HIV/AIDS and Substance Use Disorders

DR. KAPIL PANDYA

(M.D ; M.B.B.S)

I/C & AP (INFECTIOUS DISEASES MEDICINE)

DEPARTMENT OF MEDICINE

GOVERNMENT MEDICAL COLLEGE & HOSPITAL

JAMNAGAR (GUJARAT

Lecture Overview

HIV/AIDS

Substance use disorders

Connection between HIV and substance use disorders

Implications for patient care

2

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

4

HIV Transmission Categories

5

Centers for Disease Control, 2005

Males Females

Male-Male Sex 60% -

Hetero Sex 13% 71%

Injection Drug Use 26% 27%

Other 1% 2%

Lecture Overview

HIV/AIDS

Substance use disorders (SUD)

Connection between HIV and substance use disorders

Implications for patient care

6

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 criteriaPhysical dependenceCompulsive 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

11

Lecture Overview

HIV/AIDS

Substance use disorders

Connection between HIV and substance use disorders

Implications for patient care

12

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

15

Stimulants Affect HIV Course

CocaineCauses immunosuppression of T-cells viral replication brain cells infected neurotoxicity

AmphetamineSimilar effect to cocaineResearch 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 18

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Alcohol

Apoptosis

CNS Barrier

↑ Viral Replication

Neurotoxicity

↓ Immune System

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Opioids

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Stimulants

Opioids Affect AntiretroviralsOpioids high risk behavior /

noncompliance

Drug-drug interactionsMethadone levels with medsMethadone dose adjustment

needed blood levels of meds

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Stimulants Affect AntiretroviralsCocaine

risk behaviorsResistance 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 22

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Alcohol

Resistance

Drug Interactions

Noncompliance

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Opioids

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Stimulants

Substance Use and Compliance with Medications

Inconsistent outpatient care

Noncompliance with medication regimen44% 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

25

Treatment Guidelines

Maximizing care for HIV and SUD

Medical treatmentAsymptomatic infection: antiretroviral meds

Symptomatic infection: treat opportunistic infection

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Treatment Guidelines

SUD treatmentReduce HIV risk behaviorHarm reduction model

Methadone maintenanceSyringe 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

29