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HIV and Injection Drug Use. HAIVN Harvard Medical School AIDS Initiative in Vietnam. Learning Objectives. By the end of this session, participants will be able to: Explain the link between HIV and intravenous drug use in Vietnam Explain how to diagnose drug addiction
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HIV and Injection Drug Use HAIVNHarvard Medical School AIDS Initiative in Vietnam
Learning Objectives By the end of this session, participants will 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)
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
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
Distribution of HIV/AIDS Cases in Vietnam Source: MOH
HIV Prevalence Among IDUs, 2009 HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009
HIV Trends Among IDUs, 2006-2009 HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009
Overview of Opioids (1) • Opioids: • relieve pain and bring on feelings of well-being • slow down functions of the central nervous system, including respiration • Class of drug that includes: • Morphine • Heroin • Methadone • Buprenorphine • Opium • Codeine
Overview of Opioids (2) • High doses can cause respiratory depression, coma and death • In Vietnam, most commonly used illicit opioids are heroin and opium
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
Heroin (2) • Pregnancy: withdrawal dangerous to fetus, pregnant women should be maintained on methadone • Overdose: when mixing drugs or after period of abstinence
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
Opioid Withdrawal Symptoms • Physical signs: • Dilated pupils • Tachycardia • Hypertension • Hyperactive bowel signs • Withdrawal symptoms: • Muscle and joint pain • Abdominal cramps • Nausea, vomiting • Diarrhea • Cough • Chills
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
Medical Complications of IDU (2) • Viral infections • HIV, HCV, HBV • Mycobacterial infections • 10X increased risk for TB among HIV negative IDU • Bacterial infections • Bacterial endocarditis • Osteomyelitis • Skin and soft tissue infections • Septic thrombophlebitis • Septicemia
Skin Lesions of Injection Drug Users • Non-healed puncture wounds along vein with accompanying inflammatory changes
Barriers to Care for IDU • Stigma • Discrimination • Social marginalization • Closed settings, including incarceration • Unsafe injecting practices • Communicable disease • Physical and sexual violence
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
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
What is the Harm Reduction Approach? What are Some Examples of Harm Reduction?
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
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
What is Methadone Maintenance?What are the Goals of Methadone Maintenance?
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
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
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.
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
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.
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 or reducing risk behaviors • 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
Thank you! Questions?