1. HIV and Injection Drug Use
HAIVN Harvard Medical School AIDS Initiative in Vietnam
HAIVN advanced training for nursing
N_M1-07_HIV and Injection Drug Use-EN
Revised 9/2013

2. Learning Objectives
By the end of this session, participants will be able to:
Explain the link between HIV and intravenous drug use in Vietnam
Explain how to diagnose drug addiction
Explain benefits of harm reduction
Describe how to provide ART to intravenous drug users (IDU)

3. Epidemiology of HIV and IDU
IDU is the major source of HIV infections in Vietnam
Risk associated with:
needle-sharing
exposure to contaminated injection equipment
IDU often engage in other high risk behaviors, such as unsafe sex, that can transmit HIV to non-IDU partners
EXPLAIN that IDU is common among other high-risk populations including commercial sex workers, prisoners, and marginalized groups.

4. Epidemiology of IDU in Asia
Estimated 3.3 million IDU in South and South East Asia
Estimated at least 20% of IDU are HIV-positive in Vietnam
Commercial sex work among IDU has been called a “bridge” to the general population

5. Distribution of HIV/AIDS Cases in Vietnam
EMPHASIZE that most HIV infections in Vietnam are due to Intravenous drug use (about 50-60%)
Many CSW (commercial sex workers) also inject drugs.
EXPLAIN that many of the other categories reported to the MOH are not true risk groups and probably include IDU as well.
These include TB patients, military recruits, AIDS suspects, and blood donors
Source: MOH

6. HIV Prevalence Among IDUs, 2009
HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009
EXPLAIN that the chart shows prevalence rates among IDUs in select provinces.
STRESS that rates remain high in many provinces.

7. HIV Trends Among IDUs,
HIV/STI Integrated Behavioral and Biological Surveillance in Vietnam, IBBS, 2009
EXPLAIN that :
This chart shows the trend in prevalence since 2006
HIV prevalence has gone down among IDUs in many provinces

8. Opioids
ASK participants, “What are opioids? What are some examples of opioids?”
ALLOW time for them to answer.
USE discussion to move on to the next few slides.

9. Overview of Opioids (1) Class of drug that includes: Opioids:
Morphine
Heroin
Methadone
Buprenorphine
Opium
Codeine
Opioids:
relieve pain and bring on feelings of well-being
slow down functions of the central nervous system, including respiration
EXPLAIN that all opioids work on the same receptors in the brain and have the same effects on humans.

10. Overview of Opioids (2)
High doses can cause respiratory depression, coma and death
In Vietnam, most commonly used illicit opioids are heroin and opium
STRESS that overdose of opioid medications can cause death by suppressing respiration.

11. Heroin (1) Use: smoked, injected, nasal, oral
Effects: euphoria, sedation, pain reduction
Negative effects: dependence, overdose, injection related illnesses
Withdrawal: severe, but not life threatening
EXPLAIN that smoking and injecting are common in Vietnam, however oral use is rare because the drug isn’t absorbed well this way.
EXPLAIN further about heroin withdrawal:
Virus like symptoms: abdominal cramps, diarrhea, runny nose, aches, fever.
Combined with anxiety and sense of impending doom.
Feels life threatening to many users.

12. Heroin (2)
Pregnancy: withdrawal dangerous to fetus, pregnant women should be maintained on methadone
Overdose: when mixing drugs or after period of abstinence

13. Characteristics of Opioid Dependence
Definition (ICD-10): A cluster of behavioral, cognitive, and physiological phenomena develop after repeated substance use that include:
Strong desire to take drug
Difficulties in controlling use
Persisting in use despite harmful consequences
Higher priority given to drug use than other activities and obligations
Increased tolerance
Physical withdrawal symptoms if drug stopped
EXPLAIN that this slide lists criteria for diagnosing opioid dependence.
EXPLAIN the term “tolerance” = needing a higher and higher dose to attain the same effect.

14. Opioid Withdrawal Symptoms
Physical signs:
Dilated pupils
Tachycardia
Hypertension
Hyperactive bowel signs
Withdrawal symptoms:
Muscle and joint pain
Abdominal cramps
Nausea, vomiting
Diarrhea
Cough
Chills
EXPLAIN that these withdrawal symptoms begin to show within 24 hours of last opioid use.
EXPLAIN that withdrawal symptoms are what the patient may complain about; physical signs are what the doctor may see on examination.
EXPLAIN that additional withdrawal symptoms include:
Rhinorrhea
Eye tearing
Cutaneous pilo-erection

15. Treatment for IDU

16. Medical Complications of IDU (1)
Directly related to drug use:
Respiratory depression from opioids
Pulmonary problems from inhaled drugs
Malnutrition
Mental health issues: mental disorders may appear during drug use or with sudden stopping of drug
EXPLAIN that there are many medical complications of IDU, some of which are directly related to the drug use, and some are secondary to the drug use.

17. Medical Complications of IDU (2)
Bacterial infections
Bacterial endocarditis
Osteomyelitis
Skin and soft tissue infections
Septic thrombophlebitis
Septicemia
Viral infections
HIV, HCV, HBV
Mycobacterial infections
10X increased risk for TB among HIV negative IDU

18. Skin Lesions of Injection Drug Users
Non-healed puncture wounds along vein with accompanying inflammatory changes

19. Skin Abscess from Injection Drug Use
EXPLAIN that abscesses are common from unsanitary injecting practices.

20. Barriers to Care for IDU
Stigma
Discrimination
Social marginalization
Closed settings, including incarceration
Unsafe injecting practices
Communicable disease
Physical and sexual violence
Note that this slide is animated. ASK participants the question below BEFORE clicking through to the answers on the slide.
ASK participants “What do you think are some of the barriers to care for IDU?”
ALLOW time for them to respond.
CLICK through to show the answers on the slide.

