Advancing the prevention and treatment of chronic illnesses UCLA Department of Family Medicine Psychoactive Drugs and HIV Steven Shoptaw, PhD UCLA Center for Behavioral and Addiction Medicine Department of Family Medicine September 5, 2014

Advancing the prevention and treatment of chronic illnesses UCLA Department of Family Medicine What You Need to Know Most users of substances don’t inject Proposed mechanisms linking substance use and HIV transmission for people who do not inject Indirect links between drug abuse treatment as HIV prevention Two evidence-based case examples Discussion

Substances Sedative/barbs – ALCOHOL, benzodiazepines, GHB Sedative/barbs – ALCOHOL, benzodiazepines, GHB Stimulants – cocaine, speed, NICOTINE, Ecstasy (MDMA) Stimulants – cocaine, speed, NICOTINE, Ecstasy (MDMA) Opiates – heroin, percodan, dilaudid, vicodin Opiates – heroin, percodan, dilaudid, vicodin Hallucinogens – LSD, mescaline, peyote Hallucinogens – LSD, mescaline, peyote Tranquilizers/anesthetics – ketamine, PCP Tranquilizers/anesthetics – ketamine, PCP Cannabinoids – POT, hash Cannabinoids – POT, hash Inhalants – poppers, solvents Inhalants – poppers, solvents

Advancing the prevention and treatment of chronic illnesses UCLA Department of Family Medicine Substance Use Prevalence, U.S. Adults 2012 Substance Δ from 2011% Current Cigarette Smokers % Alcohol Use (any in past month) % Heavy Alcohol Drink (5+ drinks, 5+ days past month) --6.5% Marijuana Use (past month)  5.8% in % Prescription Drug Misuse (past month) --2.6% Heroin Use (past month)  from , 07, % Cocaine Use (past month) ↓ from % Methamphetamine Use (past month) --0.5% National Survey on Drug Use and Health,

Drug Dependence in America In 2012, 22.2 million (8.5% of adults aged 12 and over met) criteria for substance abuse or dependence not including tobacco dependence (National Survey on Drug Use and Health, 2011). Alcohol abuse and dependence represents the majority (17.7 million; 6.8% of adults and 80% of total substance abuse/dependence) – remainder splits between drug disorders only and comorbid illicit drug use and alcohol use disorders. NSDUH, 2013 Advancing the prevention and treatment of chronic illnesses UCLA Department of Family Medicine

Advancing the prevention and treatment of chronic illnesses UCLA Department of Family Medicine A Word About Marijuana Frances Jensen and David Urion

AIDS in America: Overlooked Epidemic El-Sadr, Mayer, Hodder. (2010). NEJM. 362: Prevalence of HIV among MSM in Los Angeles County is about 19% Substance use involved in 28% to 33% of incident cases among MSM

High HIV incidence among people who inject drugs (PWID) in Eastern Europe, Central, Southeast and South Asia and Africa Increasing importance of non-injection substance use Globally, coverage of ART, medication assisted treatment and sterile syringes is low among PWID, due to structural barriers and unavailability Limited HIV research among women and adolescent substance users Growing emphasis on implementation science strategies to improve intervention coverage Limited data to inform efficacy and timing of HIV treatment as prevention (TasP) among PWID Limited integration of substance use into active HPTN protocols

Non-injection stimulant use accounts for between 16% and 33% of new HIV infections among MSM in the U.S. 1,2 Consistent linkages between use of methamphetamine and binge drinking with serodiscordant unprotected anal intercourse. 3 Evidence for onset of methamphetamine use both before and after HIV seroconversion. 4 What we Know: Non-injection Stimulant Use and HIV among MSM 1 Koblin et al., AIDS Ostrow et al., JAIDS Vosburgh et al., AIDS & Behav, Halkitis et al, Health Psychol 2014

Women, HIV and Substance Use Females who inject drugs tend to have higher HIV prevalence than men who inject drugs 5 Among U.S. women in HPTN 064, 76% reported binge drinking or using ≥1 drug in the last 6 months 6 : Binge drinking: 63% Cocaine use: 25% Opiates: 17% Poly-substance users less likely to decrease frequency of use over time 5 des Jarlais, Drug Alc Depend Kuo et al, Drug Alc Depend 2014

What We Know: Emerging Substance Use Trends and HIV among Adolescents What We Know: Emerging Substance Use Trends and HIV among Adolescents Emerging drug trends: – Prescription drug use which may facilitate transitions to injection 7 – Synthetic cannibinoids (e.g., Spice) and cathinones (e.g., bath salts); links to HIV risk under-studied HIV incidence increased by 20% among young people (ages 15-24) in Eastern Europe between 2001 and 2011; the majority of whom use or inject drugs. 8 7 UNODC, UNAIDS 2012

– Once daily HCV treatments - high efficacy regimens for all genotypes provides opportunity for TasP, integrating HCV and HIV treatment approaches – Long-acting formulations for ARVs - provide opportunities for HIV treatment and prevention that sidestep medication adherence – Drug treatment as prevention - Injectable treatments for alcohol, stimulant and opioid addiction (Naltrexone, Probuphine) allow opportunities for new concepts – New developments in behavioral sciences, especially technology/social media, offer new intervention approaches New treatments for HCV, HIV, substance abuse