1. 1 HIV and Injection Drug Use HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 2 Learning Objectives By the end of this session, participants should 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)

3. 3 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

4. 4 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

5. 5 Distribution of HIV/AIDS Cases in Vietnam Source: MOH

6. 6 HIV Prevalence Among IDUs, 2009 HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009

7. 7 HIV Trends Among IDUs, 2006-2009 HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009

8. 8 Opioids

9. 9 Overview of Opioids (1) Class of drug that includes: 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

10. 10 Overview of Opioids (2) High doses can cause respiratory depression, coma and death In Vietnam, most commonly used illicit opioids are heroin and opium

11. 11 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

12. 12 Heroin (2) Pregnancy: withdrawal dangerous to fetus, pregnant women should be maintained on methadone Overdose: when mixing drugs or after period of abstinence

13. 13 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

14. 14 Opioid Withdrawal Symptoms Withdrawal symptoms: Muscle and joint pain Abdominal cramps Nausea, vomiting Diarrhea Cough Chills Physical signs: Dilated pupils Tachycardia Hypertension Hyperactive bowel signs

15. 15 Treatment for IDU

16. 16 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

17. 17 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

18. 18 Skin Lesions of Injection Drug Users Non-healed puncture wounds along vein with accompanying inflammatory changes

19. 19 Skin Abscess from Injection Drug Use

20. 20 Barriers to Care for IDU Stigma Discrimination Social marginalization Closed settings, including incarceration Unsafe injecting practices Communicable disease Physical and sexual violence

21. 21 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

22. 22 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

23. 23 What is the Harm Reduction Approach? What are Some Examples of Harm Reduction?

24. 24 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

25. 25 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

26. 26 What is Methadone Maintenance? What are the Goals of Methadone Maintenance?

27. 27 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

28. 28 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

29. 29 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 Kuehn, JAMA 2005.

30. 30 ART for Intravenous Drug Users

31. 31 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

32. 32 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 Wood E et al. AIDS, 2005, 19:1189–1195.

33. 33 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 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

34. 34 Thank you! Questions?