drug abuse treatment in hiv prevention and care: past successes and future challenges david s....
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Drug Abuse Treatment in HIV Prevention and Drug Abuse Treatment in HIV Prevention and Care: Past Successes and Future ChallengesCare: Past Successes and Future Challenges
David S. Metzger, Ph.D.
University of PennsylvaniaUniversity of Pennsylvania
Center for Studies of AddictionCenter for Studies of Addiction
HIV Prevention Research DivisionHIV Prevention Research Division
Philadelphia, PAPhiladelphia, PA
OverviewOverview
• HIV infection and drug useHIV infection and drug use
• Does drug treatment prevent HIV infections?Does drug treatment prevent HIV infections?
• Does drug treatment facilitate HIV treatment?Does drug treatment facilitate HIV treatment?
• Challenges in maximizing the public health Challenges in maximizing the public health impact of drug treatmentimpact of drug treatment
HIV prevalence rates among New York IDUs by methadone treatment
(MMRW, 1984)
87%
10%
86 Active Users 35 Long Term MM 0%
20%
40%
60%
80%
100%
Current AIDS epidemiologyCurrent AIDS epidemiology
• Approximately 1,300,000 living with HIV/AIDSApproximately 1,300,000 living with HIV/AIDS
• 956,666 AIDS diagnoses (as of 2005)956,666 AIDS diagnoses (as of 2005)
• 425,910 PWLA (increase of 28% since 2001)425,910 PWLA (increase of 28% since 2001)
• 25% have a history of injection drug use25% have a history of injection drug use
HPTN 015: Project Explore HPTN 015: Project Explore
Two-armed trial
4250 MSM
10 counseling sessions + boosters
VCT every six months
Overall seroincidence = 2.1 (1.9, 2.4) per 100 py
Intervention arm: 115 events / 6,037 pyStandard arm: 144 events / 6,203 py
Multivariate analysis of seroconversion: Multivariate analysis of seroconversion: Drug and alcohol useDrug and alcohol use
Drug N at baseline
No. of infections
Hazard ratio*
95% CI
Heavy alcohol** 419 41 1.87 1.24, 2.81
Amphetamines 527 67 1.93 1.41, 2.64
Alcohol or drugs before sex
2952 205 1.57 1.08, 2.27
* REF = no, light or moderate use of alcohol; no speed use; no use before sex
** Heavy alcohol = 4+ drinks every day or 6+ drinks on a typical day
Substance-related HIV riskSubstance-related HIV risk
• Direct and indirect sharing of injection Direct and indirect sharing of injection equipment and materialsequipment and materials
• Unprotected sexual activity Unprotected sexual activity
Consequences of substance use in all risk Consequences of substance use in all risk groups: MSMs, IDUs, Heterosexualsgroups: MSMs, IDUs, Heterosexuals
HIV prevention strategies for drug HIV prevention strategies for drug using populationsusing populations
• Education about HIV transmissionEducation about HIV transmission
• HIV counseling and testingHIV counseling and testing
• Increased access to sterile injection Increased access to sterile injection resources and condomsresources and condoms
• Drug treatmentDrug treatment
• HIV treatmentHIV treatment
How does drug treatment prevent HIV How does drug treatment prevent HIV infection and transmission?infection and transmission?
