1. HIV/AIDS and Substance Use Disorders Olivera J. Bogunovic, M.D. State University of New York at Buffalo Alcohol Medical Scholars Program

2. Copyright Alcohol Medical Scholars Program2 Lecture Overview  HIV/AIDS  Substance use disorders  Connection between HIV and substance use disorders  Implications for patient care

3. Copyright Alcohol Medical Scholars Program3 Patient: John 40-year old white male presents to ER with: –Diarrhea >1 month, thrush, weight loss History: –Intravenous heroin user –Failed inpatient rehabilitation Labs: –CD4 <400

4. Copyright Alcohol Medical Scholars Program4 HIV - Human Immunodeficiency Virus RNA virus Principally infected cell: CD4 T cell Progressive loss of cell

5. Copyright Alcohol Medical Scholars Program5 Epidemiology >39 million HIV+ ~40,000 persons infected/year (CDC) High-risk populations: –Injection drug users: 26% of all infections –Homosexual males: 60% of all infections

6. Copyright Alcohol Medical Scholars Program6 HIV Transmission Categories Centers for Disease Control, 2005 MalesFemales Male-Male Sex60% - Hetero Sex13%71% Injection Drug Use26%27% Other1%2%

7. Copyright Alcohol Medical Scholars Program7 Other HIV Transmission Categories Maternal transmission during childbirth Health workers Blood transfusions Tattoos

8. Copyright Alcohol Medical Scholars Program8 Course of HIV Infection Six stages of infection: 1.Initial 2.Latency 3.Lymphadenopathy 4.Early symptomatic infection 5.AIDS 6.End stage

9. Copyright Alcohol Medical Scholars Program9 Treatment of HIV/AIDS Prevention of HIV transmission Antiretroviral treatment:  immune function  viral replication Treatment of opportunistic infections

10. Copyright Alcohol Medical Scholars Program10 Antiretroviral Medications Nucleoside and nucleotide analogs (zidovudine) Protease inhibitors (saquinavir) Non-nucleoside transcriptase (nevirapine)

11. Copyright Alcohol Medical Scholars Program11 Lecture Overview HIV/AIDS  Substance use disorders (SUD)  Connection between HIV and substance use disorders  Implications for patient care

12. Copyright Alcohol Medical Scholars Program12 Relevant Drugs to HIV/AIDS Opioids Stimulants –Amphetamine –Cocaine Alcohol

13. Copyright Alcohol Medical Scholars Program13 Substance Use Disorders Misuse = use to get high Abuse = dysfunction in 1+ life areas Dependence = 3+ of 7 criteria –Physical dependence –Compulsive use/loss of control

14. Copyright Alcohol Medical Scholars Program14 Lifetime Prevalence Opioids –Abuse/dependence of heroin <1% Stimulants –Amphetamine Abuse/dependence < 2% –Cocaine Abuse/dependence 2% Alcohol Abuse or dependence 10-15% men, 8-10% women

15. Copyright Alcohol Medical Scholars Program15 Routes of Administration Injection: highest risk of infection Intranasal Smoking Oral

16. Copyright Alcohol Medical Scholars Program16 Treatment Individual and group psychotherapy Pharmacotherapy Self help groups

17. Copyright Alcohol Medical Scholars Program17 Lecture Overview HIV/AIDS Substance use disorders  Connection between HIV and substance use disorders  Implications for patient care

18. Copyright Alcohol Medical Scholars Program18 Prevalence High prevalence of HIV in patients with SUD –35% of cocaine users –22% of opioid users High prevalence of SUD in HIV+ patients –25% alcohol dependent –25% use illicit opioids –33% use cocaine

19. Copyright Alcohol Medical Scholars Program19 Drug Use and HIV Transmission Highest risk with intravenous use Increased risk with intranasal use More sexual partners, unsafe sex Associated with alcohol use

20. Copyright Alcohol Medical Scholars Program20 Opioids Affect HIV Course Cause immunosuppression Induce apoptosis  viral replication Co-infection of HIV and other pathogens

21. Copyright Alcohol Medical Scholars Program21 Stimulants Affect HIV Course Cocaine –Causes immunosuppression of T-cells –  viral replication –  brain cells infected  neurotoxicity Amphetamine –Similar effect to cocaine –Research beginning to accumulate

22. Copyright Alcohol Medical Scholars Program22 Alcohol Affects HIV Course  immune response to HIV infection  viral replication Promotes progression of illness  permeability of blood brain barrier to infectious agents

23. Copyright Alcohol Medical Scholars Program23 Drugs/Alcohol Affect HIV ▲ ▲ ▲ Alcohol Apoptosis CNS Barrier ↑ Viral Replication Neurotoxicity ↓ Immune System ▲ ▲ ▲ Opioids ▲ ▲ ▲ ▲ Stimulants

24. Copyright Alcohol Medical Scholars Program24 Opioids Affect Antiretrovirals Opioids  high risk behavior / noncompliance Drug-drug interactions –Methadone levels  with meds –Methadone dose adjustment needed –  blood levels of meds

25. Copyright Alcohol Medical Scholars Program25 Stimulants Affect Antiretrovirals Cocaine –  risk behaviors –Resistance to antiretrovirals in 30% due to noncompliance Amphetamine –↑ risk behavior

26. Copyright Alcohol Medical Scholars Program26 Alcohol Affects Antiretrovirals  risk behavior and noncompliance  viral replication  response to antiretroviral medications Impairs pharmacokinetics and pharmacodynamics of antiretrovirals

27. Copyright Alcohol Medical Scholars Program27 Drugs/Alcohol Affect Meds ▲ ▲ ▲ Alcohol Resistance Drug Interactions Noncompliance ▲ ▲ ▲ Opioids ▲ ▲ Stimulants

28. Copyright Alcohol Medical Scholars Program28 Substance Use and Compliance with Medications Inconsistent outpatient care Noncompliance with medication regimen –44% users vs. 22% non-users Poor social support Methadone maintenance programs  better adherence to treatment

29. Copyright Alcohol Medical Scholars Program29 Psychiatric Disorders, HIV & SUD Drugs/alcohol cause & exacerbate psychiatric symptoms –Psychiatric symptoms more common –HIV+ more sensitive to illicit drugs

30. Copyright Alcohol Medical Scholars Program30 Lecture Overview HIV/AIDS Substance use disorders Connection between HIV and substance use disorders  Implications for patient care

31. Copyright Alcohol Medical Scholars Program31 Treatment Guidelines Maximizing care for HIV and SUD –Medical treatment Asymptomatic infection: antiretroviral meds Symptomatic infection: treat opportunistic infection

32. Copyright Alcohol Medical Scholars Program32 Treatment Guidelines SUD treatment –Reduce HIV risk behavior –Harm reduction model Methadone maintenance Syringe exchange programs –Mental health treatment

33. Copyright Alcohol Medical Scholars Program33 What About John HIV: treat with antiretrovirals SUD treatment: –Consider methadone maintenance –Cognitive-behavioral therapy –Self-help groups Mental health treatment if indicated

34. Copyright Alcohol Medical Scholars Program34 Summary HIV/AIDS Substance use disorders Connection between HIV and substance use disorders Implications for patient care