Aligning Efforts to Boost Medications for Opioid Use Disorder and Pre-Exposure Prophylaxis for HIV

Abstract

Among the many harmful consequences of opioid use disorder (OUD), two outcomes are particularly critical: opioid overdose and HIV infection. Fortunately, two interventions—medications for OUD (MOUD) and pre-exposure prophylaxis (PrEP) for HIV–effectively reduce the risk of opioid overdose and HIV, respectively. Despite the safety and availability of MOUD and PrEP, their uptake remains quite low. Efforts to increase use of MOUD and PrEP have occurred largely independently, yet these interventions integrate well in the setting of office-based treatment of OUD. To develop strategies that promote utilization of both medications, an integrated framework is needed. The OUD care cascade, a model describing treatment stages through which a patient may progress, has been increasingly used to facilitate monitoring and strategically expand MOUD services. Integrating PrEP into this framework could bring increased attention to PrEP utilization and strengthen efforts to enhance uptake of both medications. While real-world challenges exist along the continuum from diagnosis to retention, integrated measurement frameworks such as dashboards can help track progress, identify gaps, and optimize treatment strategies. To accelerate progress in the fight against HIV and opioid overdose, it is time to integrate monitoring and research of MOUD and PrEP.

Over 9 million people in the USA currently struggle with opioid use disorder (OUD).¹ Of the personal harms that can stem from OUD, two outcomes are particularly notable: fatal opioid overdose and acquisition of the human immunodeficiency virus (HIV). Annually, over 80,000 people lose their lives to opioid overdose² and 3000–6000 individuals acquire HIV^3–5 in association with injection drug use. Given the profound significance of these outcomes, researchers and public health practitioners have strived to reverse these trends with some success: in recent years, utilization of treatment for OUD has expanded across the USA⁶ and new HIV cases have been decreasing annually.^3,7,8 Yet, a significant need to optimize prevention remains for the millions of adolescents and adults living with OUD in the USA.¹ Notably, efforts to strengthen opioid overdose and HIV prevention have largely occurred independently. Strategic alignment of resources, supported by an integrated measurement framework, would accelerate progress in the fight against HIV infection and opioid overdose deaths.

The HIV and opioid overdose epidemics intertwine among people with OUD through a common antecedent: nonprescribed opioid use. Nonprescribed opioid use increases risk of fatal overdose by depressing respiratory drive, particularly when using synthetic opioids like fentanyl. Nonprescribed opioid use also increases risk for HIV through associated behaviors such as use of nonsterile injection equipment or in association with condomless sex (by enhancing behaviors associated with HIV acquisition^9,10). Opioid use can also increase risk for condomless sex via various social drivers of health like unsafe living conditions (increasing risk for sexual assault), poverty (increasing reliance on sex work or sex trade), and increased risk of sex trafficking.^9,11–13 As a result, treating OUD is an important strategy to reduce opioid overdose deaths and HIV incidence.

For individuals with OUD, HIV and opioid overdose deaths are further linked through key prevention medications. Two medications for OUD (MOUD) have been shown to substantially reduce the risk of opioid overdose deaths, methadone and buprenorphine.¹⁴ Preexposure prophylaxis (PrEP) for HIV has been shown to reduce risk of HIV by > 70% when taken with high adherence.¹⁵ FDA-approved formulations of PrEP include extended-release cabotegravir or two daily oral combinations of emtricitabine and tenofovir; of these three formulations, only one is labeled for patients at risk of HIV due to injection drug use.¹⁶ When fully optimized, these interventions can dramatically change the health trajectory of individuals living with OUD. Unfortunately, the vast majority of people living with OUD use neither.¹ Data on past-year treatment rates suggest that, among individuals living with OUD, fewer than 15–25%^1,6,17 have received MOUD, and among those with injection drug use, < 1%¹⁸ have received PrEP. More effective strategies to deliver MOUD and PrEP to individuals with OUD are needed.

The alignment of strategies to prevent HIV infection and opioid overdose deaths through PrEP and MOUD calls for integrated strategies to promote utilization of both medications. Yet, most research and public health programming when focusing on these opportunities have addressed these outcomes separately.^19,20 This siloing results in missed opportunities to strengthen dual-purpose prevention and treatment efforts for at-risk individuals. One example stands out: office-based opioid treatment (OBOT).²¹ Since regulatory changes implemented in 2002,²² community physicians have been allowed to prescribe buprenorphine to treat OUD. With the passing years and additional regulatory easing,^23,24 a growing pool of providers (and patients) have turned to buprenorphine for the treatment of OUD.^25,26 As a result, many patients seeking OUD treatment now present to offices that could, but do not always, administer PrEP. To this point, the majority of clinicians prescribing buprenorphine are primary care providers,^25,26 clinicians fundamentally trained to think holistically about health.

To encourage health systems, clinicians, and researchers to emphasize MOUD and PrEP simultaneously through both individual- and system-level innovations⁷, a conceptual framework of OUD treatment that integrates MOUD and PrEP is needed. The care cascade framework, which originally comes from the HIV treatment literature, presents a pragmatic approach to support integrated intervention and monitoring of MOUD and PrEP. A care cascade identifies the essential stages of healthcare utilization through which a patient is identified, engaged, and treated. Over the past decade, the OUD care cascade has been increasingly used to facilitate monitoring and strategic expansion of MOUD services.^17,27,28 Not insignificantly, quality indicators have incentivized healthcare organizations to set outcomes like MOUD utilization as system priorities.²¹ Fewer scholars in HIV prevention have attempted population-based analyses estimating treatment indicators across the cascade within a single cohort defined by substance use.³⁰ Incorporating PrEP into the MOUD care cascade could help bring increased attention to PrEP utilization and strategically strengthen dual efforts to enhance uptake of both medications.

