Wesat2202

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  • Concept slide – serve as the outline of talk
    In the aqua-marine boxes is the pathway HIV infected patients must follow to reach the ideal endpoint
    Go through each step
    Risk factors can act at every step to impede progress
    What are these risk factors? – Lets start with this first step
  • Wesat2202

    1. 1. Drug Abuse Treatment as HIVDrug Abuse Treatment as HIV Prevention: ThePrevention: The StateState of the Scienceof the Science 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
    2. 2. OverviewOverview • Drug driven epidemics -- overviewDrug driven epidemics -- overview • Prevention impacts of drug treatmentPrevention impacts of drug treatment • Drug treatment, access, and adherence to HIVDrug treatment, access, and adherence to HIV carecare • Challenges in maximizing the public healthChallenges in maximizing the public health impact of drug treatmentimpact of drug treatment
    3. 3. Current AIDS epidemiologyCurrent AIDS epidemiology • Approximately 33,000,000 living withApproximately 33,000,000 living with HIV/AIDSHIV/AIDS • Over 10,000,000 infections among IDUOver 10,000,000 infections among IDU • Outside of Africa, over 33% of all newOutside of Africa, over 33% of all new infections are estimated to be attributableinfections are estimated to be attributable to injection drug useto injection drug use • No estimates of non-injection drug useNo estimates of non-injection drug use
    4. 4. 91% of the world adult population (4 billion) is covered by the data. Information unavailable for 119 countries. Estimated size of IDU population S. & S-E Asia: 3.33m S. & S-E Asia: 3.33m E. Europe & C. Asia: 3.2m E. Europe & C. Asia: 3.2m E. Asia & Pacific 2.35m E. Asia & Pacific 2.35mMENA:0.44mMENA:0.44m S. Saharan- Africa 0.009m S. Saharan- Africa 0.009m L. America: 0.97m L. America: 0.97m Caribbean: 0.028m Caribbean: 0.028m N. America 1.43m N. America 1.43m W. Europe: 1.24m W. Europe: 1.24m Australia & N. Zealand: 0.19m Australia & N. Zealand: 0.19m UN Reference Group on HIV/AIDS prevention and care among IDU www.idurefgroup.org 10.3m (78%) in developing/transitional countries
    5. 5. What drugs are most commonly injected? Opiates ATS Opiates ATS Opiates ATS Opiates ATS Opiates ATS Opiates ATS OpiatesOpiates Opiates ATS Opiates ATSCocaineCocaine Cocaine Opiates Cocaine Opiates Opiates Cocaine ATS Opiates Cocaine ATS Opiates ATS Opiates ATS Opiates ATS Opiates ATS
    6. 6. 0 10 20 30 40 50 60 70 80 90 Arm enia Azerbaijan Belarus G eorgia Kazakhstan Kyrgastan M oldova Poland Russia Tajikistan Ukraine Uzbekistan Column 1 IDUs as Percent of Total Registered HIV Cases Eastern Europe and Central Asian Countries, 2007 Countries with Injection Driven Epidemics, OSI, 2008
    7. 7. Source: UNAIDS 2008 Report on the Global AIDS Epidemic 0 10 20 30 40 50 60 70 80 C hina Indonesia M alaysia VietN am IDUs as Percent of Total Registered HIV Cases East and South East Asian Countries, 2007
    8. 8. Dependence is a medical condition with common Dx and consequences: ASI Composite Scores: Porto Alegre, Philadelphia and Wuhan 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Alcohol Drug Emp/supp Family Legal Medical Psychiatric Porto Alegre Philadelphia Wuhan
    9. 9. Substance-related HIVSubstance-related HIV transmissiontransmission • Direct and indirect sharing ofDirect and indirect sharing of injection equipment and materialsinjection equipment and materials • Unprotected sexual activityUnprotected sexual activity Consequences of substance use inConsequences of substance use in all risk groups: MSMs, IDUs,all risk groups: MSMs, IDUs, HeterosexualsHeterosexuals
    10. 10. HIV prevention strategies forHIV prevention strategies for drug using populationsdrug using populations • Education about HIV transmissionEducation about HIV transmission • HIV counseling and testingHIV counseling and testing • Increased access to sterileIncreased access to sterile injection resources and condomsinjection resources and condoms • Drug treatmentDrug treatment • HIV treatmentHIV treatment
