INJECTION DRUG USERS AND HIV: EVIDENCE-BASED REVIEW OF CLINICAL TREATMENT CONSIDERATIONS

ANTIRETROVIRAL TREATMENT FOR INJECTING DRUG USERS: A QUARTERLY BULLETIN 2008 Dec;1(4):

Transcription: Simon Collins, HIV i-Base

Several oral presentations on IDU issues relating to treatment were included in a symposium on IDU and global responses.

Eric Goosby from University of California, San Francisco provided an evidence-based review of clinical treatment considerations for IDU, including ARVs as effective and life saving treatments, that recognised drug addiction as a chronic progressive relapsing condition and a treatable medical problem.^[1]

Factors driving the importance of this emphasis on IDUs, include: drug use being globally the second most prevalent risk behavior associated with HIV transmission, later stage of presentation of IDUs to medical services, co-morbidities, and adherence difficulties associated with active psychoactive substance use and untreated co-morbid mental illness. He also stated that IDUs in western countries have high rates of HIV risk behaviors: 90% were sexually active in the previous year, 20% reported having sex with >5 partners and low rates of condom use (9% to 34%).

Unique aspects of management and care for IDUS include recognising existing prejudices from the medical system and social and legal differences. These factors are particularly prominent in prison populations.

Medical Schools do not always emphasise the complex medical and psychosocial aspects of the HIV-positive IDU, among whom rates of relapse to active drug use are high at >75-97%. Empathy, and a nonjudgmental approach are critical in obtaining a comprehensive and accurate personal and treatment history. Understanding that the addiction may involve multiple substances makes taking a medical history, but this is important, because the use of stimulants and alcohol are associated with increased sexual activity.

Specific history should include substances used, route of administration over time (IV, sc/IV, intranasal, inhaled, oral, anal, other), pattern of use (amount, frequency, most recent use, needle sharing), treatment history, both outpatient and inpatient.

Medical complications of substance use include needle-induced (viral, bacterial, fungal infections, peripheral vascular disease); drug-induced (overdose, withdrawal, organ-specific complications e.g. nephropathy due to heroin, cardiac ischemia due to cocaine, gastrointestinal, cardiac and neurologic disease due to alcohol); and major coinfections (TB, HBV, HCV and other STIs). Social complications include unemployment, family disruption, legal problems and homelessness.

Many effective risk reduction strategies already have a strong evidence base. These include: syringe exchange programs; opiate substitution therapy (OST) (methadone/buprenorphine maintenance, which all have better outcomes when combined with cognitive behavioral therapy, motivational enhancement techniques or contingency management); peer-driven interventions; community outreach; risk reduction counseling; and diagnosis and treatment of mental illness. Methadone has been proven to reduce injecting drug use by 40% and use of shared equipment by 75%.

It is important to have a versatile and holistic approach which, for the most part, should come from the patients’ preference and that ‘one single approach does not always apply to the medical presentation’. Sometimes reducing drug use is more important that treating any psychiatric condition and sometimes vice versa, though both need to be addressed in order to optimise treatment of HIV or other illnesses.

The presentation then outlined management of a range of OIs and coinfections, all generally more prevalent in HIV-positive IDUs including bacterial infections (>4 times higher than HIV-negative IDUs), TB (IDU increased risk and HIV worsens outcome), hepatitis B and C, STIs, HTLV-1 and 2, cancer (more aggressive), before reviewing approaches to HIV treatment. The presentation also included an overview of interactions between methadone and ARVs and other medications that is summarised in Table 1.

The presentation concluded with three summary points relating to provider-patient interactions:

• The physician/providers attitude related to drug abuse is critical to the development of a trusting relationship.
• Providers who openly diminish the needs, complaints and requests of addicted patients are most often excluded from decisions that impact the patients ability to maintain adherence or enter care.
• Despite multiple and repeated documentation of the efficacy of drug treatment programmes, care givers and politicians often view treatment programmes as ineffective.

Principles to enhance physician-patient relationship include: mutual respect (educating the patient about HIV and addiction, recognising the effects of continued drug use, the impact on adherence, and transmission. Providers need to acknowledge that patients can benefit from drug treatment and HIV treatment.

References

This presentation was part of a symposium on issues important to a global response relating to injecting drug use: Injecting Drug Use and Infectious Diseases: Implications for the Global HIV/AIDS Response (An IAS/IDSA Partnership). Symposium TUSY06. http://www.aids2008.org/Pag/PSession.aspx?s=18.

1. Eric Goosby. Comprehensive care for injecting drug users: Syringe exchange, methadone and HIV care and treatment. Abstract TUSY0601.

2008-12-10
ARV4IDU2008-12-03

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