The extant OUD care cascade (Fig. 1) incorporates quality indicators from the National Center for Quality Assurance (NCQA). Specifically, OUD diagnosis precipitates the need for treatment initiation (with a goal of starting medication within 14 days of diagnosis). Following initiation, the cascade marks two subsequent goals: engagement (i.e., a second prescription by 34 days) and retention (i.e., continuous medication for at least 180 days). A dual care cascade adding PrEP among people with OUD would involve few modifications (Fig. 2). OUD diagnosis represents the essential time point indicating potential eligibility for PrEP, depending on drug use behaviors and HIV status (all patients diagnosed with OUD should be offered HIV testing).¹⁶ If eligible,^a the framework then supports initiation of MOUD as well as PrEP by 14 days from OUD diagnosis, recognizing that competing priorities and patient preference can pose barriers to initiating both MOUD and PrEP simultaneously. Once initiated, a provider would recommend close follow-up, no later than 34 days from initiation, to assess adherence, side effects, and dose (buprenorphine only), as well as to coordinate medication refills. (While injectable cabotegravir is ultimately administered at 2-month intervals, the second dose, 1 month later, would mirror the measure of engagement). After the first month, the framework emphasizes retention through at least 180 days, achieved through recurrent office visits and refills. The new integrated framework also calls for repeat assessment of renal function, HIV status, and testing for sexually transmitted infections in accordance with Centers for Disease Control and Prevention (CDC) PrEP guidelines (Fig. 2). As with the other cascade steps, these labs can be ordered by the outpatient provider teams managing both medications.

Figure 1.

Care cascade for treatment of opioid use disorder.

Figure 2.

Care cascade integrating HIV prevention.

Walking through an individual- and system-level example demonstrates the utility of this integrated framework. Imagine a patient who presents to the emergency department (ED) with an opioid overdose. In the ED, the attendant clinician coordinates the interventions required for overdose reversal, assesses for metabolic and organ dysfunction, collects a urine toxicology to confirm etiology, and screens for associated risks such as STIs and HIV (HIV screen #1). Based on this information and interview with the patient, the clinician diagnoses (let’s assume) OUD and notifies the relevant social work (SW) team. SW supports the patient with referrals to outpatient services, according to the patient’s goals, such as registration with a primary care clinician (PCC). Both the emergency medicine clinician and SW team prime the patient to consider initiating MOUD and PrEP, pending HIV test results. Ideally, ED documentation is transmitted to the PCC’s office in time for the patient’s appointment. When the patient arrives, the PCC reviews the patient’s clinical history and treatment goals and together decides what medications to initiate. They make a follow-up plan. If the patient continues to engage, medication refills are observed in health record or claim data at 1 month and 6 months (retention) along with interval laboratory monitoring (HIV screen #2).²

The above example demonstrates how cascade benchmarks can inform clinical workflows. Yet, all too often, patient cases deviate from idealized scenarios because of the numerous barriers and challenges that present along the continuum from diagnosis to retention. Patients with OUD, for example, exhibit high rates of MOUD discontinuation, particularly in the first month of treatment.^33–35 Rather than dissuade use of a care cascade, however, these treatment gaps reveal the importance of population-level monitoring. Using an integrated care cascade, healthcare organizations could track rates of initiation, engagement, and retention side by side for PrEP and MOUD, an approach not done in the vast majority of healthcare settings. Systems could then use these data to implement strategies tailored to mitigate or even eliminate the specific gaps observed. Systems thinking can support this process.³⁶ For example, data might suggest strategies that focus on specific practice settings (EDs, clinic sites, hospital discharge) and/or populations (those with co-occurring SUDs and psychiatric diagnoses, or certain demographic groups²⁸) that lag behind on key metrics. In response, a health system could implement new interventions or relocate existing interventions to new practice settings. Resulting benefits to the health system may include improved outcomes and associated financial incentives,²⁹ higher patient satisfaction, and even reduced costs (if MOUD and PrEP uptake leads to fewer ED visits for overdose or prolonged hospitalizations for patients with HIV-related complications). In particular, learning health systems offer key settings in which to implement and evaluate evidence-based interventions such as MOUD and PrEP.³⁷

Leveraging health system data to facilitate organizational change is easier said than done. To this end, implementation strategies are needed to facilitate the translation of health system data to health system decision-making. While internal monitoring might begin to identify cascade gaps, dashboards (adapted for internal utilization or streamlined for public viewing) could increase capacity for organizational change. Dashboards could also support health system marketing and facilitate community rapport by enhancing transparency, highlighting improvements, and signaling priorities.^38–40 Strategies and specific techniques to implement and evaluate the impact of dashboards for health system change and outcomes improvement are needed.⁴⁰

CONCLUSIONS

Opioid overdose deaths and HIV acquisition need not be consequences of OUD for people living in the USA. We have safe and effective medications to prevent both outcomes: MOUD and PrEP. While efforts to increase use of MOUD and PrEP have largely occurred independently, strategic alignment of resources to boost the use of these medications, supported by an integrated measurement framework such as dashboards, would accelerate progress in the fight against HIV infection and opioid overdose deaths. It is time to formally intertwine PrEP and MOUD as two valuable parallel interventions for people living with OUD.