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Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Prevention of HIV Transmission by Blood Through Treatment of Addiction
Steven Shoptaw, PhDUCLA Center for Behavioral and
Addiction MedicineDepartment of Family Medicine
September 5, 2014
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
What You Need to Know• Understanding Addiction• Experiences of ART for Drug Users• Evidence-based Treatments and
the Rationale for their Efficacy as HIV Prevention
• Case Presentations and Discussion
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
DSM-5 Definition: Substance Use DisorderDSM-5 Definition: Substance Use DisorderMaladaptive pattern of use, clinically significant impairment or distress and 2+ of the following in the same 12-month period:
1. Tolerance2. Withdrawal3. Used for longer periods than intended4. Can’t cut down or quit5. Time spent getting, using or recovering6. Give up social, work or fun activities7. Craving or a strong desire or urge to use a substance8. Continued use despite knowledge of negative consequences9. Failure to fulfill major role obligations 10. Use in physically hazardous situations11. Continued use despite social and interpersonal problems
Opioids
• About 1 million Americans• Only 160,000 in opioid agonist
treatment• New developments make it
possible for office-based treatment (Suboxone)
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Opioid Detoxification: A Prescription for Failure
While detox sounds good, less than 2 in 100 successfully achieve drug free status (Day et al., 2005)
Most don’t consider this treatment, but a necessity for convincing addicts to use agonist Psychosocial strategies are less effective (Mayet et al., 2005)
Newly detoxified individuals are extremely vulnerable to relapse. The vast majority fail to remain drug-free.Opioid maintenance should be the first-line treatment for heroin dependence.
Opioid Agonist Treatments
• Cheap (especially for methadone)
• Potent • Safe (especially for
buprenophine)• Portable (especially
for buprenorphine)
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Treatment of Substance Use Disorders as HIV Prevention
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Mechanism: Opioid Replacement as HIV Prevention
Reduced craving for and use of illicit opioids
Reduced frequency of injecting drug use
Concomitant reductions in sex for money or drugs
Better cognitive function and ability to understand prevention messages
Less sharing of paraphernalia
Regular contact with NTP, which increases chance for medical and psychosocial interventions
Gowing et al., 2008
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Summary: Methadone and HIV Seroconversion
Early cohort studies demonstrated effects of methadone for reducing HIV-incidence
Continuous methadone maintenance is seroprotective; interrupted maintenance is not (Moss et al., 1994)
Opioid substitution may slow transmission of treatment resistant virus (Tetrault et al., 2013)
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Methadone Promotes ART Use
Uhlmann et al., 2010. Addiction, 105, 917-913
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
ART Adherence and MMT in 545 Homeless IDUS in Vancouver
Palepu et al., 2011. J Urban Health, 88: 545-555
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
ART in IDUs and NIDUs: Access Denied
EVER Get ART?N=1730
ART for 95%+ of TimeN=1275
Age (per year) 1.03 CI 1.02-1.04 1.02 CI 1.01-1.04
Baseline CD4<200 cell 4.43 CI 3.19-6.16 1.15 CI 0.89-1.48
Baseline PVL>5 log10 1.68 CI 1.2-2.35 0.68 CI 0.47-0.81
Black Race 0.57 CI 0.44-0.73 0.65 CI 0.51-0.83
IDU History 0.47 CI 0.33-0.67 0.63 CI 0.44-0.90
NIDU History 0.62 CI 0.47-0.81 0.66 CI 0.52-0.85
McGowan et al., 2011. PLOSOne, 6:e18462
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Effects of ART Among IDUs
Nolan et al., 2011. AIDS Care, 23:980-987
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Strategy for HIV Combination Prevention in HIV+ Substance Users
• Reduce Infectiousness: Reduce viral loads in HIV-positive groups of substance users– Reduces “transmission potential” across
population– Foundation of the seek, test, treat, retain
approach– Departure from advocacy strategies guiding HIV
prevention– No data yet to test TasP in HIV+ drug users
Kurth et al., 2011, Current HIV/AIDS Reports,1-11
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Reducing HIV Incidence in IDUs
Degenhardt et al., 2010, Lancet, 376:285-301
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
IDUs and Their Risk Environments
Ensuring access to ART, OST and NSP is important;
IDUs interact with individuals outside IDU networks
Opportunities for structural interventions
Strathdee et al., 2010, Lancet, 376, 268-284
Evidence on Outcomes for PWID Injecting frequency
Injecting risks
Sex risks HIV infectivity
HIV incidence
HIV testing -- ↓ ↓ -- --Individual interventions for HIV risk ↓ ↓ ↓ -- --Network/peer interventions for HIV risk ↓ ↓ ↓ -- --Needle syringe programs (NSP) ↓ -- -- ↓Condom provision -- -- ↓ -- ↓Opioid substitution therapy (OST) ↓ ↓ -- ↓Naltrexone – Oral -- -- --Naltrexone – Implant ↓ ↓ ? -- --Pharmacotherapy for stimulant dependence -- --CBT for stimulant dependence ↓ -- -- -- --STI treatment -- -- -- -- ↓Antiretroviral treatment (ART) -- -- -- ↓ ↓Safe injecting centres (SICs) ↓ -- -- --Compulsory detention of drug users -- ↑ ↑ -- --
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
HIV Treatment as Prevention
ART as Disease Prevention
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Profound Effects of ART in Preventing Death
• CASCADE Collaboration • 22 cohorts pooled with
known dates of HIV seroconversion
• Gains not even:– MSM decreased deaths
from malignancies and Ois– IDUs increased deaths due
to unintentional deaths
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
HPTN 052: TasP
Cohen et al., 2011, NEJM, 365: 493-505
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Apathy, Addictophobia, Inattention
Limited access to ARTs for HIV+ IDUs in resourced and in developing countries
Begs the question of starting ART early
Political stances against opioid substitution therapies and needle and syringe programs present structural barriers to averting infections
Inattention to marginalized groups (e.g., street youth, sex workers; itinerant workers) who engage IDU
Strathdee et al., 2012, Curr Opin HIV/AIDS
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Current Status
Models suggest, but no data exist to determine benefits of TasP for IDU or non-IDU substance users
Proof of concept studies excluded these due to concerns over medication adherence problems.
