Modified by: Patrick Clay, PharmD UNT System College of Pharmacy [email protected]O: (817) 735-2798 Originally designed and developed by: Frank Romanelli, Pharm.D., MPH, BCPS Professor of Pharmacy, Medicine, & Health Sciences Associate Dean for Education, University of Kentucky Recreational Drugs, HIV, and Antiretroviral Therapy
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Originally designed and developed by: Frank Romanelli, Pharm.D., MPH, BCPS Professor of Pharmacy, Medicine, & Health Sciences Associate Dean for Education,
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450 MSM/bisexual men 293 (65%) reported MA use in the
previous 4 month time-span AA men less likely to report MA use
(p<0.001) Mean age of MA users: 33±7.9
years
Recreational Drug UseMansergh G, et al. Am J Pub Health 2001.
Cross-sectional study of 295 gay and bisexual males in SF Bay Area who attended a circuit party in previous year.
75% reported use of MDMA 58% reported use of Ketamine 25% reported use of GHB 49% reported having had protected anal
sex and 28% unprotected
Recreational Drug UseMansergh G, et al. Klitzman RL, et al. Am J Psychiatry 2000.
Pilot study of 169 gay and bisexual men at three NYC clubs.
One-third of all respondents reported use of MDMA at least monthly.
Use of MDMA was statistically significantly correlated with recent and repeated unprotected anal sex.
Recreational Drug Use Colfax GN, et al. J Acquir Immune Defic Syndr 2001.
Cross-sectional study of gay and bisexual males in SF to examine prevalence of club drug use and high risk sex practices during circuit parties.
80% reported use of MDMA 66% reported use of Ketamine 29% reported use of GHB 21% of HIV+ and 9% of HIV- persons
reported having unprotected anal sex.
Recreational Drug Use Mattison AM, et al. Journal of Substance Abuse 2001.
Non-random sample of 1169 circuit party attendees in 3 separate venues.
50% of respondents reported using MDMA within last 30 days
Use of MDMA and ketamine were associated with high risk sexual practices.
Most common reason for attending circuit party was “to have uninhibited sex.”
Recreational Drug Use Ostrow D, Plankey M, Cox C, et al. JAIDS 2009;51:349-55.
MACS cohort of HIV-seronegative MSM 1998-2008 (n=6,972 males)
Reporting use of both PDEs and other recreational drugs (n=1,667)
Results Ostrow D, Plankey M, Cox C, et al. JAIDS 2009;51:349-55.
HIV + (n=57) HIV – (1610)
No drug use 33% 60%
2 or + URASP 21% 5%
Poppers +/- PDEs 33% 23%
Stimulants 33% 16%
Ethanol (low-mod) 60% 68%
Ethanol (mod- high) 25% 23%
Risk of seroconversion increased from: 2.99 (single drug) [95% CI 1.02-8.76]
8.45 (3 drugs (MDMA, ‘poppers’, PDEs) [95% CI 2.67-26.71]
Results Ostrow D, Plankey M, Cox C, et al. JAIDS 2009;51:349-55.
Agent Risk Stimulant
2.99
‘Poppers’
3.89
PDE 3.443 drugs 8.45
Recreational Drug Use Semple SJ, Strathdee sa, Zians J, et al. BMC Public Health 2010;10:1-6.
321 participants in a safer-sex intervention surveyed
Survey: drug use and sexual behavior Cohort split into groups based on preferred
sexual venue: private (home); commercial (bathhouse); public (restroom)
Recreational Drug Use Semple SJ, Strathdee sa, Zians J, et al. BMC Public Health 2010;10:1-6.
Commercial:> gay, better educated, ↑ club drugs
High risk sex greatest in commercial and public groups
Public group:> alcohol use, heavier overall drug use, ↑ depression
Mean 4.2-7.3 gm of MA in last 30 d
Implications
Rec drugs inc high risk sexual encounters inc rate of STIs.
Potential for fatal interactions in HIV seropositive patients using rec/club drugs.
Potential effects of club drug use on adherence to antiretrovirals?
Potential deleterious disease-related effects withstanding issues surrounding other STIs and ARV adherence
-PEARLS-
‘Respect ritonavir’ Start low and have friends nearby Don’t neglect ethanol (ddI, ABC) Sildenafil: 25 mg q48h
Vardenafil: 2.5 mg q72hTadalafil: 10 mg q 72h
Adherence to ARVs, ancillary meds, appointments, etc.
Don’t forget the needles Patients use recreational drugs … just ask …
Why Adopt a Broad View of
Adherence? A broad view of adherence:
– recognizes that adherence is not only about taking one’s medications
– actively engages patients in health care and treatment
– values the health impacts of “non-medical” interventions, including controlled drug use, stable housing, social supports, harm reduction, and good nutrition
– improves patients’ self-efficacy– provides more opportunities for success
Adherence: defined
Any action that improves, supports, or promotes the health of a person living with HIV with respect to HIV treatment and care, including physical, mental, and psychosocial well-being.
Adherence through HP
“..helping a patient who uses drugs adhere to a
complex medical regimen can support an upward
spiral of self-esteem and the adoption of healthier
practices.”
Why focus on adherence in substance abusers?
There is systemic discrimination against substance users– Less access to care– Less access to ART– Slower decline in morbidity and
mortality Providers often lack training in the care
of substance users and may have negative attitudes towards them
Poor Adherence = …
(audience participation time!)
HIV resistance:adherence
Audience poll:
A. “An individual should be drug free for one month before they can start antiretroviral therapy.”
B. “An individual should be drug free for three months before they can start antiretroviral therapy.”
C. “An individual should be drug free for six months before they can start therapy.”
Correct answer:
Yes.
Adherence & Drug of Choice
Heroin: use may be more regimented– Users may have an easier time w/
adherence Cocaine/Crack: use may be more sporadic
– Intense mood swings may interfere with adherence
Methamphetamine: unclear, but use may be more sporadic and interfere with adherence
Alcohol: may have most negative impact on adherence due to blackouts and memory loss
HIV, Psyche, Substance Abuse
Up to 50% to 80% of HIV-infected persons are affected by mental illness.
Triple diagnosis of HIV, substance use, and mental illness is common.
Up to 80% of HIV-infected patients in methadone maintenance require psychiatric consultation for mental illness.
Untreated depression can compromise medication adherence and make HIV infection more disabling.
Health Promotion I
Taking all antiretrovirals, on time exactly as prescribed
Taking meds to prevent opportunistic infections
Keeping regular medical appointments
Eating a nutritious diet Exercising regularly
Health Promotion II
Participating in a drug treatment program
Controlling drug use or sobriety Practicing safer sex and drug
injection Taking a multivitamin Stopping smoking Connecting with a support network
Take Home Points
Individualize treatment plans to each patient’s needs.
Recognize the specific challenges of working with HIV infected substance users.
Use knowledge and tools to overcome these challenges and to advocate for patients.
Consider the boundaries for non-medical providers offering HIV adherence and health promotion counseling.
Explore opportunities to link with providers across disciplines to strengthen adherence support.