Treatment Overview

Treatment of substance use in people living with HIV

Treatment of substance dependence in people living with HIV (PLWHIV) is complex. Management should involve linked services and a multidisciplinary approach1

Treatment of HIV in injecting drug users (IDUs) with HIV

The World Health Organisation (WHO) states that ‘injecting drug users [IDUs] should have equitable and universal access to HIV/AIDS prevention, treatment and care, including [highly active antiretroviral therapy] HAART’.1

  • Initiation of ART for HIV-infected IDUs should follow the recommendations for other HIV-infected individuals1

Three important aspects to consider when treating IDUs living with HIV include:

  • drug–drug interactions, particularly between methadone and concomitantly administered agents, including:5
    • ART (NRTIs, NNRTIs, PIs, integrase inhibitors)
    • illicit/recreational drugs
    • medications for concomitant hepatitis C/hepatitis B/tuberculosis, and other opportunistic infections
    • other agents that are typically used by PLWHIV (e.g. psychiatric medications).
  • adherence to ART
    • strict adherence is required to achieve optimal treatment benefits; the consequences of poor (≤95%) adherence should be explained to the patient1
    • adherence may be difficult for an IDU if they are receiving treatment for concomitant hepatitis C or tuberculosis infections1
    • Unscheduled treatment interruption (UTI) may impact adherence2,3 (see below)
  • simplification of ART regimens to maximise adherence
    • the selection of ART regimens should take into account:1
      • the likelihood for continued active illicit drug use if the patient is not receiving opioid substitution therapy (OST)
      • patient lifestyle, e.g. are they homeless and/or difficult to contact
      • comorbidities including mental illness (e.g. depression) and alcohol dependence
    • a once-daily ART regimen may be favoured for HIV/hepatitis C virus (HCV) co-infected patients1

 

The drug–drug Interactions section provides an overview of the possible interactions between ARV with a range of drugs that are typically used in this population.

Unscheduled treatment interruption

A study of 1,707 ART-naïve patients with HIV reported that 37% had UTI, defined as >3/12 months off ART.2

  • Treatment interruptions were associated with:
    • a history of injecting drug use
    • high baseline CD4+ count
    • hepatitis C co-infection.
  • UTI is also common amongst recently imprisoned HIV patients.3 A study of 450 IDUs with HIV, imprisoned in British Columbia, reported:
    • treatment interruptions that sometimes lasted over a week, during which time inmates were unable to obtain HIV medications through institutional healthcare
    • that short-term interruptions to treatment were common during entry into prison and when being released from custody
    • high levels of HIV discrimination in the prison motivated prisoners to hide their HIV-positive status by taking their medications discreetly, which occasionally resulted in missed doses.

Prison discharge planning is required to ensure people with HIV receive continuous treatment and preserve the health advances achieved while receiving ART in prison1

Management of antiretroviral toxicity and side-effects in injecting drug users with HIV

Clinical side-effects of ARVs are reported in almost 50% of patients,6 and are a leading cause of poor adherence to drug regimens.7 As with the treatment of PLWHIV, both clinical staff and HIV-infected IDUs should be aware of the causes and nature of treatment side-effects, and the importance of early reporting to:1

  • organise adherence support
  • adjust treatment regimens so that they are safe and effective
  • minimise the risk of drug resistance through poor adherence or premature switching of HAART

For example, side-effects such as headaches, anxiety and diarrhoea are also characteristic signs of opioid withdrawal syndrome. As such, signs and symptoms that arise during treatment  should be clinically assessed to determine their cause, and enable their appropriate management without stopping or changing the patient’s HAART regimens1

Management of opioid dependence

Heroin and cocaine are most closely associated with HIV infection, as such, the majority of treatment options for managing substance use focus on opioid dependence.1 In addition, research and guidance on the treatment of amphetamine-type stimulant (ATS) dependence is emerging1,8

Opioid substitution therapy

Generally, medication-assisted therapy is reserved for IDUs and chronic (≥2 years) opioid users.9 OST pharmacotherapies include:1

  • methadone
    • well studied, having been available for over 40 years5
    • acts by blocking the euphoric effects of heroin, discouraging illicit use and relieving the user of the need or desire to seek heroin9
    • administered orally (liquid or tablet form) once-daily. Doses range from 20 to 120mg/day; doses above 60–80mg/day are associated the prevention/reversal of withdrawal symptoms, greater treatment retention, and reduced illicit drug use5,9
    • highly regulated because of its narrow therapeutic index, problems with drug diversion, and the possibility of overdose5
    • metabolised via the cytochrome P450 system, and is associated with many drug–drug interactions. See the drug–drug interactions section to learn more
  • buprenorphine or buprenorphine/naloxone combination5
    • doses can range from 12 to 34mg (average of 16mg), taken sublingually
    • may be safer in overdose than methadone due to its pharmacological function and partially antagonistic effect
    • there is potential for sublingual buprenorphine to be crushed and injected, which has been linked with some cases of hepatitis in IDUs1
    • associated with fewer pharmacokinetic drug interactions with ART compared with methadone. See the drug–drug interactions section. 

