Methamphetamine and Methamphetamine and HIV:HIV:
Intersecting epidemics Intersecting epidemics among MSMamong MSM
Grant Colfax, MDGrant Colfax, MDCo-DirectorCo-Director
HIV EpidemiologyHIV EpidemiologyAIDS OfficeAIDS Office
San Francisco Department of San Francisco Department of Public HealthPublic Health
What’s new?What’s new?
Update epidemiology of MSM Update epidemiology of MSM methamphetamine use methamphetamine use
Describe relationship between Describe relationship between methamphetamine use and HIV risk methamphetamine use and HIV risk among MSMamong MSM
Describe current and potential Describe current and potential future methamphetamine/HIV future methamphetamine/HIV prevention research among MSMprevention research among MSM
Methamphetamine use among Methamphetamine use among MSM MSM
CDC CDC National HIV Behavioral National HIV Behavioral Surveillance SurveySurveillance SurveySiteSite Meth use Meth use
Last 12 months Weekly or Last 12 months Weekly or moremore
San FranciscoSan Francisco 21% 6%21% 6%
MiamiMiami 18% NA18% NA
San DiegoSan Diego 15% NA15% NA
New YorkNew York 14% 3%14% 3%
Los AngelesLos Angeles 13% 4%13% 4%
ChicagoChicago 10% 2%10% 2%
BaltimoreBaltimore 7% 3%7% 3%
Characteristics of meth Characteristics of meth users, SF NHBSusers, SF NHBS
No difference in prevalence of meth No difference in prevalence of meth use by race/ethnicityuse by race/ethnicity
66% reported meth use during 66% reported meth use during recent sexrecent sex
8% were injectors8% were injectors 93% also reported using poppers or 93% also reported using poppers or
cocainecocaine 24% had 24% had everever sought meth treatment sought meth treatment
Molitor 1998
Sexual RiskBehavior
STD/ HIV Risk
Colfax 2001
Molitor 1998
Hirshfield 2004
Celetano 2005
Buchacz 2005
Chesney 1998
Rusch 2004
Page- Shafer 1997
OR
Purcell 2001
Harawa 2004
0 1 2 3 4 5 6 7
Koblin 2006
Wong 2005
Mansergh 2006
Morin 2005
Schwarcz 2007
Ostrow 2007 2007
Methamphetamine and HIV riskMethamphetamine and HIV risk
Methamphetamine and HIV Methamphetamine and HIV seroconversionseroconversion
EXPLORE study resultsEXPLORE study results
Risk factor for HIVRisk factor for HIV AHR AHR 95% CI95% CI AttributablAttributable fractione fraction
Methamphetamine Methamphetamine useuse
1.91.9 1.4-2.61.4-2.6 1616
URA with HIV+URA with HIV+ 3.43.4 2.2-5.12.2-5.1 1818
URA with unknown URA with unknown statusstatus
2.82.8 2.1-3.82.1-3.8 2828
GonorrheaGonorrhea 2.52.5 1.4-4.21.4-4.2 44
Koblin, Husnik, Colfax, et. al, AIDS 2006
How can methamphetamine How can methamphetamine use be independently use be independently associated with HIV associated with HIV
infection?infection? Unmeasured behavioral confoundersUnmeasured behavioral confounders
More traumatic sexMore traumatic sex Partner selectionPartner selection
More likely to be HIV-positiveMore likely to be HIV-positive Biased reportingBiased reporting
Direct biologic effectsDirect biologic effects Impaired T-cell responsesImpaired T-cell responses Pro-inflammatoryPro-inflammatory Increased viral loadIncreased viral load
Non-adherence due to methamphetamine use Non-adherence due to methamphetamine use
68
58 53
3226
0
20
40
60
80
100
Ability
to
Ability
to
Eat/D
rink
Eat/D
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Par
tying
/
Partyi
ng/
Med
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Med
icatio
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Vacat
ions
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ility t
o
Inab
ility t
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tain
Main
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ule
Sched
ule
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gh
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ng D
rug
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ng D
