University of PennsylvaniaHIV Prevention Research Division

Department of Psychiatry

Substance Abuse Treatment as HIV Prevention

Overview

• Overview of injection drug use and the HIV epidemic

Small segment of the community are IDU

Non injection drug use facilitates HIV transmission

• Proof of Concept : Drug treatment is HIV prevention

• Minimal treatment “coverage”

• Expanding treatment options

• Targeting treatment to those most likely to become infected

Current AIDS epidemiology

• Approximately 33,000,000 living with HIV/AIDS

• Over 3,000,000 IDUs living with HIV/AIDS

• Outside of sub-Saharan Africa, over 33% of all new infections are estimated to be attributable to injection drug use

• No estimates of the major role of alcohol and non-injection drug use

Predictors of seroconversion in Explore: drug and alcohol use

Drug N at baseline

No. of infections

Hazard ratio*

95% CI

Heavy alcohol** 419 41 1.87 1.24, 2.81

Amphetamines 527 67 1.93 1.41, 2.64

Alcohol or drugs before sex

2952 205 1.57 1.08, 2.27

* REF = no, light or moderate use of alcohol; no speed use; no use before sex** Heavy alcohol = 4+ drinks every day or 6+ drinks on a typical day

(Koblin et al, AIDS 2006)

December 2009

Total: 33.4 million (31.1 – 35.8 million)

Western & Central Europe

850 000[710 000 – 970 000]

Middle East & North Africa

310 000[250 000 – 380 000]

Sub-Saharan Africa

22.4 million[20.8 – 24.1 million]

Eastern Europe & Central Asia

1.5 million [1.4 – 1.7 million]

South & South-East Asia

3.8 million[3.4 – 4.3 million]

Oceania

59 000[51 000 – 68 000]

North America

1.4 million[1.2 – 1.6 million]

Latin America

2.0 million[1.8 – 2.2 million]

East Asia

850 000[700 000 – 1.0 million]Caribbean

240 000[220 000 – 260 000]

Adults and children estimated to be living with HIV, 2008

Mode of use varies

Globalization of drug use

IDUs as Percent of Total Registered HIV CasesEastern Europe and Central Asian Countries, 2007

Countries with Injection Driven Epidemics, OSI, 2008

Source: UNAIDS 2008 Report on the Global AIDS Epidemic

IDUs as Percent of Total Registered HIV CasesEast and South East Asian Countries, 2007

Prevalence of HIV and HCV among WHO study participants by site

Lawrinson et al, Addiction, 2008

HIV prevention strategies for drug using populations

• Education about HIV transmission

• HIV counseling and testing

• Increased access to sterile injection resources and condoms

• Drug treatment

• HIV treatment

Addiction is a chronic medical condition

• Biological components (dependence)

• Behavioral components (addiction)

• Effective management requires attention to both--medication assisted treatment

Percent of subjects reporting

injection prior to, during, and

following methadone treatment

0

20

40

60

80

100

(Ball and Ross, 1991)

Injection Prior to Tx

Entry

Injection After Tx

Entry

Injection in Prior Year

Injection in Prior Month

Injection in Year After Tx

Rate of needle sharing reported by In-Treatment IDUs compared to Out-of-Treatment IDUs

0

0.2

0.4

0.6

0.8

1

Selwyn et al

1987

Martin

et al

1990

Klee

et al

1991

Williams et al

1992

Longshore et al

1993

Metzger

et al

1993

Stark

et al

1994

Capplehorn

et al

1995

Drug use and injection among 557 heroin users by methadone treatment status, Sichuan Province, China

(Han-Zhu Qian et al, 2008)

Needle sharing among 557 heroin users by methadone treatment status, Sichuan Province, China

(Han-Zhu Qian et al, 2008)

Six year HIV infection rates by treatment status at time of enrollment

(Metzger et al. 1993)

Incidence of HBV and HCV 12 Months Following Treatment Entry

(Thiede,Hagan,and Murrill, 2000)

MANIF 2000: Drug treatment and injection as predictors of poor adherence to HAART

(N=276; 1558 patient visits)

(Roux P et al 2008)

Adherence by past and current drug and alcohol diagnoses

AlcoholDrug

Current diagnosesp<.01 p<.01

Lifetime diagnoses NS NS

How does drug treatment prevent HIV infection and transmission?

