored.

HEPATITIS C

Dr. Lianping Ti shared good news regarding Hepatitis C (HCV) including a reduction in price for life saving drugs for Canadians, the introduction of safer and more tolerable medications, the development of new guidelines around the testing for HCV and the potential for universal coverage under BC’s Pharmacare program in 2018-19 for those living with the virus.

However, there continue to be challenges around testing for HCV. Only 44 percent of people living with HCV are aware of their status. While mortality related to tuberculosis, HIV and malaria is on the decline, HCV-related mortality continues to rise. Despite a large body of evidence and clinical guidelines to support one-time screening for HCV among baby boomers, the Canadian Task Force on Preventive Health Care recommended against screening for this population stating it found “no evidence on the effectiveness of screening HCV in the asymptomatic adult population”.

Following Dr. Ti’s presentation, Dr. Alnoor Ramji discussed the importance of providing timely HCV treatment to ensure improvement in all-cause mortality and decreases in liver related mortality, liver failure and liver cancer. Ramji says HCV elimination is a reality, provided physicians actively check patients for fibrosis and offer treatment regimens that are simple and effective in 90-95 percent of patients.

HIV

In Canada, 70 percent women living with HIV are between the reproductive ages of 15 and 39. Dr. Melanie Murray spoke about birth control options for HIV positive women, considerations for conception, preparing for pregnancy and pregnancy outcomes in HIV positive women.

She pointed out that almost 50 percent of pregnancies among women with HIV are not planned, and that healthcare providers should consider the possibility of pregnancy throughout the reproductive years. Murray says planning for pregnancy must consider pre-conception health (undetectable viral load and adherence to therapy as well as management of co-morbidities), possibility of transmission between partners during conception, transmission from mother to infant and management of infertility issues.

Dr. Reuben Granich discussed the current state of global HIV care continua, global HIV policy and the worldwide progress on the 90-90-90 target.

There are 2 million new HIV infections every year, 37 million people with HIV worldwide and 1.1 million deaths. Roughly 60 percent of people know their status, 50 percent are on treatment and $20 billion is being spent on HIV globally per year. One of the biggest challenges to “ending AIDS” is the global inconsistency in adopting the policy of testing and offering immediate treatment, but countries are rapidly moving towards this strategy.

Dr. Granich says the end of AIDS is feasible, but for the 90-90-90 target to be truly successful, the goal is to engage and keep 37 million people on life-long treatment until a vaccine and/or cure is available.

Dr. Réka Gustafson delivered Dr. Rolando Barrios’ presentation discussing the gaps in the HIV continuum of care in British Columbia. Gustafson highlighted the significant drop that occurs between linked to care and retained in care among people over 50 and under 30.

An area identified for further study was the low percentage of viral suppressions among women. The numbers show a major drop between diagnosis and linkage to care for women under 30.

Dr. Ronald Werb spoke about the effects of HIV on renal tissues, the immune response to the virus and the reaction within the kidneys as well as the impact of HIV treatment on renal function.

Dr. Greg Bondy discussed the management of obesity and metabolic disorders among people with HIV. Most patients who see body fat redistribution and increased obesity may be seeing these changes due to a higher baseline viral load, anti-retroviral therapy, chronic inflammation, body type, or hormones.

Dr. Robin Hsiung presented an update on HIV-associated neurocognitive disorders (HAND) and the range of disorders that fall under that category - from HIV associated dementia, mild neurocognitive disorders to asymptomatic neuro-cognitive impairment. Hsiung also discussed the current issues related to the diagnosis and management of HAND.

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BC-CfE 2017 Spring HIV/Antiretroviral Update: Overdose epidemic will worsen, continuing hope for expanded HCV treatment and coverage

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