Transcript Prevention of HIV Transmission by Blood Through

Prevention of HIV Transmission by
Blood Through Treatment of Addiction
Steven Shoptaw, PhD
UCLA Center for Behavioral and
Addiction Medicine
Department of Family Medicine
[email protected]
September 5, 2014
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
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
UCLA
Department of Family Medicine
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Tolerance
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
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Department of Family Medicine
Opioids
• About 1 million Americans
• Only 160,000 in opioid agonist
treatment
• New developments make it
possible for office-based
treatment (Suboxone)
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
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Department of Family Medicine
Opioid Agonist Treatments
• Cheap (especially for
methadone)
• Potent
• Safe (especially for
buprenophine)
• Portable (especially
for buprenorphine)
Treatment of Substance Use
Disorders as HIV Prevention
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
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
UCLA
Department of Family Medicine
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
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
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Department of Family Medicine
Methadone Promotes ART Use
Uhlmann et al., 2010. Addiction, 105, 917-913
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Department of Family Medicine
ART Adherence and MMT in 545
Homeless IDUS in Vancouver
Palepu et al., 2011. J Urban Health, 88: 545-555
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UCLA
Department of Family Medicine
ART in IDUs and NIDUs:
Access Denied
EVER Get ART?
N=1730
ART for 95%+ of Time
N=1275
Age (per year)
1.03 CI 1.02-1.04
1.02 CI 1.01-1.04
Baseline CD4<200 cell
4.43 CI 3.19-6.16
1.15 CI 0.89-1.48
Baseline PVL>5 log10
1.68 CI 1.2-2.35
0.68 CI 0.47-0.81
Black Race
0.57 CI 0.44-0.73
0.65 CI 0.51-0.83
IDU History
0.47 CI 0.33-0.67
0.63 CI 0.44-0.90
NIDU History
0.62 CI 0.47-0.81
0.66 CI 0.52-0.85
McGowan et al., 2011. PLOSOne, 6:e18462
Advancing the prevention and treatment of chronic illnesses
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Department of Family Medicine
Effects of ART Among IDUs
Nolan et al., 2011. AIDS Care, 23:980-987
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
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
UCLA
Department of Family Medicine
Reducing HIV Incidence in IDUs
Degenhardt et al., 2010, Lancet, 376:285-301
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
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
UCLA
Department of Family Medicine
Evidence on Outcomes for PWID
HIV testing
Individual interventions for HIV risk
Network/peer interventions for HIV risk
Needle syringe programs (NSP)
Condom provision
Opioid substitution therapy (OST)
Naltrexone – Oral
Naltrexone – Implant
Pharmacotherapy for stimulant dependence
CBT for stimulant dependence
STI treatment
Antiretroviral treatment (ART)
Safe injecting centres (SICs)
Compulsory detention of drug users
Injecting
frequency
Injecting
risks
Sex risks
HIV
infectivity
HIV
incidence
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ART as Disease Prevention
HIV Treatment as Prevention
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
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
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Department of Family Medicine
HPTN 052: TasP
Cohen et al., 2011, NEJM, 365: 493-505
Advancing the prevention and treatment of chronic illnesses
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Department of Family Medicine
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
UCLA
Department of Family Medicine
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
UCLA
Department of Family Medicine
Treatment of Non-Injection
Substance Use Disorders as HIV
Prevention
Advancing the prevention and treatment of chronic illnesses
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Department of Family Medicine
Not Just the Needle: A Complicated
Equation for HIV Transmission
NIDU
Substance Use
Type of Substance
• Stimulant
• Alcohol
• NOT cannabis
Route of Use
• Oral
• Eating
• Smoked
• Inhaled
• Inserted anally
+
HIV
Prevalence
Local Factors on HIV
Prevalence
• Dual Diagnosed
• Poverty
• Incarceration
• MSM
• Street youth
• Women
• Race/ethnicity
=
Risk
Transmission Potential
HIV Transmission Risks
• Blood (?)
• Drug-facilitated
sexual transmission
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
Policy Model for Methamphetamine Use,
HIV Prevalence and Interventions
Shoptaw & Reback, J Urban Health, 2006
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
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
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Department of Family Medicine
HIV Prevention Strategies for NonTreatment Seeking Substance Users
Advancing the prevention and treatment of chronic illnesses
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Department of Family Medicine
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
UCLA
Department of Family Medicine
iPrEX Results
Grant RM et al N Engl J Med. 2010 363:2587-99.
Advancing the prevention and treatment of chronic illnesses
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Department of Family Medicine
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
UCLA
Department of Family Medicine
PEP in MSM
In Project EXPLORE, MSM who reported any noninjection 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
UCLA
Department of Family Medicine
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 – nonadherent to meds and multiple exposures
Landovitz et al. 2012 AIDS Pt Care STDS, 26:320-328
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
Behavioral Prevention for HIVNegative Substance Users
Woman focused HIV risk reduction program for
African American crack smokers (Wechsberg et
al., 2004)
Fast Lane, HIV-risk reduction program for HIVnegative heterosexual meth users (Mausbach
et al., 2007)
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
Behavioral Prevention for HIVPositive 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
UCLA
Department of Family Medicine
Final Thoughts
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine