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HIV/AIDS and Substance Use Disorders
Olivera J. Bogunovic, M.D.State University of New York at Buffalo
Alcohol Medical Scholars Program
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Lecture Overview
HIV/AIDS
Substance use disorders
Connection between HIV and substance use disorders
Implications for patient care
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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
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HIV - Human Immunodeficiency Virus
• RNA virus
• Principally infected cell: CD4 T cell
• Progressive loss of cell
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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
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HIV Transmission Categories
Centers for Disease Control, 2005
Males Females
Male-Male Sex 60% -
Hetero Sex 13% 71%
Injection Drug Use 26% 27%
Other 1% 2%
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Other HIV Transmission Categories
• Maternal transmission during childbirth
• Health workers
• Blood transfusions
• Tattoos
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Course of HIV Infection
• Six stages of infection:1. Initial 2. Latency 3. Lymphadenopathy4. Early symptomatic infection5. AIDS6. End stage
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Treatment of HIV/AIDS
• Prevention of HIV transmission
• Antiretroviral treatment: immune function viral replication
• Treatment of opportunistic infections
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Antiretroviral Medications
• Nucleoside and nucleotide analogs (zidovudine)
• Protease inhibitors (saquinavir)
• Non-nucleoside transcriptase (nevirapine)
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Lecture Overview
HIV/AIDS
Substance use disorders (SUD)
Connection between HIV and substance use disorders
Implications for patient care
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Relevant Drugs to HIV/AIDS
• Opioids
• Stimulants
–Amphetamine
–Cocaine
• Alcohol
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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
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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
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Routes of Administration
• Injection: highest risk of infection
• Intranasal
• Smoking
• Oral
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Treatment
•Individual and group psychotherapy
•Pharmacotherapy
•Self help groups
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Lecture Overview
HIV/AIDS
Substance use disorders
Connection between HIV and substance use disorders
Implications for patient care
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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
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Drug Use and HIV Transmission
• Highest risk with intravenous use
• Increased risk with intranasal use
• More sexual partners, unsafe sex
• Associated with alcohol use
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Opioids Affect HIV Course
• Cause immunosuppression
• Induce apoptosis
viral replication
• Co-infection of HIV and other pathogens
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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
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Alcohol Affects HIV Course
immune response to HIV infection
viral replication
• Promotes progression of illness
permeability of blood brain barrier to infectious agents
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Drugs/Alcohol Affect HIV
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Alcohol
Apoptosis
CNS Barrier
↑ Viral Replication
Neurotoxicity
↓ Immune System
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Opioids
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Stimulants
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Opioids Affect Antiretrovirals
• Opioids high risk behavior / noncompliance
• Drug-drug interactions– Methadone levels with meds
– Methadone dose adjustment needed blood levels of meds
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Stimulants Affect Antiretrovirals
• Cocaine risk behaviors
–Resistance to antiretrovirals in 30% due to noncompliance
• Amphetamine –↑ risk behavior
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Alcohol Affects Antiretrovirals
risk behavior and noncompliance
viral replication
response to antiretroviral medications
• Impairs pharmacokinetics and pharmacodynamics of antiretrovirals
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Drugs/Alcohol Affect Meds
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Alcohol
Resistance
Drug Interactions
Noncompliance
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Opioids
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Stimulants
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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
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Psychiatric Disorders, HIV & SUD
• Drugs/alcohol cause & exacerbate
psychiatric symptoms
–Psychiatric symptoms more common
–HIV+ more sensitive to illicit drugs
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Lecture Overview
HIV/AIDS
Substance use disorders
Connection between HIV and substance use disorders
Implications for patient care
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Treatment Guidelines
• Maximizing care for HIV and SUD
–Medical treatment
• Asymptomatic infection: antiretroviral meds
• Symptomatic infection: treat opportunistic infection
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Treatment Guidelines
• SUD treatment–Reduce HIV risk behavior
–Harm reduction model
• Methadone maintenance
• Syringe exchange programs
–Mental health treatment
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What About John
• HIV: treat with antiretrovirals
• SUD treatment:
– Consider methadone maintenance
– Cognitive-behavioral therapy
– Self-help groups
• Mental health treatment if indicated
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Summary
HIV/AIDS
Substance use disorders
Connection between HIV and substance use disorders
Implications for patient care
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