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HIV/AIDS and Drug Use in the United States: Models for Strategic Planning. Steve Shoptaw, Ph.D. UCLA Integrated Substance Abuse Programs June 6, 2005. Key Points. Concentrated versus generalized AIDS epidemics AIDS-related behaviors vary by geography

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hiv aids and drug use in the united states models for strategic planning

HIV/AIDS and Drug Use in the United States: Models for Strategic Planning

Steve Shoptaw, Ph.D.

UCLA Integrated Substance Abuse Programs

June 6, 2005

key points
Key Points
  • Concentrated versus generalized AIDS epidemics
  • AIDS-related behaviors vary by geography
    • Risk behaviors emerge and change with time
  • Drug abuse is more than injection behaviors
  • Interventions for AIDS prevention with drug users
    • Behavioral risk reduction, needle exchange, substance abuse treatment, prevention for positives, post exposure prophylaxis, pre-exposure prophylaxis
international generalized epidemic
International: Generalized Epidemic
  • HIV passed efficiently in general population
  • Primary signal of generalized epidemic is high numbers of infected pregnant women
u s concentrated epidemic
U.S.: Concentrated Epidemic
  • Defined behavioral risk groups associated with HIV infection
    • Injecting drug users (IDU)
    • Men who have sex with men (MSM)
    • IDU+MSM
geography hiv prevalence and idus
Geography, HIV Prevalence and IDUs
  • West of the Mississippi River, prevalence rates remain much lower than in the East
  • No differences in risk behaviors
  • May be attributes of the heroin itself can be protective

HIV Prevalence in IDU 1994-1996



Garfein et al., 2004

sexual hiv transmission in idus san francisco
Sexual HIV Transmission in IDUs: San Francisco
  • 58 HIV incident infections, 1134 case controls who remained negative from 1986-1998
  • MSM 8.8 times as likely to seroconvert as hetero men (95% CI 3.7-20.5)
  • Women who traded sex for cash 5.1 times as likely to seroconvert (95% CI 1.9-13.7)
  • Women younger than 40 2.8 times more likely than older women to seroconvert (95% CI 1.1-7.6)

Kral et al., 2001

los angeles aids epidemic cumulative male aids cases

Los Angeles AIDS Epidemic:Cumulative Male AIDS Cases

Los Angeles*United States**

MSM 76% 58%

MSM and IDU 7% 8%

IDU 6% 22%

Other 11% 12%

*January 2004 HIV Epidemiology Report, LA County

**March 2005 HIV/AIDS Surveillance Report, CDC


U.S. Adult Male AIDS Cases by Risk Behavior by Year

CDC, 2004

L.A. County Adult Male AIDS Cases by Risk Behavior by Year

L.A. County HIV Epi Pgm, 2004


U.S. Adult Female AIDS Cases by Risk Behavior by Year

CDC, 2004

L.A. County Adult Female AIDS Cases by Risk Behavior by Year

L.A. County HIV Epi Pgm, 2004

summary epidemiology i
Summary: Epidemiology I
  • All epidemics are local: Prevalence and incidence rates of HIV and AIDS vary by geography
    • In the Western U.S., metropolitan areas have lower HIV prevalence rates among IDUs than in less populated cities/areas
    • A model is provided, complete with internet resources that can help you develop a “snapshot” of your local epidemic
associations between drug dependence sexual orientation and hiv risk behaviors
Associations Between Drug Dependence, Sexual Orientation, and HIV Risk Behaviors
  • Analysis of 13 treatment research studies
    • Four classes of drug dependence
    • Common assessments at identical points

Shoptaw et al., in review



  • Stimulant dependent groups, especially MSM who are dependent on methamphetamine, have highest risks for HIV transmission
  • MSM methamphetamine users 61% HIV infected; no non-MSM methamphetamine users detected to date.
  • Risk is a function of drug class, sexual orientation and proximity to infectious disease
some more numbers
Some More Numbers…
  • HIV prevalence in methadone clinics ~ 5-10%
  • Incidence of HIV infection observed ~ 8-10 ppy for MSM in Seattle STD clinics (Golden 2003)
  • Methamphetamine use, past 6 months
    • 11.2% of MSM in Los Angeles
    • 13.3% of MSM in San Francisco (Stall et al., 2001)
  • Prevalent in clubs in New York (Halkaitis, 2003)
  • Methamphetamine use in HIV care clinics ~ 30-40% (St Mary’s Hospital, Long Beach)
msm in commercial sex venues
MSM in Commercial Sex Venues

