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Prevention of HIV Transmission by Blood through Treatment of Addiction

This article explores the use of opioid agonist treatments, such as methadone and buprenorphine, as a means to prevent the transmission of HIV among drug users. It discusses the efficacy of these treatments and their impact on reducing drug use, high-risk behaviors, and HIV incidence.

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Prevention of HIV Transmission by Blood through Treatment of Addiction

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  1. Prevention of HIV Transmission by Blood Through Treatment of Addiction Steven Shoptaw, PhD UCLA Center for Behavioral and Addiction Medicine Department of Family Medicine sshoptaw@mednet.ucla.edu September 5, 2014 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  2. What You Need to Know • Understanding Addiction • Experiences of ART for Drug Users • Evidence-based Treatments and the Rationale for their Efficacy as HIV Prevention • Case Presentations and Discussion Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  3. DSM-5 Definition: Substance Use Disorder Maladaptive pattern of use, clinically significant impairment or distress and 2+ of the following in the same 12-month period: 1. Tolerance 2. Withdrawal Used for longer periods than intended Can’t cut down or quit Time spent getting, using or recovering Give up social, work or fun activities Craving or a strong desire or urge to use a substance Continued use despite knowledge of negative consequences Failure to fulfill major role obligations Use in physically hazardous situations Continued use despite social and interpersonal problems Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  4. Opioids • About 1 million Americans • Only 160,000 in opioid agonist treatment • New developments make it possible for office-based treatment (Suboxone)

  5. Opioid Detoxification: A Prescription for Failure While detox sounds good, less than 2 in 100 successfully achieve drug free status (Day et al., 2005) Most don’t consider this treatment, but a necessity for convincing addicts to use agonist Psychosocial strategies are less effective (Mayet et al., 2005) Newly detoxified individuals are extremely vulnerable to relapse. The vast majority fail to remain drug-free. Opioid maintenance should be the first-line treatment for heroin dependence. Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  6. Opioid Agonist Treatments • Cheap (especially for methadone) • Potent • Safe (especially for buprenophine) • Portable (especially for buprenorphine)

  7. Treatment of Substance Use Disorders as HIV Prevention Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  8. Mechanism: Opioid Replacement as HIV Prevention Reduced craving for and use of illicit opioids Reduced frequency of injecting drug use Concomitant reductions in sex for money or drugs Better cognitive function and ability to understand prevention messages Less sharing of paraphernalia Regular contact with NTP, which increases chance for medical and psychosocial interventions Gowing et al., 2008 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  9. Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  10. Summary: Methadone and HIV Seroconversion Early cohort studies demonstrated effects of methadone for reducing HIV-incidence Continuous methadone maintenance is seroprotective; interrupted maintenance is not (Moss et al., 1994) Opioid substitution may slow transmission of treatment resistant virus (Tetrault et al., 2013) Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  11. Methadone Promotes ART Use Uhlmann et al., 2010. Addiction, 105, 917-913 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  12. ART Adherence and MMT in 545 Homeless IDUS in Vancouver Palepu et al., 2011. J Urban Health, 88: 545-555 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  13. ART in IDUs and NIDUs: Access Denied McGowan et al., 2011. PLOSOne, 6:e18462 Advancing the prevention and treatment of chronic illnesses UCLA Department of Family Medicine

