Is buprenorphine as effective as methadone in supporting people who use drugs to become virally suppressed?
Vietnam trial offered people who use drugs buprenorphine during HIV clinic visits to see if was as effective at supporting viral suppression as getting methadone from specialist clinics.
Mixed results were reported in a trial that compared rates of viral suppression among people living with HIV receiving buprenorphine/naloxone therapy at HIV clinics, with those receiving methadone at OST clinics.
The BRAVO trial, which ran between 2015 and 2018, found the two opioid substitution treatment (OST) models were as effective at supporting people already on antiretroviral treatment (ART) to achieve viral suppression – but buprenorphine plus naloxone had less impact among those starting ART for the first time.
Methadone therapy is widely offered to people who use drugs. It’s known to decrease opioid dependency, lower rates of HIV transmission, improve engagement in HIV care and lead to fewer deaths. However, methadone treatment requires strict clinic monitoring and can result in drug-drug interaction with ART and tuberculosis drugs.
Buprenorphine/naloxone therapy is newer and more expensive than methadone treatment. However, it has fewer side effects, requires less strict monitoring and can be taken at home – although the Vietnamese national policy did not allow for this in this study. Buprenorphine therapy is more feasible for busy HIV clinics to offer people who use drugs as a way to integrate OST and ART.
Both are effective therapies for heroin dependency. However, different populations may benefit from one over the other depending on programmatic implications, client preferences, tolerance of side effects, or extent of opioid dependency.
Over 12 months, half of BRAVO’s participants were given buprenorphine plus naloxone by HIV clinics along with antiretroviral treatment (ART), and half received ART plus referral to a methadone clinic.
Most participants were men (97%). The mean age was 38. Just over two-thirds (68%) were on ART at the study’s start and all were using heroin.
The number of participants on ART increased over 12 months in both groups, rising from 73% to 84% in the buprenorphine group, and from 68% to 89% in the methadone group.
At the study’s start, 69% of people in the buprenorphine group were virally suppressed, rising to 81% at 12 months. In comparison, 66% of those in the methadone group were virally suppressed at the study’s start, with 93% at 12 months.
Among those already on ART, buprenorphine was as effective as methadone at supporting viral suppression. But among participants who had not been on ART before, more people in the methadone group were virally suppressed after 12 months, meaning buprenorphine was less effective.
People in the buprenorphine group were also more likely to leave OST, with just 40% of people offered buprenorphine retained on OST at 12 months, compared to 65% of people in the methadone group.
The fact that both viral suppression and OST adherence were lower in the buprenorphine group may be due to methadone clinics providing more structured behavioural support than HIV clinics, which can help people stay on OST and also adhere to HIV treatment.
Some participants who were new to ART reported feeling uncomfortable visiting an HIV clinic, as they feared their HIV status would be made public. This suggests HIV-related stigma also played a part in the lower viral suppression and OST adherence rates among the buprenorphine group.
Allowing take-home doses of buprenorphine could improve retention, as could enhancing adherence support in HIV clinics and community-based support involving families, community health workers and peers.
Overall, 35% of participants stopped using heroin entirely after 12 months, with little difference between groups.
Ten people died during the trial: seven (5%) in the buprenorphine group and three (2%) in the methadone group. This included three heroin overdoses and three AIDS-related deaths.
Deaths typically occurred among people no longer taking ART or OST. The biggest cause of treatment interruption was incarceration.