Percent Reporting

Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049

Reback, 2004

drug risks msm in commercial sex venues
Drug Risks, MSM in Commercial Sex Venues

Percent Reporting

Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049

Reback, 2004

hollywood street outreach msm
Hollywood Street Outreach, MSM

Reback, Grella, & Shoptaw, 2003

drug use where there is no virus is a drug abuse problem
Drug Use Where There Is No Virus Is A Drug Abuse Problem…

In Los Angeles County, heroin injectors at low risk; gay male meth users at extreme risk

LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)

treatment outcomes and risk
Treatment Outcomes and Risk
  • Influence of culture on treatment: materials, outcomes, and processes
    • Sophisticated culture
    • Disdain for total abstinence
    • Sensitivity to judgment and rejection
  • Issue of risk and its reduction
    • Meaning of sex without crystal use in recovery

The Formative StudyThe Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los

methamphetamine and hiv in msm a time to response association
Methamphetamine and HIV in MSM: A time-to-response association?

1Deren et al., 1998, Molitor et al., 1998; 2Reback et al., in review; 3Reback, 1997; 4Shoptaw et al., 2002; 5VNRH, unpublished data

if one believes there is a problem what are the intervention choices
If one believes there is a problem, what are the intervention choices?

Broad Based Approach: Provide HIV prevention to current users (and non-users) at all levels (e.g., condom distributions)

  • Presumes intact decisions/choices around sexual behaviors in most people

Targeted Approach: Provide drug abuse treatment to users with abuse or dependence

  • Centrality of drug/sex link in decisions/choices for small, heavily drug involved group



interventions methamphetamine using msm
Interventions:Methamphetamine Using MSM

Behavioral Prevention

Biological Adjuncts

  • To evaluate the comparative efficacy of behavioral drug abuse treatments in gay and bisexual, methamphetamine-dependent men in Los Angeles :
      • Methamphetamine use
      • High-risk sexual behaviors
      • Depression ratings


Randomization and Baseline




CM (n=42)

CBT (n=40)


CM + CBT (n=40)

GCBT (n=40)

2 Week Baseline

16 Week 1st Follow-up

6 Months

12 Months 2nd Follow-up


Adaptation of a Gay-Specific Intervention

Standard CBT CBT+ gay-specific HIV-Risk Reduction

External Triggers: Sporting Events Gay Pride Festival Concerts Bathhouse Movies Halloween

Relapse Justification: “I just got injured. “My friend just died I might as well use.” [AIDS] and using will make me forget for awhile.”

One Day at a Time: “Tomorrow something “I seroconverted even will happen to ruin though I knew about this.” safer sex.”

Specific Topics:

* Coming Out All Over Again: Reconstructing Your Gay Identity

* Being Gay and Doing Gay

* Preventing Relapse to High-risk Sex

* Living in an HIV World

* Several session that involve “Aunt Tina”

  • Contingency Management (CM)
    • Peeing for Dollars!
    • $415 earned in vouchers; 34% of total possible
  • Combination CBT+CM
    • Talk and behavioral therapy
    • $662 (SD=478) earned or 51.8% of possible
      • (t (80) = -2.4, p = .019)
sample demographics
Mean age: 36.6 (SD=6.4)


