Integration of Methadone Maintenance Treatment … Melliandari.pdf · Integration of Methadone...
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Integration of Methadone Maintenance
Treatment (MMT) and HIV Care
for Injecting Drug Users (IDU) :
A Cohort Study in Bandung, Indonesia
Yanni Melliandari Achmad 1, D.Norviatin1
AN.Istiqomah1,2, R.Wisaksana1,3, I.Afriandi1,4, R.van Crevel1,5, T.Hidayat1,2
1IMPACT, Health Research Unit, Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung, West Java, Indonesia2Department of Psychiatric, Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung, West Java, Indonesia
3Department of Internal Medicine, Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung, West Java, Indonesia4Department of Public Health, Faculty of Medicine, Padjadjaran University, Bandung, West Java, Indonesia
5Department of Internal Medicine, Radboud University Nijmegen Medical Centre, The Netherlands
Presented in Brother in Arms, Nijmegen, The Netherlands
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• High prevalence, low CD4, high mortality
IDUs and HIV
IDUs don’t like regular clinics…..
and regular clinics don’t like IDUs…
Common belief
• Low adherence, high drop-out
• Many problems, low success rate
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• Cause of death :
– 2 unknown
– 2 over-dose
– 13 HIV-related
Mortality (n=17)
– 13 HIV-related
• Median age (IQR) : 28 (25 – 32)
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HIV-care integrated with methadone
• ‘one-stop care’ (patient friendly)
• Established doctor – patient relation
• Opportunity for more frequent counselling• Opportunity for more frequent counselling
(adherence, side effects etc)
• Comprehensive
(drug interactions, toxicity)
• Cost-effective
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Research Questions
1. Does methadone maintenance treatment (MMT) increase access to HIV-care?
2. How effective is HIV-treatment when combined with methadone service?
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Results: MMT increases access to HIV Care
Total Tested/started in MMT
HIV-tested 102 41 (40.2%)
HIV-positive 75 25 (33.3%)
HIV treatment 38 19 (50%)
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How effective is ART for MMT-clients ?
• Endpoints
- Retention to ART
- Mortality
-Virological failure-Virological failure
• Control group:
patients taking ART outside MMT
with history of IDU, matched for starting ART date
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MMT
(n=35)
Control
(n=175)
p-value
Male gender, % 97.1 93.7 0.425
Mean age, years (SD) 29.9 (3.8) 29.1 (3.4) 0.165
Marital status; Single, % 54.3 46.3 0.387
Education; Academy or university, % 51.4 38.3 0.148
Baseline Characteristics
Education; Academy or university, % 51.4 38.3 0.148
Median BMI, kg/m2 (IQR) 19.4
(17.8-20.6)
19.7
(17.9-21.7)
0.299
HBsAg-positive, % 2.9 8.2 0.266
Anti HCV-positive, % 90.3 92.5 0.673
CD4
< 200 cells/mm3, %
median, cells/mm3, %
65.7
177 (47-244)
57.9
133 (34-269)
0.817
0.392
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Results : Retention in ART : 2 years
100% versus 93.1%
HR loss to FU = 0.30 (95% CI : 0.04 – 2.10)
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Results : Survival in ART : 2 years
93.9% versus 92.3%
HR mortality = 0.8 (95% CI : 0.2 – 3.2)
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Results: Virological Response after ART ( > 6 months)
MMT
(n=27)
Control
(n=114)
HIV-RNA
< 400 copies/ml, % 100 89.5
RR virological failure for patients in MMT:
0.35 (95% CI 0.02-2.3)
400 - 10000 copies/ml, %
> 10000 copies/ml, %
0
0
0.9
9.6
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ART combined with MMT
• Mortality
• Retention in treatment
• Virological response
• Similar between MMT and control group
– Possibly better in MMT (small numbers…)
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median: 55mg
(1.9-195 mg)
Last month average methadone dose
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Methadone dose and retention to MMT
59.4% versus 38.8%
HR = 1.91 (95% CI : 0.99 – 3.68)
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Drop out
(n=101)
Non drop out
(n=122)
Stable dose (2 months) 70(10-175)
80(15-150)
Last dose 35 65
Methadone Dose*
Last dose 35(4-170)
65(1-195)
Last month average dose 40(6.38-166.2)
67.7(1.9-195)
Last 3 months average dose 39.4(7.1-165.8)
62.5(12.13-195)
* Median, mg
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Methadone Dose
Methadone Metabolism
ARTefavirenz, nevirapine
Higher dose
* Induction of liver metabolism ~ 1 week
- withdrawal symptoms with same dose methadone
Methadone Metabolism
TB drugrifampicin
Higher dose
of methadone*
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Last month methadone dose
n=31n=21 n=33
Logistic regression : p value 0.024
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Conclusions
• High HIV-prevalence among MMT patients (73%)
• MMT : entry point for HIV-testing & treatment
• Outcome similar between MMT and control group
• ‘One-stop care’ – patient friendly & efficient• ‘One-stop care’ – patient friendly & efficient
• Higher methadone dose with ART & TB drugs
Challenges
• Securing access & quality of services
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Acknowledgements
Hasan Sadikin Hospital
• Psychiatric Department : Ike MP Siregar, Lucky Saputra, Shelly
• MMT Clinic : Agus, Warsa, Tria, Novi, Hera, Danis, Julianto, Atu
• Teratai Clinic : Agnes R. Indrati, Laila, Kiki, Nuni
IMPACT
• Lucas Pinxten
University of AntwerpUniversity of Maastricht University of NijmegenPadjadjaran University
Nijmegen Institute for Scientist-Practitioners in Addiction, The Netherlands
• Prof Cor de Jong
Financial support: European Union, Cordaid, Nuffic/Neso