Transcript Risk Mitigation in Vulnerable Populations in Los Angeles

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
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
National Prevalence
AIDS is Drug Abuse
Males
Females
(N=697,718)
(N=152,060)
MSM
55%
--
IDU
22%
39%
MSM+IDU
8%
--
Heterosexual
5%
42%
Other
9%
17%
CDC, 2003
Exposure Risks by Geography, 2002
MSM
IDU
MSM
+IDU
6.6%
Het
Other
LA
71.3% 7.0%
4.6%
10.4%
SF
74.3% 8.8% 13.5% 1.7%
1.7%
Bakersfield
42.7% 28.4% 12.4% 10.3%
6.2%
Rvrsd/SnBrn 61.1% 14.4% 10.2% 6.8%
8.1%
NYC
16.0%
29.5% 41.5% 3.2%
9.8%
CDC, WONDER, 2004
Injection Risk Behaviors:
East vs West Coast of U.S.
25
20
15
10
East
West
• 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)
5
0
Garfein et al., 2004
MSM+IDU in San Francisco:
HIV and Risk Behaviors
45
40
35
30
25
1989
1996
2000
20
15
10
5
0
• In July 2000, 1/3 of
respondents shared
syringes or UAI
(n=1594)
• Suggests amphetamine
drug treatment, sex
risk reduction
programs are needed
Year
Bluthenthal et al., 2001
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
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
Demographics
Male %
Coc Dual MA G-MA Her
(476) (120) (1308) (162) (338)
75.0 55.0 48.4 100.0 68.3
Ethnicity %
White
Afr Amer
Hisp
Asian
Other
29.4
41.6
25.6
2.1
1.2
39.2
31.7
25.8
1.7
1.7
63.5
1.7
18.4
13.7
2.7
75.9
3.1
13.0
3.1
1.2
P<0.0004
42.0
20.4
33.1
2.1
2.1
Drug Related Variables
Years, Life
Coc Dual MA G-MA Her
(476) (120) (1308) (162) (338)
9.5
10.3
7.9
5.1
13.9
Days in 30
10.9
12.0
11.9
9.7
17.4
Route of
Admin
Nasal
Smoking
IV
20.0
75.4
3.2
4.2
50.8
45.0
11.9
64.6
22.9
28.4
29.6
37.0
6.2
10.1
80.8
P<0.0001
Risk Associations
Comparisons
Shared Needles/
Works
(n=1,313)
Cocaine
Dual
Methamphet
MSM+Meth
OR
95% C.I.
0.04
1.67
1.90
1.40
0.02-0.09
1.34-2.08
1.39-2.60
1.07-1.83
Risk Associations
Comparisons
>1 Sex partner,
6 months
(n=2,071)
Cocaine
Dual
Methamphet
MSM+Meth
OR
95% C.I.
2.11 1.64-2.72
1.72 1.31-2.27
10.7 28.5-46.1
Risk Associations
Comparisons
OR
95% C.I.
Cocaine
Dual
Methamphet
MSM+Meth
5.65 3.43-9.29
6.04 2.67-13.7
-
Exchange Sex
(n=986)
Risk Associations
Unprotected
Intercourse
(n=2,389)
Comparisons
OR
95% C.I.
Cocaine
Dual
Methamphet
MSM+Meth
1.49
1.16
1.72
10.7
1.27-1.73
1.00-1.35
8.64-13.2
1.47-2.01
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
The Los Angeles AIDS Epidemic:
Cumulative Male AIDS Cases
MSM
Los Angeles*
76%
United States**
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
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 ~ 3040% (St Mary’s Hospital, Long Beach)
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
Percent HIV+
Methamphetamine and HIV in MSM: A
time-to-response association?
100
90
80
70
60
50
40
30
20
10
0
Probability
Sample1
1Deren
Street
Recreational Outpatient Residential5
Outreach2
User3
Drug free4
et al., 1998, Molitor et al., 1998; 2Reback et al., in review;
3Reback, 1997; 4Shoptaw et al., 2002; 5VNRH, unpublished data
MSM in Commercial Sex Venues
50
Percent Reporting
50
40
30
20
13
14
10
0
HIV +
Bisexual
Men of Color
Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049
Reback, 2004
Drug Risks,
MSM in Commercial Sex Venues
80
Percent Reporting
70
60
50
40
30
20
10
0
Alcohol
MJ
Poppers
Crystal
Ecstasy
GHB
IDU
Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049
Reback, 2004
www.crystalneon.org
www.tweaker.org
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)
1
– Presumes intact decisions/choices around sexual
behaviors in most people
Targeted Approach: Provide drug abuse treatment to
users with abuse or dependence
2
– Centrality of drug/sex link in decisions/choices
for small, heavily drug involved group
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
A Working Model
Figure 1: McKirnan et al.(1996) Escape Model of Substance Use and Sexual
Risk Behaviors for gay and bisexual men.
