HRSA Offers Guidance on Buprenorphine

By: Ranier Simons, ADAP Blog Guest Contributor

There is a higher prevalence of substance use disorder (SUD) among people living with HIV/AIDS (PLWHA) compared to the population at large.[1] Among PLWHA, nearly 50 percent report a current or past history of substance use disorders (SUD).[2] As such, in May 2023, the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) sent a letter to all Ryan White HIV/AIDS Program (RWHAP) Part B Aids Drug Assistance Program (ADAP) recipients encouraging them to include medications used to treat SUD in their formularies. HRSA additionally emphasized adding buprenorphine and naloxone.[3] 

Photo Source: HRSA

Buprenorphine is used to treat opioid addiction as an agonist treatment. It is a long-acting drug compared to the short-acting opioids to which people have addictions, such as heroin and oxycodone. Buprenorphine stays in the blood for 24-36 hours, in contrast to shorter-acting drugs people abuse that require consumption multiple times a day to prevent withdrawal symptoms.[4] Proper dosage of buprenorphine does not cause a euphoric high, and it allows substance abusers to stabilize their lives and gain control. Any drug can be abused and overdosed. However, an overdose of buprenorphine is less likely than an overdose of methadone, another medication used for agonist treatment. Naloxone is a drug that can temporarily reverse the effects of an opioid overdose giving a person time to allow medical assistance to arrive.

Roughly 40 percent of ADAPs do not have buprenorphine or naloxone on their formularies.[3] While most health insurance plans cover medications to treat SUD, 37.4 percent of ADAP patients have no health coverage.[3] Each ADAP determines the composition of its formulary. They use advisory boards of professionals to examine their populations and determine the cost/benefit analysis of including certain medications. ADAP clients without health insurance who also have SUD are left without the means to obtain SUD drugs that could drastically improve their lives.

PLWHA dealing with substance use addictions have poorer health outcomes than those without addictions. Drug abuse causes inconsistent antiretroviral adherence resulting in lower rates of viral suppression. SUD causes people to not engage in behaviors necessary for a productive, stable existence. Additionally, substance abuse can result in dangerous drug interactions between therapeutic medications and the drugs being abused, in addition to excessive wear on organs such as the liver and kidneys. To effectively fight the HIV/AIDS epidemic, it is vital to treat PLWHA wholistically. This means dealing with their mental and physical co-morbidities in addition to their HIV.

Photo Source: Baton Rouge Behavioral Hospital

The World Health Organization (WHO) also recognizes the importance of buprenorphine and naloxone. Both are listed on the 2021 22nd WHO model list of essential medicines, which is updated every two years. The essential medicine list are medicines: “that satisfy the priority health care needs of a population…selected with due regard to disease prevalence and public health relevance, evidence of efficacy and safety and comparative cost-effectiveness…intended to be available in functioning health systems at all times, in appropriate dosage forms, of assured quality and at prices individuals and health systems can afford…“[5] 

RWHAP's ADAP manual states that ADAPs may include medications used to treat chronic medical and mental health conditions in addition to some of the mandatory requirements, such as including at least one drug from each class of HIV antiretroviral medications.[6] If more ADAPs heed the suggestion of the HRSA letter, more PLWHA with substance addictions can get treatment and relief. Many ADAPs are facing funding challenges. However, including buprenorphine and naloxone would be worthwhile formulary additions as their usage is evidence-based.

[1] Shiau, S., Arpadi, S. M., Yin, M. T., & Martins, S. S. (2017). Patterns of drug use and HIV infection among adults in a nationally representative sample. Addictive behaviors, 68, 39–44. https://doi.org/10.1016/j.addbeh.2017.01.015

[2] Durvasula, R., & Miller, T. R. (2014). Substance abuse treatment in persons with HIV/AIDS: challenges in managing triple diagnosis. Behavioral medicine (Washington, D.C.), 40(2), 43–52. https://doi.org/10.1080/08964289.2013.866540

[3] HRSA. (2023, May 11). Ryan White Letter. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/rwhap-partb-aids-drug-assistance.pdf

[4] Centre for Addiction and Mental Health. (2023). Buprenorphine. Retrieved from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/buprenorphine#:~:text=Overview,pain%20relief%20for%20seven%20days

[5] World Health Organization. (2023). WHO model list of essential medicines - 22nd list, 2021. Retrieved from https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.02

[6] HRSA. (2016). AIDS Drug Assistance Program Manual. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/resources/adap-manual.pdf

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

Finding Emotional & Physical Health in Sobriety

By: Jonathan J. Pena

Philosopher Kahlil Gibran once wrote, “Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.”

I believe that we are all products of our environment. That the experiences we are exposed to greatly influences our behavior and process of thinking, which we carry with us throughout our entire lifetime. The products of my environment lead me down a path of immense suffering; it was one I desperately tried masking by altering myself with my great escape into drugs. My addiction, my sexuality, my HIV-positive diagnosis, and the loss of my mother to cancer were all struggles that have left there mark.

When I was five years old my parents got divorced because my dad was unfaithful to her. I was totally devastated. As I got older, I started to carry feelings of blame and started to believe that I had done something wrong to cause my father not be around my mom and his two first-born sons.  Around this same time, I was also feeling displaced from my peers because I just felt different from everybody else. I didn’t necessarily fit in with any of the kids or groups in school, and feelings of loneliness seeped in. I don’t believe that children are capable of processing the emotions of a divorce, nor the complexities of ones sexuality. All I knew for sure is that I was in a lot of pain and feeling very inadequate.

All of that emotional weight and pressure needed a place to go or a way to be released, and I found my escape in drugs. It started with pot and escalated into harder drugs. In the end, I became addicted to crystal meth and my life became completely unmanageable. My relationships with family and friends suffered or completely disappeared. I was losing countless jobs, tons of money, along with my dignity...and my life. My addiction to crystal meth led me into prostitution. I couldn’t hold down a steady job so in order to manage any sort of bills and my habit, I sold my body to any man who was willing to open up his wallet. Somewhere, in the middle of all that, I became HIV-positive. I was already struggling with the mere idea of my self worth, and testing HIV-positive completely shattered me because who was going to love me knowing that I was so tainted?

In 2015, I checked myself into a drug rehabilitation center in Philadelphia and during this time my mom’s battle with Leukemia was taking its toll. The cancer had spread to her brain and one month after I completed my program she passed away. I was holding her hand when she passed and the pain of her loss was unbearable. However, I was grateful that sobriety gave me the opportunity to be present for her death. I relapsed shortly afterwards because I was unable to process my emotions of pain and loss. But...I didn't give up on myself.

Today, I am living a sober life and approaching my one-year anniversary. My outlook on being HIV-positive has changed, and I no longer view myself as being tainted or unlovable. I am completely adherent with my medication and as such, my viral load is undetectable. I have realized the importance of maintaining and respecting my emotional and physical health, which includes taking my medication every day. Being HIV-positive doesn’t define me, but rather it is a part of me. 

Through sobriety and therapy, I have also become employed and living in my own apartment. I was recently accepted into North Carolina State University, where I will begin classes in the Fall 2017. I am studying to be an Oncology social worker with the hopes of being a support system for those who have lost a loved one due to cancer. I have re-established my connections with the people that I love and that love me in return. I am grateful, humbled, and renewed in my purpose in life through my sobriety.

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.