HIV Treatment As HIV Prevention

Transcription

1 HIV Treatment As HIV Prevention HIV/AIDS and Substance Abuse Nora D. Volkow, M.D. Director National Institute on Drug Abuse National Institutes of Health

2 Few could have imagined that we d be talking about the real possibility of an AIDS-free generation President Obama, December 1, 2011 HPTN 052 Early ART prevented linked HIV transmission Early ART reduced the number of clinical events observed

3 Numbers of AIDS Diagnoses Among Adults and Adolescents, by Transmission Category, Cumulative through 2010 Total cumulative cases of AIDS attributable to IDU and IDU MSM since the beginning of the epidemic is 32.6% 18.7% 1.6% 47.4% 7.1% 25.2% MSM IDU IDU MSM Heterosexual Other

4 HAART as HIV Prevention Montaner et al., Lancet 2008 Decline in Community Viral Load is Strongly Associated with Declining HIV Incidence among IDUs (ALIVE) GD Kirk, N Galai1, J Astemborski, B Linas, D Celentano, SH Mehta, D Vlahov Poster presented at the 18 th Conference on Retroviruses and Opportunistic Infections (CROI), Boston MA, February 27-March 3, 2011

5 Major Challenges 1. Treating Substance Abusers with HAART 2. Treating HIV+ Patients for Substance Abuse

6 IDU HIV+ Are Much Less Likely to Receive HAART Percentage Of Providers Who Would Defer ART By CD4+ Count and Injection Drug Use Status Westergaard RP et al., J Int AIDS Soc 2012; 15:10.

7 Improved Virological Outcomes in BC Concomitant with Decreasing Incidence of HIV Drug Resistance Mortality Rate Among 3116 Antiretroviral-Naive Patients Initiating HAART Incidence/yr Viral load < 50/mL (%) Acquired resistance falling Gil et al Plasma viral load suppression rising Cumulative Incidence of Mortality, % No. at risk All-Cause Mortality IDU Non-IDU Wilcoxon test P = Months Non-IDU IDU Gill et al., CID 2010:50 HIV/AIDS Wood, E. et al. JAMA 2008;300:

8 Methadone Maintenance Therapy Improves HIV Outcomes in IDU Methadone Maintenance Therapy Promotes Initiation Of Antiretroviral Therapy IDU Antiretroviral Adherence and HIV Treatment Outcomes Among HIV/HCV Co-Infected IDU: Role of Methadone Uhlmann S et al., Addiction 2010; 105(5): Adjusted Odds Ratio Uhlmann S et al., Addiction 2010; 105(5): Palepu A et al., Drug and Alcohol Dependence 2006; 84:

9 Treatments For SUD Are Not Being Used By Many Who Need Them In 2010, 22.1M Americans 12 or Older Were Dependent On Drugs or Alcohol Only 4.1M (19%) Received Some Type of Tx In Past Year; few in healthcare 2.2 M opioid dependent Self Help Group Outpatient Rehab Inpatient Rehab Outpatient Mental Health Center Location TX Received ,688 SA treatment facilities only 1,132 (8%) prescribe OST Less <12% of opioid dependent patients received OST Hospital Inpatient Doctor s Office Emergency Room Prison or Jail Numbers in Millions Source: 2010 NSDUH, National Findings, SAMHSA, OAS, 2011.

10 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Incarceration Predicts Virologic Failure for HIV+IDU Receiving ART 0% No incarceration Incarceration during prior 6 months Had clinic visit got ART Clinic visit, did not get ART Got ART, no clinic visit Did not get ART, no clinic visit Westergaard RP et al., HIV/AIDS 2011; 53: In a Given Year About 14% of all people in the US with HIV will pass through a correctional facility. ADULTS (+7M) > 5.5M need SUD TX JUVENILES (650K) 253,034 need SUD TX Source: Bureau of Justice Statistics, 2009

11 Global Challenges For Treatment of IDU Many Countries Are Reluctant to Use OST and to Treat IDU with ART IDUs Receiving Methadone or BuprenorphineTx, 2009 IDUs as Share of Total HIV Cases & of Patients Receiving ART, 2008 Wolfe D et al., Lancet 2010; 376:

12 What is NIDA doing? 1. NEW THERAPEUTICS for IDU Long lasting medications to improve compliance Medications not based on opioid substitution Vaccines and other immunotherapies 2. STTR IMPLEMENTATION Criminal justice system, Substance abuse treatment programs, Health care system (ie STD clinics), Countries where IDU is driver of HIV epidemic ` ` ` Khan -- UCSF Gwadz Cunningham New York Albert University Samet Boston Medical Center El-Sadr -- Columbia Einstein Metsch University of Miami Lucas `Johns Hopkins Ann Duerr Fred Hutchinson Kurth Cancer New RC` York University Wechsberg Research Triangle Institute

13 Josiah Rich Moupali Das HIV/AIDS in America Don DesJarlais Steven Shoptaw Grant Colfax Steffanie Strathdee & Thomas Patterson ` ` Carlos Del Rio

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