1. The Meth-HIV Nexus: A clinician’s perspective Neil Flynn, M.D., M.P.H. Professor of Internal Medicine University of California, Davis

2. Prologue Providing medical care to HIV-infected meth users for over 20 years HIV prevention work among meth users since 1987 Many “successes” with meth users Some become colleagues and co- workers Some become friends

3. The meth-HIV Nexus How strong is the association? Why is meth use associated with HIV? Implications for HIV treaters and others Observations on the determinants of meth use in HIV and non-HIV populations

4. The meth-HIV Nexus Why is meth use a risk factor for HIV? ↑ Injection risks 3-5 X over heroin injection Increased risk-taking with injections? More frequent syringe sharing Disinhibition, bravado Feelings of increased control, confidence and invulnerability

5. The meth-HIV Nexus Why is meth use a risk factor for HIV? ↑ Sexual activity/risk More partners More frequent and prolonged intercourse Testosterone replacement therapy “Crystal dick” and Viagra Dry sex Delayed orgasm Infrequent use of condoms

6. Attractions of meth as related to me by my patients: Sexuality, socialization, partying Pure pleasure – enjoy the feeling Relief of unpleasant feelings, states Depression Self-doubt, recrimination, worthlessness Relief of ADD Weight control (especially women) ↑ Stamina, “energy”, capacity for work

7. Implications of different reasons for meth use: Approach to management of use/addiction is different Strategies for medical management of their HIV infection are different Professional expectations and rewards are different

8. Some effects of meth on HIV medical management: Progression of disease May be accelerated by meth itself Poor nutrition may play a significant role Adherence Reduced in meth users vs. heroin users “Who needs it? I’m fine!” attitude when using Depression when not using Don’t keep appointments Drug interactions complicate treatment ARV’s, psychoactive drugs, cardiac, GI, pulmonary medications

9. Providing HIV care to meth users Extremely frustrating for providers if traditional outcomes and measures of success are expected Patient’s priorities different from provider’s Provider sense of failure, reduced satisfaction Provider loss of feelings of control Patients unreliable, miss appointments Difficult to spend a half hour with patient

10. Patient perceptions Perceived judgmentalism, moralism Provider more frustrated than judgmental Miscommunication is frequent, easy Provider dull, slow-witted, can’t keep up “Pt. distractible, flight of ideas, pressured speech.” Doesn’t understand drug use, culture Like talking to a priest about sex

11. Treatment Approaches Goals Patient safety – reducing risk Prevention of major disease Early diagnosis of illness/disease Averting hospitalization, ER utilization Maintaining a trusting relationship Promoting patient introspection, counseling, general welfare Reduce transmission of HIV to others

12. Treatment Approaches: Re-define success Any ongoing relationship at all with the patient is a major success! Intermittent periods of reduced meth use and adherence to treatment Increased patient satisfaction with life Temporary improvements in viral load and CD4 cell counts Maintaining functionality and reducing illness

13. Treatment Approaches Drug treatment Abstinence-based Harm-reduction-based Cognitive-behavioral Substitution Treatment of underlying psychiatric disorders

14. Treatment Approaches Treatment of underlying major psychiatric disorders (“drug treatment” must include this!) Schizophrenia, psychotic disorders Bipolar disorder Depression Sexual addiction/intimacy problems Directly observed therapy (DOT)

15. Treatment Approaches Directly observed therapy (DOT) “Who needs ARVs? I’m fine!” Difficulty finding patient Paranoia Drug interactions

16. Prevention with meth positives Motivational interviewing techniques Determine stage of change Build patient interest in change Identify target behavior Skills building for change Commitment to make a change The brief intervention Follow-up until as much change as possible has been achieved It takes two for transmission – someone willing to give and someone who will take the risk of receiving

17. Summary Meth use is associated with ↑ HIV risk ↑ Injection and sexual risk behaviors Relations between medical providers and meth users are often strained It is a two-way street Harm reduction is a viable strategy for treating the dual/triple diagnoses Many meth users have major underlying, treatable psychiatric disorders

18. Summary HIV can be successfully treated with meth users Attention must be paid to individual’s reason(s) for meth use Definitions of success may need to be modified Prevention of transmission is part of medical management

19. Contact Information Neil Flynn, M.D., M.P.H. nmflynn@ucdavis.edu