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

1. HIV/AIDS and Drug Use in the United States: A case for Strategic Planning Steve Shoptaw, Ph.D. UCLA Integrated Substance Abuse Programs Friends Research Institute, Inc. May 19, 2004

2. Main Points • 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

3. National Prevalence

4. AIDS is Drug Abuse CDC, 2003

5. Exposure Risks by Geography, 2002 CDC, WONDER, 2004

6. Injection Risk Behaviors:East vs West Coast of U.S. • Adjusting for risk factors, East Coast IDUs (n=1528) 12.1 times more likely to be HIV+ (95% CI 7.4-20) than West Coast IDUs (n=1149) Garfein et al., 2004

7. MSM+IDU in San Francisco: HIV and Risk Behaviors • In July 2000, 1/3 of respondents shared syringes or UAI (n=1594) • Suggests amphetamine drug treatment, sex risk reduction programs are needed Bluthenthal et al., 2001

8. 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 youngers to seroconvert (95% CI 1.1-7.6) Kral et al., 2001

9. 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

10. Demographics P<0.0004

11. Drug Related Variables P<0.0001

12. Risk Associations

13. Risk Associations

14. Risk Associations

15. Risk Associations

16. 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

17. The Los Angeles AIDS Epidemic:Cumulative Male AIDS Cases Los Angeles*United States** MSM 76% 55% MSM and IDU 7% 5% IDU 6% 16% Other 11% 24% *January 2004 HIV Epidemiology Report, LA County **October, 2003 HIV/AIDS Surveillance Report, CDC

18. 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)

19. 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

20. 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

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

22. 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. www.crystalneon.org

26. www.tweaker.org

27. 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

28. 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

29. A Working Model

30. 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

31. 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”

32. Contingency Management Conditions • Contingency Management Only (CM) • Behavioral intervention delivered thrice weekly that provides increasingly valuable vouchers for successive drug abstinence (Higgins et al., 1993) • Subjects averaged $415 (SD=453) in vouchers over 16 wks, or 34% of total possible • Combination CBT+CM (CBT+CM) • Participated fully in both elements of the interventions • Subjects assigned to combined condition averaged $662 (SD=478) in vouchers or 51.8% of possible, a significantly higher rate over CM alone (t (80) = -2.4, p = .019)

33. 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

34. 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)

35. 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

36. Psychiatric Diagnostic Impressions by Reported HIV Serostatus at Baseline HIV-infected (n=98) HIV non-infected (n=57) Total Sample (n=162) ECA General Population Estimates Participants with any Axis I diagnosis, excluding substance abuse or dependence Lifetime 50.0% 43.9% 47.7% 22.0% Participants with any Mood Disorder Lifetime 55.1% 47.4% 52.3% 9.5% Participants with Bipolar I Disorder Lifetime (p<.04) 7.1% 0.0% 4.5% 0.9%

37. Psychiatric Diagnostic Impressions (cont’d) HIV-infected (n=98) HIV non-infected (n=57) Total Sample (n=162) ECA General Population Estimates Participants with any Anxiety Disorder Lifetime (p<.03) 34.7% 17.5% 28.4% 12.7% Participants with alcohol dependence or abuse diagnosis Lifetime 63.3% 63.2% 63.2% 7.3% Participants with Substance Dependence diagnoses other than Amphetamine and Alcohol Dependence Lifetime (p<.02) 49.0% 28.1% 41.3%

38. Treatment Outcomes

39. Retention in Treatment F(3,158)=3.78, p<.01; CBT < CM and CBT+CM, p<.05

40. Consecutive Negative Urine Samples F(3,158)=11.08, p<.001; CBT < CM and CBT+CM, p<.001

41. Percent Negative Urine Samples

42. Percent Urine Samples Positive; Baseline to 12-Months McNemar’s Q = 18.69, p<.0001

43. Self-Report of Methamphetamine Use, Past 30 Days

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

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

46. Summary of Findings • Structural Effects of Treatment Preserve Treatment Gains to Distal Evaluations • Maximal suppression of methamphetamine use produced by CM conditions during treatment • Maximal reductions in high-risk sexual behaviors by GCBT during treatment

47. Behavioral Prevention • Behavioral prevention methods efficiently reduce risk behaviors (Pequegnot and Stover, 2000) • Voluntary counseling and testing • Prevention role • Early access to HIV medical care for positives • Federal funding declining • 200,000 Americans unaware of HIV infection (Summers et al., 2000)

48. Needle Exchange • NE conceptualized within larger set of services (Des Jarlais, 2000) • Number of NEPs increasing 20% per year • NEP attendees less likely to share needles and more likely to clean skin (Longshore et al., 2001) • NEP attendance protective against HIV (Monterroso et al., 2000)

49. Substance Abuse Treatment • Drug abuse treatment, particularly methadone maintenance, is associated with decreased injection and sex-related HIV risk behaviors (Sorenson and Copeland, 2000) • Methadone maintenance reduces drug injection and protects against seroconversion • Substance abuse treatment reduces drug-associated sexual behaviors

50. Prevention for Positives • Medication compliance programs • Medication efficiently reduces viral load, but is dependent on stable levels; virus mutates with fluctuating medication levels • Behavior maintenance programs • Access to substance abuse treatment