Factors Associated with Current Substance Use among Injecting Drug Users Receiving Antiretroviral Treatment in Jakarta and Bali, Indonesia

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Abraham Fowler
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1 Factors Associated with Current Substance Use among Injecting Drug Users Receiving Antiretroviral Treatment in Jakarta and Bali, Indonesia Pilot Study 1 Phase 1 Introduction Ongoing substance abuse forms a major barrier to the successful antiretroviral (ARV) treatment of HIV seropositive injecting drug users (IDUs). Current use of illicit drugs has been found to predict a poorer HIV outcome and worse biological responses to treatment among infected IDUs 1, possibly mediated by lower medication adherence and elevated risk behaviors 2. Depression represents the most common comorbid mental disorder among HIV-infected individuals, with a prevalence rate of people living with the virus almost double that of the general population 1. The disorder has been linked to poorer biological response to treatment and faster HIV disease progression possibly mediated by low antiretroviral (ARV) treatment adherence 2 and elevated risk behaviors 3. Injection drug users (IDUs) who are HIV seropositive are especially vulnerable to mental health challenges due to the combined negative effects of substance abuse and HIV infection. This study examined factors associated with current illicit substance use among HIV positive IDUs receiving ARV therapy in Jakarta and Bali, two main HIV epi-centers in Indonesia. The country has one of the largest, mainly drug-driven HIV epidemics in Asia 4. This study also examined risk factors for mental depression among former or current IDUs receiving ARV therapy in Jakarta and Bali. Methods A cross-sectional study was conducted from September 2008 to June 2009 enrolling 142 HIV seropositive, adult IDUs (former or current) who had received ARVs for at least 3 months from one of five HIV care facilities in Jakarta and Bali. Participants were interviewed for demographics, family and social support, use of services and HIV care, drug-use behavior and treatment, depressive symptoms, and ARV adherence.

2 Severity of Depressive symptoms was di-chotomously assessed using a 9-item version of the Center for Epidemiologic Studies Depression Scale (CES-D) 5. Subjects having 4 or more items scored 1 versus 0 will be determined to have severe symptoms Logistic regression was used to examine the association between candidate factors and current use of illicit drugs (defined as ever using in the last 30 days any of heroin, cocaine, amphetamines/stimulants, tranqui-lizers, downers, other narcotics/opiates, and hallucinogens). Findings Demographic findings (Table 1): Participants were predominantly young, male and high-school educated. Less than half had full-time jobs or were married. Median monthly income for this group was about the equivalent of $100 USD. One-third of the participants were assessed to have severe depressive symptoms. Subjects with SD are younger, less likely to have full-time jobs, and more likely to have an income below the median. Presence of SD does not vary significantly by education level, marriage status or recruiting sites. Table 1. Characteristics of the participants. SD (N=40) NoSD (N=80) Total* (N=120) P Mean Age (Stdv.) 29.6 (3.5) 31.4 (4.9) 30.8 (4.6) n (%) n (%) n (%) Male 37 (92.5) 72 (90) 109 (91) 0.7 Education: high school or above 35 (87.5) 73 (91.3) 108 (90) 0.53 Employment: full-time 13 (32.5) 39 (48.8) 52 (43.3) 0.09 Last month income above median 15 (37.5) 43 (54.4) 58 (48.7) 0.08 Married 18 (45) 37 (46.3) 55 (45.8) 0.9 Site: Jakarta 14 (35) 36 (45) 50 (41.7) Bali 26 (65) 44 (55) 70 (58.3) 0.29 Twenty-two participants were excluded from the analysis due to missing answers for the CES-D scale.

3 Table 2. Comparison of characteristics for current substance users and non users Current drug use* Total Yes (n=36) No (n=101) N=137 P n (%) n (%) n (%) Mean age (Stdv.) 30 (5.3) 31 (4.2) 30.7 (4.5) 0.3 Some high school or above 32 (89) 92 (91) 124 (90.5) 0.7 Income above median 15 (41.7) 50 (50) 65 (47.8) 0.4 Married 17 (47.2) 49 (48.5) 66 (48.2) 0.9 Site: Jakarta 18 (50) 50 (49.5) 68 (49.6) 0.96 Bali 18 (50) 51 (50.5) 69 (50.4) Any one kind as indicated in the methods section. Five participants were excluded due to missing answers to the drug use questions. P-vales were obtained from either t-tests (for continuous variables) or chi-square tests (for categorical variables). Demographic characteristics (Table 2): More than 25% of the participants reported recent use of indicated substances. Users were similar to non-users with respect to the demographic features examined. Methadone treatment, substance use and SD (Table 3): Thirty four subjects were using methadone maintenance, and they were about 3 times more likely to have SD than those non-users. Although only a minority of participants reported current substance use and recent contact with active IDUs, they were at a significantly higher risk of SD. Current substance users were almost 5 times more likely to have SD than the non-users.

