Brown University

Briefly review the epidemiology of drug use disorders and HIV in the United States

Discuss the relationship between HIV and specific drugs of abuse; including non-IDU

Review the impact of illicit drug use on HIV acquisition and progression; the laboratory and clinical experience

Discuss the syndemics that link substance misuse and HIV

Briefly discuss the impact of substance misuse on the acquisition of other infectious diseases

Close with HIV prevention highlights

Nearly 50% of U.S. population >12 years have tried an illicit drug

Approximately 2% of current U.S. population meets the DSM-IV criteria for having a drug use disorder

Almost 1 million substance use / misuse-related ED visits annually

Strong link between substance use and other risk-taking behaviors1,2

1.1 million Americans infected

Incidence has been stable for past 20 years

Over 20% of seropositive Americans are yet to be diagnosed; approximately 1:3 known HIV-positive patients are not actively engaged in care

A disproportionate burden of disease is seen within minority populations: Blacks, Hispanics, MSM, IDU

23-56% of all HIV-infected patients have a history of illicit drug use3

IDU account for almost 13% of all new HIV diagnoses4

HIV incidence among IDU has dropped by nearly 80% in past 30 years5

Excess use of alcohol or other non-injection drugs is a well recognized risk factor for the acquisition of HIV infection

Sub-Saharan Africa experience45

Increased ETOH quantity and risky sexual behaviors

The impact of drug use on HIV disease progression is mixed. To date, there is inconclusive evidence that substance use directly affects HIV disease progression7

Drug abuse may exacerbate HIV disease progression

Illicit drug use can have direct immunosuppressive affects

Opiate withdrawal can have negative impact on immune function and virus activity25,26

Mouse models have shown significant increases in circulating HIV load among mice exposed to cocaine27

Animal models suggest alcohol may increase HIV susceptibility28,29

Results from large cohort studies done in U.S. and Europe present mixed findings with regard to immune status, viral replication, time to AIDS and death

No significant difference in T-cell decline

Pezzotti et al.30

▪Active v. Inactive IDU

▪ALIVE Study31

▪Risk category

Lyles et al.32

▪Different patterns of drug use

Neurological Outcomes

No difference in neuropsych testing among seronegative v. seropostive

IDU41-44

Time of Progression to AIDS

Most recent studies suggest no difference according to current drug use status or frequency of IDU33,34

Smoking illicits drugs increases rates of pulmonary AIDS illnesses including bacterial pneumonias such as MTb35,36

▪Women’s Interagency HIV Study49

Mortality

Among those who survive long enough to develop an AIDS-defining illness, no difference in survival length between IDU and other risk groups37,38

No significant difference in HIV progression among IDU v. other RFs

Higher HAART-associated PVL in active IDU a/w adherence issues39

Disease-free survival among IDU’s lower in HAART era40

Drug misuse is NOT a contraindication to prescribing HAART

Two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population11

Substance misuse, Mental health disorders, and HIV

Bing et al. Among 2,684 individuals living with and receiving care for HIV:12

50% screened positive for a psychiatric disorder

40% reported using an illicit drug other than marijuana

Nugent et al. 87% of “distressed”YLH reported significantly more past-month ARV nonadherence (odds ratio [OR] = 7.15) and were more likely to have unprotected sex under the influence (OR = 5.14) than nondistressed youth10

Substance misuse, Violence, and HIV

Substance misuse, MSM, and HIV

MAPHS46

Polydrug use during sex significantly associated with UAS

Most drug use among MSM is sporadic and a/w social events and sex47,48

Urban Men’s Health Study48

High prevalence of substance misuse within MSM / Bisexual community13

High level of depression / distress within the study cohort14

MACS15

CM (1.46) and AN (2.10) use was significantly associated with HIV seroconversion

A multiplicative effect was seen with combined CM and “poppers” (3.05)

Joint dose–response relationship between CM and URASP with HIV seroconversion (2.71 – 13.57)

Those with dual and triple diagnoses are more likely to

15-24 year olds acquire nearly half of all incident STDs while accounting for just 25% of the sexually active population8

Young adults who drink heavily are twice as likely to have an STD than those who do not drink or use drugs (3.1 v 1.4%)9

Almost 4% of all young adults who abuse both illicit drugs and alcohol have been diagnosed with an STI within the past 12- months (abusing females – 7.9%, All young adults – 2.1%)9

Background:

Symptomatic HCV infections declined in the US from 1992-2005 then stabilized

18-24yo cohort has highest rate of HIV testing and lowest rate of HCV testing

Average annual number of heroin initiates in the U.S. nearly doubled between 2002-2009; particularly among young users

Increase in HCV observed among 15-24 year-old cohort in MA between 2002-2006

Active surveillance done by MDPH between 2007-2009

Mostly seen among non-Hispanic whites (78%)

Equally distributed among males and females

IDU most common RF (72% h/o current or past IDU)

Similar trends seen in other states

FIGURE 1: The figure shows rates of newly reported cases of hepatitis C virus infection (confirmed and probable) among persons aged 15- 24 years and among all other age groups in Massachusetts during 2002-2009. Rates increased from 65 to 113 cases per 100,000 population.

* N = 6,281; excludes 35 cases with missing age or sex information.

† N = 3,904; excludes 346 cases with missing age or sex information.

FIGURE 2: The figure shows age distribution of newly reported confirmed cases of hepatitis C virus infection in Massachusetts for 2002 and 2009. The data shifted from a unimodal age distribution in 2002 to a bimodal age distribution in 2009, with the latter showing substantially more reports of HCV infection among adolescents and young adults compared with the earlier period

Drug addiction treatment programs, irrespective of modality, associated with improved adherence to ART17

Opioid agonist therapy associated with improvements in HAART uptake and adherence18,19

NNRTI’s and PI’s are potent inducers of the P450 enzymatic pathway significantly reducing methadone levels potentiating complications of withdrawal

BPN/NLX therapy acceptable, safe and effective among released HIV-infected and opiate abusing, prisoners20

Substance use disorders are frequently interrelated with other co-morbidities that increase the risk of HIV-acquisition and progression

Effective HIV-care is dependent upon integrated substance misuse screening, treatment, and prevention efforts

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