Technical Guide to HIV
Prevention, Treatment and
Care for People Who Use
Stimulants
CDARI Press
March 2014
Dr Marcus Day, Director
Take Home Messages
• Not all stimulant use is associated with HIV
• Incidence is critical Vulnerability to HIV is
heightened in certain contexts when in high
incidence environments stimulant use involves
concomitant sexual behaviours creating HIV
“blossoms”
• Certain subgroups are at heightened vulnerability
for the sexual transmission of HIV
• Drug treatment is NOT effective in reducing HIV .
Take Home Messages
• immuno-depressiveness of crack and
cocaine
• Efficacy of ART despite immunodepressiveness
• Prohibition and criminalisation compound
the vulnerability
• This technical guide fully embraces
existing strategies and guidelines of the
Joint United Nations Programme on
HIV/AIDS (UNAIDS), the United Nations
Office on Drugs and Crime (UNODC) and
the World Health Organization (WHO)
regarding HIV prevention, treatment and
care for all persons, including for people
who use drugs ].
[1],[2],[3
•
•
•
•
[1] Joint United Nations Programme on HIV/AIDS, Getting to Zero: 2011-2015 Strategy — Joint United Nations Programme on HIV/AIDS
(UNAIDS) (Geneva, 2010). Available from
www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/JC2034_UNAIDS_Strategy_en.pdf
[2] WHO, UNODC, UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for
Injecting Drug Users (Geneva, World Health Organization, 2009). Available from www.who.int/hiv/pub/idu/idu_target_setting_guide.pdf
[3] WHO, UNODC, UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for
Injecting Drug Users – 2012 Revision (Geneva, World Health Organization, 2012). Available from
http://apps.who.int/iris/bitstream/10665/77969/1/9789241504379_eng.pdf
World Drug Report 2012 (United Nations publication, Sales No. E.12.XI.1). Available from http://www.unodc.org/unodc/en/data-andanalysis/WDR-2012.html
Intended Use
• This Guide is intended for use by all
stakeholders, service providers,
policymakers and agencies at the local,
national or regional levels, who undertake
to have a positive impact on HIV
prevention, treatment and care among
stimulant users.
Purpose of this Guide
• The purpose of this guide is to facilitate
access to HIV prevention, treatment and
care for people who use stimulants
• The Guide describes how evidence-based
and recommended interventions may be
helpful to people who use stimulants as a
group whose primary risk of HIV
transmission is through sexual behaviours
correlated to their stimulant use.
This Technical Guide provides:
• A package of core health interventions for
people who use stimulants, whose route of use
is primarily through non-injecting means.
• A framework and process for setting targets
• A non exhaustive set of recommended indicators
and targets (or “benchmarks”) for setting
programme objectives and monitoring and
evaluating outcomes of core health interventions
for stimulant users
• Examples of data sources
Operational Definition
• People who use stimulants include:
– individuals who use cocaine,
– various forms of smokeable cocaine base,
commonly referred to as crack cocaine,
– paste or pasta base, paco, basuco:
– amphetamine-type stimulants (ATS)
– or any of the other varieties of psycho
stimulant drugs.
Variability of Stimulant Use
• wide range of variability in levels of
stimulant use, from minimal to occasional
to regular/daily use.
Range of Responses
• People who use stimulant drugs differ in
their range of responses:
• experience may vary from little or no
consequences to various levels of
distress,
• Responses often compounded by other
physical, mental or external factors that
are exacerbated by use in a criminalised
environment.
A comprehensive package of
efficacious interventions for HIV
prevention, treatment and care
1.
2.
3.
4.
5.
6.
7.
8.
HIV testing and counselling
Antiretroviral therapy (ART)
Needle and syringe programmes for people who inject
stimulants
Harm reduction services targeting stimulant use.
Condom programmes for people who use stimulants and
for their sexual partners
Screening, prevention and treatment of STIs, hepatitis B,
hepatitis C, and tuberculosis (TB)
Behavioural interventions aimed at reducing HIV
transmission
Targeted information, education and communication
programmes
Overlap between stimulant use and
HIV
Factors determining the overlap between
stimulant use and HIV transmission
include three dimensions that require
consideration :
• the type of stimulant used;
• the way in which it is used and;
• contexts in which that use occurs.
