Research at the Intersection of HIV with Substance Use Disorders amidst the COVID-19 Pandemic

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I have written previously about intersections of substance use and substance use disorders (SUDs) with vulnerability to COVID-19 and adverse clinical outcomes. But we also cannot overlook important research on the overlaps of substance use and HIV and AIDS. NIDA and other NIH institutes are using supplementary funds to expand or adapt existing research projects to study the intersection of various health issues with the COVID-19 pandemic. We are prioritizing research into how the coexisting crises of COVID-19, HIV, and substance use, including the opioid crisis, combine to create a disastrous storm, taking lives and overtaxing America’s public health systems.

Research has demonstrated that people with SUDs are at increased risk for acquiring and transmitting HIV, both as a result of sharing injection equipment and because substance use may increase the likelihood of impulsive sex and sex without use of condoms or other HIV prevention tools. For decades, NIDA has devoted considerable resources to support research at the intersection of HIV and substance use. NIDA has the second largest HIV research portfolio at NIH, building unique knowledge related especially to the vulnerable SUD population.

To encourage transformative science and coordinate HIV related research across the institute, NIDA created its AIDS Research Program (ARP) in 2004. In 2008, the ARP established the Avant Garde Awards for HIV/AIDS Research to support individual scientists who propose research relevant to HIV and substance use with high impact potential and that would not typically be funded because of its high risk. In 2015, we launched the Avenir Awards for HIV/AIDS Research to provide grants to early-stage investigators who also propose highly innovative studies.

These commitments to research have led to several significant scientific contributions. A decade ago,  NIDA supported a seminal study demonstrating that HIV treatment is prevention, finding that scaling up HIV treatment in people who inject drugs resulted in reductions in community-level viral load and HIV transmission. NIDA-funded research also demonstrated that addiction treatment, especially medications for opioid use disorder, is a necessary part of HIV care and leads to improved viral load, CD4 cell count, and retention in HIV care. A study from NIDA’s Clinical Trials Network found that HIV testing can be integrated into SUD treatment and that counseling offered no additional benefit—findings with broad clinical and public health implications.

The ARP aims also to expand support of basic science research including HIV pathogenesis and the immune response in the presence of addictive substances, including those substances’ ability to promote or interfere with HIV reservoirs in the brain. We are also funding clinical research to develop effective interventions for HIV, substance use, and SUD prevention and treatment, as well as implementation and services research including developing integrated models of care for HIV and SUDs, implementing effective evidence-based practices in routine healthcare settings, and determining the cost and cost-effectiveness of HIV and SUD care. Developing new pre-exposure prophylaxis (PrEP) products to prevent HIV transmission is an ongoing area of research, and NIDA is committed to supporting research to determine feasibility and acceptability of PrEP among people who use drugs.

With additional funds now available to study COVID-19, there is great opportunity for HIV and addiction researchers to make important advances in understanding how COVID-19 intersects with substance use, the opioid epidemic, and HIV.  It is already clear that these crises are intertwined and especially impacting vulnerable populations, but many gaps in our understanding remain.

Several co-occurring health problems, including cardiovascular and pulmonary diseases and diabetes, confer greater risk of SARS-CoV-2 infection, severity of disease, and poor outcomes. Additional research could inform us about the clinical impact of COVID-19 on people who use drugs and are living with HIV, as well as the impact that mitigation strategies like social distancing is having on individual health, mental health, and substance use and access to HIV and SUD treatment services. And while knowledge is expanding on how substance use and HIV impact the brain and central nervous system, we know nothing of synergistic short or long-term effects in the presence of COVID-19.  There is great potential for knowledge and experience from AIDS care to inform COVID-19 treatment, and conversely, care strategies learned during the COVID-19 crisis could be adapted to HIV outbreaks still seen worldwide that are often connected to injection drug use.

Simply developing effective treatments is no guarantee people using drugs will receive benefit, therefore we cannot expect the development of vaccines or treatments for COVID-19 to confer benefit to this population.  When these interventions are available, research will be needed to ensure people using drugs and living with HIV have access.  Particularly crucial to study are intersections of HIV, SUD, and COVID-19 among racial and ethnic minority groups, including African Americans, who are consistently disproportionately burdened with poor outcomes across these health conditions.  With African Americans suffering and dying from COVID-19 and HIV at higher rates and facing rapidly increasing rates of overdose mortality, research into structural racism and resulting health disparities is more critical than ever. This should include research into stigma within healthcare, which can impede access to care for people of color and those living with HIV and drug addiction.  

We cannot forget that in the intense climate of COVID-19, HIV remains a high-priority research area for NIDA.  We must develop interventions that are both effective and widely available to address HIV among people who use drugs.  The ambitious goal of ending the transmission of HIV will never be realized if we do not also address drug use while ensuring there are no disparities in access to treatment of HIV and SUD. 

More information, including funding opportunities, is available through NIDA’s AIDS Research Program.