HIV and Injection Drug Use HAIVN Harvard Medical School AIDS Initiative in Vietnam HAIVN advanced training for nursing N_M1-07_HIV and Injection Drug Use-EN Revised 9/2013

Learning Objectives By the end of this session, participants will be able to: Explain the link between HIV and intravenous drug use in Vietnam Explain how to diagnose drug addiction Explain benefits of harm reduction Describe how to provide ART to intravenous drug users (IDU)

Epidemiology of HIV and IDU IDU is the major source of HIV infections in Vietnam Risk associated with: needle-sharing exposure to contaminated injection equipment IDU often engage in other high risk behaviors, such as unsafe sex, that can transmit HIV to non-IDU partners EXPLAIN that IDU is common among other high-risk populations including commercial sex workers, prisoners, and marginalized groups.

Epidemiology of IDU in Asia Estimated 3.3 million IDU in South and South East Asia Estimated at least 20% of IDU are HIV-positive in Vietnam Commercial sex work among IDU has been called a “bridge” to the general population

Distribution of HIV/AIDS Cases in Vietnam EMPHASIZE that most HIV infections in Vietnam are due to Intravenous drug use (about 50-60%) Many CSW (commercial sex workers) also inject drugs. EXPLAIN that many of the other categories reported to the MOH are not true risk groups and probably include IDU as well. These include TB patients, military recruits, AIDS suspects, and blood donors Source: MOH

HIV Prevalence Among IDUs, 2009 HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009 EXPLAIN that the chart shows prevalence rates among IDUs in select provinces. STRESS that rates remain high in many provinces.

HIV Trends Among IDUs, 2006-2009 HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009 EXPLAIN that : This chart shows the trend in prevalence since 2006 HIV prevalence has gone down among IDUs in many provinces

Opioids ASK participants, “What are opioids? What are some examples of opioids?” ALLOW time for them to answer. USE discussion to move on to the next few slides.

Overview of Opioids (1) Class of drug that includes: Opioids: Morphine Heroin Methadone Buprenorphine Opium Codeine Opioids: relieve pain and bring on feelings of well-being slow down functions of the central nervous system, including respiration EXPLAIN that all opioids work on the same receptors in the brain and have the same effects on humans.

Overview of Opioids (2) High doses can cause respiratory depression, coma and death In Vietnam, most commonly used illicit opioids are heroin and opium STRESS that overdose of opioid medications can cause death by suppressing respiration.

Heroin (1) Use: smoked, injected, nasal, oral Effects: euphoria, sedation, pain reduction Negative effects: dependence, overdose, injection related illnesses Withdrawal: severe, but not life threatening EXPLAIN that smoking and injecting are common in Vietnam, however oral use is rare because the drug isn’t absorbed well this way. EXPLAIN further about heroin withdrawal: Virus like symptoms: abdominal cramps, diarrhea, runny nose, aches, fever. Combined with anxiety and sense of impending doom. Feels life threatening to many users.

Heroin (2) Pregnancy: withdrawal dangerous to fetus, pregnant women should be maintained on methadone Overdose: when mixing drugs or after period of abstinence

Characteristics of Opioid Dependence Definition (ICD-10): A cluster of behavioral, cognitive, and physiological phenomena develop after repeated substance use that include: Strong desire to take drug Difficulties in controlling use Persisting in use despite harmful consequences Higher priority given to drug use than other activities and obligations Increased tolerance Physical withdrawal symptoms if drug stopped EXPLAIN that this slide lists criteria for diagnosing opioid dependence. EXPLAIN the term “tolerance” = needing a higher and higher dose to attain the same effect.

Opioid Withdrawal Symptoms Physical signs: Dilated pupils Tachycardia Hypertension Hyperactive bowel signs Withdrawal symptoms: Muscle and joint pain Abdominal cramps Nausea, vomiting Diarrhea Cough Chills EXPLAIN that these withdrawal symptoms begin to show within 24 hours of last opioid use. EXPLAIN that withdrawal symptoms are what the patient may complain about; physical signs are what the doctor may see on examination. EXPLAIN that additional withdrawal symptoms include: Rhinorrhea Eye tearing Cutaneous pilo-erection

Treatment for IDU

Medical Complications of IDU (1) Directly related to drug use: Respiratory depression from opioids Pulmonary problems from inhaled drugs Malnutrition Mental health issues: mental disorders may appear during drug use or with sudden stopping of drug EXPLAIN that there are many medical complications of IDU, some of which are directly related to the drug use, and some are secondary to the drug use.

Medical Complications of IDU (2) Bacterial infections Bacterial endocarditis Osteomyelitis Skin and soft tissue infections Septic thrombophlebitis Septicemia Viral infections HIV, HCV, HBV Mycobacterial infections 10X increased risk for TB among HIV negative IDU

Skin Lesions of Injection Drug Users Non-healed puncture wounds along vein with accompanying inflammatory changes

Skin Abscess from Injection Drug Use EXPLAIN that abscesses are common from unsanitary injecting practices.

Barriers to Care for IDU Stigma Discrimination Social marginalization Closed settings, including incarceration Unsafe injecting practices Communicable disease Physical and sexual violence Note that this slide is animated. ASK participants the question below BEFORE clicking through to the answers on the slide. ASK participants “What do you think are some of the barriers to care for IDU?” ALLOW time for them to respond. CLICK through to show the answers on the slide.

