HIV Specialist - March 2021 - 41

BY: William E. Cooke, MD, FAAFP, FASAM, AAHIVS
OMETIMES it takes an extraordinary event to allow us to see ordinary

people and truths. As horrendous as the opioid, HIV, and COVID-19 crises
have been for America, some good may come from these calamities if they
help bring the unseen people out of the shadows and into the light.

According to the CDC, more than 81,000
people lost their lives to drug overdoses during
the one-year stretch of May 2019 through May
2020. That represents an 18 percent increase
over the previous year and the most annual
overdose deaths ever recorded.1 The American
Medical Association (AMA) announced in
September 2020 that more than forty states
had reported increases in the number of overdose deaths during the pandemic.2
The national opioid epidemic has also resulted in a dramatic rise in soft tissue infections, endocarditis, and blood-borne diseases
including hepatitis C and HIV. These trends
threatens years of advances in the prevention
and treatment of infectious diseases. With
regards to HIV, while transmission in the
U.S. has declined by more than two-thirds
from its historic peak, CDC data indicate
further progress has stalled. New cases have
remained around 38,000 a year since 2014.3
Transmission of HIV among people who
inject drugs (PWID) threatens the tremendous progress we have made. Since 2014-as
I witnessed firsthand when southern Indiana
became the epicenter of the convergence
of the opioid and HIV epidemics-new
transmissions have increased by 51 percent
nationally among white PWID.4

Meanwhile, only about 25 percent of
PWID access treatment compared with 54
percent of the general population of people
living with HIV globally.5
Increasing access to addiction services
by leveraging technology is one way we can
make a difference. Integrating the treatment
of addiction into HIV prevention and treatment makes sense.

Integrating HIV
and Addiction Medicine

Physicians take a pledge to " do no harm. " That
feels passive when we know that most of what
harms our patients happens outside of our
clinic walls. I'd challenge my colleagues to
pledge to a modern Hippocratic Oath to " protect from harm. " This requires us to proactively respond to the needs of our patients by
connecting with them as people, not diseases.
One way to accomplish this is to integrate
medication for opioid use disorder (MOUD)
with HIV prevention and treatment.
Providers may harbor preconceptions
that people who use drugs will be difficult or
nonadherent, and that ongoing drug use will
undermine any provided treatment.
Conversely, patients may be reluctant to
fully engage in care for fear of being policed

or judged for ongoing substance use.6
Despite the strong links between opioid
use disorder (OUD) and HIV/AIDS, services
for these two conditions have been fragmented in the U.S. However, studies have shown
that successful linkage and engagement in
care is possible in this population when substance use treatment services are combined
with conventional HIV care.7
Holistic, integrated care moves us away
from just treating a disease and toward a
more life-affirming model of care.

Buprenorphine
X-waiver
A few months ago, the U.S. Department of
Health and Human Services (HHS) removed
the X-waiver requirement for physicians to be
able to prescribe buprenorphine to people living with OUD.8 The new guidelines allow any
physician to treat up to thirty patients living
with OUD at any one time.9 Of significant note,
this thirty-patient cap does not apply to hospital-based physicians (such as those working in
the emergency department). This simple policy change has the potential of reducing the cost
of healthcare while significantly increasing the
years of life saved and thus life expectancy.
Safety
Providers should be reassured that buprenorphine's safety profile ensures that adverse
events like fatal overdoses are rare This risk

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HIV Specialist - March 2021

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