Drug Abuse Treatment as HIV Prevention The State

Drug Abuse Treatment as HIV Prevention: The State of the Science l David S. Metzger, Ph. D. l University of Pennsylvania Center for Studies of Addiction HIV Prevention Research Division Philadelphia, PA

Overview • Drug driven epidemics -- overview • Prevention impacts of drug treatment • Drug treatment, access, and adherence to HIV care • Challenges in maximizing the public health impact of drug treatment

Current AIDS epidemiology • Approximately 33, 000 living with HIV/AIDS • Over 10, 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 non-injection drug use

Estimated size of IDU population N. America 1. 43 m Caribbean: 0. 028 m L. America: 0. 97 m W. Europe: 1. 24 m E. Europe & C. Asia: 3. 2 m MENA: 0. 44 m S. Saharan. Africa 0. 009 m E. Asia & Pacific 2. 35 m S. & S-E Asia: 3. 33 m Australia & N. Zealand: 0. 19 m 10. 3 m (78%) in developing/transitional countries 91% of the world adult population (4 billion) is covered by the data. UN Reference Group on HIV/AIDS prevention and care Information unavailable for 119 countries. among IDU www. idurefgroup. org

What drugs are most commonly injected? Opiates Cocaine ATS Opiates Cocaine Opiates ATS

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

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

Dependence is a medical condition with common Dx and consequences: ASI Composite Scores: Porto Alegre, Philadelphia and Wuhan

Substance-related HIV transmission • Direct and indirect sharing of injection equipment and materials • Unprotected sexual activity Consequences of substance use in all risk groups: MSMs, IDUs, Heterosexuals

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

How does drug treatment prevent HIV infection and transmission? • Effective treatments reduce the frequency of drug use • Fewer drug-related risk behaviors • Fewer new infections • • Increased access to HIV treatment and primary care Increased adherence to HIV medications

How does drug treatment prevent HIV infection and transmission? • Effective treatments reduce the frequency of drug use • Fewer drug-related risk behaviors • Fewer new infections

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

Injection rates 12 months following treatment entry by retention status (Thiede, Hagan, and Murrill, 2000)

Drug use and injection among 557 heroin users by methadone treatment status, Sichuan Province, China (Han-Zhu Qian et al, 2008)

Study outcomes: opiate abstinence Schottenfeld, R. S. , Chawarski, M. C. , & Mazlan, M. Lancet 2008, 371: 2192– 200

How does drug treatment prevent HIV infection and transmission? • Effective treatments reduce the frequency of drug use • Fewer drug-related risk behaviors • Fewer new infections

Rate of needle sharing reported by In-Treatment IDUs compared to Out-of-Treatment IDUs 1 0. 8 0. 6 0. 4 0. 2 0 Selwyn et al 1987 Martin et al 1990 Klee et al 1991 Williams Longshore Metzger et al 1992 1993 Stark et al 1994 Capplehorn et al 1995

Needle sharing among 557 heroin users by methadone treatment status, Sichuan Province, China (Han-Zhu Qian et al, 2008)

How does drug treatment prevent HIV infection and transmission? • Effective treatments reduce the frequency of drug use • Fewer drug-related risk behaviors • Fewer new infections

HIV prevalence rates among New York IDUs by methadone treatment 100% 87% 80% 60% 40% 20% 0% 10% 86 Active Users (MMRW, 1984) 35 Long Term MM

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

(Metzger et al. 1993)

Incidence of HBV and HCV 12 Months Following Treatment Entry (Thiede, Hagan, and Murrill, 2000)

Agonist treatment is more than substitution • Safe, stable dosing • Drug use monitored • Drug counseling • Access to other services

Naltrexone and drug counseling treatment in St. Petersburg Percent remaining in Treatment 1, 0 N+F , 9 N+P , 8 F+P P+P , 7 N+F>P+P N+F>F+P N+P>P+P N+P>F+P F+P=P+P N+F=N+P , 6 , 5 , 4 , 3 , 2 0 3 6 9 12 Weeks 15 18 21 24 27 30

Buprenorphine/Naloxone offers new opportunities for treatment in HIV care settings • Partial agonist, longer half-life • Reduced risk of overdose • Less severe withdrawal • Fewer interactions with anti-retrovirals

Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial. Schottenfeld, R. S. , Chawarski, M. C. , & Mazlan, M. Lancet 2008, 371: 2192– 200

Maintenance treatment with buprenorphine, naltrexone, and counseling for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial. Schottenfeld, R. S. , Chawarski, M. C. , & Mazlan, M. Lancet 2008, 371: 2192– 200

Study outcomes: opiate abstinence Schottenfeld, R. S. , Chawarski, M. C. , & Mazlan, M. Lancet 2008, 371: 2192– 200

Study outcomes: HIV risk reduction Schottenfeld, R. S. , Chawarski, M. C. , & Mazlan, M. Lancet 2008, 371: 2192– 200

Seroconversion by treatment participation: retention is critical 4 3 2 1 0 One or More Years of Methadone Treatment (Moss et al. 1994) Less Than One Year of Methadone Treatment

Limitations of treatment studies • Measurement variability • Treatment variability • Short follow-up • Focus on opiate dependent injectors • No randomized trials with HIV endpoints

HPTN 058 Study Design Opiate injectors recruited from community and screened If not eligible, referred to local resources Short term Suboxone At Bx and 6 months plus one year counseling; Referral to local resources 12 month Suboxone plus one year counseling; Referral to local resources HIV testing and counseling Every 6 months Year 02

Adherence Durable Viral Suppression = Start therapy Substance Abuse Engage in medical care HIV Infected Population

Adherence with antiretroviral therapy is adversely affected by drug use Not using cocaine (n=57) Using cocaine (n=20) P value Adherence (MEMS Caps) 68% 27% 0. 005 Viral suppression 46% 13% 0. 005 Arnsten JH. J Gen Intern med 2002; 17: 377

Adherence to HIV medications by drug use Lucas et al, 2002

Risk of developing new opportunistic infection according to drug use status Lucas et al. Am J Epidemiol 2006

Adherence by past and current drug and alcohol diagnoses Alcohol Drug Current diagnoses p<. 01 Lifetime diagnoses NS NS

Maximizing the impact of drug abuse treatment as HIV prevention • Accessible • Acceptable • Affordable

Continuum of Drug Use and Treatment Use Abuse Dependence Outreach Harm Reduction Counseling Out-patient Residential Drug free Antagonist Counseling Detoxification + Agonist/Antagonist Out-patient Counseling

Estimated Opiate dependent Drug Users in Agonist Treatment per 100, 000 population

HIV prevention and care implications: Necessary but not sufficient Drug Treatment Community Outreach HIV Care Harm Reduction

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

Conclusions • Data suggests effective treatments for drug users: recognize addiction as a chronic disease (at least one year) use pharmacologic and counseling interventions are accessible, acceptable, and affordable

Future directions • Expand access to effective treatments • Target drug users earlier in the continuum of use • Test interventions for use of multiple substances • Measure HIV risk endpoints in clinical trials of new medications • Urgent need to sustain search for pharmacologic treatments for stimulant abuse

Ignorance Poverty Sexism Access To Care Discrimination Disempowered Women Stigmatization Human Rights Abuses Prejudice Denial Complacency Courtesy of Jim Hoxie High Risk Behavior