Download Guidelines for the Use of Methadone and Buprenorphine for OST, published by the New York State Department of Health, in collaboration with John Hopkins University Division of Infectious Diseases. 

Detoxification (medically supervised withdrawal)

Detoxification is an initial component of some treatment programmes, but should not itself be considered a treatment for opioid dependence. Detoxification from opioids should be tailored to the patient, to reduce the symptom severity and medical complications of withdrawal.1 Of note:

  • methadone and buprenorphine reduction should be negotiated with the IDU, and emerging withdrawal symptoms must be appropriately managed
  • there must be access to psychological support throughout the programme

Other treatment options for people living with HIV with opioid dependence

In addition to OST, treatment and management options for PLWHIV with opioid dependence include:1

  • self-help groups
  • therapeutic communities
  • residential rehabilitation
  • psychological interventions
  • peer support programmes
  • social skill training
  • vocational training
  • heroin replacement treatment (heroin, morphine)

Treatment of nonopioid dependence in people living with HIV

Substance dependence is not exclusive to opioids. PLWHIV may be dependent upon:5

  • sedatives
  • cocaine
  • ATSs

Monitoring the treatment of drug dependence in injecting drug users with HIV

  • Care plans are useful for setting short, medium and long-term goals, and reviewing progress to ensure optimal outcomes are achieved.1 Several methods can be adopted to monitor the effectiveness of substance dependence treatment:
    • comprehensive patient records – for documenting good practice and informing evaluation
    • standardised assessment tools – to monitor progress more formally
    • screening for illicit drug use (using hair, breath, saliva, urine, blood) – may indicate the degree of response to treatment
    • drug screening – can be conducted with informed consent, although it should not be used to terminate treatment
    • laboratory indicators such as CD4 cell count and viral load – should be assessed regularly to ensure a continuity of care, whether a patient is receiving ART or not.

Treatment of alcohol dependence in people living with HIV

Behavioral interventions (e.g. 12-step programmes) have been the mainstay of treatment of alcohol disorders in PLWHIV for several decades, however, they have been associated with a small-to-modest benefit.5

  • Pharmacotherapy for alcohol-use disorders has demonstrated greater efficacy than behavioural interventions, however, few medications are available, and they have not been systematically assessed in PLWHIV5
  • Naltrexone is effective for relapse prevention and treatment of alcohol-use disorders5

References

  1. World Health Organization. HIV/AIDS Treatment and Care. Clinical Protocols for the WHO European Region, 2007.  Accessed 25 October 2011.
  2. Moore DM, Zhang W, Yip B, et al. Non-medically supervised treatment interruptions among participants in a universally accessible antiretroviral therapy programme. HIV Med 2010;11(5):299–307.
  3. Small W, Wood E, Betteridge G, Montaner J, Kerr T. The impact of incarceration upon adherence to HIV treatment among HIV-positive injection drug users: a qualitative study. AIDS Care 2009;21(6):708–714.
  4. Clarke S, Delamere S, McCullough L, et al. Assessing limiting factors to the acceptance of antiretroviral therapy in a large cohort of injecting drug users. HIV Medicine 2003;4:33–37.
  5. Altice F, Kamarulzaman A, Soriano V, et al. Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. Lancet 2010;376:367–387.
  6. Fellay J, Boubaker K, Ledergerber B, et al. Prevalence of adverse events associated with potent antiretroviral treatment: Swiss HIV cohort study. Lancet 2001;358:1322–1327.
  7. Dieleman JP, Jambroes M, Gussens IC, et al. Determinants of recurrent toxicity-driven switches of highly active antiretroviral therapy. AIDS 2002;16:737–745.
  8. Colfax G, Santos GM, Chu P, et al. Amphetamine-group substances and HIV. Lancet 2010;376:458–474.
  9. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2009;3:CD002209.