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Advancing the prevention and treatment of chronic illnesses

Prevention of HIV Transmission by Blood and Through Treatment of Addiction . Steven Shoptaw, PhD UCLA Center for Behavioral and Addiction Medicine Department of Family Medicine sshoptaw@mednet.ucla.edu August 26 , 2013. Advancing the prevention and treatment of chronic illnesses .

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Advancing the prevention and treatment of chronic illnesses

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  1. Prevention of HIV Transmission by Blood and Through Treatment of Addiction Steven Shoptaw, PhD UCLA Center for Behavioral and Addiction Medicine Department of Family Medicine sshoptaw@mednet.ucla.edu August 26, 2013 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, CurrOpin 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. Final Thoughts Advancing the prevention and treatment of chronic illnesses UCLADepartment of Family Medicine

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