Epidemiology

HIV/AIDS and illicit drug use adversely impact tens of millions of people, with explosive epidemics of both described worldwide. Non-injection drug use such as alcohol and stimulant use (e.g. cocaine and methamphetamines) contribute to risky sexual behaviors leading to HIV acquisition [1]. Injection drug use (IDU), largely of opioids, has been reported in 136 countries and 114 of these have reported HIV cases [2]. The link between drug use, particularly IDU, and HIV has been well described since the beginning of the HIV pandemic [3]. The world’s most volatile and emerging HIV epidemics are in areas that are fueled by illicit drug use, particularly heroin. New IDU epidemics continue to emerge with some of the newest in Kenya and Tanzania. Recently, HIV seroprevalence of 42% has been reported among 534 male and female injectors in Dar es Salaam, Tanzania [4]. Particularly troubling is that many of these epidemics are among individuals younger than 30 and within the most densely populated regions of the world. Injection drug use is especially important in the HIV/AIDS epidemic among women and children.

In light of the increasingly central role of drug use, particularly IDU, in the global HIV/AIDS epidemic, issues of HIV clinical care and therapeutics in this population are of great importance. Of particular relevance are the special clinical features of HIV disease in drug-dependent patients, the treatment of HIV disease itself in this population, the special difficulties in providing care to drug users and the treatment of drug addiction and special issues of HIV prevention [5].

HIV Disease in Drug Users

The natural history of HIV disease among drug users has been demonstrated to be similar to that in other transmission risk categories [6]. Drug users are, however, at an increased risk for a number of other infections compared with other risk categories. Although most of these infections and other complications were common among drug users prior to the HIV epidemic, their incidence and severity have been accentuated, and clinical presentation affected by HIV infection. In both inpatient and outpatient settings, these are more common than the designated AIDS indicator diseases or specific HIV-related complications and often confound both diagnosis and treatment [5].

Multiple features of injection drug use that contribute to the increased risk of infection are summarized in Box 40.1, A detailed discussion of these infections and their management is beyond the focus of this chapter. Table 40.1 offers a summary of substance use-related complications in HIV-infected injection drug users. This chapter will address specific issues for co-managing and treating HIV infection itself among users of illicit drugs.

Treatment of HIV Infection in Drug Users

Combination antiretroviral therapy (cART) has resulted in impressive benefit for people living with HIV/AIDS, including decreasing morbidity, mortality, and hospitalization, and has been demonstrated from a societal perspective to be cost-effective [7]. Despite the widespread availability of antiretroviral medications in resource-rich settings, IDUs have derived less benefit than other populations. This disparity in benefit among IDUs has been and will likely continue to be experienced in resource-limited settings even as cART becomes increasingly available for adults and children with HIV disease. The reasons for the disparity are multifactorial.

In many societies worldwide, both HIV and illicit drug use are stigmatized such that either or both conditions are often cloaked in secrecy and may result in a lack of detection and treatment [8]. Drug users are among the most socially marginalized populations and often hidden by circumstances and/or choice from mainstream medical care. Even when available, healthcare services are often constructed in ways that are difficult for many drug users to access, either by their absence in communities with high prevalence of drug use or by their organization that does not accommodate the chaotic and sometimes unpredictable use of services characteristic of drug-using populations. In addition, clinical care for drug users with HIV disease is often challenging and stressful for clinicians and other healthcare workers as a result of the complex array of substance misuse-related medical, psychological and social problems. The frequent co-morbid underlying psychiatric disease often contributes to these difficulties. Substance misusers may also have increased difficulties with adherence to cART, which may be compounded by their underlying co-morbid diseases, increased side effects, and drug interactions.

There is often mutual suspicion between drug users and healthcare providers. Clinicians tend to have stereotypic views of drug users and may harbor negative feelings about their social worth. As with other “difficult” patients, physicians may come to view drug users as manipulative, unmotivated, and undeserving of care. The chronic relapsing nature of addiction as a medical disease is often not appreciated by clinicians, nor is the fact that drug users may be quite diverse and heterogeneous. Many physicians assume that drug users’ antisocial behavior and drug use indicate a lifelong lack of concern for others and indifference to their own well-being, rather than a consequence of addiction. Conversely, drug users often are mistrustful of the healthcare system and harbor expectations that they will be treated punitively. Drug users often conceal their continuing drug use from healthcare professionals out of fear of rejection prompted by previous difficult encounters with the healthcare system. In turn, clinicians are sometimes reluctant to confront patients with their suspicions about ongoing drug use, fearing that the confrontation will compromise their relationship. The failure to acknowledge ongoing drug use itself, however, can compromise the clinician–patient relationship since one of the most important aspects of the patient’s health is off-limits for discussion.

