Transcript HIV and Injection Drug Use

HIV and Injection Drug Use
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
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Learning Objectives
By the end of this session, participants
will be able to:
 Explain the link between HIV and
intravenous drug use in Vietnam
 Explain how to diagnose drug
addiction
 Explain benefits of harm reduction
 Describe how to provide ART to
intravenous drug users (IDU)
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Epidemiology of HIV and IDU
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IDU is the major source of HIV
infections in Vietnam
Risk associated with:
• needle-sharing
• exposure to contaminated injection
equipment
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IDU often engage in other high risk
behaviors, such as unsafe sex, that
can transmit HIV to non-IDU
partners
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Epidemiology of IDU in Asia
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Estimated 3.3 million IDU in South
and South East Asia
Estimated at least 20% of IDU are
HIV-positive in Vietnam
Commercial sex work among IDU
has been called a “bridge” to the
general population
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Distribution of HIV/AIDS Cases
in Vietnam
STDs
1.56%
TB patients
Blood
4.81%
donors
0.58%
CSWs
2.68%
AIDS
suspects
10.01%
Military
recruits
1.31%
IDUs
53.40%
Other
19.19%
Unknown
6.45%
Source: MOH
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HIV Prevalence Among IDUs, 2009
HIV/STI Integrated Behavioral and Biological Surveillance in
Vietnam, IBBS, 2009
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HIV Trends Among IDUs, 2006-2009
HIV/STI Integrated Behavioral and Biological Surveillance in
Vietnam, IBBS, 2009
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Opioids
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Overview of Opioids (1)
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Class of drug that
includes:
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Morphine
Heroin
Methadone
Buprenorphine
Opium
Codeine
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Opioids:
• relieve pain and
bring on feelings of
well-being
• slow down functions
of the central
nervous system,
including
respiration
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Overview of Opioids (2)
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High doses can cause respiratory
depression, coma and death
In Vietnam, most commonly used
illicit opioids are heroin and opium
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Heroin (1)
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Use: smoked, injected, nasal, oral
Effects: euphoria, sedation, pain
reduction
Negative effects: dependence,
overdose, injection related illnesses
Withdrawal: severe, but not life
threatening
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Heroin (2)
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Pregnancy: withdrawal dangerous
to fetus, pregnant women should be
maintained on methadone
Overdose: when mixing drugs or
after period of abstinence
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Characteristics of Opioid Dependence
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Definition (ICD-10): A cluster of behavioral,
cognitive, and physiological phenomena
develop after repeated substance use that
include:
Strong desire to take drug
Difficulties in controlling use
Persisting in use despite harmful consequences
Higher priority given to drug use than other
activities and obligations
• Increased tolerance
• Physical withdrawal symptoms if drug stopped
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Opioid Withdrawal Symptoms
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Withdrawal
symptoms:
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Muscle and joint pain
Abdominal cramps
Nausea, vomiting
Diarrhea
Cough
Chills
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Physical signs:
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Dilated pupils
Tachycardia
Hypertension
Hyperactive bowel
signs
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Treatment for IDU
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Medical Complications of IDU (1)
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Directly related to drug use:
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Respiratory depression from opioids
Pulmonary problems from inhaled drugs
Malnutrition
Mental health issues: mental disorders
may appear during drug use or with
sudden stopping of drug
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Medical Complications of IDU (2)
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Bacterial infections
• Bacterial
endocarditis
• Osteomyelitis
• Skin and soft tissue
infections
• Septic
thrombophlebitis
• Septicemia
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Viral infections
• HIV, HCV, HBV
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Mycobacterial
infections
• 10X increased risk
for TB among HIV
negative IDU
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Skin Lesions of Injection Drug Users
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Non-healed
puncture
wounds along
vein with
accompanying
inflammatory
changes
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Skin Abscess from Injection Drug
Use
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Barriers to Care for IDU
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Stigma
Discrimination
Social marginalization
Closed settings, including
incarceration
• Unsafe injecting practices
• Communicable disease
• Physical and sexual violence
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Treatment of Drug Users with HIV
Infection
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Drug users are less likely to receive HIV
therapy due to:
• Failure to follow-up
• Poor adherence with ARV and other
medications
• Reluctance of medical providers to
prescribe therapy due to concerns about
adherence
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However, if adherence is good, IDUs
respond to ART as well as any other
patients
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Treatment of Drug Addiction
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Drug abuse treatment and HIVrelated care must be both addressed
or neither treatment approach will be
effective
Drug users in drug treatment
programs are very adherent with HIV
therapy
The challenge: determine specific
ways to integrate care for drug
addiction and HIV therapy
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What is the Harm
Reduction Approach?
What are Some Examples
of Harm Reduction?
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Harm Reduction Approach (1)
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Rather than telling drug users to completely
stop using drugs, the harm reduction
approach focuses, literally, on reducing
harm and includes:
• Community outreach focus on peer approaches
• Behavior change communication, including risk
reduction information
• Clean needles, syringes and their safe disposal
• Drug dependence treatment, particularly
opiate substitution therapy (Methadone)
• HIV testing and counseling
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Harm Reduction Approach (2)
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Prevention of sexual transmission
through interventions
HIV care and treatment, including ART
Primary health care
• hepatitis B vaccination
• vein and abscess/ulcer care
• overdose management
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Supportive policy and legislative
environment
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What is Methadone
Maintenance?
What are the Goals of
Methadone Maintenance?
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Methadone Maintenance Therapy (1)
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Dispensed daily on site and directly
observed
• Daily observed dosing reduces potential
for abuse
• Daily contact with methadone program
facilitates treatment of other chronic
medical conditions
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Methadone Maintenance Therapy (2)
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Usual starting dose: 20-30 mg daily,
increasing by 5-10 mg every 3 days
until adequate dose is reached to:
• treat withdrawal symptoms
• reduce drug craving
• improve daily functioning
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Most patients effectively treated at
daily doses of 60-100 mg of
methadone
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Results of Methadone Treatment
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Increase:
• overall survival
• drug-treatment retention
• employment
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Decrease:
• illicit opioid use
• hepatitis and HIV seroconversion
• criminal activity
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Improve birth outcomes for pregnant
women
Kuehn, JAMA 2005.
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ART for Intravenous
Drug Users
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ART for IDU
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Same ARV regimens and doses as nonIDU
Active IDU is NOT a contraindication to
providing ARV
• Dose of methadone may need to be
adjusted due to drug interactions when
starting ARV
• No need to adjust doses of ARV drugs
when taking methadone
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Closely follow adherence and provide
extra counseling to IDU patients and
treatment supporters
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Adherence for IDU on ART
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High levels of adherence are necessary
for optimal outcomes on ART
IDU may have greater barriers to
adherence
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Side effects of ARV, real and perceived
Active drug use
Psychiatric illness or symptoms
Stigma against IDU
Resistance to ARVs is similar among
people who inject drugs and those who
do not
Wood E et al. AIDS, 2005, 19:1189–1195.
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Key Points
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IDU and sharing of infected injecting
material are major factors of HIV epidemic
in Vietnam
Harm reduction programs lead to:
• reducing drug use or reducing risk behaviors
• decreasing spread of HIV
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Methadone maintenance is an effective and
proven modality for treating opiate
addiction
IDU can respond well to ARV treatment, if
the ARV are taken with good adherence
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Thank you!
Questions?
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