• Effective treatments reduce the frequency of drug useEffective treatments reduce the frequency of drug use
• Fewer drug-related risk behaviorsFewer drug-related risk behaviors
• Fewer new infectionsFewer new infections
• Increased access to HIV treatmentIncreased access to HIV treatment
• Increased adherence to HIV medicationsIncreased adherence to HIV medications
Percent of subjects reporting injection prior to, during, and following methadone treatment
0
20
40
60
80
100
(Ball and Ross, 1991)
Injection Prior to Tx
Entry
Injection After Tx
Entry
Injection in Prior Year
Injection in Prior Month
Injection in Year After Tx
Rate of needle sharing reported by In-Treatment IDUs compared to Out-of-Treatment IDUs
0
0.2
0.4
0.6
0.8
1
Selwyn et al 1987
Martin et al 1990
Klee et al 1991
Williams et al 1992
Longshore et al 1993
Metzger et al 1993
Stark et al 1994
Capplehorn et al 1995
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Injected
Left
Interupted
Remained
Injection rates 12 months following treatment entry by retention status
(Thiede,Hagan,and Murrill, 2000)
Seroconversion by treatment participation:retention is critical
(Moss et al. 1994)
One or More Years
of Methadone Treatment
Less Than One Year of Methadone
Treatment
0
1
2
3
4
21%
13%
18%
51%
21%
39%
0%
10%
20%
30%
40%
50%
60%
B 6 12 18 24 30 36 42 48 60 72
Months
In Treatment Out of Treatment
Six year HIV infection rates by treatment Six year HIV infection rates by treatment status at time of enrollmentstatus at time of enrollment
Percent infected after 18 months by treatment status
4.50%
22%
3.50%
0%
5%
10%
15%
20%
25%
Tx Partial Tx No Tx
(Metzger et al. 1993)
0%
2%
4%
6%
8%
10%
12%
HBV HCV
Left
Interupted
Remained
Incidence of HBV and HCV 12 Months Following Treatment Entry
(Thiede,Hagan,and Murrill, 2000)
Methadone treatment is more than Methadone treatment is more than substitutionsubstitution
• Safe, stable dosingSafe, stable dosing
• Drug use monitoredDrug use monitored
• Drug counselingDrug counseling
• Access to other services Access to other services
Rate of opiate positive in three approaches to methadone treatment
0
10
20
30
40
50
60
70
B 1 2 3 4 5 6
month
Minimal
Standard
Enhanced
Weeks
302724211815129630
Cu
m S
urv
ival
1,0
,9
,8
,7
,6
,5
,4
,3
,2
F+P
N+F
P+P
N+P
N+F>P+PN+F>F+PN+P>P+PN+P>F+PF+P=P+PN+F=N+P
Naltrexone and drug counseling treatment in Naltrexone and drug counseling treatment in St. PetersburgSt. Petersburg
Naltrexone treatment in St. PetersburgNaltrexone treatment in St. Petersburg
Drug risk Sex risk
remission relapse
2,00
4,00
6,00
8,00
Scor
e
remission relapse
Zvartaw et al, 2006
Drug treatment as HIV preventionDrug treatment as HIV prevention
• In treatment subjects reduce risk over timeIn treatment subjects reduce risk over time
• Treated subjects have lower risk than untreatedTreated subjects have lower risk than untreated
• Treated subjects have lower prevalence and Treated subjects have lower prevalence and incidence of HIVincidence of HIV
(Sorensen J. and Copeland A, 2000)(Sorensen J. and Copeland A, 2000)
Limitations of treatment studiesLimitations of treatment studies
• Measurement variabilityMeasurement variability
• Short follow-up Short follow-up
• Focus on opiate dependent injectorsFocus on opiate dependent injectors
• No randomized controlled trialsNo randomized controlled trialswith HIV endpointswith HIV endpoints
HPTN 058HPTN 058
Opiate dependent drug users recruited from the community
Detoxification at 0 and 6 months
3 Months of Weekly and 9 months of Monthly
Drug and Risk Reduction Counseling
12 Months Buprenorphine/Naloxone
+3 Months of Weekly and 9 months of Monthly Drug and Risk Reduction
Counseling
18 and 24+ month follow-up
Drug use and HIV disease progression Drug use and HIV disease progression and viral activityand viral activity
• In vivo: No clear evidence of impact of In vivo: No clear evidence of impact of drug use on survival from past cohort drug use on survival from past cohort studiesstudies
• In vitro: opiates, cocaine, alcohol enhance In vitro: opiates, cocaine, alcohol enhance viral activation and replication; viral activation and replication; suppression of immune responsesuppression of immune response
HIV Infected Population
Engage in medical care
Start therapy
Adherence
Substance Abuse
Durable ViralSuppression
=
