Preventable deaths, including those due to drug overdose (OD), are a significant public health concern in New York City (NYC), with rates increasing during the past decade, according to Sarah L. Braunstein, PhD, MPH. “NYC also has a large and long-standing HIV epidemic, with approximately 90,800 people living with HIV (PLWHIV) in 2018,” she says. “In addition, more than 14,000 people diagnosed with HIV/AIDS, and presumed to be living at of the end of 2018, had a history of injection drug use. Studies have shown that PLWHIV have an increased risk of OD compared with people without HIV, due to a range of clinical, behavioral, and socio-structural and environmental factors. Furthermore, PLWHIV who inject drugs have increased mortality rates, including because of OD. Despite these observations, trends in OD deaths among PLWHIV have not been well described.”

For a paper published in the Journal of Acquired Immune Deficiency Syndrome, Dr. Braunstein and colleagues analyzed trends in OD deaths among PLWHIV in NYC and examined pre-death HIV care engagement among PLWHIV who died of an overdose during 2007-2017. They used data from the NYC HIV Registry to identify PLWHIV whose deaths were classified on the death certificate with OD as the underlying cause.

Engaged in HIV Care Prior to OD Death

“Using HIV-related laboratory tests from the Registry, we evaluated HIV outcomes in the 12 months prior to death, including linkage to care, retention in care, history of antiretroviral treatment prescriptions, and viral suppression,” Dr. Braunstein explains. “We called this 12-month period the ‘intervenable period,’ during which engagement in HIV care and treatment should represent an opportunity to implement healthcare system-based interventions to reduce death from preventable causes, including OD.” The researchers observed that nearly one-half of PLWHIV who died of OD during this period appeared to be engaged in HIV care in the year prior to death. “They were virally suppressed before death, suggesting they had sustained interaction with providers and the healthcare system,” Dr. Braunstein says. “However, this is substantially lower than the 74% of PLWHIV in NYC in 2017 who were virally suppressed.”

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Opportunity for Clinical Intervention

Dr. Braunstein and colleagues also discovered that PLWHIV who died of an accidental OD were more frequently Black or Latino, younger, and had a history of injection drug use when compared with PLWHIV who died of an intentional OD, who were mostly White, older, and men who reported having sex with men (Table).

This study, Dr. Braunstein notes, stresses the importance of HIV providers engaging PLWHIV at risk of OD in OD prevention services and mental health care and treatment and underscores the need to retain PLWHIV in HIV care so that their multifaceted health needs can be addressed. The study team notes the need for future research on expansion of HIV medical care on a clinical level to address this further. “A healthcare system with a robust database that includes information on patient encounters, care, and treatment could replicate this analysis to corroborate, and more deeply explore, level and quality of care engagement among PLWHIV prior to death to identify specific opportunities for intervention,” explains Dr. Braunstein.