HIV/AIDS-and Substance Use Disorders

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HIV/AIDSand Substance Use Disorders

Preparedby Olivera Bogunovic, MD

 Alcohol Medical Scholars Program

April7, 2006            slide[1]

INTRODUCTION       

Lecture addresses twoclinically important topics

HIV/AIDS: a commonand deadly disease

Substance use disorders:i.e., dependence on alcohol and illicit drugs

It is important tounderstand how they relate

Each increasesthe risk of the other

Each impactson treatment

Clinicians must learnabout both conditions to give optimal treatment; therefore this lectureaddresses:

Importance ofHIV Ð public health issue

Connectionbetween HIV and substance use disorders

Implicationsfor patient care                                                         slide[2]

Vignette

40 year-oldwhite male presents to the emergency room with symptoms

Diarrhea >1month

Fatigue

Weight loss

thrush

History

Used heroinintravenously for past 10 years

Multiplefailed inpatient rehabilitation treatment

Few periods ofsustained sobriety in past 10 years

On and offdepressed mood

Pertinentlaboratory data

CD4 risk of anus carcinoma   slide[9]

Treatment withantiretroviral drugs

 Antiretroviral treatment to increaseimmune function and decrease viral replication

Guidelines forstarting antiretroviral treatment

Use for everyone(symptomatic or not) if CD4< 500 cells/ml

Use if plasmaviral load > 5000-10000 copies/ml.

Reevaluate needfor treatment every 3-6 months

 Nucleosideand nucleotide analogs

Act as chainterminators for HIV reverse transcriptase when incorporated in the elongatingstrain of DNA (e.g. they stop viral replication)

Specificdrugs:

Zidovudine(Retrovir)

Didanosine(Videx)

Zalcitabine(Hivid)

Stavudine(Zerit)

Lamivudine(Epivir)

Protease inhibitors

Act at thestage of viral release; prevent the action of proteases which are essential toproduction of viral particles (e.g. reduce production of infectious virusesfrom host cell)

Specificdrugs:

 Saquinavir(Invirase)

Indinavir(Crixivan)

Ritonavir(Norvir)

Nelfinavir(Viracept)

Non-nucleosidereverse transcriptase

Bind toreverse transcriptase of the virus; prevent RNA conversion into DNA (e.g. virusnot able to replicate in host cell)

Specificdrugs:

Nevirapine(Viramine)

Delaviridine(Rescriptor)                                                                    slide[10]

Treatment andprophylaxis of Pneumocystic Carrini with antibiotics (when CD4 50% of patients)

Noncompliancewith medication regimen

44% of activedrug users noncompliant compared to 22% of non drug users

Suboptimalvirologic and immunologic responses associated with noncompliance

Substancedependent often lack of medical insurance

Poor socialsupport

Methadone andbuprenorphine maintenance programs 

Associatedwith better adherence to HIV/AIDS medical treatments

Methadoneprograms require daily follow up

Associatedwith less active drug use [25, 46-52]                                  slide[28]

Effects of substanceuse disorders in HIV patients in relation to psychiatric disorders: Drugs/alcohol can cause/exacerbate most psychiatric symptoms

Psychiatric symptoms more common among substanceusers

HIV+ moresensitive to illicit drugs [41,42,43,44,45]                                   slide[29]

GUIDELINESFOR TREATMENT           slide[30]

Treatmentfor substance use disorders and HIV/AIDS should consider both

 Case management model: patient shouldhave a single clinician who coordinates treatment plan

Establish andmaintain treatment plan that supports patientÕs complete set of needs

Maximizecare for HIV/AIDS and substance use disorders

Medical treatment

Variesdepending on stage of infection

 Asymptomatic infection

Treat withantiretroviral therapy

Risk of disease progression (assessed by CD4 countand viral load)

Willingness to begin therapy and remain adherent

Patients withgood adherence have ⎠ morbidity, mortality

 Symptomatic infection

Treatopportunistic infections

Prophylactictreatment for Pneumocystis carrini and cytomegalovirus

Treat acuteand chronic pain

Localmeasures as first line therapy

Use ofnarcotics for a limited time and as a last resort 

        slide[31]

Substance usedisorder treatment

Abstinence isthe goal

 Reduce HIV risk behavior:

 Safe sex practices

Use of cleanneedles should any injection drug use occur, but emphasize that abstinence isthe ultimate and best goal

Harm reductionapproaches may be appropriate

Methadonemaintenance programs more available (associated with normalization of immunefunction, ⎠spread of HIV infection, ⎠ use of medical services, ⎠ spread of HIV infection)

Syringeexchange programs provide information about safer injection techniques (e.g.,use of clean needles, use of disinfectant) and reduce spread of HIV and otherinfectious diseases

Mental healthtreatment

Highcomorbidity in HIV+ patients with substance use disorders

Assessment anddiagnosis challenging

Patients atincreased risk of suicide (20% increased risk compared to general population)

Standardpharmacologic approaches may be used to treat psychiatric disorders [53]                                                slide[32]

Vignette:

What next:

Treat withantiretroviral meds: educate re management of pills,

 Substance use disorder treatment:

Considermethadone maintenance program to⎠ reduce risk of reinfection andneedle sharing; consider need dose of antiretroviralregimen when determining methadone dose

Encourageself-help meetings re both for HIV and opioid dependence

Mental healthtreatment:

Evaluatepossible need for treatment

Use meds(e.g. antidepressants) if an independent disorder is indicated

Initiatecognitive behavioral therapy re: coping skills and positive behaviors topromote improvement of mood

Monitorcompliance with HIV medications, maintenance of safe sexual practices,compliance with substance use disorder treatment, and mood state          slide[33]

D. Summary        slide[34]

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