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HIV and Injection Drug Use

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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By the end of this session, participants will be able to:

Explain the link between HIV and intravenous drug use in Vietnam

Explain how to diagnose drug addiction

Explain benefits of harm reduction Describe how to provide ART to

intravenous drug users (IDU)

Learning Objectives

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IDU is the major source of HIV infections in Vietnam

Risk associated with:• needle-sharing • exposure to contaminated injection

equipment IDU often engage in other high risk

behaviors, such as unsafe sex, that can transmit HIV to non-IDU partners

Epidemiology of HIV and IDU

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Estimated 3.3 million IDU in South and South East Asia

Estimated at least 20% of IDU are HIV-positive in Vietnam

Commercial sex work among IDU has been called a “bridge” to the general population

Epidemiology of IDU in Asia

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Distribution of HIV/AIDS Cases in Vietnam

I DUs53.40%

CSWs2.68%

STDs1.56%

TB patients4.81%

Blood donors0.58%

AI DS suspects10.01%

Military recruits1.31%

Other19.19%

Unknown6.45%

Source: MOH

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HIV Prevalence Among IDUs, 2009

HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009

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HIV Trends Among IDUs, 2006-2009

HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009

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Opioids

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Class of drug that includes:• Morphine• Heroin• Methadone• Buprenorphine• Opium• Codeine

Opioids:• relieve pain and

bring on feelings of well-being

• slow down functions of the central nervous system, including respiration

Overview of Opioids (1)

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High doses can cause respiratory depression, coma and death

In Vietnam, most commonly used illicit opioids are heroin and opium

Overview of Opioids (2)

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Use: smoked, injected, nasal, oral Effects: euphoria, sedation, pain

reduction Negative effects: dependence,

overdose, injection related illnesses Withdrawal: severe, but not life

threatening

Heroin (1)

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Pregnancy: withdrawal dangerous to fetus, pregnant women should be maintained on methadone

Overdose: when mixing drugs or after period of abstinence

Heroin (2)

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Definition (ICD-10): A cluster of behavioral, cognitive, and physiological phenomena develop after repeated substance use that include:• Strong desire to take drug• Difficulties in controlling use• Persisting in use despite harmful consequences• Higher priority given to drug use than other

activities and obligations• Increased tolerance• Physical withdrawal symptoms if drug stopped

Characteristics of Opioid Dependence

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Withdrawal symptoms:• Muscle and joint pain• Abdominal cramps• Nausea, vomiting• Diarrhea• Cough• Chills

Physical signs: • Dilated pupils• Tachycardia• Hypertension• Hyperactive bowel

signs

Opioid Withdrawal Symptoms

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Treatment for IDU

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Directly related to drug use:• Respiratory depression from opioids• Pulmonary problems from inhaled drugs• Malnutrition• Mental health issues: mental disorders

may appear during drug use or with sudden stopping of drug

Medical Complications of IDU (1)

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Bacterial infections• Bacterial

endocarditis• Osteomyelitis• Skin and soft tissue

infections• Septic

thrombophlebitis• Septicemia

Viral infections• HIV, HCV, HBV

Mycobacterial infections• 10X increased risk

for TB among HIV negative IDU

Medical Complications of IDU (2)

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Non-healed puncture wounds along vein with accompanying inflammatory changes

Skin Lesions of Injection Drug Users

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Skin Abscess from Injection Drug Use

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Stigma Discrimination Social marginalization Closed settings, including

incarceration• Unsafe injecting practices• Communicable disease• Physical and sexual violence

Barriers to Care for IDU

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Drug users are less likely to receive HIV therapy due to:• Failure to follow-up• Poor adherence with ARV and other

medications• Reluctance of medical providers to

prescribe therapy due to concerns about adherence

However, if adherence is good, IDUs respond to ART as well as any other patients

Treatment of Drug Users with HIV Infection

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Drug abuse treatment and HIV-related care must be both addressed or neither treatment approach will be effective

Drug users in drug treatment programs are very adherent with HIV therapy

The challenge: determine specific ways to integrate care for drug addiction and HIV therapy

Treatment of Drug Addiction

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What is the Harm Reduction Approach?

What are Some Examples of Harm Reduction?

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Rather than telling drug users to completely stop using drugs, the harm reduction approach focuses, literally, on reducing harm and includes:• Community outreach focus on peer approaches• Behavior change communication, including risk

reduction information• Clean needles, syringes and their safe disposal• Drug dependence treatment, particularly

opiate substitution therapy (Methadone)• HIV testing and counseling

Harm Reduction Approach (1)

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Prevention of sexual transmission through interventions

HIV care and treatment, including ART Primary health care

• hepatitis B vaccination• vein and abscess/ulcer care• overdose management

Supportive policy and legislative environment

Harm Reduction Approach (2)

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What is Methadone Maintenance?

What are the Goals of Methadone Maintenance?

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Dispensed daily on site and directly observed• Daily observed dosing reduces potential

for abuse • Daily contact with methadone program

facilitates treatment of other chronic medical conditions

Methadone Maintenance Therapy (1)

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Usual starting dose: 20-30 mg daily, increasing by 5-10 mg every 3 days until adequate dose is reached to: • treat withdrawal symptoms • reduce drug craving• improve daily functioning

Most patients effectively treated at daily doses of 60-100 mg of methadone

Methadone Maintenance Therapy (2)

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Increase: • overall survival• drug-treatment retention• employment

Decrease: • illicit opioid use• hepatitis and HIV seroconversion• criminal activity

Improve birth outcomes for pregnant women

Results of Methadone Treatment

Kuehn, JAMA 2005.

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ART for Intravenous Drug Users

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Same ARV regimens and doses as non-IDU

Active IDU is NOT a contraindication to providing ARV• Dose of methadone may need to be

adjusted due to drug interactions when starting ARV

• No need to adjust doses of ARV drugs when taking methadone

Closely follow adherence and provide extra counseling to IDU patients and treatment supporters

ART for IDU

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High levels of adherence are necessary for optimal outcomes on ART

IDU may have greater barriers to adherence• Side effects of ARV, real and perceived• Active drug use• Psychiatric illness or symptoms• Stigma against IDU

Resistance to ARVs is similar among people who inject drugs and those who do not

Adherence for IDU on ART

Wood E et al. AIDS, 2005, 19:1189–1195.

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IDU and sharing of infected injecting material are major factors of HIV epidemic in Vietnam

Harm reduction programs lead to:• reducing drug use or reducing risk behaviors• decreasing spread of HIV

Methadone maintenance is an effective and proven modality for treating opiate addiction

IDU can respond well to ARV treatment, if the ARV are taken with good adherence

Key Points

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Thank you!

Questions?