• Effective treatments reduce the frequency of drug use

• Fewer drug-related risk behaviors

• Fewer new infections

• Increased access to HIV treatment and primary care

• Increased adherence to HIV medications

Despite these findings

• Selected expansion of methadone treatment

• Need for treatment expansion

• Need for improvements in efficacy of existing treatments

• Need for new delivery strategies

• Need for new medications and formulations

Mathers et al., the Lancet , 2010

Clear need for more treatment options

Methadone Maintenance Program in ChinaIn Dec. 2003, 8 clinics in 5 provinces were approved to be China’s 1st

wave of community-based methadone maintenance program

西藏

青海

甘肃 内蒙古

黑龙江

吉林

辽宁

贵州

广西 广东

湖南

江西

福建

台湾

浙江

江苏

上海

山东

陕西

山西

宁夏

新疆

四川 湖北

河南

安徽

云南

河北

北京

天津

香港澳门

Premier Wen Jiabao, visited Wuhan Detox. Center in June 2004

Milestones in China’s National Response to HIV/AIDS & Drug

Abuse

Methadone treatment in 2009

青海

2 甘肃

17

吉林

2

贵州

54

GuangxiMMT=53

广东

41

湖南

47江西

12福建

8

浙江

18

江苏

11

陕西

18

宁夏

3

XinjiangMMT=27

四川

32湖北

32安徽

云南

67

北京

8

海南19

重庆

26

上海

87

560 MMT Clinics166,000 heroin users

河南

1

N=7702n=3041

N=12001n=5810

Improving the efficacy of treatment: Counseling

p<0.05

Chawarski et al, 2010

Buprenorphine/Naloxone offers new opportunities for HIV prevention and care

• Partial agonist, longer half-life

• Reduced risk of overdose

• Less severe withdrawal

• Fewer interactions with anti-retrovirals

HPTN 058: comparing new delivery strategies

Opiate injectorsrecruited from

communityand screened

Short-Term Medication Assisted Treatment

Suboxone detox At Bx and 6 months

plus one year counseling;Referral to

local resources

Long-Term Medication

Assisted Treatment 12 months of Suboxone

plus one year counseling;Referral to

local resources

HIV testing and counseling

Every 6 months Year 02

HIV testing and counseling

Every 6 months Year 02

If not eligible, referred to local resources

Weeks

302724211815129630

Perc

ent

rem

aini

ng i

n T

reat

men

t1,0

,9

,8

,7

,6

,5

,4

,3

,2

F+P

N+F

P+P

N+P

N+F>P+PN+F>F+PN+P>P+PN+P>F+PF+P=P+PN+F=N+P

New treatment approaches: Oral Naltrexone treatment in St. Petersburg (N=280)

With Naltrexone

No Naltrexone

Krupitsky et al, 2006

New formulations: Implantable Naltrexone

Effective drug treatments

• recognize addiction as a chronic disease

• use pharmacologic and counseling interventions

• are accessible, acceptable, and affordable-- to those users most likely to become infected

Drug treatment is necessary but not sufficient for HIV prevention in communities

Drug Treatment

Community Harm Outreach Reduction

HIV Care

Summary

● IDUs are small segment of the populationbut a major part of the HIV infected population

● Neglecting the health of even a small segment of the community jeopardizes the public health

● Alcohol and non-injection drug use is a major risk factor in all risk groups

● Research on opiate injectors in methadone treatment has provided “proof of concept” that drug treatment is HIV prevention

● Despite selected expansion of methadone treatmentas harm reduction—coverage remains extremely limited

● Need for expanded treatments, improved efficacy, formulations and delivery strategies

Complacency

High Risk Behavior

HumanRightsAbuses

Stigma-tization

Access To

Care

SexismIgnorance

Poverty

Discrimin-ation

Disem-poweredWomen

Prejudice

Denial

Courtesy of Jim Hoxie