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Addiction Treatment as HIV Prevention

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Addiction Treatment as HIV Prevention . Charles P. O’Brien, MD, PhD David Metzger, PhD George E. Woody, MD University of Pennsylvania Treatment Research Center. Current AIDS epidemiology. Approximately 33,000,000 living with HIV/AIDS Over 10,000,000 infections among IDU

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slide1

Addiction Treatment

as HIV Prevention

Charles P. O’Brien, MD, PhD

David Metzger, PhD

George E. Woody, MD

University of Pennsylvania

Treatment Research Center

slide2

Current AIDS epidemiology

  • Approximately 33,000,000 living with HIV/AIDS
  • Over 10,000,000 infections among IDU
  • Outside of Africa, over 33% of all new infections are estimated to be attributable to injection drug use
  • No estimates of the major role of alcohol and non-injection drug use such as crack cocaine
predictors of seroconversion in explore drug and alcohol use
Predictors of seroconversion in Explore: drug and alcohol use

* REF = no, light or moderate use of alcohol; no speed use; no use before sex

** Heavy alcohol = 4+ drinks every day or 6+ drinks on a typical day

slide5

IDUs as Percent of Total Registered HIV Cases

Eastern Europe and Central Asian Countries, 2007

Countries with Injection Driven Epidemics, OSI, 2008

slide6

IDUs as Percent of Total Registered HIV Cases

East and South East Asian Countries, 2007

Source: UNAIDS 2008 Report on the Global AIDS Epidemic

slide7

HIV prevention strategies for drug using populations

  • Education about HIV transmission
  • HIV counseling and testing
  • Increased access to sterile injection resources and condoms
  • Drug addiction treatment
  • HIV treatment
slide8

Treatment Options for Opioid Addiction

  • Outpatient drug free counseling- not effective
  • Medication-free therapeutic community-
    • Expensive, not widely available, effective with small proportion of patients
  • Methadone-1964, national program 1971
  • Partial agonist- Buprenorphine
              • Suboxone (combination)
  • Naltrexone oral, depot and implant
slide9

Methadone

  • Full agonist
  • Cross tolerance with all opioids
  • Reduces craving
  • Prevents withdrawal
  • Prevents pleasure from other opioids
  • Low dose not effective
slide11

Suboxone

Buprenorphine Combined with antagonist

Reduces abuse potential

Bup 2 mg: Nal 0,5 mg

Bup 8 mg: Nal 2 mg

(*Bup 16 mg: Nal 4 mg)

(*Bup 32 mg: Nal 8mg)

*tested, not marketed

slide12

Report good effects

60

Placebo

2 mg Bup

8 mg Bup

2 mg Bup/Nx

8 mg Bup/Nx

50

40

Evaluation

30

20

10

0

BL 0h 0.5h 1.5h 2.5h 3.5h 24h 48h

Comer and Collins,The Journal of Pharmacology and Experimental Therapeutics, 303(2), 695-703, 2002

slide13

Treatment Options for Opioid Addiction

  • Naltrexone effective in special populations
  • Physicians, pharmacists, nurses
  • Parolees, Probationers
  • Countries where agonists are not available
  • ADHERENCE
    • Oral
    • Depot
    • Pellet implant
percent opioid free subjects by visit
Percent opioid-free subjects, by visit

Weeks ≤4:

Grace period

Weeks 5 to 24: Assessment period

Note: “Opioid-free” is indicated by urine drug tests (negative for opioids), naloxone challenge results, and TLFB data. Weeks with missing urine test results were imputed as positive.

slide16

Treatment Options for Alcoholism

  • Outpatient drug free counseling- with self-help
    • Alcoholics Anonymous
  • Medication-free therapeutic community-
    • Expensive, not widely available, effective with small proportion of patients
  • Naltrexone: oral, depot
  • Acamprosate
  • Topiramate (off label)
slide17

Treatment Options for Stimulant Addiction

Cocaine, Methamphetamine

Injection, nasal, smoked

  • No FDA approved medication
  • Outpatient counseling
    • Cognitive Behavioral Therapy
  • Medications in clinical trials
  • Vigabatrin
  • Topiramate
  • Modafinil
  • Baclofen
slide18

1

0.8

0.6

0.4

0.2

0

Rate of needle sharing reported by

In-Treatment IDUs compared to

Out-of-Treatment IDUs

Selwyn

Martin

Klee

Williams

Longshore

Metzger

Stark

Capplehorn

et al

et al

et al

et al

et al

et al

et al

et al

1987

1990

1991

1992

1993

1993

1994

1995

slide19

100

80

60

40

20

0

Percent of subjects reporting

injection prior to, during, and

following methadone treatment

Injection

Injection

Injection

Injection

Injection

After Tx

in Prior

in Prior

in Year

Prior to Tx

Entry

Entry

Year

Month

After

Tx

(Ball and Ross, 1991)

slide20

Percent infected after 18 months

by treatment status

22%

Percentage

3.5%

4.5%

Metzger et al 1993

slide21

Conclusions

  • Data suggests effective treatments for drug users:
  • - recognize addiction as a chronic disease - use pharmacologic and counseling
  • interventions
  • - are accessible, acceptable, and affordable
conclusions
Conclusions
  • Behavioral and serologic data support the hypotheses that drug users in treatment: - significantly reduce the frequency of use - practice fewer risk behaviors - have greater access to HIV treatment

- are more adherent to HIV care