If an adult goes to the emergency department following a fentanyl overdose, they are nine times more likely to have HIV than the general population, recently published research suggests.
The research article, “Prevalence and predictors of HIV among patients presenting to US emergency departments with opioid overdose,” was published in the international journal Drug and Alcohol Dependence. It is the latest paper from a national team of investigators led by University of Colorado School of Medicine faculty member Jeffrey Brent, MD, PhD, working to better understand the opioid crisis, particularly fentanyl and its alterations, called fentanyl analogs or “fentalogs.”
Brent, a distinguished clinical professor in CU’s Division of Pulmonary Sciences and Critical Care Medicine and clinical faculty member in the Department of Emergency Medicine, is a national leader in medical toxicology. In 2009, he co-founded the Toxicology Investigators Consortium (ToxIC), a national multicenter research network that offers pivotal data on toxicology cases and contributes to several research projects, including a Fentanyl Analog (Fentalog) Study.
“As the opioid crisis grew in the country — and the proliferation of fentanyl and various fentanyl derivatives, which are called fentalogs, started appearing — we saw an opportunity to try to learn a lot about what was going on and what people were being exposed to,” says Brent, a co-investigator on the study.
The five-year study, supported by the National Institute on Drug Abuse, aims to investigate the fentalog epidemic by characterizing novel synthetic opioids and evaluating risk factors. As part of the project, since 2020, 10 emergency departments across nine states, including Colorado, have been enrolling patients aged 18 and older who come to the emergency department with a suspected opioid overdose into the study’s cohort.
“Over the course of the study, we’ve seen how the complexion of what opioid users are using has changed,” says Brent. “It appears heroin has slowly been replaced with fentanyl and various fentanyl analogs — and other classes of opioids, as well, that are even more dangerous than fentanyl.”
The study, though still ongoing, has already made an impact. The Centers for Disease Control and Prevention (CDC) launched an online dashboard that uses data from the study to track and monitor non-fatal overdose trends associated with fentanyl. As part of the study, investigators have also published several papers since 2021 with important findings, such as the identification of a novel opioid called N-piperidinyl etonitazene.
“We want to find out what is in the drug supply and what drugs people are being exposed to,” Brent says. “We’re also learning about the patients, including their HIV status.”
Investigating the prevalence of HIV
HIV, or human immunodeficiency virus, weakens an infected person’s ability to fight off infections and cancers. With available treatments, a person with HIV can live for many years or even a full lifetime. If left untreated, HIV can progress to AIDS (acquired immunodeficiency syndrome), which can leave a person vulnerable to opportunistic infections, including pneumonia, candidiasis, toxoplasmosis, and tuberculosis.
Given that injection drug use is a known risk factor for HIV, the study’s latest research paper focused on the prevalence of HIV and risk factors of HIV among patients who come to the emergency department with an acute opioid overdose.
The study involved 1,690 patients aged 18 and older who visited one of the 10 participating emergency departments between September 2020 and May 2023 with a suspected opioid overdose and had leftover blood — also called “waste serum” — from routine laboratory testing.
“Very often, once the patient is discharged from the emergency department, there is some blood left over in the lab. Normally, the lab would discard it, but all the sites got permission from their institutional review boards to be able to use that blood for additional testing,” Brent says.
Of the 1,690 patients, 60 were HIV-positive, 1,002 were HIV-negative, and it is unknown whether the other 628 had HIV. Out of the 1,062 patients whose HIV status was known (negative or positive), the HIV prevalence was 5.6% (60 positive cases out of 1,062). If the other 628 patients were HIV-negative, then the HIV prevalence for the total cohort of 1,690 patients would be 3.6% (60 positive cases out of 1,690).
The study’s authors estimated the overall prevalence of HIV in the U.S. among adults is approximately 0.46%. This means that, in this study’s cohort, the prevalence of HIV for emergency department patients with illicit opioid overdose was nine times higher than that expected by the general population.
Why it matters
Understanding the higher prevalence of HIV among adult patients coming to the emergency department following an opioid overdose is important “because one of the challenges for people who use drugs is that they have lots of medical problems, including high prevalence of HIV,” Brent explains.
“One of the problems fentanyl has caused is that people need to take it much more frequently compared to a substance like heroin. I’ve had a patient who was injecting up to 18 times a day,” he says. “For those patients, their whole life is figuring out ways of procuring fentanyl, and that doesn’t give them a lot of time to interact with the medical care system and get their medical needs taken care of.”
At the same time, the medical care system has historically had issues interacting with people with addiction and substance abuse issues, such as a lack of empathy and stigma negatively affecting patient care, he explains.
“That’s been changing over the years, but there traditionally was a bias against these patients and it was clear to them. It was difficult for them to get the medical care they needed,” he says.
As a result, historically, when these patients were brought to the emergency department and resuscitated from an opioid overdose, many wanted to immediately leave even though they had other health issues that the health care providers could help with.
“A lot of these people have HIV and it’s untreated. We saw this research as important because when they come in with a drug overdose, it is an opportunity to bring them into the medical care system,” Brent says. “If we, as practitioners, can work with them in a non-stigmatizing way and are sympathetic to their needs, we could start to develop relationships that would provide meaningful care to them — not only in terms of their HIV treatment, but in terms of their drug use in general.”
Bipolar disorder appears to be HIV risk factor
The data from the study’s cohort also suggests that bipolar psychiatric history was “a significant independent predictor of HIV positivity” in this population, meaning that bipolar disorder appears to be a novel risk factor for HIV positivity.
Brent was not surprised by this, as patients with bipolar disorder may experience more hyperactive behavior and, if combined with illicit stimulants, it can lead to more impulsive behavior — whether that be sexual behavior and/or drug use behavior — whereby they are more likely to encounter HIV.
“As the opioid crisis continues, clinicians should consider HIV screening in bipolar ED (emergency department) patients who present following an opioid overdose,” wrote the authors of the research article.
Continuing the work
Looking ahead, Brent says the Fentalog Study will continue its surveillance and monitoring of the drugs people are consuming, as well as investigating lingering questions such as: Why are people overdosing?
“Some of these people who have overdosed are individuals who’ve been using drugs for years, so what happened that caused them to overdose?” he says. “We’re trying to figure out what were the contributing factors, such as whether a person had a new drug dealer or was experiencing suicidal thoughts.”
Although the medical care system has come a long way in improving its care of patients who face addiction and substance abuse issues, Brent says there are still ways to improve.
“We should know when to test for HIV and how to best care for these patients so they can engage better with the medical care system, because we have very good treatments for HIV and opioid addiction,” he says. “We need to have resources available so that we can help transition patients to buprenorphine (helps prevent withdrawal symptoms and reduces drug cravings) or methadone (helps treat people with addiction issues) from the time they leave the emergency department.”
