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Addiction Treatment as HIV Prevention

Addiction Treatment as HIV Prevention . Charles P. O’Brien, MD, PhD David Metzger, PhD George E. Woody, MD University of Pennsylvania Treatment Research Center. Current AIDS epidemiology. Approximately 33,000,000 living with HIV/AIDS Over 10,000,000 infections among IDU

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Addiction Treatment as HIV Prevention

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  1. Addiction Treatment as HIV Prevention Charles P. O’Brien, MD, PhD David Metzger, PhD George E. Woody, MD University of Pennsylvania Treatment Research Center

  2. Current AIDS epidemiology • Approximately 33,000,000 living with HIV/AIDS • Over 10,000,000 infections among IDU • Outside of 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 such as crack cocaine

  3. Predictors of seroconversion in Explore: drug and alcohol use * 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

  4. IDUs as Percent of Total Registered HIV Cases Eastern Europe and Central Asian Countries, 2007 Countries with Injection Driven Epidemics, OSI, 2008

  5. IDUs as Percent of Total Registered HIV Cases East and South East Asian Countries, 2007 Source: UNAIDS 2008 Report on the Global AIDS Epidemic

  6. HIV prevention strategies for drug using populations • Education about HIV transmission • HIV counseling and testing • Increased access to sterile injection resources and condoms • Drug addiction treatment • HIV treatment

  7. Treatment Options for Opioid Addiction • Outpatient drug free counseling- not effective • Medication-free therapeutic community- • Expensive, not widely available, effective with small proportion of patients • Methadone-1964, national program 1971 • Partial agonist- Buprenorphine • Suboxone (combination) • Naltrexone oral, depot and implant

  8. Methadone • Full agonist • Cross tolerance with all opioids • Reduces craving • Prevents withdrawal • Prevents pleasure from other opioids • Low dose not effective

  9. Six year HIV infection rates by treatment status at time of enrollment

  10. Suboxone Buprenorphine Combined with antagonist Reduces abuse potential Bup 2 mg: Nal 0,5 mg Bup 8 mg: Nal 2 mg (*Bup 16 mg: Nal 4 mg) (*Bup 32 mg: Nal 8mg) *tested, not marketed

  11. Report good effects 60 Placebo 2 mg Bup 8 mg Bup 2 mg Bup/Nx 8 mg Bup/Nx 50 40 Evaluation 30 20 10 0 BL 0h 0.5h 1.5h 2.5h 3.5h 24h 48h Comer and Collins,The Journal of Pharmacology and Experimental Therapeutics, 303(2), 695-703, 2002

  12. Treatment Options for Opioid Addiction • Naltrexone effective in special populations • Physicians, pharmacists, nurses • Parolees, Probationers • Countries where agonists are not available • ADHERENCE • Oral • Depot • Pellet implant

  13. Opioid craving VAS scores: Change from baseline P<0.0002

  14. Percent opioid-free subjects, by visit Weeks ≤4: Grace period Weeks 5 to 24: Assessment period Note: “Opioid-free” is indicated by urine drug tests (negative for opioids), naloxone challenge results, and TLFB data. Weeks with missing urine test results were imputed as positive.

  15. Treatment Options for Alcoholism • Outpatient drug free counseling- with self-help • Alcoholics Anonymous • Medication-free therapeutic community- • Expensive, not widely available, effective with small proportion of patients • Naltrexone: oral, depot • Acamprosate • Topiramate (off label)

  16. Treatment Options for Stimulant Addiction Cocaine, Methamphetamine Injection, nasal, smoked • No FDA approved medication • Outpatient counseling • Cognitive Behavioral Therapy • Medications in clinical trials • Vigabatrin • Topiramate • Modafinil • Baclofen

  17. 1 0.8 0.6 0.4 0.2 0 Rate of needle sharing reported by In-Treatment IDUs compared to Out-of-Treatment IDUs Selwyn Martin Klee Williams Longshore Metzger Stark Capplehorn et al et al et al et al et al et al et al et al 1987 1990 1991 1992 1993 1993 1994 1995

  18. 100 80 60 40 20 0 Percent of subjects reporting injection prior to, during, and following methadone treatment Injection Injection Injection Injection Injection After Tx in Prior in Prior in Year Prior to Tx Entry Entry Year Month After Tx (Ball and Ross, 1991)

  19. Percent infected after 18 months by treatment status 22% Percentage 3.5% 4.5% Metzger et al 1993

  20. Conclusions • Data suggests effective treatments for drug users: • - recognize addiction as a chronic disease - use pharmacologic and counseling • interventions • - are accessible, acceptable, and affordable

  21. Conclusions • Behavioral and serologic data support the hypotheses that drug users in treatment: - significantly reduce the frequency of use - practice fewer risk behaviors - have greater access to HIV treatment - are more adherent to HIV care

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