Drug Abuse Treatment as HIV Drug Abuse Treatment as HIV Prevention: The Prevention: The State State of the of the Science Science David S. Metzger, Ph.D. University of Pennsylvania University of Pennsylvania Center for Studies of Addiction Center for Studies of Addiction HIV Prevention Research Division HIV Prevention Research Division Philadelphia, PA Philadelphia, PA
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Drug Abuse Treatment as HIV Drug Abuse Treatment as HIV Prevention: The Prevention: The StateState of the Science of the Science
David S. Metzger, Ph.D.
University of PennsylvaniaUniversity of Pennsylvania
Center for Studies of AddictionCenter for Studies of Addiction
HIV Prevention Research DivisionHIV Prevention Research Division
Philadelphia, PAPhiladelphia, PA
OverviewOverview
• Drug driven epidemics -- overviewDrug driven epidemics -- overview
• Prevention impacts of drug treatmentPrevention impacts of drug treatment
• Drug treatment, access, and adherence to HIV careDrug treatment, access, and adherence to HIV care
• Challenges in maximizing the public health impact of Challenges in maximizing the public health impact of drug treatmentdrug treatment
Current AIDS epidemiologyCurrent AIDS epidemiology
• Approximately 33,000,000 living with HIV/AIDSApproximately 33,000,000 living with HIV/AIDS
• Over 10,000,000 infections among IDUOver 10,000,000 infections among IDU
• Outside of Africa, over 33% of all new infections Outside of Africa, over 33% of all new infections are estimated to be attributable to injection are estimated to be attributable to injection drug usedrug use
• No estimates of non-injection drug useNo estimates of non-injection drug use
91% of the world adult population (4 billion) is covered by the data.Information unavailable for 119 countries.
Estimated size of IDU population
S. & S-E Asia: 3.33m
S. & S-E Asia: 3.33m
E. Europe & C. Asia: 3.2mE. Europe &
C. Asia: 3.2m
E. Asia & Pacific 2.35m
E. Asia & Pacific 2.35mMENA:0.44mMENA:0.44m
S. Saharan-Africa
0.009m
S. Saharan-Africa
0.009mL. America:
0.97mL. America:
0.97m
Caribbean: 0.028m
Caribbean: 0.028m
N. America 1.43m
N. America 1.43m
W. Europe: 1.24m
W. Europe: 1.24m
Australia & N. Zealand:
0.19m
Australia & N. Zealand:
0.19m
UN Reference Group on HIV/AIDS prevention and care among IDU www.idurefgroup.org
10.3m (78%) in developing/transitional countries
What drugs are most commonly injected?
OpiatesATS
OpiatesATS
OpiatesATS
OpiatesATS
OpiatesATS
OpiatesATS
OpiatesOpiates
OpiatesATS
OpiatesATSCocaineCocaine
CocaineOpiatesCocaineOpiates
OpiatesCocaine
ATS
OpiatesCocaine
ATSOpiates
ATSOpiates
ATS
OpiatesATS
OpiatesATS
0102030405060708090
Armenia
Azerbaijan
Belarus
Georgia
Kazakhstan
Kyrgastan
Moldova
Poland
Russia
Tajikistan
Ukraine
Uzbekistan
Column 1
IDUs as Percent of Total Registered HIV CasesEastern Europe and Central Asian Countries, 2007
Countries with Injection Driven Epidemics, OSI, 2008
Source: UNAIDS 2008 Report on the Global AIDS Epidemic
01020304050607080
China
Indonesia
Malaysia
Viet Nam
IDUs as Percent of Total Registered HIV CasesEast and South East Asian Countries, 2007
Dependence is a medical condition with common Dx and consequences: ASI Composite Scores: Porto Alegre, Philadelphia and Wuhan
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Alcohol Drug Emp/supp Family Legal Medical Psychiatric
Porto AlegrePhiladelphiaWuhan
Substance-related HIV transmissionSubstance-related HIV transmission
• Direct and indirect sharing of injection Direct and indirect sharing of injection equipment and materialsequipment and materials
• Unprotected sexual activity Unprotected sexual activity
Consequences of substance use in all Consequences of substance use in all risk groups: MSMs, IDUs, risk groups: MSMs, IDUs, HeterosexualsHeterosexuals
HIV prevention strategies for drug HIV prevention strategies for drug using populationsusing populations
• Education about HIV transmissionEducation about HIV transmission
• HIV counseling and testingHIV counseling and testing
• Increased access to sterile injection Increased access to sterile injection resources and condomsresources and condoms
• Drug treatmentDrug treatment
• HIV treatmentHIV treatment
How does drug treatment prevent HIV How does drug treatment prevent HIV infection and transmission?infection and transmission?
