HIV infection in injecting drug users

(1)

HIV infection in injecting

drug users

Marika Raukas

West-Tallinn Central Hospital

Estonia

HIV Clinical Skills Series

4th _{International Training Course} Tallinn 2010

(2)

Injection Drug Users

Transmission via injection drug use is most

common transmission route in the

Estonia

Injection drug users (IDU)

–

_{Often have multiple comorbidities,}

–

_{Increased morbidity and mortality,}

–

_{Decreased access to HIV care}

• _{Are less likely to receive ARV}

(3)

Transmission of

HIV infection

1987 - 2003

32% 0

6% 4%

46%

HETERO HOMO IVDU DOONOR emalt lapsele

0,20% 7%

0,20% 1,30%

91%

HETERO HOMO IVDU DOONOR emalt lapsele

(4)

Main features of HIV infection and IDU in

Estonia.

• _{Infection spreading through contaminated watersupplies and drugs,}

not so much via sharing needles and syringes

• _{Very young age while getting infected during the first years of}

epidemic.(12-24 y)

• _{HIV genotype G, less A and AG, the infection entering Estonia}

different times from different sources.

• _{Use of drugs : iv opiates as the very first drug ever}

• _{Use of different drugs (eg.opiates+amphetamines, opiates and}

alcochol etc) simultaneously to enhance mind-altering properties and lessen detection by relatives/friends or on first physical examination

• _{IV TRIO: phentanyl (,,Belõi kitajets”=,,valge hiinlane”), “afganets”=“}

(5)

IDU have multiple comorbidities resulting

in higher mortality

Time from getting HIV infection till AIDS diagnosis for

• _{transfusion patients 7 years}

• _{IDU and haemophilia patients 10 years}

• _{MSM 8-12 years}

Still IDU patients have higher morbidity and mortality . Other causes of death like other infections,

(6)

• _{Skin and soft tissue (cellulitis, abscess,necrotizing fastcitis, septic}

thrombophlebitis of Streptococci spp and Staph. aureus)

• _{Cardiovascular (endocarditis : Streptococci, Staph. aureus, enteric G}

negative rods)

• _{Pulmonary (community acquired pneumonia from Strept.}

pneumoniae, H. influenza, atypical organisms, tuberculosis or septic emboli)

• _{Liver ( HBV and HCV)}

• _{Neurology altered}mental status _{(substance induced, dementia,}

trauma)

neuropathy

cerebrovascular accident (substance induced cocaine or amphetamines

brain abscess,

(7)

Predictors of Inadequate

Adherence

• _{Age, race, sex, educational level,}

socioeconomic status (SES), and a past

history of alcoholism or drug use do NOT

reliably predict suboptimal adherence.

• _{Higher SES and education levels and lack of}

history of drug use do NOT reliably predict

optimal adherence.

(8)

Injection Drug Users

Efficacy of HIV treatment

• _{In IDU who are not actively using, efficacy similar}

to other populations

• _{Active drug use may interfere with adherence and}

ARV success

• _{In patients, substance abuse treatment may be}

required for ARV success

(9)

Factors Affecting Adherence: Patient

In and out of prison

is everyday life for

(14)

System of Care Factors Impacting

Adherence

• _{In the unique setting of correctional facilities, additional}

factors that can impact HAART adherence are:

-Lockdowns may limit inmates’ ability to access medical or pharmacy care in a timely manner for medication dosing. -Inmate facility transfers or court dates may result in

problems coordinating medical care/supplying needed medications in a timely fashion

-Limited formularies may result in some medications not being available.

-Cell searches may result in the confiscation of medications.

(15)

Between DOT and KOP

• _{Both have advantages and disadvantages that can impact}

treatment adherence. Changes in and out of prison.

(1) Directly Observed Therapy (DOT): system in which the

inmate goes directly to the medical unit or pharmacy for all medication doses. Used now in correctional facilities and in West- Tallinn Central Hospital for those with HAART+

Methadon +/- TB DOT treatment, who are not reliable in taking their medication.

(2) Keep on Person (KOP): system which allows patients to

keep their medications and take them independently. Monthly or two month supplies are obtained at the medical unit.

(16)

(17)

(18)

(19)

(20)

Injection Drug Users

Drug toxicities and interactions

• _{IDU may have more ARV-related adverse effects}

• _{Methadone may interact significantly with ARV}

– _{NRTI: no significant effects on methadone levels; AZT}

levels increased

– _{NNRTI: EFV and NVP decrease methadone levels}

– _{PI: APV, NFV, LPV decrease methadone levels; methadone}

decreases APV levels

• _{Buprenorphine: limited data on interactions with}

(21)

Strategies for overcoming health care

disparities for HIV – infected drug users.

1. Pharmacologic (eg.methadone or buprenorphine) and/or nonpharmacologic treatment (eg. 12 steps) for

substance use

2. Flexible outpatient and community-care settings (eg. Walk-in clinics, mobile healthcare programs)

3. Low-threshold sites to engage active users (eg. Syringe exchange sites)

4. Directly administered antiretroviral therapy

5. Intensive outreach and case-management services 6.Treatment during incarceration

(22)

Conclusions

Large number if IDU among HIV + patients has

considerable impact on our medical and social system

IDU s may be as adherent to taking their medication as other patients

With different programs and support those patients may have as good efficacy of HAART as other HIV patients Lessening damage is now the only option for Estonia

(23)

1.What will be your choice of HAART for IDU female with CD4+ nadir >250 cells/mm3 ?

a.ZDV/3TC+EFV b.TDF/FTC+EFV c.ZDV/3TC+NVP d.ZDV/3TC+LPV/r

2. What will be your choice of HAART for HIV male patient , previously injecting, now taking methadone and still on TB treatment

containing RIF+INH

a.ZDV/3TC+EFV and increase methadone dose b.ZDV/3TC+LPV/r

HIV infection in injecting drug users