Transcript Slides - View the full AIDS 2016 programme

Optimizing Care for PWIDs
Frederick L. Altice, M.D.
Director of Clinical and Community Research
Professor of Medicine
Yale University
The Doctor-Patient
Relationship
Hippocratic Oath
• First do no harm.
• I will remember that I do not treat a
fever chart, a cancerous growth, but a
sick human being, whose illness may
affect the person's family and
economic stability. My responsibility
includes these related problems, if I
am to care adequately for the sick.
• I will prevent disease whenever I can,
for prevention is preferable to cure.
The Future HIV Healthcare Providers:
Professional Students in Malaysia
P=0.001
P=0.001
P=0.001
P=NS
Percent Who Would Defer Antiretroviral Therapy
Definition: Syndemic
• A set of linked health problems involving two
or more conditions, interacting synergistically,
and contributing to excess burden of disease
in a population.
• Syndemics occur when health-related
problems cluster by person, place, or time.
Triple Layers of Stigma
HIV
Arrest
Incarceration
Substance
Use
Disorder
Substance Use
Disorder
Infectious
Diseases (HIV,
HCV, TB)
Mental Illness
(Mood or
Thought
Disorders)
ADDICTION IS A DISEASE OF THE BRAIN
as other diseases it affects the tissue function
Decreased Brain Metabolism in
Addiction Patient
High
Healthy Control
Decreased Heart Metabolism in
Cocaine Abuse
Heart Disease Patient
Low
Healthy Heart
Diseased Heart
Sources: From the laboratories of Drs. N. Volkow and H. Schelbert
Ann Jones
John Walker
JaneWalker
JaneJones
James Hill
Richard Hill
Mary Walters
Steven Adams
Susan Adams
Allison Fields
Mary Hill
Thomas Jones
Rebecca Wilson
William Price
Alice Price
Alice Benson
Walter
Jones
JonathanCook
JamesCook
Amy Mason
AnneCook
Edward Bryson
Beth Bryson
Beth Carter
John Jones
James Smith
John Smith
EdwardSmith
John Smith
Susan Edwards
ThomasSmith
ADDICTION INVOLVES MULTIPLE FACTORS
Biology/Genes
DRUG
Brain Mechanisms
Addiction
Reward (Pleasure) Pathway
Alcohol
Stimulants
Heroin
Nicotine
Ventral Tegmental Area
Stimulants
Heroin
The Problem!
12
Integrating Care for PLWHA
Secondary HIV Prevention and Adherence Counseling
Pharmacologist
Addiction Treatment Specialist
Guidelines for Integrating
Collaborative Services
• Common comorbidities in
people who use drugs
– TB, HIV, HCV, STIs
– Mental illness
• Studies where services are
NOT integrated have
poorer treatment outcomes
– patients don’t travel to
new sites for treatment
(convenience, mistrust,
etc)
14
Integration is Internationally
Recommended
15
Steps in Organizational Change
Toward Healthcare Integration
OAT
Coordination
Communication
OAT
OAT
HIV
HIV/
OAT
HIV
HIV
16
Separate
Sites
Co-Located
Services
Partial
Integration
Complete
Integration
Specific Recommendations for PLH and SUDs
• Prescribing opioid agonist therapy with either
methadone or buprenorphine for individuals with
opioid use disorders
• Integration of HIV and addiction services
• Directly administered antiretroviral therapy
(DAART), including into methadone treatment
Portugal Experience (Decentralization)
Prisons
Addiction Centers
TB Centers
Hospitals: Integrated Services
Primary Care Centers
Pharmacies
Testing Center
Outreach Teams
18
ART
OAT
TB treatment
HIV testing
NSP
TB screening
HCV
treatment
Addiction Integration into Primary Care
• Correlates of retention on buprenorphine:
– Having a primary care rather than an addiction specialist
prescribing treatment
– Not using cocaine
– Being prescribed anti-depressant medications
– Receipt of addiction counseling
19
Addiction Integration into Primary Care
• Correlates of higher quality health indicators:
– Having a primary care rather than an addiction
traetment doctor prescribing treatment
– Being retained on buprenorphine ≥3 months
– Being HIV-infected
– Male gender
21
Quality Health Indicators
22
23
25
Altice, JAIDS, 2011
• Required multiple prescribers within a
“practice”
• Needed a “glue” person to anchor the
program (counselor, nurse, etc)
• Challenges of “culture” between HIV and
addiction and new practices (urine screens)
• Polysubstance use and mental illness
comorbidities created additional challenges
Integration in Ukraine:
Improvements in Health
27
Overview
• Cross-sectional study of 296 HIV+ opioid
dependent patients in Kiev and
Dnipropetrovsk regions in Fall 2010
• Randomly recruited from three settings
– Integrated & Co-Located Clinics (ICL)
– Non-Co-Located Narcology Clinics (NCL)
– Harm Reduction & Outreach Sites (HRO)
• Primary Outcomes
– Performance on Quality Health Indicators (QHI)
– Health-related Quality of Life (HRQoL)
Quality Health Indicators
• An index that is created to measure health
outcomes across a number of diseases
• HIV Index (N=3)
– CD4 monitoring in previous 6 months; receipt
of ART; receipt of ART if CD4<200
• OST Index (N=3)
– Methadone dose ≥80mg; any IDU in previous
30 days; daily IDU in previous 30 days
• TB Index (N=2)
– TB screening in past 12 months; isoniazid
preventive therapy
HIV Quality Indicators
OAT Quality Indicators
TB Quality Indicators
Mean Quality Health Indicator Score
P<.001
P<.001
Health-Related Quality of Life
P<0.001
P<0.001
Health Services Integration
OAT and TB Treatment
OAT and HCV Treatment
OAT and TB Treatment
Hospitalized Patients in Ukraine
P=0.031
P=0.009
P,0.001
Morozova et al, IJDP, 2013
South Central Rehabilitation Center
SCRC Services Provided
• Treatment for alcohol and substance use
disorders, including 7 day inpatient
detoxification
• Methadone and buprenorphine
maintenance
• Routine screening of ALL patients for HIV,
TB, HBV, HCV and mental illness
• Onsite treatment for HIV, HCV and
uncomplicated mental illness
• DOT for HIV, HCV and TB prophylaxis
treatment
OAT and HCV Treatment
Onsite vs Referral for HCV Treatment
The Solution!
HIV
OST
Medical Care
Mental Illness