Transcript Risk Mitigation in Vulnerable Populations in Los Angeles

HIV/AIDS and Drug Use in the
United States:
Models for Strategic Planning
Steve Shoptaw, Ph.D.
UCLA Integrated Substance Abuse Programs
June 6, 2005
Key Points
• Concentrated versus generalized AIDS epidemics
• AIDS-related behaviors vary by geography
– Risk behaviors emerge and change with time
• Drug abuse is more than injection behaviors
• Interventions for AIDS prevention with drug users
– Behavioral risk reduction, needle exchange, substance
abuse treatment, prevention for positives, post
exposure prophylaxis, pre-exposure prophylaxis
International: Generalized Epidemic
• HIV passed efficiently
in general population
• Primary signal of
generalized epidemic
is high numbers of
infected pregnant
women
U.S.: Concentrated Epidemic
• Defined behavioral
risk groups associated
with HIV infection
– Injecting drug users
(IDU)
– Men who have sex
with men (MSM)
– IDU+MSM
National Prevalence
United States:
Recent HIV/AIDS Cases
CDC, 2005
AIDS Prevalence by Behavioral
Risks, 1981-2002
MSM
IDU
Los Angeles
71.3%
MSM+
IDU
7.0%
6.6%
Het
Other
4.6%
10.4%
San Francisco
74.3%
8.8%
13.5%
1.7%
1.7%
Denver
71.3%
7.5%
11.1%
5.1%
4.9%
Albuquerque
68.6%
8.9%
10.7%
4.6%
7.2%
Salt Lake City
64.2%
18.1%
8.5%
4.7%
1.9%
New York City
29.5%
41.5%
3.2%
9.8%
16.0%
http://wonder.cdc.gov
Geography, HIV Prevalence and IDUs
• West of the Mississippi
River, prevalence rates
remain much lower than in
the East
• No differences in risk
behaviors
• May be attributes of the
heroin itself can be
protective
HIV Prevalence in IDU
1994-1996
21.5%
2.3%
Garfein et al., 2004
Sexual HIV Transmission in IDUs:
San Francisco
• 58 HIV incident infections, 1134 case controls
who remained negative from 1986-1998
• MSM 8.8 times as likely to seroconvert as hetero
men (95% CI 3.7-20.5)
• Women who traded sex for cash 5.1 times as likely
to seroconvert (95% CI 1.9-13.7)
• Women younger than 40 2.8 times more likely
than older women to seroconvert (95% CI 1.1-7.6)
Kral et al., 2001
Los Angeles AIDS Epidemic:
Cumulative Male AIDS Cases
MSM
Los Angeles*
76%
United States**
58%
MSM and IDU
7%
8%
IDU
6%
22%
Other
11%
12%
*January 2004 HIV Epidemiology Report, LA County
**March 2005 HIV/AIDS Surveillance Report, CDC
U.S. Adult Male AIDS Cases by Risk Behavior by Year
90
80
70
60
50
40
30
20
10
0
MSM
MSM+IDU
IDU
Hetero
Other
CDC, 2004
1990 1991 1992
1993 1994 1995 1996 1997 1998
1999 2000 2001
L.A. County Adult Male AIDS Cases by Risk Behavior by Year
90
80
70
60
50
40
30
20
10
0
MSM
MSM+IDU
IDU
Hetero
Other
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
L.A. County
HIV Epi
Pgm, 2004
U.S. Adult Female AIDS Cases by Risk Behavior by Year
70
60
50
IDU
Hetero
Other
40
30
20
10
CDC, 2004
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
L.A. County Adult Female AIDS Cases by Risk Behavior by Year
70
60
50
IDU
Hetero
Other
40
30
20
10
0
1990
1991 1992 1993
1994 1995
1996 1997
1998 1999 2000
2001
L.A. County
HIV Epi
Pgm, 2004
Summary: Epidemiology I
• All epidemics are local: Prevalence and
incidence rates of HIV and AIDS vary by
geography
– In the Western U.S., metropolitan areas have lower
HIV prevalence rates among IDUs than in less
populated cities/areas
– A model is provided, complete with internet
resources that can help you develop a “snapshot” of
your local epidemic
Associations Between Drug
Dependence, Sexual Orientation,
and HIV Risk Behaviors
• Analysis of 13 treatment research studies
– Four classes of drug dependence
– Common assessments at identical points
Shoptaw et al., in review
Demographics
Male %
Coc Dual MA G-MA Her
(476) (120) (1308) (162) (338)
75.0 55.0 48.4 100.0 68.3
Ethnicity %
White
Afr Amer
Hisp
Asian
Other
29.4
41.6
25.6
2.1
1.2
39.2
31.7
25.8
1.7
1.7
63.5
1.7
18.4
13.7
2.7
75.9
3.1
13.0
3.1
1.2
P<0.0004
42.0
20.4
33.1
2.1
2.1
Drug Related Variables
Years, Life
Coc Dual MA G-MA Her
(476) (120) (1308) (162) (338)
9.5
10.3
7.9
5.1
13.9
Days in 30
10.9
12.0
11.9
9.7
17.4
Route of
Admin
Nasal
Smoking
IV
20.0
75.4
3.2
4.2
50.8
45.0
11.9
64.6
22.9
28.4
29.6
37.0
6.2
10.1
80.8
P<0.0001
Risk Associations
Comparisons
Shared Needles/
Works
(n=1,313)
Cocaine
Dual
Methamphet
MSM+Meth
OR
95% C.I.
