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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 – 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 • HIV passed efficiently in general population • Primary signal of generalized epidemic is high numbers of infected pregnant women 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 National Prevalence United States: Recent HIV/AIDS Cases CDC, 2005 AIDS Prevalence by Behavioral Risks, 1981-2002 MSM IDU Los Angeles 71.3% MSM+ IDU 7.0% 6.6% Het Other 4.6% 10.4% San Francisco 74.3% 8.8% 13.5% 1.7% 1.7% Denver 71.3% 7.5% 11.1% 5.1% 4.9% Albuquerque 68.6% 8.9% 10.7% 4.6% 7.2% Salt Lake City 64.2% 18.1% 8.5% 4.7% 1.9% New York City 29.5% 41.5% 3.2% 9.8% 16.0% http://wonder.cdc.gov 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 21.5% 2.3% Garfein et al., 2004 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 MSM Los Angeles* 76% United States** 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 90 80 70 60 50 40 30 20 10 0 MSM MSM+IDU IDU Hetero Other CDC, 2004 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 L.A. County Adult Male AIDS Cases by Risk Behavior by Year 90 80 70 60 50 40 30 20 10 0 MSM MSM+IDU IDU Hetero Other 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 L.A. County HIV Epi Pgm, 2004 U.S. Adult Female AIDS Cases by Risk Behavior by Year 70 60 50 IDU Hetero Other 40 30 20 10 CDC, 2004 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 L.A. County Adult Female AIDS Cases by Risk Behavior by Year 70 60 50 IDU Hetero Other 40 30 20 10 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 L.A. County HIV Epi Pgm, 2004 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 • Analysis of 13 treatment research studies – Four classes of drug dependence – Common assessments at identical points Shoptaw et al., in review Demographics Male % Coc Dual MA G-MA Her (476) (120) (1308) (162) (338) 75.0 55.0 48.4 100.0 68.3 Ethnicity % White Afr Amer Hisp Asian Other 29.4 41.6 25.6 2.1 1.2 39.2 31.7 25.8 1.7 1.7 63.5 1.7 18.4 13.7 2.7 75.9 3.1 13.0 3.1 1.2 P<0.0004 42.0 20.4 33.1 2.1 2.1 Drug Related Variables Years, Life Coc Dual MA G-MA Her (476) (120) (1308) (162) (338) 9.5 10.3 7.9 5.1 13.9 Days in 30 10.9 12.0 11.9 9.7 17.4 Route of Admin Nasal Smoking IV 20.0 75.4 3.2 4.2 50.8 45.0 11.9 64.6 22.9 28.4 29.6 37.0 6.2 10.1 80.8 P<0.0001 Risk Associations Comparisons Shared Needles/ Works (n=1,313) Cocaine Dual Methamphet MSM+Meth OR 95% C.I. 0.04 1.67 1.90 1.40 0.02-0.09 1.34-2.08 1.39-2.60 1.07-1.83 Risk Associations Comparisons >1 Sex partner, 6 months (n=2,071) Cocaine Dual Methamphet MSM+Meth OR 95% C.I. 2.11 1.64-2.72 1.72 1.31-2.27 10.7 28.5-46.1 Risk Associations Comparisons OR 95% C.I. Cocaine Dual Methamphet MSM+Meth 5.65 3.43-9.29 6.04 2.67-13.7 - Exchange Sex (n=986) Risk Associations Unprotected Intercourse (n=2,389) Comparisons OR 95% C.I. Cocaine Dual Methamphet MSM+Meth 1.49 1.16 1.72 10.7 1.27-1.73 1.00-1.35 8.64-13.2 1.47-2.01 Findings • 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… • 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 ~ 3040% (St Mary’s Hospital, Long Beach) MSM in Commercial Sex Venues 50 Percent Reporting 50 40 30 20 13 14 10 0 HIV + Bisexual Men of Color Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049 Reback, 2004 Drug Risks, MSM in Commercial Sex Venues 80 Percent Reporting 70 60 50 40 30 20 10 0 Alcohol MJ Poppers Crystal Ecstasy GHB IDU Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049 Reback, 2004 Hollywood Street Outreach, MSM Reback, Grella, & Shoptaw, 2003 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 70 60 50 40 30 20 10 0 MMT-LAC Her-LAC Meth-HWD Meth-RC LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004) 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 www.crystalneon.org www.tweaker.org The Formative Study The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeles www.uclaisap.org Methamphetamine and HIV in MSM: A time-to-response association? 100 Percent HIV+ 80 60 40 20 0 Probability Recreational Sample1 Users2 1Deren Chronic Users3 Outpatient Drug free4 Residential Treatment5 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? Broad Based Approach: Provide HIV prevention to current users (and non-users) at all levels (e.g., condom distributions) 1 – Presumes intact decisions/choices around sexual behaviors in most people Targeted Approach: Provide drug abuse treatment to users with abuse or dependence 2 – Centrality of drug/sex link in decisions/choices for small, heavily drug involved group Interventions: Methamphetamine Using MSM Behavioral Prevention Biological Adjuncts Objective • 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 Design Randomization and Baseline Follow-up Follow-up Follow-up CM (n=42) CBT (n=40) Screen 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 Concerts Movies Gay Pride Festival Bathhouse Halloween Relapse Justification: “I just got injured. I might as well use.” “My friend just died [AIDS] and using will make me forget for awhile.” One Day at a Time: “Tomorrow something will happen to ruin this.” “I seroconverted even though I knew about 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” Conditions • 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) • Education: – 95.7% > HS – 41% > 4-year degree • Ethnicity: – – – – – Caucasian: 77.2% Hispanic: 12.9% African-Am: 3.1% Asian-Am: 3.1% Native Am: 1.2% History of Sexually Transmitted Diseases by Reported HIV Serostatus STD HIV Serostatus Positive Negative (n=98) (n=64) % % Statistic Genital warts 41.1 19.4 2 (1) = 8.05, p=.005 Syphilis 28.4 8.2 2 (1) = 9.32, p=.002 Genital Gonorrhea 53.1 30.6 2 (1) = 7.72, p=.005 Yeast infection 14.9 0.0 2 (1) = 10.14, p=.001 Hepatitis B 41.5 17.7 2 (1) = 9.67, p=.002 Shoptaw et al., 2003 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) Treatment Outcomes Contingency Management Significantly longer retention Significantly more “clean urine” Significantly longer stretches of consecutive clean urine samples Unprotected Anal Receptive Intercourse; Past 30 Days 3.5 3 2.5 CBT CM CBT+CM GCBT 2 1.5 1 0.5 2(3)=6.75, p<.01 12 -M os os 6M -W ks 16 -W ks 12 ks 8W ks 4W Ba se l in e 0 Unprotected Anal Insertive Intercourse; Past 30 Days 8 7 6 5 4 3 2 1 0 2(3)=8.26, p<.01 12-Mos 6-Mos 16-Wks 12-Wks 8-Wks 4-Wks Baseline CBT CM CBT+CM GCBT 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 • “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 • $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 • 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 Needle Exchange Education HIV Counseling & Testing Opioid replacement 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 • High prevalence groups % per 100 person year 3 2.5 – < 30 yr old (2.8%) – MSM (3.0) 2 1.5 1 0.5 0 1987-1988 1989-1998 • 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 care is associated with decreased injection and sexrelated HIV risk behaviors (Sorensen and Copeland, 2000) 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 • 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 • 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... • 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) Conclusions • 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 Pre-Exposure Prophylaxis Concept • 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 Limits to 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; http://chipts.ucla.edu