Types of stimulant drugs used
•
•
•
•
crack, cocaine,
methamphetamine,
ecstasy or other psychostimulants):
HIV transmission risks vary by the type of
drugs used and by whether risk
behaviours occur in proximity to a
localised HIV epidemic particularly one
with an elevated incidence
Route of administration
• Stimulants are most commonly used via
non-injection methods such as
– oral,
– smoked,
– snorted,
– inserted anally
• Injected
Frequency of use
• Short-acting stimulants like crack or
powder cocaine are administered
frequently
• Longer-acting stimulants such as
amphetamine or methamphetamine tend
to be used less frequently.
Crucial variables
• Immediacy, duration and magnitude of the
stimulants effect
• frequency and quantity of the stimulant
used[1].
• Vulnerability to HIV is heightened in
certain contexts when stimulant use
involves concomitant sexual behaviours.
[1] Hatsukami DK, Fischman MW., 1996 Crack cocaine and cocaine
hydrochloride. Are the differences myth or reality? JAMA 1996 Nov
20; 276(19):1580-8
Unique subgroups & HIV
• Some subgroups are at heightened vulnerability
for the sexual transmission of HIV:,
• the homeless and other and street engaged
populations,
• those with untreated, co-occurring psychiatric
issues,
• men who have sex with men, sex workers,
• street youth,
• itinerant migrant labourers are examples of
these subgroups.
Barriers to access
• Local environmental factors (social,
cultural, religious, economic, political)
impact on and may create barriers to
access to HIV prevention, treatment and
care
• Requiring a sensitive, competent and
sustained response in an environment
where accessibility and utilisation of
services are a key indicator of success.
Cocaine
• Smoking cocaine correlates with HIV and
other sexually transmitted infections (STIs)
such as syphilis
[1].[2],[3],[4].
•
•
•
•
[1] R. Marx and others, “Crack, sex, and STD”, Sexually Transmitted Diseases, vol. 18,
No. 2 (1991), pp. 92-101
[2] M. L. Williams and others, “An assessment of the risks of syphilis and HIV infection
among a sample of not-in-treatment drug users in Houston, Texas”, AIDS Care, vol. 8,
No. 6 (1996), pp. 671-682
[3] M. W. Ross and others, “Sexual behaviour, STDs and drug use in a crack house
population”, International Journal of STD and AIDS, vol. 10, No. 4 (1999), pp. 224-230
[4] M. L. Williams and others, “Determinants of condom use among African Americans
who smoke crack cocaine”, Culture, Health and Sexuality, vol. 2, No. 1 (2000), pp. 1532
Increased libidinous urges
• Certain sub populations of male and
female cocaine and crack users report an
increased libidinous urge, corresponding
with high numbers of reported sexual
partners and episodic unprotected sex[1].
[1] M. W. Ross and others, “Sexual risk behaviours and STIs in drug abuse treatment populations whose drug of choice
is crack cocaine”, International Journal of STD and AIDS, vol. 13, No. 11 (2002), pp. 769-774
Desire, disinhibition,acquisition,
• The desire to acquire smokable cocaine
triggers disinhibition and, as such, it is
often found in the context of sexual
behaviours such as the exchange of sex
for drugs or money.
Immuno-depressiveness
• There are indications of the immunodepressiveness of crack and cocaine and
that its use may impede the mechanisms
that inhibit viral uptake and may enhance
viral progression.
Accelerates HIV progression
• There is evidence that cocaine and crack
use accelerates HIV disease progression,
Research conducted among women living
with HIV[1], although there is no reason to
believe that men are not similarity affected
though the mechanism for this is still
unclear.
[
1] J. A. Cook and others, “Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive
women”, AIDS, vol. 22, No. 11 (2008), pp. 1355-1363
Barriers to an enhancing
envirionment
• PWHIV who smoke cocaine have been shown to
be less likely than their non-cocaine-smoking
peers to access medical services and are more
likely to have lower rates of ART adherence[1]
There are barriers that impede the promotion of
an enhancing environment to increase utilisation
of services. The main challenge has been the
provision of HIV and other health care services
to a highly criminalised, demonised, stigmatised
and discriminated population.