rug
Mixi
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Mixi
ng
• 100% of meth users claimed that their meth use had an effect on adherence
Reback, 2004
% reporting
Methamphetamine is Methamphetamine is associated with primary associated with primary
drug resistancedrug resistance
OPTIONS cohortOPTIONS cohort 400 SF MSM with recent HIV infection 400 SF MSM with recent HIV infection 27% reported meth use in 30 days prior to 27% reported meth use in 30 days prior to
enrollment enrollment Meth use independently associated with Meth use independently associated with
primary NNRTI resistance (Adj OR 3.5, 95% primary NNRTI resistance (Adj OR 3.5, 95% 95% CI 1.2-10.8)95% CI 1.2-10.8)
Colfax, Hecht, Grant, et. al, AIDS 2007
Interventions for Interventions for methamphetamine usersmethamphetamine users
ApproachesApproaches CounselingCounseling Contingency managementContingency management Pharmacologic Pharmacologic StructuralStructural
Counseling for meth Counseling for meth dependence is associated with dependence is associated with
reduced meth usereduced meth use MATRIX intervention MATRIX intervention
Meth-dependent persons in treatment programsMeth-dependent persons in treatment programs Relapse prevention modelRelapse prevention model Primarily heterosexualsPrimarily heterosexuals
56 behavioral sessions vs. standard outpatient 56 behavioral sessions vs. standard outpatient treatment treatment
Compared with standard treatment:Compared with standard treatment: Meth use decreased more in intervention during Meth use decreased more in intervention during
active phaseactive phase Similar reductions in meth use in standard and Similar reductions in meth use in standard and
intervention arms at 6-month follow-upintervention arms at 6-month follow-up
Rawson, 2004
Risk behavior declines Risk behavior declines among MSM in meth among MSM in meth
behavioral behavioral interventionsinterventions
0
1
2
3
4
5
6
7
8B
asel
ine
4-W
ks
8-W
ks
12-W
ks
16-W
ks
6-M
os
12-M
os
CBT n = 40GCBT n = 40
Mean
nu
mb
er
of
ep
isod
es
of
un
pro
tect
ed
in
sert
ive a
nal
sex
Shoptaw 2005
MSM in contingency MSM in contingency management reduce management reduce
riskrisk
0
0.5
1
1.5
2
2.5
3
3.5
Bas
elin
e
4-W
ks
8-W
ks
12-W
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6-M
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12-M
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CBT (n = 40)CM (n = 42)
Mean
nu
mb
er
of
ep
isod
es
of
un
pro
tect
ed
in
sert
ive a
nal
sex
Shoptaw 2005
Will a behavioral risk-Will a behavioral risk-reduction approach work reduction approach work among diverse SUMSM?among diverse SUMSM?
Project MIX Project MIX Multi-site CDC collaborative interventionMulti-site CDC collaborative intervention 1198 SUMSM enrolled1198 SUMSM enrolled
62% men of color62% men of color Randomized 6-session group interventionRandomized 6-session group intervention Not targeted to treatment-seeking MSMNot targeted to treatment-seeking MSM
Primary outcome: sexual risk behaviorPrimary outcome: sexual risk behavior
Behavioral interventionsBehavioral interventionsChallengesChallenges
How efficacious are they?How efficacious are they? To date, small sample sizes among MSMTo date, small sample sizes among MSM Unknown what degree of behavior change is Unknown what degree of behavior change is
necessary to reduce HIV infection ratesnecessary to reduce HIV infection rates Are behavioral effects sustained?Are behavioral effects sustained?
FeasibilityFeasibility GeneralizabilityGeneralizability
Most tested among treatment-seeking Most tested among treatment-seeking populationspopulations
Can heavy meth users consistently engage in Can heavy meth users consistently engage in and re-learn healthier behaviors?and re-learn healthier behaviors?
