HIV/AIDS and Drug Use in the United States: Models for Strategic Planning

1. HIV/AIDS and Drug Use in the United States: Models for Strategic Planning Steve Shoptaw, Ph.D. UCLA Integrated Substance Abuse Programs June 6, 2005

2. Key Points • Concentrated versus generalized AIDS epidemics • AIDS-related behaviors vary by geography • Risk behaviors emerge and change with time • Drug abuse is more than injection behaviors • Interventions for AIDS prevention with drug users • Behavioral risk reduction, needle exchange, substance abuse treatment, prevention for positives, post exposure prophylaxis, pre-exposure prophylaxis

3. International: Generalized Epidemic • HIV passed efficiently in general population • Primary signal of generalized epidemic is high numbers of infected pregnant women

4. U.S.: Concentrated Epidemic • Defined behavioral risk groups associated with HIV infection • Injecting drug users (IDU) • Men who have sex with men (MSM) • IDU+MSM

5. National Prevalence

6. United States:Recent HIV/AIDS Cases CDC, 2005

7. AIDS Prevalence by Behavioral Risks, 1981-2002 http://wonder.cdc.gov

8. Geography, HIV Prevalence and IDUs • West of the Mississippi River, prevalence rates remain much lower than in the East • No differences in risk behaviors • May be attributes of the heroin itself can be protective HIV Prevalence in IDU 1994-1996 21.5% 2.3% Garfein et al., 2004

9. Sexual HIV Transmission in IDUs: San Francisco • 58 HIV incident infections, 1134 case controls who remained negative from 1986-1998 • MSM 8.8 times as likely to seroconvert as hetero men (95% CI 3.7-20.5) • Women who traded sex for cash 5.1 times as likely to seroconvert (95% CI 1.9-13.7) • Women younger than 40 2.8 times more likely than older women to seroconvert (95% CI 1.1-7.6) Kral et al., 2001

10. Los Angeles AIDS Epidemic:Cumulative Male AIDS Cases Los Angeles*United States** MSM 76% 58% MSM and IDU 7% 8% IDU 6% 22% Other 11% 12% *January 2004 HIV Epidemiology Report, LA County **March 2005 HIV/AIDS Surveillance Report, CDC

11. U.S. Adult Male AIDS Cases by Risk Behavior by Year CDC, 2004 L.A. County Adult Male AIDS Cases by Risk Behavior by Year L.A. County HIV Epi Pgm, 2004

12. U.S. Adult Female AIDS Cases by Risk Behavior by Year CDC, 2004 L.A. County Adult Female AIDS Cases by Risk Behavior by Year L.A. County HIV Epi Pgm, 2004

13. Summary: Epidemiology I • All epidemics are local: Prevalence and incidence rates of HIV and AIDS vary by geography • In the Western U.S., metropolitan areas have lower HIV prevalence rates among IDUs than in less populated cities/areas • A model is provided, complete with internet resources that can help you develop a “snapshot” of your local epidemic

14. Associations Between Drug Dependence, Sexual Orientation, and HIV Risk Behaviors • Analysis of 13 treatment research studies • Four classes of drug dependence • Common assessments at identical points Shoptaw et al., in review

15. Demographics P<0.0004

16. Drug Related Variables P<0.0001

17. Risk Associations

18. Risk Associations

19. Risk Associations

20. Risk Associations

21. Findings • Stimulant dependent groups, especially MSM who are dependent on methamphetamine, have highest risks for HIV transmission • MSM methamphetamine users 61% HIV infected; no non-MSM methamphetamine users detected to date. • Risk is a function of drug class, sexual orientation and proximity to infectious disease

22. Some More Numbers… • HIV prevalence in methadone clinics ~ 5-10% • Incidence of HIV infection observed ~ 8-10 ppy for MSM in Seattle STD clinics (Golden 2003) • Methamphetamine use, past 6 months • 11.2% of MSM in Los Angeles • 13.3% of MSM in San Francisco (Stall et al., 2001) • Prevalent in clubs in New York (Halkaitis, 2003) • Methamphetamine use in HIV care clinics ~ 30-40% (St Mary’s Hospital, Long Beach)

23. MSM in Commercial Sex Venues Percent Reporting Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049 Reback, 2004

24. Drug Risks, MSM in Commercial Sex Venues Percent Reporting Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049 Reback, 2004

25. Hollywood Street Outreach, MSM Reback, Grella, & Shoptaw, 2003

26. Drug Use Where There Is No Virus Is A Drug Abuse Problem… In Los Angeles County, heroin injectors at low risk; gay male meth users at extreme risk LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)

27. Treatment Outcomes and Risk • Influence of culture on treatment: materials, outcomes, and processes • Sophisticated culture • Disdain for total abstinence • Sensitivity to judgment and rejection • Issue of risk and its reduction • Meaning of sex without crystal use in recovery