[1] M. K. Baum and others, “Crack-cocaine use accelerates HIV disease progression in a cohort of
HIV-positive drug users”, Journal of Acquired Immune Deficiency Syndromes, vol. 50, No. 1
(2009), pp. 93-99
Amphetamine-type stimulants
(ATS)
• The use of ATS has been reported to
facilitate particular sexual behaviours and
males have reported that it enhances
sexual stamina. Smoking is a common
route of administration[1].
•
[1] Australia, National Drug and Alcohol Research Centre, National Drug and Alcohol Research
Centre: 2007 Annual Report (Sydney, University of New South Wales, 2007). Available from
http://ndarc.med.unsw.edu.au/sites/ndarc.cms.med.unsw.edu.au/files/ndarc/resources/2007%2BA
NNUAL%2BREPORT.pdf
Methamphetamine use and HIV
• Methamphetamine use has been shown to
significantly elevate the biological vulnerability to
HIV infection[1] and increase HIV disease
progression[2],[3] in men who have sex with
men. These biological vulnerabilities are more
than likely generalisable to all humans who use
stimulants.
[1] M. W. Plankey and others, “The relationship between methamphetamine and popper use and risk
of HIV seroconversion in the multicenter AIDS cohort study”, Journal of Acquired Immune
Deficiency Syndromes, vol. 45, No. 1 (2007), pp. 85-92
[2] L. Chang and others, “Additive effects of HIV and chronic methamphetamine use on brain
metabolite abnormalities”, American Journal of Psychiatry, vol. 162, No. 2 (2005), pp. 361-369
[3] M. J. Taylor and others, “Effects of human immunodeficiency virus and methamphetamine on
cerebral metabolites measured with magnetic resonance spectroscopy”, Journal of NeuroVirology,
vol. 13, No. 2 (2007), pp. 150-159
Core interventions
• A comprehensive package of efficacious
interventions for HIV prevention, treatment
and care among stimulant users (who are
mostly non-injecting) include:
1. HIV testing and counselling
• More than 60 per cent of people living with
HIV worldwide are unaware of their HIV
status
[1].
•
1] Joint United Nations Programme on HIV/AIDS, UNAIDS World AIDS Day Report 2011 (Geneva, 2011).
Available from
www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/JC2216_WorldAIDSday_report
_2011_en.pdf
2. Antiretroviral therapy (ART)
• PWHIV cocaine users have been shown to
have accelerated HIV disease
progression[1] and mortality[2], yet the
immune-enhancing effects of consistent
ART adherence are far greater than
negative immune effects caused by
stimulant use[3],[4].
•
•
•
•
[1] Baum (2009)
[2] Cook (2008)
[3] Ellis 2003
[4] S. Shoptaw and others, “Cumulative exposure to stimulants and immune function outcomes
among and HIV-negative men in the Multicenter AIDS Cohort Study”, International Journal of STD
& AIDS, vol. 23, No. 8 (2012), pp. 576-80
High incidence environment
• stimulant users are a group may benefit
disproportionately from combination HIV
prevention strategies by reducing the pool
of PWHIV with high viral load in their
sexual networks
3 NSP for people who inject
stimulants
• Programmes whose objective is to reduce the
frequency of injecting by the provision of opioid
assisted therapy present an imperceptible yet
none the less, tangible barrier for people who
use stimulants
• No accepted substitution programme for
stimulants
• The trajectory of an NSP/OST programme that
supports the transit of people from injecting to
orally administered OST leaves stimulant users
with no comparable, accepted substitute and this
may create a barrier to integration in the
programme.
4. Harm reduction services
•
•
Harm reduction services targeting
stimulant use and other evidence-based
drug dependence treatment.
While drug dependence treatment
opportunities may be a welcome respite
from heavy episodic stimulant use,
abstinence based drug treatment has
been shown to be ineffective in
addressing HIV transmission among
the population of stimulant users
NIDU harm reduction
• Stimulant use in highly criminalised
environments face is associated with poverty,
unemployment, unstable housing and
incarceration.