    11. 11. How does drug treatment prevent HIVHow 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 treatment and primary careIncreased access to HIV treatment and primary care • Increased adherence to HIV medicationsIncreased adherence to HIV medications
    12. 12. How does drug treatment prevent HIVHow does drug treatment prevent HIV infection and transmission?infection and transmission? • Effective treatments reduce theEffective treatments reduce the frequency of drug usefrequency of drug use • Fewer drug-related risk behaviorsFewer drug-related risk behaviors • Fewer new infectionsFewer new infections
    13. 13. 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
    14. 14. 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)
    15. 15. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any use Injection No Tx (N=360) Past Tx (N=74) Current Tx (N=123) Drug use and injection among 557 heroin users by methadone treatment status, Sichuan Province, China (Han-Zhu Qian et al, 2008)
    16. 16. Study outcomes: opiate abstinenceStudy outcomes: opiate abstinence 0 1 2 3 4 5 6 7 8 9 10 Buprenorphine Placebo Meanweeksabstinent Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200
    17. 17. How does drug treatment prevent HIVHow does drug treatment prevent HIV infection and transmission?infection and transmission? • Effective treatments reduce theEffective treatments reduce the frequency of drug usefrequency of drug use • Fewer drug-related risk behaviorsFewer drug-related risk behaviors • Fewer new infectionsFewer new infections
    18. 18. 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
    19. 19. 0% 2% 4% 6% 8% 10% 12% 14% 16% Sharing No Tx (N=360) Past Tx (N=74) Current Tx (N=123) Needle sharing among 557 heroin users by methadone treatment status, Sichuan Province, China (Han-Zhu Qian et al, 2008)
    20. 20. How does drug treatment prevent HIVHow does drug treatment prevent HIV infection and transmission?infection and transmission? • Effective treatments reduce the frequency ofEffective treatments reduce the frequency of drug usedrug use • Fewer drug-related risk behaviorsFewer drug-related risk behaviors • Fewer new infectionsFewer new infections
    21. 21. 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%
    22. 22. 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 bySix year HIV infection rates by treatment status at time of enrollmenttreatment status at time of enrollment
    23. 23. 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)
    24. 24. 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)
    25. 25. Agonist treatment is more thanAgonist treatment is more than substitutionsubstitution • Safe, stable dosingSafe, stable dosing • Drug use monitoredDrug use monitored • Drug counselingDrug counseling • Access to other servicesAccess to other services
    26. 26. 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
    27. 27. Weeks 302724211815129630 PercentremaininginTreatment 1,0 ,9 ,8 ,7 ,6 ,5 ,4 ,3 ,2 F+P N+F P+P N+P N+F>P+P N+F>F+P N+P>P+P N+P>F+P F+P=P+P N+F=N+P Naltrexone and drug counseling treatment inNaltrexone and drug counseling treatment in St. PetersburgSt. Petersburg
    28. 28. Buprenorphine/Naloxone offers newBuprenorphine/Naloxone offers new opportunities for treatment in HIV care settingsopportunities for treatment in HIV care settings • Partial agonist, longer half-lifePartial agonist, longer half-life • Reduced risk of overdoseReduced risk of overdose • Less severe withdrawalLess severe withdrawal • Fewer interactions with anti-retroviralsFewer interactions with anti-retrovirals
    29. 29. Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200 Maintenance treatment with buprenorphine and naltrexone forMaintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind,heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial.placebo-controlled trial.
    30. 30. Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200 Maintenance treatment with buprenorphine, naltrexone, andMaintenance treatment with buprenorphine, naltrexone, and counseling for heroin dependence in Malaysia: a randomised,counseling for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial.double-blind, placebo-controlled trial.
