HIV infection in injecting drug users

Transcription

1 HIV Clinical Skills Series 4 th International Training Course Tallinn 2010 HIV infection in injecting drug users Marika Raukas West-Tallinn Central Hospital Estonia

2 InjectionDrug 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 Manipulative, unmotivated, and undeserving of care

3 Transmission of HIV infection % 6% 0 32% 1,30% 0,20% 7% 0,20% 46% 91% HETERO HOMO IVDU DOONOR emalt lapsele HETERO HOMO IVDU DOONOR emalt lapsele (96 cases) (3603 cases)

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 = afgaanlane, amphetamine.

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, overdose, suicides etc

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, haemorrhage due to emboli

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 Many other support mechanisms may be effective

9 Factors Affecting Adherence: Patient Related Active alcohol and substance abuse: -Without appropriate treatment and linkages to supports and follow-up treatment upon discharge, the patient is at risk for returning to high-risk behaviors and nonadherence to HAART. Mental health disorders: -Depression and other psychiatric conditions are more prevalent among IDUs and inmates than the general population. -Treatment of underlying mental health disorders should precede or occur simultaneously with the initiation of HAART to ensure successful readiness.

10 Factors Affecting Adherence: Patient Related Health beliefs: -Mistrust of the health care system and misconceptions about HIV and HAART are common among IDUs. -If the patient believes that the treatment is harmful or will not work, adherence will be poor. -The IDUsshould be educated about the disease process itself and the role of the medications, along with the potential risks and benefits of HAART.

11 Factors Affecting Adherence: Patient Related Social Supports -IDUs often come from environments lacking in support. -Fear of disclosure can case the HIV+ patient to isolate him/herself, making adherence difficult. -Use support groups can be a positive way to foster self esteem, empower inmates and aid adherence.

12 Factors Affecting Adherence: Patient Related Educational level -Low reading level are common among inmates. -It is important to use reaching tools that are appropriate in reading level and language(eg russian). -Basic HIV education prior to HAART should include: how medications work, consequences of non-adherence, names and doses of medications, and potential side effects with strategies to manage them

13 In and out of prison is everyday life for IDU-s.

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. Piliero, 2001

15 Between DOT andkop 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 patientsto keep their medications and take them independently. Monthly or two month supplies are obtained at the medical unit.

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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 ARV

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 c.tdf/ftc+efv