1. Drug Abuse Treatment as HIV Prevention: The State of the Science
David S. Metzger, Ph.D.
University of Pennsylvania
Center for Studies of Addiction
HIV Prevention Research Division
Philadelphia, PA

2. Overview Drug driven epidemics -- overview
Prevention impacts of drug treatment
Drug treatment, access, and adherence to HIV care
Challenges in maximizing the public health impact of drug treatment

3. Current AIDS epidemiology
Approximately 33,000,000 living with HIV/AIDS
Over 10,000,000 infections among IDU
Outside of Africa, over 33% of all new infections are estimated to be attributable to injection drug use
No estimates of non-injection drug use

4. Australia & N. Zealand: 0.19m
Estimated size of IDU population
E. Europe & C. Asia: 3.2m
N. America 1.43m
W. Europe: 1.24m
E. Asia & Pacific 2.35m
Caribbean: 0.028m
MENA:0.44m
S. & S-E Asia: 3.33m
S. Saharan-Africa 0.009m
Australia & N. Zealand: 0.19m
L. America: 0.97m
10.3m (78%) in developing/transitional countries
91% of the world adult population (4 billion) is covered by the data.
Information unavailable for 119 countries.
UN Reference Group on HIV/AIDS prevention and care among IDU

5. What drugs are most commonly injected?
Opiates
ATS
Opiates
Cocaine
ATS
Opiates
ATS
Opiates
ATS
Opiates
Cocaine
Opiates
Opiates
ATS
Opiates
ATS
Opiates
ATS
Cocaine

6. IDUs as Percent of Total Registered HIV Cases
Eastern Europe and Central Asian Countries, 2007
Countries with Injection Driven Epidemics, OSI, 2008

7. IDUs as Percent of Total Registered HIV Cases
East and South East Asian Countries, 2007
Source: UNAIDS 2008 Report on the Global AIDS Epidemic

8. Dependence is a medical condition with common Dx and consequences: ASI Composite Scores: Porto Alegre, Philadelphia and Wuhan

11. Substance-related HIV transmission
Direct and indirect sharing of injection equipment and materials
Unprotected sexual activity Consequences of substance use in all risk groups: MSMs, IDUs, Heterosexuals

12. HIV prevention strategies for drug using populations
Education about HIV transmission
HIV counseling and testing
Increased access to sterile injection resources and condoms
Drug treatment
HIV treatment

13. How does drug treatment prevent HIV infection and transmission?
Effective treatments reduce the frequency of drug use
Fewer drug-related risk behaviors
Fewer new infections
Increased access to HIV treatment and primary care
Increased adherence to HIV medications

14. How does drug treatment prevent HIV infection and transmission?
Effective treatments reduce the frequency of drug use
Fewer drug-related risk behaviors
Fewer new infections

15. Percent of subjects reporting injection prior to, during, and
following methadone treatment 20 40 60 80
100
Injection
Injection
Injection
Injection
Injection
Prior to Tx
After Tx
in Prior
in Prior
in Year
Entry
Entry
Year
Month
After Tx
(Ball and Ross, 1991)

16. Injection rates 12 months following
treatment entry by retention status
(Thiede,Hagan,and Murrill, 2000)

17. Drug use and injection among 557 heroin users by methadone treatment status, Sichuan Province, China
(Han-Zhu Qian et al, 2008)

18. Study outcomes: opiate abstinence
Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200

19. How does drug treatment prevent HIV infection and transmission?
Effective treatments reduce the frequency of drug use
Fewer drug-related risk behaviors
Fewer new infections

20. Rate of needle sharing reported by In-Treatment IDUs compared to
Out-of-Treatment IDUs
0.2
0.4
0.6
0.8 1
Selwyn
Martin
Klee
Williams
Longshore
Metzger
Stark
Capplehorn
et al
et al
et al
et al
et al
et al
et al
et al
1987
1990
1991
1992
1993
1993
1994
1995

21. Needle sharing among 557 heroin users by methadone treatment status, Sichuan Province, China
(Han-Zhu Qian et al, 2008)

22. How does drug treatment prevent HIV infection and transmission?
Effective treatments reduce the frequency of drug use
Fewer drug-related risk behaviors
Fewer new infections

23. HIV prevalence rates among New York IDUs by methadone treatment0%
20%
40%
60%
80%
100%
87%
10%
86 Active Users
35 Long Term MM
(MMRW, 1984)

24. Six year HIV infection rates by treatment status at time of enrollment

25. (Metzger et al. 1993)

