title: The Effects of Opioid Substitution Treatment and Highly Active Antiretroviral Therapy on the Cause-Specific Risk of Mortality Among HIV-Positive People Who Inject Drugs.
abstract: BACKGROUND
  Prior studies indicated opioid substitution treatment (OST) reduces mortality risk and improves the odds of accessing highly active antiretroviral therapy (HAART); however, the relative effects of these treatments for human immunodeficiency virus (HIV)-positive people who inject drugs (PWID) are unclear. We determine the independent and joint effects of OST and HAART on mortality, by cause, within a population of HIV-positive PWID initiating HAART.
  
  
  METHODS
  Using a linked population-level database for British Columbia, Canada, we used time-to-event analytic methods, including competing risks models, proportional hazards models with time-varying covariates, and marginal structural models, to identify the independent and joint effects of OST and HAART on all-cause as well as drug- and HIV-related mortality, controlling for covariates.
  
  
  RESULTS
  Among 1727 HIV-positive PWID, 493 (28.5%) died during a median 5.1 years (interquartile range, 2.1-9.1) of follow-up: 18.7% due to drug-related causes, 55.8% due to HIV-related causes, and 25.6% due to other causes. Standardized mortality ratios were 12.2 (95% confidence interval [CI], 9.8, 15.0) during OST and 30.0 (27.1, 33.1) during periods out of OST. Both OST (adjusted hazard, 0.34; 95% CI, .23, .49) and HAART (0.39 [0.31, 0.48]) decreased the hazard of all-cause mortality; however, individuals were at lowest risk of death when these medications were used jointly (0.16 [0.10, 0.26]). Both OST and HAART independently protected against HIV-related death, drug-related death and death due to other causes.
  
  
  CONCLUSIONS
  While both OST and HAART are life-saving treatments, joint administration is urgently needed to protect against both drug- and HIV-related mortality.
authors.affiliation: BC Centre for Excellence in HIV/AIDS, Vancouver Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
authors.forename: Bohdan
authors.initials: B
authors.lastname: Nosyk
authors.affiliation: BC Centre for Excellence in HIV/AIDS, Vancouver.
authors.forename: Jeong E
authors.initials: JE
authors.lastname: Min
authors.affiliation: University of California-Los Angeles Integrated Substance Abuse Programs.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Evans
authors.affiliation: University of California-Los Angeles Integrated Substance Abuse Programs.
authors.forename: Libo
authors.initials: L
authors.lastname: Li
authors.affiliation: Department of Preventative Medicine, Northwestern University, Chicago, Illinois.
authors.forename: Lei
authors.initials: L
authors.lastname: Liu
authors.affiliation: BC Centre for Excellence in HIV/AIDS, Vancouver Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
authors.forename: Viviane D
authors.initials: VD
authors.lastname: Lima
authors.affiliation: BC Centre for Excellence in HIV/AIDS, Vancouver Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
authors.forename: Evan
authors.initials: E
authors.lastname: Wood
authors.affiliation: BC Centre for Excellence in HIV/AIDS, Vancouver Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
authors.forename: Julio S G
authors.initials: JS
authors.lastname: Montaner
mesh_terms: D000293:Adolescent; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D058850:Opiate Substitution Treatment / Q000706:statistics & numerical data*; D015819:Substance Abuse, Intravenous / Q000150:complications / Q000188:drug therapy / Q000401:mortality; D055815:Young Adult
keywords: HIV/AIDS; highly active antiretroviral therapy; injection drug users; mortality; opioid substitution treatment