# Presentation: 500809

## Drug Abuse Treatment in HIV Prevention and Care: Past Successes and Future Challenges

**David S. Metzger, Ph.D.  **
** **

**University of Pennsylvania**
**Center for Studies of Addiction**
**HIV Prevention Research Division**
**Philadelphia, PA**

## Overview

**HIV infection and drug use**** **
**Does drug treatment prevent HIV infections?**
**Does drug treatment facilitate HIV treatment?**** **
**Challenges in maximizing the public health impact of drug treatment**

## HIV prevalence rates among New York 

** **

**IDUs by methadone treatment**

** **

**(MMRW, 1984)**

**87%**

**10%**

## Current AIDS epidemiology

**Approximately 1,300,000 living with HIV/AIDS**** **
**956,666 AIDS diagnoses  (as of 2005)**** **
**425,910  PWLA (increase of 28% since 2001)**
**25% have a history of injection drug use**

## Slide 5

## HPTN 015:  Project Explore 

**Two-armed trial**** **
**4250 MSM**** **
**10 counseling sessions + boosters**** **
**VCT every six months**** **
**Overall seroincidence = 2.1 (1.9, 2.4) per 100 py**** **

**Intervention arm: 115 events / 6,037 py**
**Standard arm:      144 events / 6,203 py**

## Multivariate analysis of seroconversion: 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

## Substance-related  HIV risk

**Direct and indirect sharing of injection equipment and materials**** **
**Unprotected sexual activity *****Consequences of substance use in all risk groups:  MSMs, IDUs, Heterosexuals***

## 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**

**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**** **
**Increased adherence to HIV medications****	****	****	**

## Percent of subjects reporting

** **

**injection prior to, during, and**

** **

**following methadone treatment**

**(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**

** **

- 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

## Injection rates 12 months following 

**Injection rates 12 months following **
**treatment entry by retention status **

**(Thiede,Hagan,and Murrill, 2000)**

**retention is critical**

** **

**(Moss et al. 1994)**

** **

- One or More

- Years

- of  Methadone

- Treatment

- Less Than One  Year

- of  Methadone

- Treatment

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

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

## (Metzger  et al. 1993)

**(Metzger  et al. 1993)**

## Incidence of HBV and HCV 12 Months Following Treatment Entry 

**Incidence of HBV and HCV 12 Months Following Treatment Entry **

**(Thiede,Hagan,and Murrill, 2000)**

## Methadone treatment is more than substitution

**Safe, stable dosing**** **
**Drug use monitored**** **
**Drug counseling**** **
**Access to other services  **** **

## Slide 19

##    Naltrexone and drug counseling treatment in St. Petersburg

**W****eek****s**

- 30

- 27

- 24

- 21

- 18

- 15

- 12

- 9

- 6

- 3

- 0

**Cum Survival**

- 1,0

- ,9

- ,8

- ,7

- ,6

- ,5

- ,4

- ,3

- ,2

**F+P**

**N+F**

**P+P**

**N+P**

**N+F>P+P**

**N+F>F+P**

**N+P>P+P**

**N+P>F+P**

**F+P=P+P**

**N+F=N+P**

-    Naltrexone and drug counseling treatment in St. Petersburg

##    Naltrexone treatment in St. Petersburg

**D****rug risk**

**S****ex risk**

**remission**

**relapse**

- 2,00

- 4,00

- 6,00

- 8,00

**Score**

- 

- 

**remission**

**relapse**

- 

- 

**Zvartaw et al, 2006**

## Slide 22

## Drug treatment as HIV prevention

**In treatment subjects reduce risk over time**** **
**Treated subjects have lower risk than untreated**
**Treated subjects have lower prevalence and incidence of HIV**

**(Sorensen J. and Copeland A,  2000)**

## Limitations of treatment studies

**Measurement variability**** **
**Short follow-up **** **
**Focus on opiate dependent injectors**** **
**No randomized controlled trials****with HIV endpoints**

## HPTN 058

**Opiate dependent drug users recruited from the community**

**Detoxification at 0 and 6 months**
**3 Months of Weekly and 9 months of Monthly  Drug and Risk Reduction Counseling **

**12 Months Buprenorphine/Naloxone**** +3 Months of Weekly and 9 months of Monthly Drug and Risk Reduction Counseling **

**18 and 24+ month follow-up**

**Drug use and HIV disease progression and viral activity**

**In vivo:  No clear evidence of impact of drug use on survival from past cohort studies**** **
**In vitro: opiates, cocaine, alcohol enhance viral activation and replication; suppression of immune response**