0.04
1.67
1.90
1.40
0.02-0.09
1.34-2.08
1.39-2.60
1.07-1.83
Risk Associations
Comparisons
>1 Sex partner,
6 months
(n=2,071)
Cocaine
Dual
Methamphet
MSM+Meth
OR
95% C.I.
2.11 1.64-2.72
1.72 1.31-2.27
10.7 28.5-46.1
Risk Associations
Comparisons
OR
95% C.I.
Cocaine
Dual
Methamphet
MSM+Meth
5.65 3.43-9.29
6.04 2.67-13.7
-
Exchange Sex
(n=986)
Risk Associations
Unprotected
Intercourse
(n=2,389)
Comparisons
OR
95% C.I.
Cocaine
Dual
Methamphet
MSM+Meth
1.49
1.16
1.72
10.7
1.27-1.73
1.00-1.35
8.64-13.2
1.47-2.01
Findings
• Stimulant dependent groups, especially MSM who
are dependent on methamphetamine, have highest
risks for HIV transmission
• MSM methamphetamine users 61% HIV infected;
no non-MSM methamphetamine users detected to
date.
• Risk is a function of drug class, sexual orientation
and proximity to infectious disease
Some More Numbers…
• HIV prevalence in methadone clinics ~ 5-10%
• Incidence of HIV infection observed ~ 8-10 ppy
for MSM in Seattle STD clinics (Golden 2003)
• Methamphetamine use, past 6 months
– 11.2% of MSM in Los Angeles
– 13.3% of MSM in San Francisco (Stall et al., 2001)
• Prevalent in clubs in New York (Halkaitis, 2003)
• Methamphetamine use in HIV care clinics ~ 3040% (St Mary’s Hospital, Long Beach)
MSM in Commercial Sex Venues
50
Percent Reporting
50
40
30
20
13
14
10
0
HIV +
Bisexual
Men of Color
Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049
Reback, 2004
Drug Risks,
MSM in Commercial Sex Venues
80
Percent Reporting
70
60
50
40
30
20
10
0
Alcohol
MJ
Poppers
Crystal
Ecstasy
GHB
IDU
Bathhouse and sex club contacts, 1/1/03 and 12/30/03; n=1,049
Reback, 2004
Hollywood Street Outreach, MSM
Reback, Grella, & Shoptaw, 2003
Drug Use Where There Is No Virus
Is A Drug Abuse Problem…
In Los
Angeles
County,
heroin
injectors at
low risk; gay
male meth
users at
extreme risk
70
60
50
40
30
20
10
0
MMT-LAC
Her-LAC Meth-HWD Meth-RC
LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)
Treatment Outcomes and Risk
• Influence of culture on treatment: materials,
outcomes, and processes
– Sophisticated culture
– Disdain for total abstinence
– Sensitivity to judgment and rejection
• Issue of risk and its reduction
– Meaning of sex without crystal use in recovery
www.crystalneon.org
www.tweaker.org
The Formative
Study
The Social
Construction of a
Gay Drug:
Methamphetamine
Use Among Gay
and Bisexual Males
in Los Angeles
www.uclaisap.org
Methamphetamine and HIV in MSM: A
time-to-response association?
100
Percent HIV+
80
60
40
20
0
Probability Recreational
Sample1
Users2
1Deren
Chronic
Users3
Outpatient
Drug free4
Residential
Treatment5
et al., 1998, Molitor et al., 1998; 2Reback et al., in review;
3Reback, 1997; 4Shoptaw et al., 2002; 5VNRH, unpublished data
If one believes there is a problem, what are
the intervention choices?
