hiv/aids and substance use disorders olivera j. bogunovic, m.d. state university of new york at...

HIV/AIDS and Substance Use Disorders

Olivera J. Bogunovic, M.D.State University of New York at Buffalo

Alcohol Medical Scholars Program

Copyright Alcohol Medical Scholars Program 2

Lecture Overview

HIV/AIDS

Substance use disorders

Connection between HIV and substance use disorders

Implications for patient care


Patient: John

• 40-year old white male presents to ER with:– Diarrhea >1 month, thrush, weight loss

• History: – Intravenous heroin user– Failed inpatient rehabilitation

• Labs:– CD4 <400


HIV - Human Immunodeficiency Virus

• RNA virus

• Principally infected cell: CD4 T cell

• Progressive loss of cell


Epidemiology

• >39 million HIV+

• ~40,000 persons infected/year (CDC)

• High-risk populations:– Injection drug users: 26% of all infections

– Homosexual males: 60% of all infections


HIV Transmission Categories

Centers for Disease Control, 2005

Males Females

Male-Male Sex 60% -

Hetero Sex 13% 71%

Injection Drug Use 26% 27%

Other 1% 2%


Other HIV Transmission Categories

• Maternal transmission during childbirth

• Health workers

• Blood transfusions

• Tattoos


Course of HIV Infection

• Six stages of infection:1. Initial 2. Latency 3. Lymphadenopathy4. Early symptomatic infection5. AIDS6. End stage


Treatment of HIV/AIDS

• Prevention of HIV transmission

• Antiretroviral treatment: immune function viral replication

• Treatment of opportunistic infections


Antiretroviral Medications

• Nucleoside and nucleotide analogs (zidovudine)

• Protease inhibitors (saquinavir)

• Non-nucleoside transcriptase (nevirapine)


Lecture Overview

HIV/AIDS

Substance use disorders (SUD)




Relevant Drugs to HIV/AIDS

• Opioids

• Stimulants

–Amphetamine

–Cocaine

• Alcohol


Substance Use Disorders

• Misuse = use to get high

• Abuse = dysfunction in 1+ life areas

• Dependence = 3+ of 7 criteria–Physical dependence

–Compulsive use/loss of control


Lifetime Prevalence

• Opioids– Abuse/dependence of heroin <1%

• Stimulants– Amphetamine

• Abuse/dependence < 2%

– Cocaine• Abuse/dependence 2%

• Alcohol• Abuse or dependence 10-15% men, 8-10% women


Routes of Administration

• Injection: highest risk of infection

• Intranasal

• Smoking

• Oral


Treatment

•Individual and group psychotherapy

•Pharmacotherapy

•Self help groups


Lecture Overview

HIV/AIDS





Prevalence

• High prevalence of HIV in patients with SUD– 35% of cocaine users

– 22% of opioid users

• High prevalence of SUD in HIV+ patients– 25% alcohol dependent

– 25% use illicit opioids

– 33% use cocaine


Drug Use and HIV Transmission

• Highest risk with intravenous use

• Increased risk with intranasal use

• More sexual partners, unsafe sex

• Associated with alcohol use


Opioids Affect HIV Course

• Cause immunosuppression

• Induce apoptosis

viral replication

• Co-infection of HIV and other pathogens


Stimulants Affect HIV Course

• Cocaine– Causes immunosuppression of T-cells viral replication brain cells infected neurotoxicity

• Amphetamine– Similar effect to cocaine

– Research beginning to accumulate


Alcohol Affects HIV Course

immune response to HIV infection

viral replication

• Promotes progression of illness

permeability of blood brain barrier to infectious agents


Drugs/Alcohol Affect HIV

▲

▲

▲

Alcohol

Apoptosis

CNS Barrier

↑ Viral Replication

Neurotoxicity

↓ Immune System

▲

▲

▲

Opioids

▲

▲

▲

▲

Stimulants


Opioids Affect Antiretrovirals

• Opioids high risk behavior / noncompliance

• Drug-drug interactions– Methadone levels with meds

– Methadone dose adjustment needed blood levels of meds


Stimulants Affect Antiretrovirals

• Cocaine risk behaviors

–Resistance to antiretrovirals in 30% due to noncompliance

• Amphetamine –↑ risk behavior


Alcohol Affects Antiretrovirals

risk behavior and noncompliance

viral replication

response to antiretroviral medications

• Impairs pharmacokinetics and pharmacodynamics of antiretrovirals


Drugs/Alcohol Affect Meds

▲

▲

▲

Alcohol

Resistance

Drug Interactions

Noncompliance

▲

▲

▲

Opioids

▲

▲

Stimulants


Substance Use and Compliance with Medications

• Inconsistent outpatient care

• Noncompliance with medication regimen– 44% users vs. 22% non-users

• Poor social support

• Methadone maintenance programs better adherence to treatment


Psychiatric Disorders, HIV & SUD

• Drugs/alcohol cause & exacerbate

psychiatric symptoms

–Psychiatric symptoms more common

–HIV+ more sensitive to illicit drugs


Lecture Overview

HIV/AIDS





Treatment Guidelines

• Maximizing care for HIV and SUD

–Medical treatment

• Asymptomatic infection: antiretroviral meds

• Symptomatic infection: treat opportunistic infection


Treatment Guidelines

• SUD treatment–Reduce HIV risk behavior

–Harm reduction model

• Methadone maintenance

• Syringe exchange programs

–Mental health treatment


What About John

• HIV: treat with antiretrovirals

• SUD treatment:

– Consider methadone maintenance

– Cognitive-behavioral therapy

– Self-help groups

• Mental health treatment if indicated


Summary

HIV/AIDS




hiv/aids and substance use disorders olivera j. bogunovic, m.d. state university of new york at...

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