Optimizing Care for PWIDs Frederick L. Altice, M.D. Director of Clinical and Community Research Professor of Medicine Yale University

The Doctor-Patient Relationship

Hippocratic Oath First do no harm. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure.

The Future HIV Healthcare Providers: Professional Students in Malaysia P=NS

Percent Who Would Defer Antiretroviral Therapy

Definition: Syndemic A set of linked health problems involving two or more conditions, interacting synergistically, and contributing to excess burden of disease in a population. Syndemics occur when health-related problems cluster by person, place, or time.

Triple Layers of Stigma HIV Arrest Incarceration Substance Use Disorder

Substance Use Disorder Infectious Diseases (HIV, HCV, TB) Mental Illness (Mood or Thought Disorders)

ADDICTION IS A DISEASE OF THE BRAIN as other diseases it affects the tissue function Decreased Brain Metabolism in Addiction Patient High Low Healthy Control Cocaine Abuse Decreased Heart Metabolism in Heart Disease Patient Healthy Heart Diseased Heart Sources: From the laboratories of Drs. N. Volkow and H. Schelbert

ADDICTION INVOLVES MULTIPLE FACTORS Biology/Genes John Smith James Smith Ann Jones John Jones Mary Hill Walter Jones James Hill Susan Adams Alice Price Thomas Jones William Price Richard Hill Steven Adams Allison Fields Mary Walters Alice Benson Rebecca Wilson ThomasSmith EdwardSmith AnneCook JaneWalker John Walker JaneJones Susan Edwards JamesCook Beth Bryson JonathanCook Edward Bryson Amy Mason Beth Carter Environment Addiction DRUG Brain Mechanisms

Reward (Pleasure) Pathway Ventral Tegmental Area Alcohol Stimulants Heroin Nicotine

HIV OST Mental Illness Medical Care The Problem!

Integrating Care for PLWHA Secondary HIV Prevention and Adherence Counseling Pharmacologist Addiction Treatment Specialist

Guidelines for Integrating Collaborative Services Common comorbidities in people who use drugs TB, HIV, HCV, STIs Mental illness Studies where services are NOT integrated have poorer treatment outcomes – patients don’t travel to new sites for treatment (convenience, mistrust, etc)

Integration is Internationally Recommended

Steps in Organizational Change Toward Healthcare Integration OAT Communication Coordination OAT HIV Co-Located Services OAT HIV Partial Integration Complete Integration HIV/OAT HIV Separate Sites

Specific Recommendations for PLH and SUDs Prescribing opioid agonist therapy with either methadone or buprenorphine for individuals with opioid use disorders Integration of HIV and addiction services Directly administered antiretroviral therapy (DAART), including into methadone treatment

Portugal Experience (Decentralization) Outreach Teams Prisons Addiction Centers TB Centers Hospitals: Integrated Services Primary Care Centers Pharmacies Testing Center ART OAT TB treatment HCV treatment HIV testing NSP TB screening

Addiction Integration into Primary Care Correlates of retention on buprenorphine: Having a primary care rather than an addiction specialist prescribing treatment Not using cocaine Being prescribed anti-depressant medications Receipt of addiction counseling

Retention on Buprenorphine

Addiction Integration into Primary Care Correlates of higher quality health indicators: Having a primary care rather than an addiction traetment doctor prescribing treatment Being retained on buprenorphine ≥3 months Being HIV-infected Male gender

Quality Health Indicators

Integration of Buprenorphine into HIV Clinical Care Settings Prospective, cohort (N=295) study of HIV+ patients at 10 diverse HIV clinical care settings Each site was organized differently Hospital-based HIV clinic (N=6) Community health centers (N=4) Research HIV Clinic (N=1) Resulted in increased number of patients initiating ART Best outcomes when both buprenorphine and ART prescribed by the same provider Succeeded best if there was a coordinator (“the glue”) Nurse (N=5) Substance abuse counselor (N=3) Health educator (N=2) Pharmacist (N=1) Altice, JAIDS, 2011; Weiss, JAIDS, 2011

Altice, JAIDS, 2011

Required multiple prescribers within a “practice” Needed a “glue” person to anchor the program (counselor, nurse, etc) Challenges of “culture” between HIV and addiction and new practices (urine screens) Polysubstance use and mental illness comorbidities created additional challenges

Integration in Ukraine: Improvements in Health

Overview Cross-sectional study of 296 HIV+ opioid dependent patients in Kiev and Dnipropetrovsk regions in Fall 2010 Randomly recruited from three settings Integrated & Co-Located Clinics (ICL) Non-Co-Located Narcology Clinics (NCL) Harm Reduction & Outreach Sites (HRO) Primary Outcomes Performance on Quality Health Indicators (QHI) Health-related Quality of Life (HRQoL)

Quality Health Indicators An index that is created to measure health outcomes across a number of diseases HIV Index (N=3) CD4 monitoring in previous 6 months; receipt of ART; receipt of ART if CD4<200 OST Index (N=3) Methadone dose ≥80mg; any IDU in previous 30 days; daily IDU in previous 30 days TB Index (N=2) TB screening in past 12 months; isoniazid preventive therapy

HIV Quality Indicators

OAT Quality Indicators

TB Quality Indicators

Mean Quality Health Indicator Score P<.001 P<.001

Health-Related Quality of Life P<0.001 P<0.001

Health Services Integration OAT and TB Treatment OAT and HCV Treatment

OAT and TB Treatment Hospitalized Patients in Ukraine Morozova et al, IJDP, 2013

South Central Rehabilitation Center

SCRC Services Provided Treatment for alcohol and substance use disorders, including 7 day inpatient detoxification Methadone and buprenorphine maintenance Routine screening of ALL patients for HIV, TB, HBV, HCV and mental illness Onsite treatment for HIV, HCV and uncomplicated mental illness DOT for HIV, HCV and TB prophylaxis treatment

OAT and HCV Treatment Onsite vs Referral for HCV Treatment

The Solution! HIV OST Medical Care Mental Illness