Broad Based Approach: Provide HIV prevention to
current users (and non-users) at all levels (e.g.,
condom distributions)
1
– Presumes intact decisions/choices around sexual
behaviors in most people
Targeted Approach: Provide drug abuse treatment to
users with abuse or dependence
2
– Centrality of drug/sex link in decisions/choices
for small, heavily drug involved group
Interventions:
Methamphetamine Using MSM
Behavioral
Prevention
Biological
Adjuncts
Objective
• To evaluate the comparative efficacy of
behavioral drug abuse treatments in gay and
bisexual, methamphetamine-dependent men
in Los Angeles :
• Methamphetamine use
• High-risk sexual behaviors
• Depression ratings
Design
Randomization and
Baseline
Follow-up
Follow-up
Follow-up
CM (n=42)
CBT (n=40)
Screen
CM + CBT (n=40)
GCBT (n=40)
2 Week
Baseline
16 Week
1st Follow-up
6 Months
12 Months
2nd Follow-up
Adaptation of a Gay-Specific Intervention
Standard CBT
CBT+ gay-specific
HIV-Risk Reduction
External Triggers:
Sporting Events
Concerts
Movies
Gay Pride Festival
Bathhouse
Halloween
Relapse Justification:
“I just got injured.
I might as well use.”
“My friend just died
[AIDS] and using will
make me forget for
awhile.”
One Day at a Time:
“Tomorrow something
will happen to ruin
this.”
“I seroconverted even
though I knew about
safer sex.”
Specific Topics:
* Coming Out All Over Again: Reconstructing Your Gay Identity
* Being Gay and Doing Gay
* Preventing Relapse to High-risk Sex
* Living in an HIV World
* Several session that involve “Aunt Tina”
Conditions
• Contingency Management (CM)
– Peeing for Dollars!
– $415 earned in vouchers; 34% of total possible
• Combination CBT+CM
– Talk and behavioral therapy
– $662 (SD=478) earned or 51.8% of possible
• (t (80) = -2.4, p = .019)
Sample Demographics
• Mean age: 36.6
(SD=6.4)
• Education:
– 95.7% > HS
– 41% > 4-year degree
• Ethnicity:
–
–
–
–
–
Caucasian: 77.2%
Hispanic:
12.9%
African-Am: 3.1%
Asian-Am:
3.1%
Native Am:
1.2%
History of Sexually Transmitted Diseases
by Reported HIV Serostatus
STD
HIV Serostatus
Positive
Negative
(n=98)
(n=64)
%
%
Statistic
Genital warts
41.1
19.4
2 (1) = 8.05, p=.005
Syphilis
28.4
8.2
2 (1) = 9.32, p=.002
Genital
Gonorrhea
53.1
30.6
2 (1) = 7.72, p=.005
Yeast infection
14.9
0.0
2 (1) = 10.14, p=.001
Hepatitis B
41.5
17.7
2 (1) = 9.67, p=.002
Shoptaw et al., 2003
Baseline drug use
• Drug use behaviors
–
–
–
–
–
–
Lifetime MA use: 8.34 yrs (SD=5.9)
Lifetime heavy MA use: 3.39 yrs (SD=4.07)
Lifetime other drugs used: 2.3 (SD=1.4)
Lifetime IV MA use: 32.1%
MA use in past 30 days: 9.7 days (SD=7.4)
$ spent on MA past 30 days: $293 (SD=$399)
Treatment Outcomes
Contingency Management
 Significantly longer
retention
 Significantly more
“clean urine”
 Significantly longer
stretches of
consecutive clean
urine samples
Unprotected Anal Receptive
Intercourse; Past 30 Days
3.5
3
2.5
CBT
CM
CBT+CM
GCBT
2
1.5
1
0.5
2(3)=6.75, p<.01
12
-M
os
os
M
6-
ks
-W
16
12
-W
ks
ks
8W
ks
4W
Ba
se
l
in
e
0
Unprotected Anal Insertive
Intercourse; Past 30 Days
8
7
6
5
4
3
2
1
0
2(3)=8.26, p<.01
12-Mos
6-Mos
16-Wks
12-Wks
8-Wks
4-Wks
Baseline
CBT
CM
CBT+CM
GCBT
Summary of Findings
• Treatment gains are sustained to 1 year
follow-up evaluation
– CM helps in the short term to reduce MA use
– GCBT helps reduce short-term high-risk sexual
behaviors
• Drug treatment methods induce sustained
risk behavior changes
Policy Implications
• “Syndemic” of drug use and HIV infection
in gay men
– Work at the core of overlapping epidemics
• Inclusion of treatment approaches in CDC
compendium of evidence based guidelines
• Treatment on demand for gay stimulant
abusers?
