Overview
Opioid use disorder is a chronic, relapsing medical disorder with available and effective treatment options. Medications for opioid use disorder (MOUD) combined with counseling is the most effective therapy, and newer medications have revolutionized the treatment landscape for opioid disorder. This case and clinical decision points review considerations for the initiation and maintenance of MOUD in patients with HIV infection or HIV/hepatitis C virus (HCV) coinfection.
Opioid use disorder is common among people with HIV, such that based on current estimates, 1 in 23 women who inject drugs and 1 in 36 men who inject drugs will be diagnosed with HIV infection during their lifetime.[1] Treatment of opioid use disorder with opioid agonists (eg, methadone or buprenorphine) can decrease the risk of HIV seroconversion, improve access to HIV care, and improve HIV clinical outcomes and quality of life.[2-8] Opioid antagonist (ie, injectable naltrexone) treatment has also been shown to improve HIV outcomes in patients with a history of incarceration who are transitioning to the community.[9]
Effective antiretroviral therapy for HIV infection and the rapidly changing landscape of HCV treatment models are markedly improving the uptake of treatment for these conditions and improving outcomes for people with HCV monoinfection or HIV/HCV coinfection. Fragmented models of care in which HIV infection, HCV infection, and opioid use disorder are each treated in a different location can lead to decreased adherence to treatment and poor clinical outcomes for all 3 conditions. Co-located models of care allow for more streamlined treatment approaches and for greater communication and improved outcomes among patients with opioid use disorder and its associated comorbidities (eg, HIV and HCV infections). Such models include the provision of MOUD delivered in an HIV or HCV treatment setting, or HIV and HCV treatments delivered in an opioid use disorder treatment setting.[10-15]
The efficacy of buprenorphine, a partial opioid agonist at the µ-opioid receptor, for the treatment of opioid use disorder has been established. Federal regulations allow substantial flexibility regarding the type of clinical setting, the frequency of patient contact, the amount of medication dispensed, and the provision of counseling services for patients receiving buprenorphine, which can translate into innovative care-delivery models.[12,16-20] The efficacy of methadone provided through opioid treatment programs is also well established and some sites are able to incorporate HIV and HCV treatment within these programs.[11,21-24]
Recent work suggests that extended release naltrexone may be feasible for the treatment of opioid use disorder in HIV treatment Data from people with HIV infection transitioning from criminal justice settings to the community demonstrate that initiation of treatment with extended-release naltrexone prior to release is associated with improved HIV related outcomes.[9] Further study to determine how these findings extend to individuals not in criminal justice settings and in HIV treatment settings is needed.
This case focuses on the clinical considerations of treatment of opioid use disorder in patients with HIV infection or HIV/HCV coinfection, including patient assessment, medication treatment options, counseling considerations, drug interactions, and patient monitoring.