    31. 31. Study outcomes: opiate abstinenceStudy outcomes: opiate abstinence 0 1 2 3 4 5 6 7 8 9 10 Buprenorphine Naltrexone Placebo Meanweeksabstinent Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200
    32. 32. Study outcomes: HIV risk reductionStudy outcomes: HIV risk reduction 0 2 4 6 8 10 12 14 16 18 20 Buprenorphine Naltrexone Placebo ARIInjectingBehaviorsCompositeScore Baseline 3 months Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200
    33. 33. 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
    34. 34. Limitations of treatment studiesLimitations of treatment studies • Measurement variabilityMeasurement variability • Treatment variabilityTreatment variability • Short follow-upShort follow-up • Focus on opiate dependent injectorsFocus on opiate dependent injectors • No randomized trials with HIV endpointsNo randomized trials with HIV endpoints
    35. 35. HPTN 058 Study DesignHPTN 058 Study Design Opiate injectors recruited from community and screened Short term Suboxone At Bx and 6 months plus one year counseling; Referral to local resources 12 month 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
    36. 36. HIV Infected Population Engage in medical care Start therapy Adherence Substance Abuse Durable Viral Suppression =
    37. 37. Adherence with antiretroviral therapy isAdherence 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
    38. 38. 0 10 20 30 40 50 60 70 80 90 100 Baseline Six Months Adherenec% Use to non- use Nonuse to use Adherence to HIV medications by drug useAdherence to HIV medications by drug use Lucas et al, 2002Lucas et al, 2002
    39. 39. Risk of developing new opportunisticRisk of developing new opportunistic infection according to drug use statusinfection according to drug use status Lucas et al. Am J Epidemiol 2006
    40. 40. Adherence by past and currentAdherence by past and current drug and alcohol diagnosesdrug and alcohol diagnoses Alcohol Drug Current diagnoses p<.01 p<.01 Lifetime diagnoses NS NS
    41. 41. Maximizing the impact of drug abuseMaximizing the impact of drug abuse treatment as HIV preventiontreatment as HIV prevention • AccessibleAccessible • AcceptableAcceptable • AffordableAffordable
    42. 42. Continuum of Drug Use andContinuum of Drug Use and TreatmentTreatment Use Abuse Dependence Out-patient Detoxification + Residential Agonist/Antagonist Outreach Drug free Out-patient Harm Reduction Antagonist Counseling Counseling Counseling
    43. 43. Estimated Opiate dependent Drug Users inEstimated Opiate dependent Drug Users in Agonist Treatment per 100,000 populationAgonist Treatment per 100,000 population 0 50 100 150 200 Australia Spain United St at es Net herlands I t aly UK Germany Denmark France Canada Sw eden Thailand China I ndia Nepal
    44. 44. HIV prevention and care implications:HIV prevention and care implications: Necessary but not sufficientNecessary but not sufficient Drug TreatmentDrug Treatment CommunityCommunity HarmHarm OutreachOutreach ReductionReduction HIV CareHIV Care
    45. 45. ConclusionsConclusions • Behavioral and serologic data supportBehavioral and serologic data support the hypotheses that drug users inthe hypotheses that drug users in treatment:treatment: significantlysignificantly reduce the frequency ofreduce the frequency of useuse practice fewer risk behaviorspractice fewer risk behaviors have greater access to HIV treatmenthave greater access to HIV treatment are more adherent to HIV careare more adherent to HIV care
    46. 46. ConclusionsConclusions • Data suggests effective treatmentsData suggests effective treatments for drug users:for drug users: recognize addiction as a chronicrecognize addiction as a chronic disease (at least one year)disease (at least one year) use pharmacologic and counselinguse pharmacologic and counseling interventionsinterventions are accessible, acceptable, andare accessible, acceptable, and affordableaffordable
    47. 47. Future directionsFuture directions • Expand access to effective treatmentsExpand access to effective treatments • Target drug users earlier in the continuum of useTarget drug users earlier in the continuum of use • Test interventions for use of multiple substancesTest interventions for use of multiple substances • Measure HIV risk endpoints in clinical trials of newMeasure HIV risk endpoints in clinical trials of new medicationsmedications • Urgent need to sustain search for pharmacologicUrgent need to sustain search for pharmacologic treatments for stimulant abusetreatments for stimulant abuse
    48. 48. Complacency High Risk Behavior Human Rights Abuses Stigma- tization Access To Care Sexism Ignorance Poverty Discrimin- ation Disem- powered Women Prejudice Denial Courtesy of Jim Hoxie

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