  14. Effects of ART Among IDUs Nolan et al., 2011. AIDS Care, 23:980-987 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  15. Strategy for HIV Combination Prevention in HIV+ Substance Users • Reduce Infectiousness: Reduce viral loads in HIV-positive groups of substance users • Reduces “transmission potential” across population • Foundation of the seek, test, treat, retain approach • Departure from advocacy strategies guiding HIV prevention • No data yet to test TasP in HIV+ drug users Kurth et al., 2011, Current HIV/AIDS Reports,1-11 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  16. Reducing HIV Incidence in IDUs Degenhardt et al., 2010, Lancet, 376:285-301 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  17. IDUs and Their Risk Environments Ensuring access to ART, OST and NSP is important; IDUs interact with individuals outside IDU networks Opportunities for structural interventions Strathdee et al., 2010, Lancet, 376, 268-284 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  18. ART as Disease Prevention HIV Treatment as Prevention Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  19. Profound Effects of ART in Preventing Death • CASCADE Collaboration • 22 cohorts pooled with known dates of HIV seroconversion • Gains not even: • MSM decreased deaths from malignancies and Ois • IDUs increased deaths due to unintentional deaths Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  20. HPTN 052: TasP Cohen et al., 2011, NEJM, 365: 493-505 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  21. Apathy, Addictophobia, Inattention Limited access to ARTs for HIV+ IDUs in resourced and in developing countries Begs the question of starting ART early Political stances against opioid substitution therapies and needle and syringe programs present structural barriers to averting infections Inattention to marginalized groups (e.g., street youth, sex workers; itinerant workers) who engage IDU Strathdee et al., 2012, Curr Opin HIV/AIDS Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  22. Current Status Models suggest, but no data exist to determine benefits of TasP for IDU or non-IDU substance users Proof of concept studies excluded these due to concerns over medication adherence problems. HPTN 074 will address TasP among IDUs in countries with  HIV incidence Measuring incidence in networks of IDUs and sexual partners Virtually no other studies planned to guide policy on TasP among HIV+ substance users Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  23. Treatment of Non-Injection Substance Use Disorders as HIV Prevention Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  24. Not Just the Needle: A Complicated Equation for HIV Transmission NIDU + HIV = Risk Substance Use Prevalence Transmission Potential • Local Factors on HIV Prevalence • Dual Diagnosed • Poverty • Incarceration • MSM • Street youth • Women • Race/ethnicity • Type of Substance • Stimulant • Alcohol • NOT cannabis • Route of Use • Oral • Eating • Smoked • Inhaled • Inserted anally • HIV Transmission Risks • Blood (?) • Drug-facilitated sexual transmission Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  25. Policy Model for Methamphetamine Use, HIV Prevalence and Interventions Shoptaw & Reback, J Urban Health, 2006 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  26. Behavioral Drug Abuse Treatment as HIV Risk Reduction Behavioral Therapies Friends Getting Off (Reback & Shoptaw, 2011) Contingency Management (Shoptaw et al., 2005) Limits to treatment settings (Menza et al., 2010) Heterosexual meth users show parallel reductions in injection and sex risk behaivors (Corsi et al., 2012) Medication Therapies Mirtazapine (30 mg/d) for meth-dependent MSM (Colfax et al., 2011) showed reductions in meth use and concomitant HIV sexual transmission behaviors Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  27. HIV Prevention Strategies for Non-Treatment Seeking Substance Users Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  28. Strategy for HIV Combination Prevention in HIV- Substance Users Lower susceptibility: Reduce infection in HIV-negative groups Biobehavioral approaches – PrEP, PEP for substance using MSM; other groups at high risk Behavioral programs – condom distribution, EBIs can address structural determinants of risk related to substance use; no evidence of infections averted Surveillance of emerging epidemics linked to drug use Kurth et al., 2011, Current HIV/AIDS Reports,1-11 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  29. iPrEX Results Grant RM et al N Engl J Med. 2010 363:2587-99. Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  30. iPrEX Findings Of 100 seroconversions, 36 in Truvada group, a reduction of 44% over placebo (p=0.005) Efficacy was higher in men who reported UAI (58%) than those who did not Adherent men (90%+) showed 73% efficacy Efficacy of all subjects was 47% (p=0.001) Questions remain about adverse effects, feasibility/acceptability/ethics No indication about substance users as they were excluded from trials Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  31. PEP in MSM In Project EXPLORE, MSM who reported any non-injection drug use increased odds for PEP by 50% (aOR: 1.5, 95% CI:1.1, 1.9) Smoked cocaine, poppers, crack cocaine, amphetamines and hallucinogens increased odds IDUs significantly higher odds of PEP use (aOR: 2.44, 95%CI: 1.69, 3.51). Marijuana or cocaine that was snorted or sniffed or alcohol drinking did not associate with increased odds for PEP No evidence of risk compensation Donnell et al., 2010, AIDS Behav 14:1182–1189 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  32. PEP in Methamphetamine Using MSM When integrated with CM, PEP use among meth-using MSM appears to be safe and feasible Time to PEP initiation (37 h) and reported adherence rates (96%) are comparable to non-meth-using PEP findings CM increased PEP adherence 2% for each MA-negative urine sample; CM increased PEP completion by 17% Meth-using MSM had high rates of risk behavior: high prevalent STI rates Small sample size (n=53), 1 incident seroconversion – non-adherent to meds and multiple exposures Landovitz et al. 2012 AIDS Pt Care STDS,26:320-328 Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  33. Behavioral Prevention for HIV-Negative Substance Users Woman focused HIV risk reduction program for African American crack smokers (Wechsberg et al., 2004) Fast Lane, HIV-risk reduction program for HIV-negative heterosexual meth users (Mausbach et al., 2007) Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  34. Behavioral Prevention for HIV-Positive Substance Users See Table 1 handout from: Shoptaw, S. (in press). HIV Positive Gay Men, MSM, and Substance Use: Perspectives on HIV Prevention. In Book edited by Leo Wilton PhD Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

  35. Final Thoughts Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

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