Treating Substance Use Disorders in HIV-infected Patients - Hanoi Medical University

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Objectives: Identify effects of substance use on HIV outcomes and transmission, Review clinic - based substance use disorder interventions including medication-assisted treatments, Identify drug interactions between medicationassisted treatments and ART, Discuss cases from Hanoi OPCs and MMTs.

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Treating Substance Use Disorders in HIV-infected Patients Hanoi Medical University VHATTC March 1, 2013 P. Todd Korthuis, MD, MPH Vietnam Fulbright Scholar 2012-13 korthuis@ohsu.edu
Objectives 1) Identify effects of substance use on HIV outcomes and transmission 2) Review clinic-based substance use disorder interventions including medication-assisted treatments 3) Identify drug interactions between medication- assisted treatments and ART 4) Discuss cases from Hanoi OPCs and MMTs
Effects of Substance Use on HIV
HIV and Substance Use • HIV medicine dominated by addiction medicine issues • 36-50% report unhealthy alcohol use or drug use in national U.S. samples1-3 1Turner BJ, JGIM 2001 2KorthuisJSAT 2008 3Bing Arch Gen Psych 2001
Vietnam HIV-Drug Use Syndemic Registered Drug Users HIV-infected Population (n=171,400)1 (n=248,245)2 13.4% of registered 37.3% of PLWHA report drug users HIV+ 1 IDU risk2 1MOLISA 2012 report 2VAAC 2012 report
Alcohol Use in Vietnam • HIV-infected hospitalized patients:1 • Hazardous drinking: 30.1% • Binge drinking: 22.3% • Alcohol must be addressed when treating drug users in Vietnam because: • Alcohol prevalence is high • HBV and HCV prevalence is high • Some IDU increase alcohol consumption when they decrease injecting1-2 1 Tran Drug Alc Dep 2013 2 Go Intern J Drug Policy 2013
Patients with HIV and Drug Use Disorders • Are less likely to: • Engage and stay in HIV care • Receive ART1 • Have viral load testing2 • Adhere to ART3 • Receive lipid screening4 • Are more likely to: • Experience HIV-related symptoms5 1 Anderson R, HSR 2000 2 Laine C, JAIDS 2003 • Have higher hospitalization rates6 3 Lawrence P, HIV Med 2007 • Have decreased QOL7 4 Korthuis JAIDS 2004 5 Mathews WC Med Care 2000 • Experience lower quality of care8 6 Fleishman JA, Med Care 2005 7 Korthuis AIDS Pt Care 2008 • Die9 8 Korthuis JAIDS 2012 9 Wood CMAJ 2003
Patients with HIV and Alcohol Use Disorders • Are less likely to: • Engage and stay in HIV care1 • Receive ART2 • Adhere to ART3 • Have HIV viral suppression2,3 • Are more likely to: • Skip ART doses when drinking4 • Have higher hospitalization rates3,5 1 Cunningham Med Care 2006 • Have more ED visits5,6 2 Chander, JAIDS 2006 3 Azar Drug Alc Dep 2010 • Experience lower quality of care7 4 Kalichman JGIM 2013 5 Kraemer Med Care 2006 • Die8 6 Josephs HIV Med 2010 7 Korthuis JAIDS 2012 9 Braithwaite AIDS Care 2007
Decreased Survival Due to Alcohol in HIV-Infected Patients • Simulated survival due to alcohol use • Non-Hazardous Drinking: < 5 drinks at a time • Hazardous Drinking: ≥ 5 drinks at a time Years of Life Lost: Quantity Frequency 1-4 drinks ≥ 5 drinks Once/week 1.5 2.2 Twice/week 2.1 4.0 Daily 3.3 6.4 Braithwaite AIDS Care 2007
Impact of Drug Use on HIV Increased Risk of Transmission HIV Neg Injection Drug Use (IDU) Non-injection Drug Use • Cocaine: 3x more likely to be HIV- infected1 HIV Pos • Methamphetamines: HR 1.46 (1.12- 1.91)2 • Poppers: HR 2.10 (1.63-2.70)2 AIDS/Death 1CDC 2007 2Plankey, JAIDS 2007
Interrupting Substance-Related HIV Transmission • Harm Reduction • Syringe exchange reduce HIV transmission risk by estimated 33-42%1 • Treatment of Underlying Drug or Alcohol Use Disorders • Substance abuse treatment doubles HIV treatment engagement2 • Decreases risk of HIV seroconversion3 1Wodak, Subst Use Misuse 2006 2Strathdee, JAMA 1998 3Metzger, 1993
Impact of Drug Use on HIV Increased Risk of Disease Progression1 HIV Neg HIV Pos • Adverse effect on treatment • Direct effect on HIV replication? • Opioids & alcohol increase lymphocyte apoptosis, HIV entry & replication in lymphocytes2 AIDS/Death 1Kapadia, CID 2005 2Madden, JAIDS 2002 3Gavvrilin, J Neurovirol 2002 4Celentano, CID 2007
Street Drug-ART Interactions • Most street drugs don’t affect most ART levels • No P450 induction/inhibition Clinical Interaction Heroin No interactions Hydrocodone Ritonavir may effect Oxycodone Ritonavir may effect Ecstasy/Amphetamines Ritonavir may effect/toxicity Benzodiazepines Ritonavir may effect Marijuana (THC) Ritonavir may effect/toxicity Gruber Curr HIV/AIDS Rep 2010
Alcohol & HIV Interactions • No known interactions between alcohol and ART • Untreated HIV infection may decrease metabolism and clearance of alcohol1 • Higher blood alcohol concentrations (BAC) compared with after starting ART 1 McCance-Katz JAIDS 2012
Substance Use Treatment Options in HIV Care • Patient-provider discussions (SBIRT) • Can decrease drug & alcohol use! • Counseling • Medication-Assisted Treatment
Does Talking with Patients About Substance Use Help? Vâng!
Screening, Brief Intervention, & Referral for Treatment (SBIRT) • In primary care: Decreases alcohol use1, 2 and drug use2 1Kaner,Cochrane Review 2007 2Madras Drug Alc Dep 2008
Discussions of Substance Use & Receipt of Substance Abuse Treatment (n=696 Current or Former Illicit Drug Users) Received N (%) Substance Use Treatment aOR (95% CI)* Discussed Substance Abuse with Provider: No 382 (54%) 1.0 (ref) Yes 314 (46%) 2.12 (1.31-3.41) *Adjusted for site, sex, IDU, employment, race, insurance, visits, CD4, drug use severity Korthuis, JSAT 2008
HIV and Substance Use: Two Chronic Illnesses HIV (treated) Disease Activity Substance Use Disorder Time O’Connor, JAMA 1998 Lucas, JAIDS 2005
Medication-Assisted Treatment of Substance Use Disorders in HIV Care