95.7% > HS

41% > 4-year degree


Caucasian: 77.2%

Hispanic: 12.9%

African-Am: 3.1%

Asian-Am: 3.1%

Native Am: 1.2%

Sample Demographics

History of Sexually Transmitted Diseases

by Reported HIV Serostatus

HIV Serostatus Positive Negative


% %

Genital warts



2 (1) = 8.05, p=.005




2 (1) = 9.32, p=.002

Genital Gonorrhea



2 (1) = 7.72, p=.005

Yeast infection



2 (1) = 10.14, p=.001

Hepatitis B



2 (1) = 9.67, p=.002

Shoptaw et al., 2003

baseline drug use
Baseline drug use
  • Drug use behaviors
    • Lifetime MA use: 8.34 yrs (SD=5.9)
    • Lifetime heavy MA use: 3.39 yrs (SD=4.07)
    • Lifetime other drugs used: 2.3 (SD=1.4)
    • Lifetime IV MA use: 32.1%
    • MA use in past 30 days: 9.7 days (SD=7.4)
    • $ spent on MA past 30 days: $293 (SD=$399)
contingency management
Contingency Management
  • Significantly longer retention
  • Significantly more “clean urine”
  • Significantly longer stretches of consecutive clean urine samples
summary of findings
Summary of Findings
  • Treatment gains are sustained to 1 year follow-up evaluation
    • CM helps in the short term to reduce MA use
    • GCBT helps reduce short-term high-risk sexual behaviors
  • Drug treatment methods induce sustained risk behavior changes
policy implications
Policy Implications
  • “Syndemic” of drug use and HIV infection in gay men
    • Work at the core of overlapping epidemics
  • Inclusion of treatment approaches in CDC compendium of evidence based guidelines
  • Treatment on demand for gay stimulant abusers?
next steps treatment as prevention
Next Steps:Treatment as Prevention
  • $3 million State Office on AIDS RFA in California
  • Promoting effective treatment approaches for new settings
    • STD clinics (Klausner, SF)
    • Sex venues (L.A. County)
    • AIDS Care settings (Peck, UCLA)
    • HIV Prevention approaches (CHIPTS, UCLA)
  • Integration of medication treatments (Newton, UCLA)
  • Epidemiological implications (Gorbach, UCLA)
the million dollar questions
The Million Dollar Questions
  • Is HIV leaking from defined behavioral risk groups to general population?
  • At what rate is this leakage happening?
  • SATH-CAP project
prevention approaches for idus
Prevention Approaches for IDUs

Needle Exchange


HIV Counseling & Testing

Opioid replacement

needle exchange
Needle Exchange
  • NE conceptualized within larger set of services (Des Jarlais, 2000)
    • Number of NEPs increasing 20% per year
  • NEP attendees less likely to share needles and more likely to clean skin (Longshore et al., 2001)
  • NEP attendance protective against HIV (Monterroso et al., 2000)
prevention works for idus even in low prevalence cities
Prevention Works for IDUs Even in Low Prevalence Cities
  • High prevalence groups
    • < 30 yr old (2.8%)
    • MSM (3.0)
  • Prior C & T reduced odds for infection (OR=0.43; 95%CI= 0.21, 0.87)

Kral et al., 2003

opioid agonist replacement
Opioid Agonist Replacement
  • Opioid agonist care is associated with decreased injection and sex-related HIV risk behaviors (Sorensen and Copeland, 2000)
opioid detoxification a prescription for failure
Opioid Detoxification: A Prescription for Failure
  • The best available data suggest that inpatient detoxification may show acceptable outcomes (Day et al., 2005), but any outpatient pharmacological detoxifications result in indefensible relapse rates and should not be considered as treatment (Amato et al., 2004)
    • Psychosocial strategies are even less effective and also should not be considered as treatment (Mayet et al., 2005)
  • Newly detoxified individuals are extremely vulnerable to relapse. The vast majority fail to remain drug-free.
  • Opioid maintenance should be the first-line treatment for heroin dependence.
opioid replacement
Opioid Replacement
  • Methadone
    • Medication is inexpensive; staff to run licensed narcotic treatment programs push annual cost to about $4500
    • Schedule 2 narcotic
    • 160,000-200,000 people in U.S. receiving methadone
    • NTPs are efficient platforms for education and testing for HIV, Hepatitis C, Tuberculosis

Krambeer et al., 2001)

a different medical hiv prevention post exposure prophylaxis
A Different Medical HIV Prevention:Post Exposure Prophylaxis
  • Routine treatment for health care workers accidentally exposed
    • Perhaps reduces odds of seroconversion by 79% (CDC, 1997)
  • Experimental programs evaluating PEP for drug and sexual exposures
  • May have particular value as intervention in drug users
sometimes your best thinking
Sometimes Your Best Thinking...
  • 2 participants tested HIV positive at baseline
  • 15.8% had substance metabolites in urine - 10.5% methamphetamine - 5.3% cocaine - 2.1% opiates
  • 49.0% unprotected receptive anal intercourse
  • 36.5% unprotected insertive anal intercourse
  • 4.2% unprotected receptive vaginal intercourse
  • 16.7% unprotected insertive vaginal intercourse
  • 84.4% unprotected oral sex
  • 3.1% other

(Activities are not mutually exclusive)

  • PEP may be attractive theoretically
  • Not likely to be useful to the population for which it might have the most efficacy
    • PEP programs are hard to find
    • Drug users have competing demands for their time
    • Drug users have difficulty with compliance and structure
  • Boost medication efficacy for preventing HIV infection by having ARV on board at the moment of exposure to HIV
  • Some suggestion that this might be especially effective in HIV-uninfected groups who engage in high-risk sexual behaviors +/- drug use
implications of prep
Implications of PrEP
  • Analogous to “imperfect vaccine”
  • Requirements are difficult to reach for PrEP to make measurable impact on infections
    • High coverage
    • High efficacy
    • High prevalence and incidence
  • May still be strong arguments for implementing this in select groups

Szekeres et al., 2005;