21. Treatment of Drug Users with HIV Infection
Drug users are less likely to receive HIV therapy due to:
Failure to follow-up
Poor adherence with ARV and other medications
Reluctance of medical providers to prescribe therapy due to concerns about adherence
However, if adherence is good, IDUs respond to ART as well as any other patients
EXPLAIN that for all patients, the most important factor in the success of ARV treatment is adherence.
EXPLAIN further that when taking ARVs with good adherence, IDUs respond to treatment as well as other patients.

22. Treatment of Drug Addiction
Drug abuse treatment and HIV-related care must be both addressed or neither treatment approach will be effective
Drug users in drug treatment programs are very adherent with HIV therapy
The challenge: determine specific ways to integrate care for drug addiction and HIV therapy
EXPLAIN that it is important to address the issue of drug addiction for HIV patients.
If drug abuse continues, then the risk for failure of ARV treatment is high.
Therefore, HIV OPC must work with other programs to refer IDU patients for drug treatment.

23. What is the Harm Reduction Approach
What is the Harm Reduction Approach? What are Some Examples of Harm Reduction?
ASK participants the question on the slide.
ALLOW time for them to answer.
WRITE down their answers on a flip chart, generating a list.
USE discussion to lead into the next few slides.

24. Harm Reduction Approach (1)
Rather than telling drug users to completely stop using drugs, the harm reduction approach focuses, literally, on reducing harm and includes:
Community outreach focus on peer approaches
Behavior change communication, including risk reduction information
Clean needles, syringes and their safe disposal
Drug dependence treatment, particularly opiate substitution therapy (Methadone)
HIV testing and counseling
EXPLAIN that Harm reduction includes many elements. The principle is to reduce the potential harm of injecting practices to IDU patients.
EXPLAIN that HIV testing and counseling include voluntary, confidential and provider initiated.
EXPLAIN that on 21/06/ 2006, the Vietnamese National Assembly passed a new law on prevention and control of HIV/AIDS.
Article 21: HIV/AIDS harm reduction interventions
Harm reduction interventions in prevention of HIV transmission include the following measures: communication and mobilization, promotion of the use of condoms and clean needles and syringes, treatment of opioid addiction by substitution (Methadone), and other harm reduction measures to support safe behaviors to prevent HIV infection and transmission.
Source: HIV/AIDS care and treatment for IDU in Asia and pacific, WHO 2008

25. Harm Reduction Approach (2)
Prevention of sexual transmission through interventions
HIV care and treatment, including ART
Primary health care
hepatitis B vaccination
vein and abscess/ulcer care
overdose management
Supportive policy and legislative environment
EXPLAIN that interventions to prevent sexual transmission includes providing condoms and STI prevention and treatment
Source: HIV/AIDS care and treatment for IDU in Asia and pacific, WHO 2008

26. What is Methadone Maintenance
What is Methadone Maintenance? What are the Goals of Methadone Maintenance?
ASK participants, “What is Methadone Maintenance? What are the goals of Methadone Maintenance?”
ALLOW time for them to answer.
REFER them to Handout 7.1: Methadone Maintenance for further information.

27. Methadone Maintenance Therapy (1)
Dispensed daily on site and directly observed
Daily observed dosing reduces potential for abuse
Daily contact with methadone program facilitates treatment of other chronic medical conditions

28. Methadone Maintenance Therapy (2)
Usual starting dose: mg daily, increasing by 5-10 mg every 3 days until adequate dose is reached to:
treat withdrawal symptoms
reduce drug craving
improve daily functioning
Most patients effectively treated at daily doses of mg of methadone

29. Results of Methadone Treatment
Increase:
overall survival
drug-treatment retention
employment
Decrease:
illicit opioid use
hepatitis and HIV seroconversion
criminal activity
Improve birth outcomes for pregnant women
DESCRIBE the positive effects of methadone maintenance therapy.
Kuehn, JAMA 2005.

30. ART for Intravenous Drug Users

31. ART for IDU Same ARV regimens and doses as non-IDU
Active IDU is NOT a contraindication to providing ARV
Dose of methadone may need to be adjusted due to drug interactions when starting ARV
No need to adjust doses of ARV drugs when taking methadone
Closely follow adherence and provide extra counseling to IDU patients and treatment supporters
EXPLAIN that ARVs can be safely provided to IDU and the ARV regimens and doses are the same for non-IDU patients.

32. Adherence for IDU on ART
High levels of adherence are necessary for optimal outcomes on ART
IDU may have greater barriers to adherence
Side effects of ARV, real and perceived
Active drug use
Psychiatric illness or symptoms
Stigma against IDU
Resistance to ARVs is similar among people who inject drugs and those who do not
EXPLAIN that IDU patients on ART need particular support around adherence.
ASK participants “What might adherence support for IDU look like? What are some examples?”
ALLOW time for them to respond.
PROVIDE answer as needed:
Counseling and education
Aids and incentives for adherence
Tracking of people who miss appointments or fail to pick up ART
Family or community support
DOT strategies: Integrated ART and opiate substitution therapy
Provide simple ART regimens: Fixed-dose combination, once daily regimens
Wood E et al. AIDS, 2005, 19:1189–1195.

33. Key Points
IDU and sharing of infected injecting material are major factors of HIV epidemic in Vietnam
Harm reduction programs lead to:
reducing drug use or reducing risk behaviors
decreasing spread of HIV
Methadone maintenance is an effective and proven modality for treating opiate addiction
IDU can respond well to ARV treatment, if the ARV are taken with good adherence

34. Thank you!
Questions?