Transcript Drug treatment as prevention

Psychoactive Drugs and HIV
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
• Most users of substances don’t
inject
• Proposed mechanisms linking
substance use and HIV transmission for
people who do not inject
• Indirect links between drug abuse
treatment as HIV prevention
• Two evidence-based case
examples
• Discussion
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
Substances
• Sedative/barbs – ALCOHOL, benzodiazepines, GHB
• Stimulants – cocaine, speed, NICOTINE, Ecstasy (MDMA)
• Opiates – heroin, percodan, dilaudid, vicodin
• Hallucinogens – LSD, mescaline, peyote
• Tranquilizers/anesthetics – ketamine, PCP
• Cannabinoids – POT, hash
• Inhalants – poppers, solvents
Substance Use Prevalence,
U.S. Adults 2012
Substance
Δ from 2011
%
Current Cigarette Smokers
--
22.1%
Alcohol Use (any in past month)
--
51.8%
Heavy Alcohol Drink (5+ drinks, 5+ days past month) --
6.5%
Marijuana Use (past month)
 5.8% in 07
7.3%
Prescription Drug Misuse (past month)
--
2.6%
 from 2002-05, 07, 09
0.1%
↓ from 2003-07
0.6%
Heroin Use (past month)
Cocaine Use (past month)
Methamphetamine Use (past month)
0.5%
--
www.samhsa.gov National Survey on Drug Use and Health, 2013
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
Drug Dependence in America
• In 2012, 22.2 million (8.5% of adults aged 12 and
over met) criteria for substance abuse or
dependence not including tobacco dependence
(National Survey on Drug Use and Health, 2011).
• Alcohol abuse and dependence represents the
majority (17.7 million; 6.8% of adults and 80% of
total substance abuse/dependence)
– remainder splits between drug disorders only and
comorbid illicit drug use and alcohol use disorders.
www.samhsa.gov NSDUH, 2013
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
A Word About Marijuana
Frances Jensen and David Urion
Advancing the prevention and treatment of chronic illnesses
UCLA
Department of Family Medicine
AIDS in America:
Overlooked Epidemic
Prevalence of
HIV among
MSM in Los
Angeles County
is about 19%
Substance use
involved in 28%
to 33% of
incident cases
among MSM
El-Sadr, Mayer, Hodder. (2010). NEJM. 362:967-970.
• High HIV incidence among people who inject drugs (PWID) in Eastern Europe,
Central, Southeast and South Asia and Africa
• Increasing importance of non-injection substance use
• Globally, coverage of ART, medication assisted treatment and sterile syringes is
low among PWID, due to structural barriers and unavailability
• Limited HIV research among women and adolescent substance users
• Growing emphasis on implementation science strategies to improve
intervention coverage
• Limited data to inform efficacy and timing of HIV treatment as prevention
(TasP) among PWID
• Limited integration of substance use into active HPTN protocols
What we Know: Non-injection Stimulant Use and HIV among
MSM
• Non-injection stimulant use accounts for between
16% and 33% of new HIV infections among MSM in
the U.S.1,2
• Consistent linkages between use of
methamphetamine and binge drinking with
serodiscordant unprotected anal intercourse.3
• Evidence for onset of methamphetamine use both
before and after HIV seroconversion.4
1Koblin
et al., AIDS 2006
et al., JAIDS 2009
3 Vosburgh et al., AIDS & Behav, 2012
4 Halkitis et al, Health Psychol 2014
2 Ostrow
Women, HIV and Substance Use
• Females who inject drugs tend to have higher HIV prevalence
than men who inject drugs5
• Among U.S. women in HPTN 064, 76% reported binge drinking
or using ≥1 drug in the last 6 months6:
• Binge drinking: 63%
• Cocaine use: 25%
• Opiates: 17%
• Poly-substance users less likely to decrease frequency of use
over time
5 des Jarlais, Drug Alc Depend 2012
6 Kuo et al, Drug Alc Depend 2014
What We Know: Emerging Substance Use
Trends and HIV among Adolescents
• Emerging drug trends:
– Prescription drug use which may facilitate transitions to injection7
– Synthetic cannibinoids (e.g., Spice) and cathinones (e.g., bath salts);
links to HIV risk under-studied
• HIV incidence increased by 20% among young people (ages
15-24) in Eastern Europe between 2001 and 2011; the majority
of whom use or inject drugs.8
7 UNODC, 2013
8 UNAIDS 2012
New treatments for HCV, HIV, substance
abuse
– Once daily HCV treatments - high efficacy regimens for all
genotypes provides opportunity for TasP, integrating HCV
and HIV treatment approaches
– Long-acting formulations for ARVs - provide opportunities
for HIV treatment and prevention that sidestep medication
adherence
– Drug treatment as prevention - Injectable treatments for
alcohol, stimulant and opioid addiction (Naltrexone,
Probuphine) allow opportunities for new concepts
– New developments in behavioral sciences, especially
technology/social media, offer new intervention
approaches