26. Incidence of HBV and HCV 12 Months Following Treatment Entry
(Thiede,Hagan,and Murrill, 2000)

27. Agonist treatment is more than substitution
Safe, stable dosing
Drug use monitored
Drug counseling
Access to other services

29. Naltrexone and drug counseling treatment in St. Petersburg
1,0
N+F ,9
N+P ,8
F+P
P+P ,7
Percent remaining in Treatment
N+F>P+P ,6
N+F>F+P
N+P>P+P ,5
N+P>F+P
F+P=P+P ,4
N+F=N+P ,3 ,2 3 6 9 12 15 18 21 24 27 30
Weeks

30. Buprenorphine/Naloxone offers new opportunities for treatment in HIV care settings
Partial agonist, longer half-life
Reduced risk of overdose
Less severe withdrawal
Fewer interactions with anti-retrovirals

31. Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial.
Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200

32. Maintenance treatment with buprenorphine, naltrexone, and counseling for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial.
Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200

33. Study outcomes: opiate abstinence
Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200

34. Study outcomes: HIV risk reduction
Schottenfeld, R.S., Chawarski, M.C., & Mazlan, M. Lancet 2008, 371: 2192–200

35. Seroconversion by treatment participation: retention is critical1 2 3 4
One or More
Less Than One Year
Years
of Methadone
of Methadone
Treatment
Treatment
(Moss et al. 1994)

36. Limitations of treatment studies
Measurement variability
Treatment variability
Short follow-up
Focus on opiate dependent injectors
No randomized trials with HIV endpoints

37. If not eligible, referred
HPTN 058 Study Design
Short term Suboxone
At Bx and 6 months
plus one year
counseling;
Referral to
local resources
HIV testing and
counseling
Every 6 months
Year 02
Opiate injectors
recruited from
community
and screened
12 month Suboxone
plus one year
counseling;
Referral to
local resources
HIV testing and
counseling
Every 6 months
Year 02
If not eligible, referred
to local resources

38. HIV Infected Population
Durable Viral
Suppression
Adherence =
Start therapy
Substance Abuse
Engage in medical care
Concept slide – serve as the outline of talk
In the aqua-marine boxes is the pathway HIV infected patients must follow to reach the ideal endpoint
Go through each step
Risk factors can act at every step to impede progress
What are these risk factors? – Lets start with this first step
HIV Infected Population

39. Adherence with antiretroviral therapy is adversely affected by drug use
Not using cocaine (n=57)
Using cocaine (n=20)
P value
Adherence
(MEMS Caps)
68%
27%
0.005
Viral suppression
46%
13%
Arnsten JH. J Gen Intern med 2002;17:377

40. Adherence to HIV medications by drug use
Lucas et al, 2002

41. Risk of developing new opportunistic infection according to drug use status
Lucas et al. Am J Epidemiol 2006

42. Adherence by past and current drug and alcohol diagnoses
Alcohol Drug
Current diagnoses p<.01 p<.01
Lifetime diagnoses NS NS

43. Maximizing the impact of drug abuse treatment as HIV prevention
Accessible
Acceptable
Affordable

44. Continuum of Drug Use and Treatment
Abuse
Dependence
Out-patient Detoxification +
Residential Agonist/Antagonist
Outreach Drug free Out-patient
Harm Reduction Antagonist Counseling
Counseling Counseling

45. Estimated Opiate dependent Drug Users in Agonist Treatment per 100,000 population

46. HIV prevention and care implications: Necessary but not sufficient
Drug Treatment Community Harm Outreach Reduction
HIV Care

47. Conclusions
Behavioral and serologic data support the hypotheses that drug users in treatment: significantly reduce the frequency of use practice fewer risk behaviors have greater access to HIV treatment
are more adherent to HIV care

48. Conclusions Data suggests effective treatments for drug users:
recognize addiction as a chronic disease (at least one year) use pharmacologic and counseling interventions
are accessible, acceptable, and affordable

49. Future directions Expand access to effective treatments
Target drug users earlier in the continuum of use
Test interventions for use of multiple substances
Measure HIV risk endpoints in clinical trials of new medications
Urgent need to sustain search for pharmacologic treatments for stimulant abuse

50. Ignorance Poverty Sexism Access Discrimin- To ation Care Disem-
powered
Women
Stigma-
tization
Human
Rights
Abuses
Prejudice
Denial
High Risk
Behavior
Complacency
Courtesy of Jim Hoxie