1. Disclosure Information Biomedical HIV Prevention among Populations with Mental Illness and/or Substance Use: Needs and Challenges Robert Bolan, MD Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose. Robert Bolan, MD I have no financial relationships to disclose - and I will not discuss off label use and/or investigational use in my presentation

2. Biomedical HIV Prevention among Populations with Mental Illness and/or Substance Use: Needs and Challenges Robert Bolan, M.D. Medical Director, Director of Clinical Research

3. The Need: Crystal Meth continues to fuel the Epidemic 772 (8.25%) of 9,356 unique clients who tested at LALGBT Center in 2011 reported meth use within the last year CMU’s had significantly higher odds than non-CMU’s for contracting:  HIV(OR 4.18)  GC (OR 2.23)  CT (OR 1.63)  Syphilis(OR 2.83) Of incident HIV, GC, CT and Syphilis infections among CMUs, 61-63% had used within the past month

4. Frequency of Unique HIV NAAT Positive Tests, January 2011 - December 2011 (N=10,332) NAAT Results Positives*TestsPercent Meth Users 107031.42% Non-Meth Users 219,6300.22% Total 3110,3320.30% *Individuals were only counted as NAAT positives if their infection was acute, i.e. they tested rapid blood negative but HIV NAAT positive

5. Syndemics of psychosocial problems and HIV risk: In the theory of syndemics, diseases co-occur in particular temporal or geographical contexts due to harmful social conditions (disease concentration) and interact at the level of populations and individuals, with mutually enhancing deleterious consequences for health (disease interaction). Examined 34 published articles, 5 dissertations, 1 conference abstract Less than half provided sufficient information or used appropriate statistical models to interpret hypothesized interaction More rigor needed in study design to quantify and explain risk amplification Tsai AC Tsai AC 1, Burns BF 2. 2015 AugBurns BF

6. HIV prevention advice for people with serious mental illness. Authors searched the Cochrane Schizophrenia Group's Trials Register (24 January, 2012), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. They did not identify any randomised studies that evaluated advice regarding HIV for people with serious mental illness. Wright NWright N. 2014 Cochrane Database Syst Rev.

7. The effect of psychosocial syndemic production on 4- year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men Among 4295 men, there was a statistically significant positive dose-response relationship between numbers of syndemic conditions and HIV seroconversion for all comparisons (with the greatest hazard among those with 4-5 conditions, adjusted hazard ratio = 8.69) Given moderate effect sizes attained by brief behavioral interventions to date, the authors recommend an integrated assessment of psychosocial comorbidities and treatment services into HIV prevention services Mimiaga MJ Mimiaga MJ 1, et al. 2015

8. Depression and sexual risk behaviours among people who inject drugs: a gender- based analysis. Vancouver study (Dec 2005 – Nov 2009) of 1017 PID 331 (32,5%) women  At baseline the women had higher depressive sx than men (p<0.001)  More severe sx independently associated with condomless sex (AOR 1.62) and multiple sex partners (AOR 1.54) than men Call for improved integration of psychiatric screening and treatment services for HIV prevention services Since PrEP and PEP require some degree of engagement in medical services it should be easy to address referral for care for conditions predictive of HIV risk as part of PEP/PrEP services Pettes T. 2015

9. Other important opportunities to address conditions of heightened risk for HIV in terms of PEP and PrEP Histories of childhood sexual abuse (Boroughs 2015)  Estimated to be as high as 46%  Associated with increased risk of HIV acquisition  Higher incidence of alcohol use disorder, reporting an STI in past year, high risk sexual activity Poverty, depression, substance use, binge drinking strongly associated with HIV risk behaviors among a cohort study (Project DISRUPT) of incarcerated African American men (Khan 2015)

10. PrEP for PWID Bangkok Tenofovir Study (Lancet 2013)  49% reduction in HIV infections in drug arm  74% reduction among subjects with detectable levels of TDF  Injection and sexual behavior risks decreased in both arms of the study Ukranian study of PWIDs (PLoS One 2012) reported that 86% would be definitely (53%) or probably (33%) likely to take PrEP if available Challenges  Access  Adherence in real world setting without study support systems  Continuity if incarcerated

11. Street Markets for ARVs Widespread diversion of antiretroviral (ARV) medications to illicit markets for money or drugs has recently been documented among indigent patients in South Florida. (Surrat, Kurtz 2013) The selling and trading of ARVs is associated with non- adherence among diverters (Surratt et al., 2013), increasing the risk of treatment failure and disease transmission (Bangsberg et al., 2001), as well as drug resistance and PrEP failure among non-medically supervised end users (Hurt, Eron, and Cohen, 2011). Kurtz, 2014

12. Scope of Problem 515 substance using men who have sex with men in South Florida were interviewed  Median age 39  46.4% HIV positive: 79% were Rx’d ARVs: 27% reported selling/trading ARV’s  Of those who diverted their ARV’s 47% did so for trade or money  ARV diverters more likely to be substance dependent than non-diverters  Fewer than half (42%) of HIV-neg men had health care coverage (it’s Florida remember), whereas of the HIV-positive men, 86% had health care coverage