1. Treatment Of Medical, Psychiatric, and Substance Use Co-morbidities In People Infected With HIV Who Use Drugs Frederick L. Altice (US, Malaysia, Ukraine) Adeeba Kamarulzaman (Malaysia) Vincent Soriano (Spain) Mauro Schechter (Brazil) Gerald Friedland (US, South Africa)

2. HIV-infected drug users have increased medical and psychiatric co-morbidities HIV and Drug Use Mental Illness (40-60%) Polysubstance Drug Use TB Bacterial Infections Bacterial Infections Chronic Hepatitis C Virus (70-90%) Opportunistic Infections Chronic Hepatitis B Virus ART

3. Emerging Co-Morbidity Among HIV-infected Persons that Use Drugs

4. Medication-Assisted Treatments for Treating Substance Use Disorders Work Opioid dependence (methadone, buprenorphine, depot naltrexone) – Sufficient dosing – Requires management of medication interactions – Integration of services – Opportunities to retain patients in care and optimize adherence to cART – Reduces injecting, but not sexual risk behaviors Alcohol dependence (depot naltrexone, acamprosate)

5. Antiretroviral Medications Work in Drug Users, Yet They Are Seldom Prescribed Outcomes are improved if treatment is optimized – Stabilization through prescription of medication- assisted therapies (methadone, buprenorphine) – Supervised therapy (e.g. DAART) – Adherence and retention support strategies – Effective management of mental illness – Comprehensive, interdisciplinary management preferably through integration of health services – Careful management of pharmacokinetic drug interactions

6. HIV and Tuberculosis Among People Who Use Drugs TB Exposure among drug users is high; reactivation of latent disease is 9% per year Diagnosis is often complicated – Atypical chest radiographs; low (50%) sputum yield Adherence to TB and cART may be simultaneously optimized (MAT, DOT, adherence support) Medication interactions are common, but manageable – Rifampicin reduces levels of MAT and some antiretroviral medications (Rifabutin)

7. HIV and Viral Hepatitis Among People Who Use Drugs HCV infection is extremely common – Chronic HCV is emerging as the leading cause of ESLD and death among HIV+ drug users receiving cART – Treatment (PEG+RBV) is effective & expensive – more effective therapies forthcoming, but untested in HIV+s – Current therapies do not interact with MAT, but HCV treatment is optimized when in methadone treatment Chronic HBV infection is endemic in some regions – When HBV treatment is indicated, use simultaneous treatment for HIV using 2 effective HBV agents

8. Mass Incarceration of HIV+ Drug Users is Hazardous for Individual and Public Health Criminal justice settings, if properly organized, can be effective sites for the diagnosis and treatment of HIV and other co-morbid conditions – Buprenorphine or methadone treatment – Screening, isolation and treatment of TB – Screening and treatment of mental illness, viral hepatitis and STDs Requires effective transitional programs to the community that do not interrupt care

9. Overview of Clinical Management Review of commonly ingested drugs, their effect on clinical status and impact on HIV treatment & prevention Discussion of available MAT for managing dependence on opioids, alcohol and nicotine dependence Synthesis of infectious and non-infectious complications of drug use in HIV-infected persons Exhaustive review of pharmacokinetic drug interactions between MAT, psychotropic, antibacterial and antiretroviral medications Systematic review of interventions that optimize adherence in drug users, especially those with HIV

10. Dima’s Voice from Mykolaiv Co-morbid conditions include HIV, opioid dependence, TB (MDR), HCV, bacterial pneumonia Course complicated by opioid withdrawal, fragmentation of care, loss of driver’s license after getting methadone (registration), artificial ceiling for methadone dosing, forced withdrawal from methadone upon hospitalization, and lack of prescription of cART despite clinical need Has survived despite these obstacles, mostly from shear will My doctors are afraid to raise my methadone dose because they tell me I take too many pills already and that it will hurt my liver. I want to take the HIV cocktail that other guys get, but I’m told that I have to wait because the HIV medications will make me sick, be too much for my liver and eat up my methadone like my other TB medications did. The only reason I’m not in the cemetery like all of my friends is that I’m tough like the steel I weld.