Treatment of Drug Users with HIV Infection Drug users are less likely to receive HIV therapy due to: Failure to follow-up Poor adherence with ARV and other medications Reluctance of medical providers to prescribe therapy due to concerns about adherence However, if adherence is good, IDUs respond to ART as well as any other patients EXPLAIN that for all patients, the most important factor in the success of ARV treatment is adherence. EXPLAIN further that when taking ARVs with good adherence, IDUs respond to treatment as well as other patients.

Treatment of Drug Addiction Drug abuse treatment and HIV-related care must be both addressed or neither treatment approach will be effective Drug users in drug treatment programs are very adherent with HIV therapy The challenge: determine specific ways to integrate care for drug addiction and HIV therapy EXPLAIN that it is important to address the issue of drug addiction for HIV patients. If drug abuse continues, then the risk for failure of ARV treatment is high. Therefore, HIV OPC must work with other programs to refer IDU patients for drug treatment.

What is the Harm Reduction Approach What is the Harm Reduction Approach? What are Some Examples of Harm Reduction? ASK participants the question on the slide. ALLOW time for them to answer. WRITE down their answers on a flip chart, generating a list. USE discussion to lead into the next few slides.

Harm Reduction Approach (1) Rather than telling drug users to completely stop using drugs, the harm reduction approach focuses, literally, on reducing harm and includes: Community outreach focus on peer approaches Behavior change communication, including risk reduction information Clean needles, syringes and their safe disposal Drug dependence treatment, particularly opiate substitution therapy (Methadone) HIV testing and counseling EXPLAIN that Harm reduction includes many elements. The principle is to reduce the potential harm of injecting practices to IDU patients. EXPLAIN that HIV testing and counseling include voluntary, confidential and provider initiated. EXPLAIN that on 21/06/ 2006, the Vietnamese National Assembly passed a new law on prevention and control of HIV/AIDS. Article 21: HIV/AIDS harm reduction interventions Harm reduction interventions in prevention of HIV transmission include the following measures: communication and mobilization, promotion of the use of condoms and clean needles and syringes, treatment of opioid addiction by substitution (Methadone), and other harm reduction measures to support safe behaviors to prevent HIV infection and transmission. Source: HIV/AIDS care and treatment for IDU in Asia and pacific, WHO 2008

Harm Reduction Approach (2) Prevention of sexual transmission through interventions HIV care and treatment, including ART Primary health care hepatitis B vaccination vein and abscess/ulcer care overdose management Supportive policy and legislative environment EXPLAIN that interventions to prevent sexual transmission includes providing condoms and STI prevention and treatment Source: HIV/AIDS care and treatment for IDU in Asia and pacific, WHO 2008

What is Methadone Maintenance What is Methadone Maintenance? What are the Goals of Methadone Maintenance? ASK participants, “What is Methadone Maintenance? What are the goals of Methadone Maintenance?” ALLOW time for them to answer. REFER them to Handout 7.1: Methadone Maintenance for further information.

Methadone Maintenance Therapy (1) Dispensed daily on site and directly observed Daily observed dosing reduces potential for abuse Daily contact with methadone program facilitates treatment of other chronic medical conditions

Methadone Maintenance Therapy (2) Usual starting dose: 20-30 mg daily, increasing by 5-10 mg every 3 days until adequate dose is reached to: treat withdrawal symptoms reduce drug craving improve daily functioning Most patients effectively treated at daily doses of 60-100 mg of methadone

Results of Methadone Treatment Increase: overall survival drug-treatment retention employment Decrease: illicit opioid use hepatitis and HIV seroconversion criminal activity Improve birth outcomes for pregnant women DESCRIBE the positive effects of methadone maintenance therapy. Kuehn, JAMA 2005.

ART for Intravenous Drug Users

ART for IDU Same ARV regimens and doses as non-IDU Active IDU is NOT a contraindication to providing ARV Dose of methadone may need to be adjusted due to drug interactions when starting ARV No need to adjust doses of ARV drugs when taking methadone Closely follow adherence and provide extra counseling to IDU patients and treatment supporters EXPLAIN that ARVs can be safely provided to IDU and the ARV regimens and doses are the same for non-IDU patients.

Adherence for IDU on ART High levels of adherence are necessary for optimal outcomes on ART IDU may have greater barriers to adherence Side effects of ARV, real and perceived Active drug use Psychiatric illness or symptoms Stigma against IDU Resistance to ARVs is similar among people who inject drugs and those who do not EXPLAIN that IDU patients on ART need particular support around adherence. ASK participants “What might adherence support for IDU look like? What are some examples?” ALLOW time for them to respond. PROVIDE answer as needed: Counseling and education Aids and incentives for adherence Tracking of people who miss appointments or fail to pick up ART Family or community support DOT strategies: Integrated ART and opiate substitution therapy Provide simple ART regimens: Fixed-dose combination, once daily regimens Wood E et al. AIDS, 2005, 19:1189–1195.

Key Points IDU and sharing of infected injecting material are major factors of HIV epidemic in Vietnam Harm reduction programs lead to: reducing drug use or reducing risk behaviors decreasing spread of HIV Methadone maintenance is an effective and proven modality for treating opiate addiction IDU can respond well to ARV treatment, if the ARV are taken with good adherence

Thank you! Questions?