# Presentation: 376158

## Methamphetamine and HIV:Intersecting epidemics among MSM

- Grant Colfax, MD
- Co-Director
- HIV Epidemiology
- AIDS Office
- San Francisco Department of Public Health

## What’s new?

- Update epidemiology of MSM methamphetamine use
- Describe relationship between methamphetamine use and HIV risk among MSM
- Describe current and potential future methamphetamine/HIV  prevention research among MSM

## Methamphetamine use among MSM CDC National HIV Behavioral Surveillance Survey

| Site | Meth use 
Last 12 months  Weekly or more |
| --- | --- |
| San Francisco | 21%                       6% |
| Miami | 18%                        NA |
| San Diego | 15%                        NA |
| New York | 14%                       3% |
| Los Angeles | 13%                       4% |
| Chicago | 10%                       2% |
| Baltimore |  7%                        3% |

## Characteristics of meth users, SF NHBS

- No difference in prevalence of meth use by race/ethnicity
- 66% reported meth use during recent sex
- 8% were injectors
- 93% also reported using poppers or cocaine
- 24% had *ever* sought meth treatment

## Methamphetamine and HIV risk

**Methamphetamine and HIV risk**

## Methamphetamine and HIV seroconversionEXPLORE study results

| Risk factor for HIV | AHR   | 95% CI | Attributable fraction |
| --- | --- | --- | --- |
| Methamphetamine use | 1.9 | 1.4-2.6 | 16 |
| URA with HIV+ | 3.4 | 2.2-5.1 | 18 |
| URA with unknown status | 2.8 | 2.1-3.8 | 28 |
| Gonorrhea | 2.5 | 1.4-4.2 | 4 |
|  |  |  |  |
|  |  |  |  |

- Koblin, Husnik, Colfax, et. al,  AIDS 2006

## How can methamphetamine use be independently associated with HIV infection?

- Unmeasured behavioral confounders
- More traumatic sex
- Partner selection
- More likely to be HIV-positive
- Biased reporting
- Direct biologic effects
- Impaired T-cell responses
- Pro-inflammatory
- Increased viral load

## Non-adherence due to methamphetamine use 

- Ability to Eat/Drink

- Partying/ Medication Vacations

- Inability to Maintain Schedule

- Sleeping Through Doses

- Avoiding Drug Mixing

- •  100% of meth users claimed that their meth use had an effect on adherence

- Reback, 2004

- % reporting

## Methamphetamine is associated with primary drug resistance

-  OPTIONS cohort
- 400  SF MSM with recent HIV infection
- 27% reported meth use in 30 days prior to enrollment
- Meth use independently associated with primary NNRTI resistance (Adj OR 3.5, 95% 95% CI 1.2-10.8)

- Colfax, Hecht, Grant, et. al, AIDS 2007

## Interventions for methamphetamine users

- Approaches
- Counseling
- Contingency management
- Pharmacologic
- Structural

## Counseling for meth dependence is associated with reduced meth use

- MATRIX intervention
- Meth-dependent persons in treatment programs
- Relapse prevention model
- Primarily heterosexuals
- 56 behavioral sessions vs. standard outpatient treatment
- Compared with standard treatment:
- Meth use decreased more in intervention during active phase
- Similar reductions in meth use in standard and intervention arms at 6-month follow-up

- Rawson, 2004

## Risk behavior declines among MSM in meth behavioral interventions

- Mean number of episodes
- of unprotected insertive anal sex

- Shoptaw 2005

## MSM in contingency management  reduce risk

- Mean number  of episodes
- of unprotected insertive anal sex

- Shoptaw 2005

## Will a behavioral risk-reduction approach work among diverse SUMSM?

- Project MIX
- Multi-site CDC collaborative intervention
- 1198  SUMSM enrolled
- 62% men of color
- Randomized 6-session group intervention
- Not targeted to treatment-seeking MSM
- Primary outcome: sexual risk behavior

## Behavioral interventionsChallenges

- How efficacious are they?
- To date, small sample sizes among MSM
- Unknown what degree of behavior change is necessary to reduce HIV infection rates
- Are behavioral effects sustained?
- Feasibility
- Generalizability
- Most tested among treatment-seeking populations
- Can heavy meth users consistently engage in and re-learn healthier behaviors?

## Pharmacologic treatment for methamphetamine users

- Failed or unpromising agents: sertraline, amlodipine, imipramine, dextroamphetamine
- Bupropion: some promise among less heavy users (Ahmed, in press, 2007).
- Phase 2 study of bupropion among MSM in progress
- Safety
- Adherence
- Sexual risk

## Pharmacologic approaches

- Mirtazapine (Remeron)
- “Dual action” - - works on serotonergic and dopaminergic pathways
- Small RCT in Thai meth-dependent persons
- Mirtazapine reduced meth withdrawal symptoms
- Independent of effects on depression
- Efficacy study among high-risk MSM in progress

- Source: Kongsakon 2005

## Pharmacologic approaches....

- Aripiprazole (Abilify)
- “Atypical” antipsychotic
- D2 partial agonist
- May prevent meth withdrawal
- May decrease effects of meth use
- Some drug discrimination studies show aripiprazole blocks meth’s effects compared with placebo

- Sources: Lile 2005; De la Garza, 2005

##  Pharmacologic interventionsChallenges

- Likely will need to be combined with behavioral therapy for greatest efficacy
- But very intensive behavioral platforms may overwhelm any detectable drug effects
- Side effects
- Duration
- Cost

## Structural interventions

- Increased federal regulation in meth precursors  associated with declines in:
- Meth-related hospital admissions
- Meth potency
- Meth-related arrests
- Effects may be transient
- Will market forces ensure that supply = demand?
- 					                     Suo 2004, Cunningham 2005

## Conclusions and future directions

- Meth epidemic among MSM continues
- High across all areas in US
- Meth use common, frequent use less so
- What keeps most MSM from using meth?
- What causes some MSM to become heavy meth users?
- Meth use increases risk of HIV infection
- Meth about doubles risk
- Behavioral dis-inhibition
- Plausible biologic mechanisms
- Critical need for continued testing of  interventions
- Distinguish populations: heavy users vs. episodic users; injectors
- Are effects of interventions sustainable, and will they reduce HIV?
- Pharmacologic interventions promising, but not proven

## Acknowledgements

- SFDPH: Susan Buchbinder, James Gaspar, Robert Guzman, Tim Matheson, David Bandy, Jeff Klausner, Willi McFarland, Henry Raymond-Fisher
- UCSF: Robert Grant,  Rick Hecht, Paula Lum, Meg Newman, Eric Vittinghoff
- UCLA: Cathy Reback, Steve Shoptaw
- UCSD: Steffanie Strathdee, Tom Patterson
- CDC: Gordon Mansergh, David Purcell
- NIDA: Jamie Biswas, Lynda Erinoff, Elizabeth Lambert, Jacques Normand, Steve Oversby