Place of addiction-informed comprehensive treatment in HIV care
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1 Place of addiction-informed comprehensive treatment in HIV care Cecile Denis, PhD Center for Studies of Addiction, University of Pennsylvania, Philadelphia, USA University of Bordeaux, Bordeaux, France
2 Disclosures No conflict of interest Project funded by NIDA grant R01-DA (O Brien, PI) ATHS Biarritz - Oct 17-20,
3 36.7 million PLWH 2.4 million 3.3 million 25.6 million 0.36 million 3.5 million 1.5 million ATHS Biarritz - Oct 17-20,
4 Comprehensive HIV care Universal access to comprehensive health services is needed to reduce substantially HIV-related morbidity and mortality worldwide These services must effectively address six needs Voluntary and confidential counseling and testing for HIV infection Prevention of HIV transmission, including sexual, parenteral, and mother to child transmission Prophylaxis against opportunistic infections Diagnosis and treatment of HIV-related conditions including opportunistic infections and neoplasms Antiretroviral treatment Palliative care WHO Guidelines, revised 2016 ATHS Biarritz - Oct 17-20,
5 2020 target: UNAIDS, 2015 If achieved 73% of PLWH will exhibit suppressed viral load in 2020 End of AIDS epidemics by 2030 ATHS Biarritz - Oct 17-20,
6 ART coverage Dec. 2016: 19.5 million on ART 53.1% of PWLH UNAIDS/ WHO 2017 ATHS Biarritz - Oct 17-20,
7 HIV care continuum Levi et al., IAS, Vancouver, 2015 ATHS Biarritz - Oct 17-20,
8 New HIV infections mostly occur among people from key population HIV incidence in key population increases 53 62% Key population MSM PWID People in prison Sex workers Transgender 10 45% 53 62% ATHS Biarritz - Oct 17-20,
9 HIV prevalence among PWID World Drug Report, 2016 ATHS Biarritz - Oct 17-20,
10 Key population and HIV care Individuals from key population were identified as HIV transmission risk behavior Low ART adherence HIV progression Detectable viral load Poorer perceived QoL Dawson-Rose et al, 2017 ATHS Biarritz - Oct 17-20,
11 Influence ART adherence / HIV clinic attendance Stigma of HIV-status disclosure Social support as a safety net during negative life circumstances Unaddressed trauma and substance use leading to interruption of care Trusting patient/provider relationship motivating HIV clinic attendance Basic unmet needs competing with the perceived value of HIV care Levinson et al, 2017 ATHS Biarritz - Oct 17-20,
12 WHO recommendations for key population HIV prevention Condoms, PrEP, PEP, VMMC Harm reduction NEP, opiate addiction Tx, evidence-based intervention for OH and other drugs, opioid overdose HIV Testing and counseling Community-based and clinic-based HIV Tx and care Same care than non-key population Prevention and management of co-infections and comorbidities Prevention, screening and Tx for TB, HBV, HCV, routine mental health disorders and co-counseling HIV and depression Sexual and reproductive health Similar care than non-key population Critical enablers Reviews of law, policies and practices, antidiscrimination policies, access to health services, enhance community empowerment, address violence HIV prevention, diagnosis, treatment and care for key population 2016 update, WHO ATHS Biarritz - Oct 17-20,
13 ATHS Biarritz - Oct 17-20,
14 Frame for an effective treatment Seek, Test, Treat, Retain Addiction clinic HIV clinic Physical and psychological health Physical and psychological health Substance Use Treatment Harm Reduction Substance Use Treatment Harm Reduction ATHS Biarritz - Oct 17-20,
15 Go Vap Integrated Treatment Clinic Integrated Treatment provided A pharmacological opiate maintenance treatment with methadone (MET) or buprenorphine/naloxone (BUP/NX) - Introduction of BUP/NX (Suboxone ) in January First time in Vietnam Counseling: 12 weekly sessions and 10 monthly sessions thereafter HIV screening and HIV treatment if needed HCV screening Structured and manual-based standardized counseling sessions - Rooted in cognitive behavioral therapy - Sessions assess the need for intervention in six areas of functioning: 1) Adherence to SUD, HIV, TB; 2) continued drug use and related drug and sex risk; 3) cravings for drug use; 4) psychological status (depression, anxiety, symptoms of psychiatric disorder); 5) confidence in and satisfaction with SUD treatment; and, 6) strategies for the next month - Data recorded and available for review with the participant as a clinical tool to show progress and promote self-monitoring. ATHS Biarritz - Oct 17-20,
