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HIV and Injection Drug Use
HAIVNHarvard Medical School AIDS
Initiative in Vietnam
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By the end of this session, participants will be able to:
Explain the link between HIV and intravenous drug use in Vietnam
Explain how to diagnose drug addiction
Explain benefits of harm reduction Describe how to provide ART to
intravenous drug users (IDU)
Learning Objectives
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IDU is the major source of HIV infections in Vietnam
Risk associated with:• needle-sharing • exposure to contaminated injection
equipment IDU often engage in other high risk
behaviors, such as unsafe sex, that can transmit HIV to non-IDU partners
Epidemiology of HIV and IDU
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Estimated 3.3 million IDU in South and South East Asia
Estimated at least 20% of IDU are HIV-positive in Vietnam
Commercial sex work among IDU has been called a “bridge” to the general population
Epidemiology of IDU in Asia
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Distribution of HIV/AIDS Cases in Vietnam
I DUs53.40%
CSWs2.68%
STDs1.56%
TB patients4.81%
Blood donors0.58%
AI DS suspects10.01%
Military recruits1.31%
Other19.19%
Unknown6.45%
Source: MOH
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HIV Prevalence Among IDUs, 2009
HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009
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HIV Trends Among IDUs, 2006-2009
HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009
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Opioids
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Class of drug that includes:• Morphine• Heroin• Methadone• Buprenorphine• Opium• Codeine
Opioids:• relieve pain and
bring on feelings of well-being
• slow down functions of the central nervous system, including respiration
Overview of Opioids (1)
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High doses can cause respiratory depression, coma and death
In Vietnam, most commonly used illicit opioids are heroin and opium
Overview of Opioids (2)
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Use: smoked, injected, nasal, oral Effects: euphoria, sedation, pain
reduction Negative effects: dependence,
overdose, injection related illnesses Withdrawal: severe, but not life
threatening
Heroin (1)
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Pregnancy: withdrawal dangerous to fetus, pregnant women should be maintained on methadone
Overdose: when mixing drugs or after period of abstinence
Heroin (2)
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Definition (ICD-10): A cluster of behavioral, cognitive, and physiological phenomena develop after repeated substance use that include:• Strong desire to take drug• Difficulties in controlling use• Persisting in use despite harmful consequences• Higher priority given to drug use than other
activities and obligations• Increased tolerance• Physical withdrawal symptoms if drug stopped
Characteristics of Opioid Dependence
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Withdrawal symptoms:• Muscle and joint pain• Abdominal cramps• Nausea, vomiting• Diarrhea• Cough• Chills
Physical signs: • Dilated pupils• Tachycardia• Hypertension• Hyperactive bowel
signs
Opioid Withdrawal Symptoms
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Treatment for IDU
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Directly related to drug use:• Respiratory depression from opioids• Pulmonary problems from inhaled drugs• Malnutrition• Mental health issues: mental disorders
may appear during drug use or with sudden stopping of drug
Medical Complications of IDU (1)
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Bacterial infections• Bacterial
endocarditis• Osteomyelitis• Skin and soft tissue
infections• Septic
thrombophlebitis• Septicemia
Viral infections• HIV, HCV, HBV
Mycobacterial infections• 10X increased risk
for TB among HIV negative IDU
Medical Complications of IDU (2)
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Non-healed puncture wounds along vein with accompanying inflammatory changes
Skin Lesions of Injection Drug Users
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Skin Abscess from Injection Drug Use
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Stigma Discrimination Social marginalization Closed settings, including
incarceration• Unsafe injecting practices• Communicable disease• Physical and sexual violence
Barriers to Care for IDU
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Drug users are less likely to receive HIV therapy due to:• Failure to follow-up• Poor adherence with ARV and other
medications• Reluctance of medical providers to
prescribe therapy due to concerns about adherence
However, if adherence is good, IDUs respond to ART as well as any other patients
Treatment of Drug Users with HIV Infection
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Drug abuse treatment and HIV-related care must be both addressed or neither treatment approach will be effective
Drug users in drug treatment programs are very adherent with HIV therapy
The challenge: determine specific ways to integrate care for drug addiction and HIV therapy
Treatment of Drug Addiction
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What is the Harm Reduction Approach?
What are Some Examples of Harm Reduction?
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Rather than telling drug users to completely stop using drugs, the harm reduction approach focuses, literally, on reducing harm and includes:• Community outreach focus on peer approaches• Behavior change communication, including risk
reduction information• Clean needles, syringes and their safe disposal• Drug dependence treatment, particularly
opiate substitution therapy (Methadone)• HIV testing and counseling
Harm Reduction Approach (1)
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Prevention of sexual transmission through interventions
HIV care and treatment, including ART Primary health care
• hepatitis B vaccination• vein and abscess/ulcer care• overdose management
Supportive policy and legislative environment
Harm Reduction Approach (2)
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What is Methadone Maintenance?
What are the Goals of Methadone Maintenance?
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Dispensed daily on site and directly observed• Daily observed dosing reduces potential
for abuse • Daily contact with methadone program
facilitates treatment of other chronic medical conditions
Methadone Maintenance Therapy (1)
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Usual starting dose: 20-30 mg daily, increasing by 5-10 mg every 3 days until adequate dose is reached to: • treat withdrawal symptoms • reduce drug craving• improve daily functioning
Most patients effectively treated at daily doses of 60-100 mg of methadone
Methadone Maintenance Therapy (2)
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Increase: • overall survival• drug-treatment retention• employment
Decrease: • illicit opioid use• hepatitis and HIV seroconversion• criminal activity
Improve birth outcomes for pregnant women
Results of Methadone Treatment
Kuehn, JAMA 2005.
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ART for Intravenous Drug Users
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Same ARV regimens and doses as non-IDU
Active IDU is NOT a contraindication to providing ARV• Dose of methadone may need to be
adjusted due to drug interactions when starting ARV
• No need to adjust doses of ARV drugs when taking methadone
Closely follow adherence and provide extra counseling to IDU patients and treatment supporters
ART for IDU
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High levels of adherence are necessary for optimal outcomes on ART
IDU may have greater barriers to adherence• Side effects of ARV, real and perceived• Active drug use• Psychiatric illness or symptoms• Stigma against IDU
Resistance to ARVs is similar among people who inject drugs and those who do not
Adherence for IDU on ART
Wood E et al. AIDS, 2005, 19:1189–1195.
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IDU and sharing of infected injecting material are major factors of HIV epidemic in Vietnam
Harm reduction programs lead to:• reducing drug use or reducing risk behaviors• decreasing spread of HIV
Methadone maintenance is an effective and proven modality for treating opiate addiction
IDU can respond well to ARV treatment, if the ARV are taken with good adherence
Key Points
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Thank you!
Questions?