Considerations when prescribing opioid agonist therapies for people living with HIV

ABSTRACT

Introduction

Medications for opioid use disorder (MOUD) include opioid agonist therapies (OAT) (buprenorphine and methadone), and opioid antagonists (extended-release naltrexone). All forms of MOUD improve opioid use disorder (OUD) and HIV outcomes. However, the integration of services for HIV and OUD remains inadequate. Persistent barriers to accessing MOUD underscore the immediate necessity of addressing pharmacoequity in the treatment of OUD in persons with HIV (PWH).

Areas covered

In this review article, we specifically focus on OAT among PWH as it is the most commonly utilized form of MOUD. Specifically, we delineate the intersection of HIV and OUD services, emphasizing their integration into the United States Ending the HIV Epidemic (EHE) plan by offering comprehensive screening, testing, and treatment for both HIV and OUD. We identify potential drug interactions of OAT with antiretroviral therapy (ART), address disparities in OAT access, and present the practical benefits of long-acting formulations of buprenorphine, ART, and pre-exposure prophylaxis for improving HIV prevention and treatment, and OUD management.

Expert opinion

Optimizing OUD outcomes in PWH necessitates careful attention to diagnosing OUD, initiating OUD treatment, and ensuring medication retention. Innovative approaches to healthcare delivery, such as mobile pharmacies, can integrate both OUD and HIV and reach underserved populations.

KEYWORDS:

• Buprenorphine
• HIV
• Methadone
• MOUD
• OUD
• substance use disorder
• integrated care models
• mobile pharmacy

Disclaimer

As a service to authors and researchers we are providing this version of an accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proofs will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to these versions also.

Article highlights

• Urgent integration efforts are recommended in medical settings for screening, diagnosis, prevention, and treatment of both HIV and opioid use disorder (OUD).

• Opioid agonist therapies (OAT) can be used to treat opioid withdrawal and co-manage OUD and pain and, as such, are more easily initiated than opioid antagonist treatments in the community.

• OAT are associated with improved antiretroviral therapy (ART) adherence, viral suppression, and reduced HIV risk behavior, and should be readily available for people with HIV and OUD.

• Methadone, a long-acting full opioid agonist used for long-term management of OUD, has to be prescribed and managed in a licensed opioid treatment program (OTP) in the United States and requires gradual tapering and monitoring for toxicities as well as potential drug-drug interactions with some forms of ART.

• Buprenorphine, a partial opioid agonist and antagonist, can be prescribed in a non-OTP setting and can be initiated for treatment of opioid withdrawal as well as in those who are not yet in withdrawal and also co-management in pain and has very few side effects and minimal concerns for drug-drug interactions with ART in PWH.

• Inequities in access to OAT, especially for Black and ethnic minority populations, individuals that are unhoused, live in rural areas, and individuals involved with the criminal justice system reflects historical parallels in HIV care disparities. Ensuring access to both methadone and buprenorphine in people with HIV is critical to ending the HIV epidemic for these marginalized communities.

Declaration of interest

S Springer has provided paid scientific consultation to Alkermes Inc. S Springer has received in-kind study drug donations from Alkermes Inc and Indivior Pharmaceutical Company for NIH-funded research. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This research was funded by the National Institutes on Drug Abuse (NIDA; 1DP1DA056106-01, Springer). The funders were not involved in the research for this review or the decision to publish the manuscript.