Because the life of a patient struggling with substance use disorders (SUDs) is often chaotically organized around their substance use needs, successful programs for this population have developed some or all of the following characteristics: (1) pharmacologic (e.g. methadone and buprenorphine programs) and/or non-pharmacological treatment (e.g. 12 steps) for SUDs; (2) flexible outpatient and community care settings (e.g. walk-in clinics, mobile healthcare programs); (3) low-threshold sites to engage active users (e.g. syringe exchange sites); (4) modified directly observed therapy; (5) intensive outreach and case management services; or (6) treatment during incarceration [5].

Clinicians involved in the care of drug users with HIV, should be aware of several key principles, which include the following: (1) Become educated about substance abuse and its wide array of treatment options. (2) Establish a multidisciplinary team of individuals with expertise in managing HIV, substance abuse, and mental illness, and broadened to include social work, nursing, case management, and community outreach. Identify a single provider to maximize consistency. (3) Obtain a thorough history of the patient’s substance abuse history, practices, needle and syringe source, drug abuse complications, and treatment history. Non-judgmental, clinical assessment of this information is essential. Non-judgmental discussion of the adverse health and social consequences of drug use and the benefits of abstinence may increase the patient’s understanding of his or her disease and interest in change. (4) Be aware of pharmacological drug interactions between HIV therapies and substance abuse therapies and provide simplified, low pill burden regimens to improve treatment adherence. (5) Link HIV and substance abuse treatment goals such that success in one arena is linked to improved outcomes in the other. (6) Establish a relationship of mutual respect. Avoid moral condemnation or attribution of addiction to moral or behavioral weakness. Acknowledge that SUDs are medical diseases, compounded by psychological and social circumstances. As such, they should be treated using evidence-based guidelines with a combination of pharmacological and behavioral interventions. Reducing or stopping drug use is difficult, as is sustaining abstinence. Success may require several attempts and relapse is common. Complete abstinence may not be a realistic goal for many substance-misusing patients. Rather, increasing the proportion of days, weeks, and months free from mind-altering substances is an acceptable goal. (7) Work closely with a drug treatment program. (8) Define and agree on the roles and responsibilities of both the healthcare team and the patient. Establish a formal treatment contract that specifies the services to be provided to the patient, the caregiver’s expectations about the patient’s behavior, and periodic urine toxicology for substances, and delineate the consequences of behaviors that violates the contract. Such a contract should be agreeable to both parties, and not simply a contract of the physician’s expectations. (9) Set appropriate limits and respond consistently to behavior that violates those limits. These should be imposed in a professional manner that reflects the aim of enhancing patients’ well-being, and not in an atmosphere of blame or judgment. (10) Carefully evaluate pain syndromes and provide sufficient analgesia as medically indicated. (11) Always consider acute substance ingestion when evaluating behavior change and neurologic disease. Use urine toxicology testing to evaluate behavioral changes and to discourage illicit drug use by HIV-infected injection drug users during hospital stay. (12) Work consistently as a team. Do not make agreements about treatment decisions until the entire team has become involved. This will avoid ‘splitting’ behaviors that often unravel the fabric of a multidisciplinary team. (13) Consider integrating drug treatment into the HIV clinical care settings or HIV clinical care into a drug treatment setting (e.g., a methadone program). While there are no specific recommendations for accomplishing this goal, a number of key approaches have been described. These include complete integration where all clinicians are stakeholders in the treatment of both conditions, the integration of a specialized addiction specialist team or a hybrid model where both are implemented [9].

Commonly Used Drugs

The illicit drugs most closely associated with the acquisition of HIV infection globally are heroin, cocaine, and methamphetamine use. Each of these can be administered by a variety of routes. Injection with shared contaminated needles and syringes or other injection paraphernalia carry the greatest risk for HIV transmission and other complications. Non-injection use of cocaine and methamphetamine, however, increasingly facilitates HIV transmission through its association with the exchange of drugs for sex or money or as a result of intoxication. It is important to be aware of local patterns of drug availability and routes of use.

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