Next Steps:
Treatment as Prevention
• $3 million State Office on AIDS RFA in California
• Promoting effective treatment approaches for new
settings
–
–
–
–
STD clinics (Klausner, SF)
Sex venues (L.A. County)
AIDS Care settings (Peck, UCLA)
HIV Prevention approaches (CHIPTS, UCLA)
• Integration of medication treatments (Newton, UCLA)
• Epidemiological implications (Gorbach, UCLA)
The Million Dollar Questions
• Is HIV leaking from
defined behavioral risk
groups to general
population?
• At what rate is this
leakage happening?
• SATH-CAP project
Prevention Approaches for IDUs
Needle Exchange
Education
HIV Counseling & Testing
Opioid replacement
Needle Exchange
• NE conceptualized within larger set of
services (Des Jarlais, 2000)
– Number of NEPs increasing 20% per year
• NEP attendees less likely to share needles
and more likely to clean skin (Longshore et al.,
2001)
• NEP attendance protective against HIV
(Monterroso et al., 2000)
Prevention Works for IDUs
Even in Low Prevalence Cities
• High prevalence
groups
% per 100 person year
3
2.5
– < 30 yr old (2.8%)
– MSM (3.0)
2
1.5
1
0.5
0
1987-1988
1989-1998
• Prior C & T reduced
odds for infection
(OR=0.43; 95%CI=
0.21, 0.87)
Kral et al., 2003
Opioid Agonist Replacement
• Opioid agonist
care is associated
with decreased
injection and sexrelated HIV risk
behaviors (Sorensen
and Copeland, 2000)
Opioid Detoxification:
A Prescription for Failure
• The best available data suggest that inpatient
detoxification may show acceptable outcomes (Day et
al., 2005), but any outpatient pharmacological
detoxifications result in indefensible relapse rates and
should not be considered as treatment (Amato et al.,
2004)
– Psychosocial strategies are even less effective and also should
not be considered as treatment (Mayet et al., 2005)
• Newly detoxified individuals are extremely vulnerable
to relapse. The vast majority fail to remain drug-free.
• Opioid maintenance should be the first-line treatment
for heroin dependence.
Opioid Replacement
• Methadone
– Medication is inexpensive; staff
to run licensed narcotic treatment
programs push annual cost to
about $4500
– Schedule 2 narcotic
– 160,000-200,000 people in U.S.
receiving methadone
– NTPs are efficient platforms for
education and testing for HIV,
Hepatitis C, Tuberculosis
Krambeer et al., 2001)
A Different Medical HIV Prevention:
Post Exposure Prophylaxis
• Routine treatment for health care workers
accidentally exposed
– Perhaps reduces odds of seroconversion by
79% (CDC, 1997)
• Experimental programs evaluating PEP for
drug and sexual exposures
• May have particular value as intervention in
drug users
Sometimes Your Best Thinking...
• 2 participants tested HIV positive at baseline
• 15.8% had substance metabolites in urine
- 10.5% methamphetamine
- 5.3% cocaine
- 2.1% opiates
•
•
•
•
•
•
49.0% unprotected receptive anal intercourse
36.5% unprotected insertive anal intercourse
4.2% unprotected receptive vaginal intercourse
16.7% unprotected insertive vaginal intercourse
84.4% unprotected oral sex
3.1% other
(Activities are not mutually exclusive)
Conclusions
• PEP may be attractive theoretically
• Not likely to be useful to the population for
which it might have the most efficacy
– PEP programs are hard to find
– Drug users have competing demands for their
time
– Drug users have difficulty with compliance and
structure
Pre-Exposure Prophylaxis
Concept
• Boost medication efficacy for preventing
HIV infection by having ARV on board at
the moment of exposure to HIV
• Some suggestion that this might be
especially effective in HIV-uninfected
groups who engage in high-risk sexual
behaviors +/- drug use
Limits to PrEP?
Implications of PrEP
• Analogous to “imperfect vaccine”
• Requirements are difficult to reach for PrEP
to make measurable impact on infections
– High coverage
– High efficacy
– High prevalence and incidence
• May still be strong arguments for
implementing this in select groups
Szekeres et al., 2005; http://chipts.ucla.edu