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Monthly Naltrexone for Alcohol Abuse Helps
Viral Suppression After Prison Release
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21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa
Mark Mascolini
HIV-positive people released from prison maintained or improved rates of viral suppression significantly more often if randomized to monthly extended-release naltrexone (XR-NTX Vivitrol) than to placebo in a 100-person US trial [1]. Receiving four or more intramuscular XR-NTX shots boosted odds of HIV control.
HIV prevalence stands 4 to 5 times higher in prisoners than in the general US population, noted Yale School of Medicine researchers who conducted this study. HIV suppression rates often rise during incarceration, but poor antiretroviral adherence and loss of viral suppression are common after release. Alcohol use disorders are also highly prevalent among people who pass through the US criminal justice system and may affect postrelease adherence and viral control. XR-NTX is licensed for treatment of alcohol use disorders but has not been closely studied in people with HIV or those released from prison [2].
The Yale team conducted this 6-month double-blind, placebo-controlled trial to assess the impact of XR-NTX on viral load in people released from prison. They recruited participants who met DSM-IV criteria for alcohol use disorders during incarceration and randomized them 2-to-1 to naltrexone or placebo. Participants received one injection every month for 6 months, including one injection in prison and five in the community. Endpoints were proportions of participants in each study arm with an undetectable viral load 6 months after release at levels below 400 copies, 200 copies, or 50 copies.
The researchers randomized 67 people to XR-NTX and 33 to placebo. The groups did not differ substantially in age (average 45 overall) or in proportions of men (77%), blacks (65%), Hispanics (19%), or duration of incarceration (average 13.2 months). Most participants, 85%, had a current antiretroviral prescription, 67% had a viral load below 400 copies, and 90% had a CD4 count above 200. Whereas 59% of participants received 0 to 3 injections, the rest received 4 to 6.
In the XR-NTX arm the proportion of participants with a viral load below 50 copies rose from about 30% at baseline to about 40% at 6 months, whereas proportions below 50 copies in the placebo arm were about 40% at baseline and about 30% at 6 months (P
Logistic regression analysis determined that receiving four or more XR-NTX injections, compared with fewer XR-NTX injections or placebo, raised odds of having a viral load below 50 copies at 6 months more than 12-fold (odds ratio [OR] 12.5, 95% confidence interval [CI] 2.1 to 75.2, P = 0.006). Receiving four or more XR-NTX shots, versus fewer or placebo, boosted the odds of a viral load below 200 copies at 6 months almost 14-fold (OR 13.9, 95% CI 2.3 to 83.0, P = 0.004).
The researchers concluded that their findings link XR-NTX to maintaining or improving HIV suppression in incarcerated people with alcohol use disorders after release to the community. They encouraged authorities to assess incarcerated people with alcohol use disorders for XR-NTX, particularly as they approach release from prison.
References
1. Springer S, Azar M, Barbour R, Altice F, Di Paola A. Extended-release naltrexone is associated with sustained virologic suppression among HIV+ prisoners with alcohol use disorders after release to the community. 21st International AIDS Conference (AIDS 2016). July 18-22, 2016. Durban, South Africa. Abstract LBPE012.
2. Substance Abuse and Mental Health Services Administration. Naltrexone. http://www.samhsa.gov/medication-assisted-treatment/treatment/naltrexone
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