Pharmacologic treatment Pharmacologic treatment for methamphetamine for methamphetamine
usersusers Failed or unpromising agents: Failed or unpromising agents:
sertraline, amlodipine, imipramine, sertraline, amlodipine, imipramine, dextroamphetaminedextroamphetamine
Bupropion: some promise among less Bupropion: some promise among less heavy users heavy users (Ahmed, in press, 2007).(Ahmed, in press, 2007). Phase 2 study of bupropion among MSM Phase 2 study of bupropion among MSM
in progress in progress SafetySafety AdherenceAdherence Sexual riskSexual risk
Pharmacologic approachesPharmacologic approaches
Mirtazapine (Remeron)Mirtazapine (Remeron) ““Dual action” - - works on serotonergic Dual action” - - works on serotonergic
and dopaminergic pathwaysand dopaminergic pathways Small RCT in Thai meth-dependent Small RCT in Thai meth-dependent
personspersons Mirtazapine reduced meth withdrawal Mirtazapine reduced meth withdrawal
symptomssymptoms Independent of effects on depressionIndependent of effects on depression
Efficacy study among high-risk MSM in Efficacy study among high-risk MSM in progressprogress
Source: Kongsakon 2005
Pharmacologic Pharmacologic approaches….approaches….
Aripiprazole (Abilify)Aripiprazole (Abilify) ““Atypical” antipsychoticAtypical” antipsychotic D2 partial agonistD2 partial agonist
May prevent meth withdrawalMay prevent meth withdrawal May decrease effects of meth useMay decrease effects of meth use
Some drug discrimination studies show Some drug discrimination studies show aripiprazole blocks meth’s effects aripiprazole blocks meth’s effects compared with placebocompared with placebo
Sources: Lile 2005; De la Garza, 2005
Pharmacologic Pharmacologic interventionsinterventionsChallengesChallenges
Likely will need to be combined with Likely will need to be combined with behavioral therapy for greatest behavioral therapy for greatest efficacyefficacy But very intensive behavioral platforms But very intensive behavioral platforms
may overwhelm any detectable drug may overwhelm any detectable drug effectseffects
Side effectsSide effects DurationDuration CostCost
Structural interventionsStructural interventions
Increased federal regulation in meth Increased federal regulation in meth precursors associated with declines in:precursors associated with declines in: Meth-related hospital admissionsMeth-related hospital admissions Meth potency Meth potency Meth-related arrests Meth-related arrests
Effects may be transientEffects may be transient Will market forces ensure that supply = Will market forces ensure that supply =
demand?demand?
Suo 2004, Cunningham 2005Suo 2004, Cunningham 2005
Conclusions and future Conclusions and future directionsdirections
Meth epidemic among MSM continuesMeth epidemic among MSM continues High across all areas in USHigh across all areas in US Meth use common, frequent use less soMeth use common, frequent use less so
What keeps most MSM from using meth? What keeps most MSM from using meth? What causes some MSM to become heavy meth users?What causes some MSM to become heavy meth users?
Meth use increases risk of HIV infection Meth use increases risk of HIV infection Meth about doubles riskMeth about doubles risk
Behavioral dis-inhibitionBehavioral dis-inhibition Plausible biologic mechanismsPlausible biologic mechanisms
Critical need for continued testing of interventionsCritical need for continued testing of interventions Distinguish populations: heavy users vs. episodic users; Distinguish populations: heavy users vs. episodic users;
injectors injectors Are effects of interventions sustainable, and will they Are effects of interventions sustainable, and will they
reduce HIV?reduce HIV? Pharmacologic interventions promising, but not provenPharmacologic interventions promising, but not proven
AcknowledgementsAcknowledgements SFDPH: Susan Buchbinder, James Gaspar, SFDPH: Susan Buchbinder, James Gaspar,
Robert Guzman, Tim Matheson, David Robert Guzman, Tim Matheson, David Bandy, Jeff Klausner, Willi McFarland, Henry Bandy, Jeff Klausner, Willi McFarland, Henry Raymond-FisherRaymond-Fisher
UCSF: Robert Grant, Rick Hecht, Paula UCSF: Robert Grant, Rick Hecht, Paula Lum, Meg Newman, Eric VittinghoffLum, Meg Newman, Eric Vittinghoff
UCLA: Cathy Reback, Steve ShoptawUCLA: Cathy Reback, Steve Shoptaw UCSD: Steffanie Strathdee, Tom PattersonUCSD: Steffanie Strathdee, Tom Patterson CDC: Gordon Mansergh, David Purcell CDC: Gordon Mansergh, David Purcell NIDA: Jamie Biswas, Lynda Erinoff, Elizabeth NIDA: Jamie Biswas, Lynda Erinoff, Elizabeth
Lambert, Jacques Normand, Steve OversbyLambert, Jacques Normand, Steve Oversby