HPTN 074 will address TasP among IDUs in countries with HIV incidence
Measuring incidence in networks of IDUs and sexual partners
Virtually no other studies planned to guide policy on TasP among HIV+ substance users
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Treatment of Non-Injection Substance Use Disorders as HIV Prevention
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Not Just the Needle: A Complicated Equation for HIV Transmission
Type of Substance•Stimulant •Alcohol•NOT cannabisRoute of Use•Oral•Eating•Smoked•Inhaled•Inserted anally
HIV Transmission Risks•Blood (?)•Drug-facilitated sexual transmission
Local Factors on HIV Prevalence•Dual Diagnosed•Poverty•Incarceration•MSM•Street youth•Women•Race/ethnicity
NIDU + HIV = RiskSubstance Use Prevalence Transmission Potential
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Policy Model for Methamphetamine Use, Policy Model for Methamphetamine Use, HIV Prevalence and InterventionsHIV Prevalence and Interventions
Shoptaw & Reback, Shoptaw & Reback, J Urban Health, J Urban Health, 20062006
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Behavioral Drug Abuse Treatment as HIV Risk Reduction
Behavioral TherapiesFriends Getting Off (Reback & Shoptaw, 2011)Contingency Management (Shoptaw et al., 2005)
Limits to treatment settings (Menza et al., 2010)Heterosexual meth users show parallel reductions in injection and sex risk behaivors (Corsi et al., 2012)
Medication TherapiesMirtazapine (30 mg/d) for meth-dependent MSM (Colfax et al., 2011) showed reductions in meth use and concomitant HIV sexual transmission behaviors
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
HIV Prevention Strategies for Non-Treatment Seeking Substance Users
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Strategy for HIV Combination Prevention in HIV- Substance Users
Lower susceptibility: Reduce infection in HIV-negative groups
Biobehavioral approaches – PrEP, PEP for substance using MSM; other groups at high riskBehavioral programs – condom distribution, EBIs can address structural determinants of risk related to substance use; no evidence of infections avertedSurveillance of emerging epidemics linked to drug use
Kurth et al., 2011, Current HIV/AIDS Reports,1-11
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
iPrEX Results
Grant RM et al N Engl J Med. 2010 363:2587-99. Grant RM et al N Engl J Med. 2010 363:2587-99.
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
iPrEX FindingsOf 100 seroconversions, 36 in Truvada group, a reduction of 44% over placebo (p=0.005)
Efficacy was higher in men who reported UAI (58%) than those who did not
Adherent men (90%+) showed 73% efficacy
Efficacy of all subjects was 47% (p=0.001)
Questions remain about adverse effects, feasibility/acceptability/ethics
No indication about substance users as they were excluded from trials
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
PEP in MSMIn Project EXPLORE, MSM who reported any non-injection drug use increased odds for PEP by 50% (aOR: 1.5, 95% CI:1.1, 1.9)
Smoked cocaine, poppers, crack cocaine, amphetamines and hallucinogens increased oddsIDUs significantly higher odds of PEP use (aOR: 2.44, 95%CI: 1.69, 3.51). Marijuana or cocaine that was snorted or sniffed or alcohol drinking did not associate with increased odds for PEPNo evidence of risk compensation
Donnell et al., 2010, AIDS Behav 14:1182–1189
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
PEP in Methamphetamine Using MSM
When integrated with CM, PEP use among meth-using MSM appears to be safe and feasible
Time to PEP initiation (37 h) and reported adherence rates (96%) are comparable to non-meth-using PEP findings
CM increased PEP adherence 2% for each MA-negative urine sample; CM increased PEP completion by 17%
Meth-using MSM had high rates of risk behavior: high prevalent STI rates
Small sample size (n=53), 1 incident seroconversion – non-adherent to meds and multiple exposures
Landovitz et al. 2012 AIDS Pt Care STDS, 26:320-328
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Behavioral Prevention for HIV-Negative Substance Users
Woman focused HIV risk reduction program for African American crack smokers (Wechsberg et al., 2004)
Fast Lane, HIV-risk reduction program for HIV-negative heterosexual meth users (Mausbach et al., 2007)
Advancing the prevention and treatment of chronic illnesses
UCLA Department of Family Medicine
Behavioral Prevention for HIV-Positive Substance Users
See Table 1 handout from:
Shoptaw, S. (in press). HIV Positive Gay Men, MSM, and Substance Use: Perspectives on HIV Prevention. In Book edited by Leo Wilton PhD