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

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 UniversityTreating Substance UseDisorders in HIV-infected Patients Hanoi Medical University VHATTC March 1, 2013 P. Todd Korthuis, MD, MPH Vietnam Fulbright Scholar 2012-13 korthuis@ohsu.edu Objectives1) Identify effects of substance use on HIV outcomes and transmission2) Review clinic-based substance use disorder interventions including medication-assisted treatments3) Identify drug interactions between medication- assisted treatments and ART4) Discuss cases from Hanoi OPCs and MMTsEffects 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 2001Vietnam HIV-Drug Use SyndemicRegistered Drug Users HIV-infected Population (n=171,400)1 (n=248,245)213.4% of registered 37.3% of PLWHA reportdrug 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 toAlcohol 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 TransmissionHIV Neg Injection Drug Use (IDU) Non-injection Drug Use • Cocaine: 3x more likely to be HIV- infected1HIV Pos • Methamphetamines: HR 1.46 (1.12- 1.91)2 • Poppers: HR 2.10 (1.63-2.70)2AIDS/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 Progression1HIV NegHIV Pos • Adverse effect on treatment • Direct effect on HIV replication? • Opioids & alcohol increase lymphocyte apoptosis, HIV entry & replication in lymphocytes2AIDS/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 ma ...