The Meth-HIV Nexus: A clinician’s perspective

Neil Flynn, M.D., M.P.H.Professor of Internal MedicineUniversity of California, Davis

Prologue

Providing medical care to HIV-infected meth users for over 20 years

HIV prevention work among meth users since 1987

Many “successes” with meth usersSome become colleagues and co-

workersSome become friends

The meth-HIV Nexus

How strong is the association?Why is meth use associated with HIV?Implications for HIV treaters and othersObservations on the determinants of

meth use in HIV and non-HIV populations

The meth-HIV Nexus

Why is meth use a risk factor for HIV?↑ Injection risks

3-5 X over heroin injection Increased risk-taking with injections?

More frequent syringe sharing Disinhibition, bravado Feelings of increased control, confidence and

invulnerability

The meth-HIV Nexus

Why is meth use a risk factor for HIV?↑ Sexual activity/risk

More partnersMore frequent and prolonged intercourse

Testosterone replacement therapy “Crystal dick” and Viagra Dry sex Delayed orgasm

Infrequent use of condoms

Attractions of meth as related to me by my patients:

Sexuality, socialization, partyingPure pleasure – enjoy the feelingRelief of unpleasant feelings, states

DepressionSelf-doubt, recrimination, worthlessnessRelief of ADD

Weight control (especially women)↑ Stamina, “energy”, capacity for work

Implications of different reasons for meth use:

Approach to management of use/addiction is different

Strategies for medical management of their HIV infection are different

Professional expectations and rewards are different

Some effects of meth on HIV medical management:

Progression of disease May be accelerated by meth itself

Poor nutrition may play a significant role

Adherence Reduced in meth users vs. heroin users

“Who needs it? I’m fine!” attitude when using Depression when not using Don’t keep appointments

Drug interactions complicate treatment ARV’s, psychoactive drugs, cardiac, GI, pulmonary

medications

Providing HIV care to meth users

Extremely frustrating for providers if traditional outcomes and measures of success are expectedPatient’s priorities different from provider’sProvider sense of failure, reduced

satisfactionProvider loss of feelings of controlPatients unreliable, miss appointmentsDifficult to spend a half hour with patient

Patient perceptions

Perceived judgmentalism, moralismProvider more frustrated than judgmentalMiscommunication is frequent, easy

Provider dull, slow-witted, can’t keep up “Pt. distractible, flight of ideas, pressured

speech.”Doesn’t understand drug use, culture

Like talking to a priest about sex

Treatment Approaches

GoalsPatient safety – reducing riskPrevention of major diseaseEarly diagnosis of illness/diseaseAverting hospitalization, ER utilizationMaintaining a trusting relationshipPromoting patient introspection, counseling,

general welfareReduce transmission of HIV to others

Treatment Approaches:

Re-define successAny ongoing relationship at all with the

patient is a major success! Intermittent periods of reduced meth use

and adherence to treatment Increased patient satisfaction with lifeTemporary improvements in viral load and

CD4 cell countsMaintaining functionality and reducing

illness

Treatment Approaches

Drug treatmentAbstinence-basedHarm-reduction-basedCognitive-behavioralSubstitutionTreatment of underlying psychiatric

disorders

Treatment Approaches

Treatment of underlying major psychiatric disorders (“drug treatment” must include this!)Schizophrenia, psychotic disordersBipolar disorderDepressionSexual addiction/intimacy problems

Directly observed therapy (DOT)

Treatment Approaches

Directly observed therapy (DOT) “Who needs ARVs? I’m fine!”Difficulty finding patientParanoiaDrug interactions

Prevention with meth positives

Motivational interviewing techniques Determine stage of change Build patient interest in change Identify target behavior Skills building for change Commitment to make a change

The brief intervention Follow-up until as much change as possible

has been achieved It takes two for transmission – someone willing

to give and someone who will take the risk of receiving

Summary

Meth use is associated with ↑ HIV risk↑ Injection and sexual risk behaviors

Relations between medical providers and meth users are often strained It is a two-way street

Harm reduction is a viable strategy for treating the dual/triple diagnoses

Many meth users have major underlying, treatable psychiatric disorders

Summary

HIV can be successfully treated with meth users

Attention must be paid to individual’s reason(s) for meth use

Definitions of success may need to be modified

Prevention of transmission is part of medical management

Contact Information

Neil Flynn, M.D., M.P.H.

nmflynn@ucdavis.edu