28. www.crystalneon.org

29. www.tweaker.org

33. The Formative StudyThe Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeleswww.uclaisap.org

34. Methamphetamine and HIV in MSM: A time-to-response association? 1Deren et al., 1998, Molitor et al., 1998; 2Reback et al., in review; 3Reback, 1997; 4Shoptaw et al., 2002; 5VNRH, unpublished data

35. If one believes there is a problem, what are the intervention choices? Broad Based Approach: Provide HIV prevention to current users (and non-users) at all levels (e.g., condom distributions) • Presumes intact decisions/choices around sexual behaviors in most people Targeted Approach: Provide drug abuse treatment to users with abuse or dependence • Centrality of drug/sex link in decisions/choices for small, heavily drug involved group 1 2

36. Interventions:Methamphetamine Using MSM Behavioral Prevention Biological Adjuncts

37. Objective • To evaluate the comparative efficacy of behavioral drug abuse treatments in gay and bisexual, methamphetamine-dependent men in Los Angeles : • Methamphetamine use • High-risk sexual behaviors • Depression ratings

38. Design Randomization and Baseline Follow-up Follow-up Follow-up CM (n=42) CBT (n=40) Screen CM + CBT (n=40) GCBT (n=40) 2 Week Baseline 16 Week 1st Follow-up 6 Months 12 Months 2nd Follow-up

39. Adaptation of a Gay-Specific Intervention Standard CBT CBT+ gay-specific HIV-Risk Reduction External Triggers: Sporting Events Gay Pride Festival Concerts Bathhouse Movies Halloween Relapse Justification: “I just got injured. “My friend just died I might as well use.” [AIDS] and using will make me forget for awhile.” One Day at a Time: “Tomorrow something “I seroconverted even will happen to ruin though I knew about this.” safer sex.” Specific Topics: * Coming Out All Over Again: Reconstructing Your Gay Identity * Being Gay and Doing Gay * Preventing Relapse to High-risk Sex * Living in an HIV World * Several session that involve “Aunt Tina”

40. Conditions • Contingency Management (CM) • Peeing for Dollars! • $415 earned in vouchers; 34% of total possible • Combination CBT+CM • Talk and behavioral therapy • $662 (SD=478) earned or 51.8% of possible • (t (80) = -2.4, p = .019)

41. Mean age: 36.6 (SD=6.4) Education: 95.7% > HS 41% > 4-year degree Ethnicity: Caucasian: 77.2% Hispanic: 12.9% African-Am: 3.1% Asian-Am: 3.1% Native Am: 1.2% Sample Demographics

42. History of Sexually Transmitted Diseases by Reported HIV Serostatus HIV Serostatus Positive Negative STD(n=98)(n=64)Statistic % % Genital warts 41.1 19.4 2 (1) = 8.05, p=.005 Syphilis 28.4 8.2 2 (1) = 9.32, p=.002 Genital Gonorrhea 53.1 30.6 2 (1) = 7.72, p=.005 Yeast infection 14.9 0.0 2 (1) = 10.14, p=.001 Hepatitis B 41.5 17.7 2 (1) = 9.67, p=.002 Shoptaw et al., 2003

43. Baseline drug use • Drug use behaviors • Lifetime MA use: 8.34 yrs (SD=5.9) • Lifetime heavy MA use: 3.39 yrs (SD=4.07) • Lifetime other drugs used: 2.3 (SD=1.4) • Lifetime IV MA use: 32.1% • MA use in past 30 days: 9.7 days (SD=7.4) • $ spent on MA past 30 days: $293 (SD=$399)

44. Treatment Outcomes

45. Contingency Management • Significantly longer retention • Significantly more “clean urine” • Significantly longer stretches of consecutive clean urine samples

46. Unprotected Anal Receptive Intercourse; Past 30 Days 2(3)=6.75, p<.01

47. Unprotected Anal Insertive Intercourse; Past 30 Days 2(3)=8.26, p<.01

48. Summary of Findings • Treatment gains are sustained to 1 year follow-up evaluation • CM helps in the short term to reduce MA use • GCBT helps reduce short-term high-risk sexual behaviors • Drug treatment methods induce sustained risk behavior changes

49. Policy Implications • “Syndemic” of drug use and HIV infection in gay men • Work at the core of overlapping epidemics • Inclusion of treatment approaches in CDC compendium of evidence based guidelines • Treatment on demand for gay stimulant abusers?

50. Next Steps:Treatment as Prevention • $3 million State Office on AIDS RFA in California • Promoting effective treatment approaches for new settings • STD clinics (Klausner, SF) • Sex venues (L.A. County) • AIDS Care settings (Peck, UCLA) • HIV Prevention approaches (CHIPTS, UCLA) • Integration of medication treatments (Newton, UCLA) • Epidemiological implications (Gorbach, UCLA)