16 Sample All HIV-negative HIV-positive Test, p (n=448) (n=295) (n=153) Age Mean (SD) 32.6 (5.9) 31.8 (6.4) 34.0 (4.4) t=4.40, p< Gender Males n (%) 433 (96.9) 284 (96.6) 149 (97.4) c 2 =0.21, p=0.65 Education High school or higher -- n (%) 168 (37.6) 110 (37.4) 58 (37.9) c 2 =4.43, p=0.35 Living condition 368 (82.3) 240 (81.6) 128 (83.7) c 2 =5.78, p=0.22 With parents/ family n (%) Currently have a job -- n (%) 235 (52.6) 161 (54.8) 74 (48.4) c 2 =1.65, p=0.23 Opiate Use Age of onset y.o. Mean (SD) 19.8 (4.5) 20.2 (4.7) 19.1 (4.2) t=2.45, p=0.007 No. years of use Mean (SD) 7.8 (6.2) 7.0 (4.8) 9.4 (8.1) t=3.36, p< No. days of use past 30 days 29.8 (1.4) 29.8 (1.4) 29.8 (1.5) t=0.03, p=0.98 Mean (SD) No. previous drug treatment Mean (SD) 5.4 (4.7) 5.0 (4.3) 6.2 (5.2) t=2.30, p=0.02 Other substance use n (%) of users past 30 days Alcohol 81 (18.1) 56 (19.0) 23 (15.0) c 2 =1.08, p=0.36 Amphet./ Methamphetamines 35 (7.8) 26 (8.9) 9 (5.9) c 2 =1.20, p=0.27 Benzodiazepines 20 (4.5) 12 (4.1) 8 (5.2) c 2 =0.32, p=0.63 Tobacco 442 (98.7) 290 (98.6) 151 (98.7) c 2 =0.09, p=0.75 Serology Hepatitis C positive n (%) 323 (72.1) 182 (61.6) 141 (92.2) c 2 =46.8, p< Psychological status Depressive symptoms (PHQ-9) yes n (%) 173 (38.6) 111 (37.6) 61 (39.9) c 2 =0.21, p=0.68 ATHS Biarritz - Oct 17-20,
17 HIV care (1) Prevalence HIV-pos. = 34.2% (n=153) New diagnosis: 6.5% (n=10) Percentage of individuals on ART High ART observance Percentage of individuals who reported taken ART 90% or more of the time 6 months: 82.1% 12 months: 98.3% BASELINE 6-MONTH 12-MONTH ATHS Biarritz - Oct 17-20,
18 HIV care (2) Percentage of individuals with suppressed viral load Viral load suppression linked to A better observance of ART (Pearson=7.18, p=0.007) The decrease of heroin use over 12 months (F(12,32)= 2.20, p=0.03) 53.7 BASELINE 6-MONTH 12-MONTH CD4 count 12-MONTH 29.5% 34.6% 35.9% 6-MONTH 32.7% 30.1% 37.2% BASELINE 41.8% 25.5% 32.6% CD4 <350 CD4 ( ) CD4 >500 ATHS Biarritz - Oct 17-20,
19 Addiction-related outcomes Retention in treatment at 12-month: 75.4% Significant decrease of heroin over the 12-month F(12,240)= 42.15, p< Difference between HIV-status Time * HIV status F(12,240) = 4.52, p< HIV-pos. were still using more often heroin at month 2, 3, 4 than HIVnegative individuals No difference between HIV-pos. and HIV-neg. after 5 months of treatment Other substances No change, no difference according to HIV status ATHS Biarritz - Oct 17-20,
20 Conclusion Integrated treatment strategy showed significant positive impact on HIV detection Initiation and adherence to HIV care Drug use Consistent with former studies USA: buprenorphine (Lucas et al, 2010, BHIVES group, 2010, Lesko et al., 2017) Psychosocial support Counseling with addiction-informed and infectious disease-informed component Integration of opiate maintenance treatment and HIV care in the same setting Not significantly increase the cost of the addiction treatment Decrease cost for HIV-positive participants by preventing them from having to travel to different locations Most of the studies in opiate use disorder individuals Similar findings with other substance, e.g, alcohol (Paolillo et al, 2017) Similar strategies to enhance adherence to PreP? ATHS Biarritz -20 Oct 17-20, 2017
21 Acknowledgments USA Charles O'Brien, MD, PhD David Metzger, PhD Center for Studies of Addiction France Marc Auriacombe, University of Bordeaux CNRS SANPSY USR 3413 Addiction lab CNRS SANPSY USR 3413 team Jean-Pierre Daulouede, Bizia Bayonne Bizia Bayonne team Expertise France team, Paris Vietnam Expertise France team, Ho Chi Minh, Vietnam Ministry of Health, Hanoi, Vietnam Provincial AIDS Committee, Ho Chi Minh, Vietnam Aquitaine Addiction Cohort ATHS Biarritz - Oct 17-20,
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