HIVInfected Substance Users: Treatment Strategies

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HIV and Substance Abuse
Chinazo Cunningham, MD
C Cunningham, MD.Presented at IASUSA/RWCA
Clinical Conference, August 2004.
The International AIDS SocietyUSA
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We Are Failing Drug Users

• Substance users have poor HIV-related health
  outcomes
• Less access to health care
• Less access to antiretroviral therapy (ART)
• Worse adherence to ART
• Slower decline in morbidity and mortality

Turner, Kalichmand, Shapiro, Celentano,
Strathdee, Arnsten, Tucker, Golin, Chesney,
Lucas, Bouhnik Knowleton, Chitwood 1999 2001,
Cronquist
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Outreach

• Project Bridge
• Intense case management for HIV prisoners in RI
  being released into the community
• Of those still enrolled after 1 year, 82
  continued to receive medical care
• Montefiore/CitiWide Program
• Doctors part of outreach team targeting
  HIV-infected SRO hotel residents in NYC
• After outreach SRO hotel residents more likely to
  report having a regular health care provider, and
  taking antiretroviral therapy
• Yale Community Health Care Van
• Mobile van visiting needle exchange sites weekly
  drug in New Haven, CT
• At 9 months 77 with undetectable viral load

Rich, Cunningham, Altice 2003
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Case Management

• Project Bridge
• HCSUS
• ? Unmet needs
• Income assistance
• Health insurance
• Home health care
• Emotional counseling
• ? HAART

Rich, Katz
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Integration of Primary Care and Substance Abuse
Treatment

• Methadone
• Feasible and safe
• ? utilization of HIV primary care services
• ? high risk behavior
• ? opioid use
• Improvement in education and employment

Selwyn Keen Samet Fiellin 2001 Novick 1988,
1993 1994 Salsitz
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Integration of Primary Care and Substance Abuse
Treatment

• Buprenorphine
• Recently approved medication to treat opioid
  dependence in the primary care setting
• Can be prescribed by physicians (MD or DO) who
  qualify for a waiver
• 8-hour training session or other mechanisms
• http//buprenorphine.samhsa.gov/index.html

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Awareness of Potential Problems Related to HIV
and Substance Use

• Illicit drugs and ART
• Methadone/Buprenorphine and ART
• Mental illness
• Pain
• Hepatitis C virus and liver disease
• TB

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Illicit Drug Interactions With ART
Antoniou, Henry, Harrington, Roth, Bagasra,
Peterson 1991 1992, Ellis, Gavrilin, Urbina,
Hales
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Methadone Interactions with PIs
Beauverie, Gourevitch, Antoniou, Clarke 2002,
Bart, Shelton, Stevens, McCance-Katz 2003,
Gerber, DHHS
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Methadone Interactions with NNRTIs
Altice 1999, Staszewski, Gourevitch, Antoniou,
Clarke 2001, Marzolini, DHHS
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Methadone Interactions with NRTIs
Rainey, Gourevitch, Antoniou, McCance-Katz 1998,
Bart, Rainey 2000 2002, DHHS
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Buprenorphine Interactions with ART

• NRTIs
• No change in AZT
• NNRTIs
• Likely ? buprenorphine levels
• PIs
• ? Buprenorphine with ritonavir gt indinavir gt
  saquinavir
• Fusion inhibitor
• No data

McCance-Katz 2001, Iribarne, Sullivan
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Redefine Health

• Health is NOT the absence of disease
• Biopsychosocial model AND
• drugs
• housing
• support system
• finances
• violence
• criminal justice issues
• Life priorities of HIV IDUs
• Only 37 ranked HIV as most important
• Top priorities housing, money, safety from
  violence

Mizuno
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Redefine Success

• Success is NOT just
• Undetectable viral load
• Abstinence from drug use
• Success also includes
• Making it to appointments
• Preventative care (PAP smears, vaccinations,
  PCP/MAC prophylaxis, PPD)
• Less, safer, more controlled drug use
• Improvement in non-medical areas (housing,
  support system, criminal activity, etc.)

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Why Adopt a Different Definition of Success?

• Recognizes that success is not only about taking
  ones medications
• Actively engages patients in health care and
  treatment
• Values the health impacts of non-medical
  interventions (e.g. controlled drug use, stable
  housing, social supports)
• Improves patients self-efficacy
• Provides more opportunities for success