• Effective treatments reduce the frequency of drug useEffective treatments reduce the frequency of drug use
HIV prevalence rates among New York IDUs by methadone treatment
(MMRW, 1984)
87%
10%
86 Active Users 35 Long Term MM 0%
20%
40%
60%
80%
100%
21%
13%
18%
51%
21%
39%
0%
10%
20%
30%
40%
50%
60%
B 6 12 18 24 30 36 42 48 60 72
Months
In Treatment Out of Treatment
Six year HIV infection rates by treatment Six year HIV infection rates by treatment status at time of enrollmentstatus at time of enrollment
Percent infected after 18 months by treatment status
4.50%
22%
3.50%
0%
5%
10%
15%
20%
25%
Tx Partial Tx No Tx
(Metzger et al. 1993)
0%
2%
4%
6%
8%
10%
12%
HBV HCV
Left
Interupted
Remained
Incidence of HBV and HCV 12 Months Following Treatment Entry
(Thiede,Hagan,and Murrill, 2000)
Agonist treatment is more than Agonist treatment is more than substitutionsubstitution
• Safe, stable dosingSafe, stable dosing
• Drug use monitoredDrug use monitored
• Drug counselingDrug counseling
• Access to other services Access to other services
Rate of opiate positive in three approaches to methadone treatment
0
10
20
30
40
50
60
70
B 1 2 3 4 5 6
month
Minimal
Standard
Enhanced
Weeks
302724211815129630
Per
cen
t r
emai
nin
g i
n T
reat
men
t
1,0
,9
,8
,7
,6
,5
,4
,3
,2
F+P
N+F
P+P
N+P
N+F>P+PN+F>F+PN+P>P+PN+P>F+PF+P=P+PN+F=N+P
Naltrexone and drug counseling treatment in Naltrexone and drug counseling treatment in St. PetersburgSt. Petersburg
Buprenorphine/Naloxone offers new opportunities Buprenorphine/Naloxone offers new opportunities for treatment in HIV care settingsfor treatment in HIV care settings
Maintenance treatment with buprenorphine and naltrexone for Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial.placebo-controlled trial.
Maintenance treatment with buprenorphine, naltrexone, and Maintenance treatment with buprenorphine, naltrexone, and counseling for heroin dependence in Malaysia: a randomised, counseling for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial.double-blind, placebo-controlled trial.
Study outcomes: opiate abstinenceStudy outcomes: opiate abstinence
Outreach Drug free Out-patientHarm Reduction Antagonist CounselingCounseling Counseling
Estimated Opiate dependent Drug Users in Estimated Opiate dependent Drug Users in Agonist Treatment per 100,000 populationAgonist Treatment per 100,000 population
0
50
100
150
200
Australia Spain United States NetherlandsItaly UK Germany DenmarkFrance Canada Sweden ThailandChina India Nepal
HIV prevention and care implications: HIV prevention and care implications: Necessary but not sufficientNecessary but not sufficient
Drug TreatmentDrug Treatment
Community Community Harm Harm Outreach Outreach ReductionReduction
HIV CareHIV Care
ConclusionsConclusions
• Behavioral and serologic data support the Behavioral and serologic data support the hypotheses that drug users in treatment:hypotheses that drug users in treatment:
significantlysignificantly reduce the frequency of usereduce the frequency of use
practice fewer risk behaviorspractice fewer risk behaviors
have greater access to HIV treatmenthave greater access to HIV treatment
are more adherent to HIV care are more adherent to HIV care
ConclusionsConclusions
• Data suggests effective treatments for Data suggests effective treatments for drug users:drug users:
recognize addiction as a chronic recognize addiction as a chronic disease (at least one year) disease (at least one year)
use pharmacologic and counseling use pharmacologic and counseling interventionsinterventions
are accessible, acceptable, and are accessible, acceptable, and affordableaffordable
Future directionsFuture directions
• Expand access to effective treatmentsExpand access to effective treatments
• Target drug users earlier in the continuum of useTarget drug users earlier in the continuum of use
• Test interventions for use of multiple substancesTest interventions for use of multiple substances
• Measure HIV risk endpoints in clinical trials of new Measure HIV risk endpoints in clinical trials of new medicationsmedications
• Urgent need to sustain search for pharmacologic Urgent need to sustain search for pharmacologic treatments for stimulant abusetreatments for stimulant abuse