University of PennsylvaniaHIV Prevention Research Division
Department of Psychiatry
Substance Abuse Treatment as HIV Prevention
Overview
• Overview of injection drug use and the HIV epidemic
Small segment of the community are IDU
Non injection drug use facilitates HIV transmission
• Proof of Concept : Drug treatment is HIV prevention
• Minimal treatment “coverage”
• Expanding treatment options
• Targeting treatment to those most likely to become infected
Current AIDS epidemiology
• Approximately 33,000,000 living with HIV/AIDS
• Over 3,000,000 IDUs living with HIV/AIDS
• Outside of sub-Saharan Africa, over 33% of all new infections are estimated to be attributable to injection drug use
• No estimates of the major role of alcohol and non-injection drug use
Predictors of seroconversion in Explore: drug 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
(Koblin et al, AIDS 2006)
December 2009
Total: 33.4 million (31.1 – 35.8 million)
Western & Central Europe
850 000[710 000 – 970 000]
Middle East & North Africa
310 000[250 000 – 380 000]
Sub-Saharan Africa
22.4 million[20.8 – 24.1 million]
Eastern Europe & Central Asia
1.5 million [1.4 – 1.7 million]
South & South-East Asia
3.8 million[3.4 – 4.3 million]
Oceania
59 000[51 000 – 68 000]
North America
1.4 million[1.2 – 1.6 million]
Latin America
2.0 million[1.8 – 2.2 million]
East Asia
850 000[700 000 – 1.0 million]Caribbean
240 000[220 000 – 260 000]
Adults and children estimated to be living with HIV, 2008
Mode of use varies
Globalization of drug use
IDUs as Percent of Total Registered HIV CasesEastern Europe and Central Asian Countries, 2007
Countries with Injection Driven Epidemics, OSI, 2008
Source: UNAIDS 2008 Report on the Global AIDS Epidemic
IDUs as Percent of Total Registered HIV CasesEast and South East Asian Countries, 2007
Prevalence of HIV and HCV among WHO study participants by site
Lawrinson et al, Addiction, 2008
HIV prevention strategies for drug using populations
• Education about HIV transmission
• HIV counseling and testing
• Increased access to sterile injection resources and condoms
• Drug treatment
• HIV treatment
Addiction is a chronic medical condition
• Biological components (dependence)
• Behavioral components (addiction)
• Effective management requires attention to both--medication assisted treatment
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
Drug use and injection among 557 heroin users by methadone treatment status, Sichuan Province, China
(Han-Zhu Qian et al, 2008)
Needle sharing among 557 heroin users by methadone treatment status, Sichuan Province, China
(Han-Zhu Qian et al, 2008)
Six year HIV infection rates by treatment status at time of enrollment
(Metzger et al. 1993)
Incidence of HBV and HCV 12 Months Following Treatment Entry
(Thiede,Hagan,and Murrill, 2000)
MANIF 2000: Drug treatment and injection as predictors of poor adherence to HAART
(N=276; 1558 patient visits)
(Roux P et al 2008)
Adherence by past and current drug and alcohol diagnoses
AlcoholDrug
Current diagnosesp<.01 p<.01
Lifetime diagnoses NS NS
How does drug treatment prevent HIV infection and transmission?
• Effective treatments reduce the frequency of drug use
• Fewer drug-related risk behaviors
• Fewer new infections
• Increased access to HIV treatment and primary care
• Increased adherence to HIV medications
Despite these findings
• Selected expansion of methadone treatment
• Need for treatment expansion
• Need for improvements in efficacy of existing treatments
• Need for new delivery strategies
• Need for new medications and formulations
Mathers et al., the Lancet , 2010
Clear need for more treatment options
Methadone Maintenance Program in ChinaIn Dec. 2003, 8 clinics in 5 provinces were approved to be China’s 1st
wave of community-based methadone maintenance program
西藏
青海
甘肃 内蒙古
黑龙江
吉林
辽宁
贵州
广西 广东
湖南
江西
福建
台湾
浙江
江苏
上海
山东
陕西
山西
宁夏
新疆
四川 湖北
河南
安徽
云南
河北
北京
天津
香港澳门
Premier Wen Jiabao, visited Wuhan Detox. Center in June 2004
Milestones in China’s National Response to HIV/AIDS & Drug
Abuse
Methadone treatment in 2009
青海
2 甘肃
17
吉林
2
贵州
54
GuangxiMMT=53
广东
41
湖南
47江西
12福建
8
浙江
18
江苏
11
陕西
18
宁夏
3
XinjiangMMT=27
四川
32湖北
32安徽
云南
67
北京
8
海南19
重庆
26
上海
87
560 MMT Clinics166,000 heroin users
河南
1
N=7702n=3041
N=12001n=5810
Improving the efficacy of treatment: Counseling
p<0.05
Chawarski et al, 2010
Buprenorphine/Naloxone offers new opportunities for HIV prevention and care
• Partial agonist, longer half-life
• Reduced risk of overdose
• Less severe withdrawal
• Fewer interactions with anti-retrovirals
HPTN 058: comparing new delivery strategies
Opiate injectorsrecruited from
communityand screened
Short-Term Medication Assisted Treatment
Suboxone detox At Bx and 6 months
plus one year counseling;Referral to
local resources
Long-Term Medication
Assisted Treatment 12 months of Suboxone
plus one year counseling;Referral to
local resources
HIV testing and counseling
Every 6 months Year 02
HIV testing and counseling
Every 6 months Year 02
If not eligible, referred to local resources
Weeks
302724211815129630
Perc
ent
rem
aini
ng i
n T
reat
men
t1,0
,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
New treatment approaches: Oral Naltrexone treatment in St. Petersburg (N=280)
With Naltrexone
No Naltrexone
Krupitsky et al, 2006
New formulations: Implantable Naltrexone
Effective drug treatments
• recognize addiction as a chronic disease
• use pharmacologic and counseling interventions
• are accessible, acceptable, and affordable-- to those users most likely to become infected
Drug treatment is necessary but not sufficient for HIV prevention in communities
Drug Treatment
Community Harm Outreach Reduction
HIV Care
Summary
● IDUs are small segment of the populationbut a major part of the HIV infected population
● Neglecting the health of even a small segment of the community jeopardizes the public health
● Alcohol and non-injection drug use is a major risk factor in all risk groups
● Research on opiate injectors in methadone treatment has provided “proof of concept” that drug treatment is HIV prevention
● Despite selected expansion of methadone treatmentas harm reduction—coverage remains extremely limited
● Need for expanded treatments, improved efficacy, formulations and delivery strategies
Complacency
High Risk Behavior
HumanRightsAbuses
Stigma-tization
Access To
Care
SexismIgnorance
Poverty
Discrimin-ation
Disem-poweredWomen
Prejudice
Denial
Courtesy of Jim Hoxie