HIV/AIDS

1. HIV/AIDS and
Substance Use Disorders
DR. KAPIL PANDYA
(M.D ; M.B.B.S)
I/C & AP (INFECTIOUS DISEASES MEDICINE)
DEPARTMENT OF MEDICINE
GOVERNMENT MEDICAL COLLEGE & HOSPITAL
JAMNAGAR (GUJARAT

2. Lecture Overview
 HIV/AIDS
 Substance use disorders
 Connection between HIV and
substance use disorders
 Implications for patient care
2

3. 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
3

4. HIV -
Human Immunodeficiency
Virus
 RNA virus
 Principally infected cell: CD4 T cell
 Progressive loss of cell
4

5. HIV Transmission Categories 5
Males Females
Male-Male Sex 60% -
Hetero Sex 13% 71%
Injection Drug Use 26% 27%
Other 1% 2%
Centers for Disease Control, 2005

6. Lecture Overview
 HIV/AIDS
 Substance use disorders (SUD)
 Connection between HIV and
substance use disorders
 Implications for patient care
6

7. Relevant Drugs to HIV/AIDS
 Opioids
 Stimulants
Amphetamine
Cocaine
 Alcohol
7

8. 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
8

9. 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
9

10. Routes of Administration
 Injection: highest risk of infection
 Intranasal
 Smoking
 Oral
10

11. Treatment
Individual and group psychotherapy
Pharmacotherapy
Self help groups
11

12. Lecture Overview
 HIV/AIDS
 Substance use disorders
 Connection between HIV and
substance use disorders
 Implications for patient care
12

13. 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
13

14. Drug Use and HIV
Transmission
 Highest risk with intravenous use
 Increased risk with intranasal use
 More sexual partners, unsafe sex
 Associated with alcohol use
14

15. Opioids Affect HIV Course
 Cause immunosuppression
 Induce apoptosis
  viral replication
15
 Co-infection of HIV and other pathogens

16. 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
16

17. Alcohol Affects HIV Course
17
  immune response to HIV infection
  viral replication
 Promotes progression of illness
  permeability of blood brain barrier
to infectious agents

18. Drugs/Alcohol Affect HIV
18
Alcohol
▲
▲
▲
↓ Immune System
Neurotoxicity
↑ Viral Replication
CNS Barrier
Apoptosis
Opioids
▲
▲
▲
Stimulants
▲
▲
▲
▲

19. Opioids Affect Antiretrovirals
 Opioids  high risk behavior /
noncompliance
 Drug-drug interactions
19
 Methadone levels  with meds
 Methadone dose adjustment needed
  blood levels of meds

20. Stimulants Affect
Antiretrovirals
 Cocaine
  risk behaviors
 Resistance to antiretrovirals in
30% due to noncompliance
 Amphetamine
 ↑ risk behavior
20

21. Alcohol Affects
Antiretrovirals
  risk behavior and noncompliance
  viral replication
21
  response to antiretroviral medications
 Impairs pharmacokinetics and
pharmacodynamics of antiretrovirals

22. Drugs/Alcohol Affect Meds
22
Alcohol
▲
▲
▲
Noncompliance
Drug Interactions
Resistance
Opioids
▲
▲
▲
Stimulants
▲
▲

23. Substance Use and
Compliance with
Medications
 Inconsistent outpatient care
23
 Noncompliance with medication regimen
 44% users vs. 22% non-users
 Poor social support
 Methadone maintenance programs better
adherence to treatment

24. Psychiatric Disorders, HIV &
SUD
 Drugs/alcohol cause & exacerbate
psychiatric symptoms
 Psychiatric symptoms more common
 HIV+ more sensitive to illicit drugs
24

25. Lecture Overview
 HIV/AIDS
 Substance use disorders
 Connection between HIV and
substance use disorders
 Implications for patient care
25

26. Treatment Guidelines
 Maximizing care for HIV and SUD
Medical treatment
Asymptomatic infection:
antiretroviral meds
Symptomatic infection:
treat opportunistic infection
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27. Treatment Guidelines
 SUD treatment
 Reduce HIV risk behavior
 Harm reduction model
Methadone maintenance
Syringe exchange programs
 Mental health treatment
27

28. What About John
 HIV: treat with antiretrovirals
 SUD treatment:
 Consider methadone maintenance
 Cognitive-behavioral therapy
 Self-help groups
 Mental health treatment if indicated
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29. Summary
 HIV/AIDS
 Substance use disorders
 Connection between HIV and
substance use disorders
 Implications for patient care
29