1. Slide #1 S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006. Evidence-Based Intervention Strategies for Methamphetamine Users in HIV Care Settings Steven Shoptaw, PhD Professor, Department of Family Medicine University of California Los Angeles

2. Methamphetamine Crystal, Tina, Speed, CrankCrystal, Tina, Speed, Crank Injection, Smoking, Insufflation, Oral, “Booty- Bump”Injection, Smoking, Insufflation, Oral, “Booty- Bump” Long lasting (9-12 h half-life), cheap (~$25-50/g), functional drugLong lasting (9-12 h half-life), cheap (~$25-50/g), functional drug Gay/bisexual men; blue collar heterosexuals, and youthGay/bisexual men; blue collar heterosexuals, and youth Metabolized by CYP2D6Metabolized by CYP2D6 –3-10% of Caucasians deficient in CYP2D6 and may increase risks for toxicity Slide #2 S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006.

3. Slide #3 S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006. Methamphetamine Acute Psychological Effects Increases Confidence Alertness Mood Sex drive Energy Talkativeness Decreases Boredom Loneliness Timidity

4. Slide #4 S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006. The “Down Side” Psychosis, depression, violence, family and social disruptions, criminal activity (Peck et al., 2005) Among MSM, abuse increases likelihood of infection with HIV (Shoptaw et al., 2005), may exacerbate neurotoxicity and other pathological processes common to HIV infection (Markowitz et al., 2005) –May worsen the HIV epidemic and complicate treatment of HIV (Urbina, 2004)

5. Slide #5 S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006. Methamphetamine and Protease Inhibitors Protease inhibitors commonly metabolized by CYP3A4 –Ritonavir also affects CYP2D6 –3- to 10-time increase in levels of MA or MDMA (Urbina & Jones, 2004) –Delavirdine partially metabolized by CYP2D6 and may interact with MA or MDMA –Deaths reported for HIV patients using MA and MDMA; all reports indicate ritonavir- containing regimens

6. Methamphetamine and HIV in MSM: A time-to-response association? Slide #6 Shoptaw & Reback, in press S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006.

7. Suggested Guideline – 5 A’s Ask Implement an officewide system that ensures that, for every MSM at every clinic visit, meth-use status is queried and documented Advise In a clear, strong, and personalized manner, urge every meth user to quit Assess Ask every meth user if he is willing to make a quit attempt now (next 30 days) Assist Help the patient plan, provide practical counseling, recommend meds, be supportive Arrange Provide for follow-up support, phone calls Adapted from Fiore et al., 2000 S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006.

8. Slide #8 S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006. Modafinil: Rationale for HIV+ Patients Non-amphetamine type stimulant Promotes wakefulness Approved for narcolepsy Improves cognitive functioning, even in healthy volunteers (Randall et al., 2004) Metabolized by esterase enzymes, only mild inducer of CYP P450 Schedule IV drug with low abuse potential See Rabkin et al., 2004, Jrnl of Clinical Psychaitry

9. Slide #9 S Shoptaw, PhD. Presented at RWCA Clinical Update, August 2006. Summary Methamphetamine has strong functional profile Use may approach abuse or dependence levels Be vigilant and warn of interactions with ritonavir Behavioral interventions reduce methamphetamine use and HIV risk behaviors In HIV+, modafinil reduces fatigue and may be a future candidate as a medication for methamphetamine abuse/dependence