Internalized
Homophobia/
Stress
Sex Risk
ESCAPE
Substance Use
Changes in Identification
Outpatient
Drug Abuse
Treatment
 Internalized Homophobia
 Cultural Group Identity
Outcomes
 Sex Risk
 Stimulant Use
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
Adaptation of a Gay-Specific Intervention
Standard CBT
CBT+ gay-specific
HIV-Risk Reduction
External Triggers:
Sporting Events
Concerts
Movies
Gay Pride Festival
Bathhouse
Halloween
Relapse Justification:
“I just got injured.
I might as well use.”
“My friend just died
[AIDS] and using will
make me forget for
awhile.”
One Day at a Time:
“Tomorrow something
will happen to ruin
this.”
“I seroconverted even
though I knew about
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”
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)
Sample Demographics
• 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%
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)
History of Sexually Transmitted Diseases
by Reported HIV Serostatus
STD
HIV Serostatus
Positive
Negative
(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
Psychiatric Diagnostic Impressions by Reported
HIV Serostatus at Baseline
HIV-infected
(n=98)
HIV noninfected
(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%
52.3%
9.5%
4.5%
0.9%
Participants with any Mood Disorder
Lifetime
55.1%
47.4%
Participants with Bipolar I Disorder
Lifetime
(p<.04)
7.1%
0.0%
Psychiatric Diagnostic Impressions (cont’d)
HIV-infected
(n=98)
HIV noninfected
(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%
Participants with Substance Dependence diagnoses other than
Amphetamine and Alcohol Dependence
Lifetime
(p<.02)
49.0%
28.1%
41.3%
7.3%
Treatment Outcomes
Retention in Treatment
14
12
10
8
Weeks
6
4
2
0
CBT (n=40)
CM (n=42)
CBT+CM (n=40)
GCBT (n=40)
F(3,158)=3.78, p<.01; CBT < CM and CBT+CM, p<.05
Consecutive Negative Urine
Samples
25
20
15
10
5
0
CBT (n=40)
CM (n=42)
CBT+CM (n=40)
GCBT (n=40)
F(3,158)=11.08, p<.001; CBT < CM and CBT+CM, p<.001
Percent Negative Urine Samples
100
90
80
70
60
50
40
30
20
10
0
CBT (n=40)
CM (n=42)
CBT+CM
(n=40)
GCBT (n=40)
Trtmt
6-Mo
12-Mo
Percent Urine Samples Positive;
Baseline to 12-Months
50
45
40
35
30
% 25
20
15
10
5
0
Baseline
McNemar’s Q = 18.69, p<.0001
12-Months
Self-Report of Methamphetamine
Use, Past 30 Days
12
10
Base
End Tx
6-Mo
12-Mo
8
Days 6
4
2
0
CBT (n=40)
CM (n=42)
CBT+CM
(n=40)
GCBT (n=40)
Unprotected Anal Receptive
Intercourse; Past 30 Days
3.5
3
2.5
CBT
CM
CBT+CM
GCBT
2
1.5
1
0.5
2(3)=6.75, p<.01
12
-M
os
os
6M
-W
ks
16
-W
ks
12
ks
8W
ks
4W
Ba
se
l
in
e
0
Unprotected Anal Insertive
Intercourse; Past 30 Days
8
7
6
5
4
3
2
1
0
2(3)=8.26, p<.01
12-Mos
6-Mos
16-Wks
12-Wks
8-Wks
4-Wks
Baseline
CBT
CM
CBT+CM
GCBT
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
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)
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)
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 drugassociated sexual behaviors
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
Post Exposure Prophylaxis
• Routine treatment for health care workers
accidentally exposed
– Perhaps reduces odds of seroconversion by
79% (CDC, 1997)
• Experimental programs evaluating PEP for
drug and sexual exposures
Conclusions
• AIDS epidemic differs by geography and time
• Risk for AIDS differs dramatically for differing
segments of the local population
• Prevention interventions efficient at reducing HIV
transmission
• Role for treatment (AIDS and drug abuse) central
to comprehensive prevention plan