1. Amphetamine-group substances and HIV 1.San Francisco Department of Public Health, San Francisco, USA 2.University of California San Francisco, San Francisco, USA 3. South African Medical Research Council, Cape Town, South Africa 4. Independent Consultant, Chennai, India 5. Columbia University, New York, NY, USA Grant Colfax 1,2, Glenn-Milo Santos 1, Priscilla Chu 1, Eric Vittinghoff 2, Andreas Pluddemann 3, Suresh Kumar 4, Carl Hart 5 HIV in people who use drugs 5

2. Key points-1 Amphetamine-group substance (AGS) use more common than opiate and cocaine use Association between AGS use and sexual risk and HIV/STI infection well-documented – “Sex drug” in many populations – Risk elevated with among episodic users – Risk elevated among non-injectors All AGS users should have access to: – Drug treatment – Testing and treatment for HIV and other STIs – Needle and syringe access Treatment not incarceration

3. Key points-2 Treatment – Intensive interventions reduce AGS use – Culturally-tailored and incentive-based interventions are most effective – Challenges and outcomes similar to tx for other substances – Treatment limited by lack of methadone/buprenorphine equivalent HIV prevention – Stopping AGS use is associated with reduced HIV risk – Need for more intervention testing in diverse populations – Interventions must scale up and reach active users – HIV care and AGS treatment should be integrated

4. AGS Prevalence In 2007, 16-51 million people used AGS – 230-640 metric tons produced; 44 tons seized Use is increasing in East and Southeast Asia, and Middle East. Most AGS use is non-injection High-prevalence among men who have sex with men (MSM)

5. AGS and Risk for HIV Infection HIV-related risks associated with AGS use well documented – Some studies show use doubles risk of HIV infection AGS may increase susceptibility to HIV through a myriad of pathways – Behavioral, psychological, physiologic, immunologic Episodic AGS use associated with HIV risk – Not just persons with dependence

6. Interventions Combination of multi-level interventions needed Structural and policy – Precursor regulation: Limited evidence of effectiveness – Social marketing Some well received, efficacy unproved Pharmacotherapy – Great need – No medication approved for treatment

7. “Nothing about us without us…” “John,” – 49 year old gay man tells of his methamphetamine dependence – Multiple sex partners, seroconverts – Loss of job, partner, home increased social isolation – Behavioral treatment successful Multiple relapses Challenge of resuming sexual activity without meth

8. Meta-analysis results Colfax, et al., Lancet, 2010. © Elsevier

9. Conclusions High-intensity interventions efficacious for reducing AGS use Additional interventions needed to address different AGS use patterns and sexual risk Need to integrate and coordinate HIV testing, prevention and care with treatment for AGS use Search for effective, scalable, and sustainable interventions for AGS use, including pharmacotherapies must be supported and realized

10. Acknowledgments SFDPH: Rand Dadasovich, Moupali Das, Barbara Garcia, Mitch Katz, Tim Matheson, Deirdre Santos, Michaela Varisto UCLA: Uyen Kao, Steve Shoptaw UCSF: Stephen Bent UCSD: Thomas Patterson Lancet: Pamela Das Series Steering Committee: Chris Beyrer, Adeeba Kamarulzaman, Kasia Malinowska-Sempruch, Steffanie Strathdee “John,” and all the AGS users who participate in research, inform policy, advocate for care, and share their stories