## HIV Infected Population

- Engage in medical care

- Start therapy

- Adherence

- Substance Abuse

- Durable Viral
- Suppression

**=**

**Notes:**
Concept slide – serve as the outline of talk

In the aqua-marine boxes is the pathway HIV infected patients must follow to reach the ideal endpoint

Go through each step

Risk factors can act at every step to impede progress

What are these risk factors? – Lets start with this first step

## Adherence with antiretroviral therapy is adversely affected by drug use 

|  | Not using cocaine (n=57) | Using cocaine (n=20)
 | P value |
| --- | --- | --- | --- |
| Adherence 
(MEMS Caps) | 68% | 27% | 0.005 |
| Viral suppression | 46% | 13% | 0.005 |

- Arnsten JH. J Gen Intern med 2002;17:377

## Drug use, adherence, and viral suppression in a large British 

- Wood, E. et al. CMAJ 2003;169:656-661

**Drug use, adherence, and viral suppression in a large British **
**Columbia Cohort of HIV-infected patients starting HAART**

## Risk of developing new opportunistic infection according to drug use status

- Lucas et al. Am J Epidemiol 2006

##  Adherence to HIV medications by drug use

** ****Adherence to HIV medications by drug use**

**Lucas et al, 2002**

## DSM IV criteria for abuse or dependence (Participants  n=237) 

- %

## Adherence by past and current drug and alcohol diagnoses

**	****	****Alcohol****	****Drug**
**    ****Current diagnoses****	****p<.01****	****p<.01**
**    ****Lifetime diagnoses** 	NS	NS

## Suboxone offers new opportunities for treatment in HIV care settings

**Suboxone offers new opportunities for treatment in HIV care settings**

## Maximizing the impact of drug abuse treatment HIV prevention

**Accessible**** **
**Acceptable**** **
**Affordable**

## Publicly funded treatment need vs. participation

**Publicly funded treatment need vs. participation**

**NNSATS, 2006**

## Barriers to treatment

**Barriers to treatment**

**NNSATS, 2006**

## Continuum of Drug Use and Treatment

**Use              **
**	****	****	****Abuse                 **
**	****	****	****	****	**** ****Dependence**

**	****	****	****Out-patient    ****	****   Detoxification +****	**
**	****	****	****Residential****	****   Agonist/Antagonist**
**Outreach****	****	****Drug free    ****	****   Out-patient****	**
**Harm Reduction** **	****Antagonist****	****   Counseling**
**Counseling****	****	****Counseling**

**Addiction**

## Geography is important

## Diagnosed AIDS cases by Race in Philadelphia: 

**Diagnosed AIDS cases by Race in Philadelphia: **
**1980 - 2006**

## HPTN 037:  HIV Prevalence among risk network members (N=697)

**HPTN 037:  HIV Prevalence among risk network members (N=697)**

## HIV prevention and care implications

**Each strategy alone may be necessary but not sufficient for public health impact:**
**	****	****	****    ****Drug Treatment****Community                            ****	****  Harm**** Outreach               ****	****	****Reduction**
**                          **
**	****	****	****	****	**** ****HIV Care**

## Conclusions

**Behavioral and serologic data support the   hypotheses that drug users in treatment:****	****	****significantly**** ****reduce the frequency of use****	****	****	****	****practice fewer risk behaviors****	****	****have greater access to HIV treatment**
**	****	****	****are more adherent to HIV care  ****	**

## Conclusions

**Data suggests effective treatments for drug users:**
**	****	****recognize addiction as a chronic  ****	****	****	****disease  (at least one year) ****	****	****	****	****use pharmacologic and counseling ****	****	****interventions**
**	****	****	****are accessible and acceptable**
**	****	****	****	****	****  ****	**

** **

** ****Implications for public health **

**New models for the delivery of treatments**** **
**Target drug users earlier in the continuum of use**** **
**Include HIV endpoints in Phase II trials**** **
**Urgent need for pharmacologic treatments for stimulant abuse**

## Complacency

**Complacency**

**High Risk **
**Behavior**

**Human**
**Rights**
**Abuses**

**Stigma-**
**tization**

**Access **
**To**
**Care**

**Sexism**

**Ignorance**

**Poverty**

**Discrimin-**
**ation**

**Disem-**
**powered**
**Women**

**Prejudice**

**Denial**

**Courtesy of Jim Hoxie**

** **

** ****Thanks  **

**Tom Mclellan**
**George Woody**
**Greg Lucas**
**Carl Latkin**
**Charles O’brien**
**Steve Douglas**
**Wenzhe Ho**
**Beryl Koblin**
**Tom Coates**