advancing the prevention and treatment of chronic illnesses ucla department of family medicine...

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

[email protected]

September 5, 2014

mailto:[email protected]



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



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)



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)



Treatment of Substance Use Disorders as HIV Prevention



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



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)



Methadone Promotes ART Use

Uhlmann et al., 2010. Addiction, 105, 917-913



ART Adherence and MMT in 545 Homeless IDUS in Vancouver

Palepu et al., 2011. J Urban Health, 88: 545-555



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



Effects of ART Among IDUs

Nolan et al., 2011. AIDS Care, 23:980-987



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



Reducing HIV Incidence in IDUs

Degenhardt et al., 2010, Lancet, 376:285-301



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 -- ↑ ↑ -- --



HIV Treatment as Prevention

ART as Disease Prevention



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



HPTN 052: TasP

Cohen et al., 2011, NEJM, 365: 493-505



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



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



Treatment of Non-Injection Substance Use Disorders as HIV Prevention



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



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



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



HIV Prevention Strategies for Non-Treatment Seeking Substance Users



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



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.



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



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



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



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)



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



Final Thoughts

advancing the prevention and treatment of chronic illnesses ucla department of family medicine...

Documents

hiv prevention slide

line treatment

prevention messages

continued use

discussion slide

buprenorphine slide

phd ucla center

opioid agonist treatments