4 Table 3. Methadone, substance use and SD. Total N (%) SD n (%) OR (95% CI) On Methadone Maintenance 34 (29) 18 (53) 3.3 (1.43, 7.50) In the last 30 days: Alcohol use > once a week* 6 (5) 3 (50) -- Heroin use* 8 (7) 5 (71.4) -- Combined substance use 36 (31) 21 (58.3) 4.8 (2.1, 11.2) In the past 6 months: Spent time with active IDUs 54 (45) 23 (42.6) 2.1? (0.97, 4.54) Too few subjects for OR estimation. ξ p = Combined category of using alcohol and/or marijuana more than once a week, and/or ever using any of heroin, cocaine (0 reported), amphetamines/stimulants, tranquilizer, downers, other narcotics or opiates, and hallucinogens. Family, services and mental health factors (Table 4): More than half of the study s participants lived with at least one parent. Of these, 1/3 were married. Those IDUs who lived with one or more parents were twice as likely to use drugs while in ARV treatment than those who did not (marginally significant). Those who received financial support from parents or relatives were 2.3 times more likely to use drugs than those did not. Use of HIV outreach services, HIV case management, and participation in a HIV support group also were examined. IDUs with a case manager were twice as likely to report current drug use than those without one (marginally significant). About 1/3 of participants reported over-threshold depressive symptoms by CES-D, who were at a 6-fold greater risk of actively using drugs. Table 4. Family support, services, and depression in relation to current drug use. Total N Current DU n (%) OR (95% CI) P Live with parents Yes (33) 2.0 (0.9, 4.5) 0.08 No (19) Receive financial support Yes (35) 2.3 (1.1, 5.0) 0.04 from parents or relatives No (19) Have a HIV case manager Yes (37) 2.0 (0.9, 4.7) 0.09 No (22.5) Severe depressive symptoms Yes (46) 5.8 (2.3, 14.6) No (13)

5 Adherence and depression (Figure 1): Forty three percent of participants reported never missing any ARV doses. Among those 68 who did miss doses, 28 (41%) missed during the past month, who were at a higher risk of being SD (OR: 2.5, p = 0.06) than the ones who never missed. This risk for those subjects who missed doses more than a month ago was similar with that for the always adherent ones. Figure 1. Among those with SD, more reported recent missing of ARV doses than those with NoSD NoSD (n=80) Within the past month (n=28) SD (n=39) More than a month ago (n=40) Never (n=51) 0% 25% 50% 75% 100%

6 Multivariate regression results (Table 5): Age, full-time employment, living with at least one parent, use of methadone and current substance use are independently associated with SD (Table 3). Table 5. Multivariate logistic regression for SD. Total n (%)* Odds Ratio? (95% C.I.) Age (in years) (0.80, 0.99) Full - time job 50 (43) 0.2 (0.07, 0.67) Living with parents 56 (48) 0.2 (0.06, 0.57) Currently on methadone 34 (29) 3.6 (1.26, 10.11) Current substance use 36 (31) 4.6 (1.70, 12.36) Percentages over 116 participants with complete data available for modeling. ξ All the p-values < Combined category as described in Table 2. Conclusion Although active injection drug use was uncommon among the ARV clients that we studied, the use of non-injected drugs was not. Overall, 25% reported current drug use, most of whom used tranquilizers and other downers. Patients who were older, lived with parents (a common adult housing practice in Indonesia), received family financial support or stayed close with IDU friends were at a higher risk of current drug use during ARV treatment. Those characteristics in an IDU patient receiving ARVs may signal the need for increased drug dependency intervention. Receiving methadone treatment or HIV case management was associated with an elevated risk for current drug use. These findings may reflect the relationship between needing such services due to drug use and seeking them. Longitudinal research is warranted to investigate if such drug-use behavior decreases with time after receiving these services. Such interventions might particularly be directed at those of younger age, without a fulltime job, not living with parents, and continuing substance use. Management of depression should be integrated into substance use and HIV care programs. The association between methadone use and SD was unexpected. Depressed persons may selectively seek methadone treatment, or the rigors of methadone treatment (daily

7 visits, geographic constraints) may contribute to depression. Regardless, methadone programs are often directed by psychiatrists, offering an opportunity to integrate depression management into methadone treatment. Severe symptoms of depression (SD) are common among Indonesian IDUs receiving ARVs. As seen in other studies, symptoms of depression are marginally associated with recent missing of ARV medications and strongly linked to ongoing substance use, suggesting that interventions are needed to help patients overcome the dual barriers to successful ARV treatment posed by drug use and depression.

8 Research Team: PI 1. Ronald Hershow, MD University of Illinois at Chicago 2. Judith Levy, Ph.D University of Illinois at Chicago 3. Prof. Irwanto, Ph.D Atma Jaya, AIDS Research Centre, Jakarta Co-PI 1. Asliati Asril, MD MMT Clinic, Fatmawati Hospital, Jakarta 2. Martin Batubara, MD AIDS Working Group, Fatmawati Hospital, Jakarta 3. Welly Kwangtana, MD 4. Tuti Parwati, MD HIV-AIDS Clinic, Sanglah Hospital, Bali 5. Prof. D.N. Wirawan, MD Kerti Praja Foundatin, Bali 6. Nyoman Hanati, MD MMT Clinic, Fatmawati Hospital, Bali Research Coordinator 1. Octavery Kamil Atma Jaya, AIDS Research Centre, Jakarta 2. I Made Setiawan Faculty of Public Health, University of Udayana, Bali Research Ass. 3. Yi Li University of Illinois at Chicago 4. Raymond A.I. Tambunan Atma Jaya, AIDS Research Centre, Jakarta 5. Sari Lenggogeni Atma Jaya, AIDS Research Centre, Jakarta Interviewer 1. Emmy Interviewer for Jakarta site 2. Agus Sulaiman Interviewer for Jakarta site 3. Natalia Christiane Interviewer for Jakarta site 4. Ni Luh K. Asih Murjayanti Interviewer for Bali site 5. A.A. Istri Citra Dewiyani Interviewer for Bali site MR Abstractor 1. I. Made Susila Utama, MD MR Abstractor for Bali site 2. Ni Wayan Septarini, MD MR Abstractor for Bali site 3. Zr. Srie Desnawati MR Abstractor for Jakarta site 4. Zr. Sarmini MR Abstractor for Jakarta site 5. Zr. Erdini Angraini MR Abstractor for Jakarta site

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