Adherence with antiretroviral therapy is Adherence with antiretroviral therapy is adversely affected by drug useadversely affected by drug use
Not using cocaine (n=57)
Using cocaine (n=20) P value
Adherence
(MEMS Caps)68% 27% 0.005
Viral suppression 46% 13% 0.005
Arnsten JH. J Gen Intern med 2002;17:377
Wood, E. et al. CMAJ 2003;169:656-661
Drug use, adherence, and viral suppression in a large British Columbia Cohort of HIV-infected patients starting HAART
Risk of developing new opportunistic Risk of developing new opportunistic infection according to drug use statusinfection according to drug use status
Lucas et al. Am J Epidemiol 2006
0102030405060708090
100
Baseline Six Months
Ad
her
enec
%
Use to non-useNonuse to use
Adherence to HIV medications by drug useAdherence to HIV medications by drug use
Lucas et al, 2002Lucas et al, 2002
DSM IV criteria for abuse or dependenceDSM IV criteria for abuse or dependence
(Participants n=237)(Participants n=237)
81%
15%
51%
20% 19%
68%
7%
23%
13%
21%
43%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Lifetime
Past Month
%
Adherence by past and current Adherence by past and current drug and alcohol diagnosesdrug and alcohol diagnoses
Alcohol Drug
Current diagnoses p<.01 p<.01
Lifetime diagnoses NS NS
Suboxone offers new opportunities for Suboxone offers new opportunities for treatment in HIV care settingstreatment in HIV care settings
Maximizing the impact of drug abuse Maximizing the impact of drug abuse treatment HIV preventiontreatment HIV prevention
• AccessibleAccessible
• AcceptableAcceptable
• AffordableAffordable
Publicly funded treatment need vs. Publicly funded treatment need vs. participationparticipation
NNSATS, 2006
Barriers to treatmentBarriers to treatment
NNSATS, 2006
Continuum of Drug Use and TreatmentContinuum of Drug Use and Treatment
Use Abuse
Dependence
Out-patient Detoxification +Residential Agonist/Antagonist
Outreach Drug free Out-patientHarm Reduction Antagonist CounselingCounseling Counseling
Addiction
Geography is importantGeography is important
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MSM IDU Heterosexual
AA/Latino
Caucasion
Diagnosed AIDS cases by Race in Philadelphia: 1980 - 2006
0%
2%
4%
6%
8%
10%
12%
14%
Member
Black
White
Hispanic
HPTN 037: HIV Prevalence among risk network members (N=697)
HIV prevention and care implicationsHIV prevention and care implications
Each strategy alone may be necessary but Each strategy alone may be necessary but not sufficient for public health impact:not sufficient for public health impact:
Drug TreatmentDrug Treatment
Community Community Harm Harm Outreach Outreach ReductionReduction
HIV CareHIV Care
ConclusionsConclusions
• Behavioral and serologic data support the Behavioral and serologic data support the hypotheses that drug users in treatment:hypotheses that drug users in treatment:
significantlysignificantly reduce the frequency of usereduce the frequency of use
practice fewer risk behaviorspractice fewer risk behaviors
have greater access to HIV treatmenthave greater access to HIV treatment
are more adherent to HIV care are more adherent to HIV care
ConclusionsConclusions
• Data suggests effective treatments for Data suggests effective treatments for drug users:drug users:
recognize addiction as a chronic recognize addiction as a chronic disease (at least one year) disease (at least one year)
use pharmacologic and counseling use pharmacologic and counseling interventionsinterventions
are accessible and acceptableare accessible and acceptable
Implications for public health Implications for public health
• New models for the delivery of treatmentsNew models for the delivery of treatments
• Target drug users earlier in the continuum of useTarget drug users earlier in the continuum of use
• Include HIV endpoints in Phase II trialsInclude HIV endpoints in Phase II trials
• Urgent need for pharmacologic treatments for Urgent need for pharmacologic treatments for stimulant abusestimulant abuse
Complacency
High Risk Behavior
HumanRightsAbuses
Stigma-tization
Access To
Care
Sexism
Ignorance
Poverty
Discrimin-ation
Disem-poweredWomen
Prejudice
Denial
Courtesy of Jim Hoxie
Thanks Thanks
• Tom MclellanTom Mclellan• George WoodyGeorge Woody• Greg LucasGreg Lucas• Carl LatkinCarl Latkin• Charles O’brienCharles O’brien• Steve DouglasSteve Douglas• Wenzhe HoWenzhe Ho• Beryl KoblinBeryl Koblin• Tom CoatesTom Coates