• Programmes that address these issues and offer
meals, shower facilities, housing, legal
assistance and other basic services may help
stimulant users in need to stabilise their living
situation, which can increase their access to
services related to HIV and other co-morbidities,
improve adherence to medication schedules and
help them maintain ongoing HIV care
Pharmacotherapies
• Pharmacotherapies or as some say substitution therapy
(agonist pharmacotherapy, agonist replacement therapy,
agonist-assisted therapy) is defined as the administration
under medical supervision of a prescribed psychoactive
substance, pharmacologically related to the one
producing dependence, to people with substance
dependence, for achieving defined treatment aims.
Substitution therapy is widely used in the management
opioid dependence (methadone, buprenorphine)[1]
•
[1] Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: position
paper / World Health Organization, United Nations Office on Drugs and Crime, UNAIDS.
Substitutution therapy
• Positive outcomes using sustained-release
dextroamphetamine and
dextroamphetamine as a
pharmacotherapy for amphetamines and
cocaine respectively have been reported.
The studies reported no adverse reactions
and recommended further studies be
conducted.
Cannabis
• Cannabis has also shown promise as a
therapeutic alternative to crack cocaine use.
More research needs to be conducted in this
area but service providers should note that
cannabis use should be considered therapeutic
and for those individuals who turn to cannabis
use should not be discouraged. There are no
know negative interactions between cannabis
and ART and cannabis use has been shown to
inhibit viral progression of HIV in treatment naïve
PWHIV[1].
•
[1] Costantino CM, Gupta A, Yewdall AW, Dale BM, Devi LA, et al. (2012) Cannabinoid Receptor
2-Mediated Attenuation of CXCR4-Tropic HIV Infection in Primary CD4+ T Cells. PLoS ONE 7(3):
e33961. doi:10.1371/journal.pone.0033961
Pharmacotherapies criteria
WHO, Drug Substitution Project, Geneva, May 1995
The following criteria should be considered essential
for a drug to be appropriate for pharmacotherapies
• It shows cross-tolerance and cross dependence
with the psychoactive substance being used.
• It reduces craving and suppresses withdrawal
symptoms.
• It facilitates psychosocial functioning and improved
health.
• It has no short or long term toxic effects.
• Affordable and available
• Does not grossly impair psychomotor functioning
HIV, stimulants and co-morbidity
• A subgroup of people who use stimulants are those with
co-morbid psychiatric conditions[1],[2],[3], yet harm
reduction services or HIV services that integrate
psychiatric care are not common.
• There is a disproportionate representation of co-morbid
psychiatric conditions in the homeless population in
many places of the world. When setting targets for
homeless populations it is important to consider the
special nature and challenge of this sub group of people
who use stimulants, have a co-morbid psychiatric
condition and are homeless.
•
•
•
[1] Lopez-Quintero and others, “Probability and predictors of transition from first use to
dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic
Survey on Alcohol and Related Conditions (NESARC)”, Drug and Alcohol Dependence, vol. 115,
Nos. 1-2 (2011), pp. 120-130
[2] M. J. Smith and others, “Prevalence of psychotic symptoms in substance users: a comparison
across substances”, Comprehensive Psychiatry, vol. 50, No. 3 (2009), pp. 245-250
[3] L. Degenhardt and W. Hall, “Extent of illicit drug use and dependence, and their contribution to
the global burden of disease”, Lancet, vol. 379, No. 9810 (2012), pp. 55-70
5. Condoms
Condom programmes for people who use
stimulants and for their sexual partners
For individuals who have used stimulants and
have reported an increased libido the
availability of condoms is critical in addressing
sexual transmission of HIV. This is especially
critical for individuals who engage in sex work,
who are very sexual active with multiple
partners, men who have sex with men, young
people, women, and the sexual partners of
stimulant users.
Capturing “condom failure”
• Most new HIV in people who use stimulants are
sexual,
• Capturing information on “condom failure” is
important. Recent unpublished data from an
internet based survey of Caribbean men who
have sex with men revealed that 27% of the
respondents reported a condom failure in the
last year[1].
•
[1] CARIMIS 2013
STI Screening
•
Screening, prevention and treatment of
STIs, hepatitis B, hepatitis C, and
tuberculosis (TB)
6. Screening
•
•
Screening, prevention and treatment of
STIs, hepatitis B, hepatitis C, and
tuberculosis (TB)
Screening for infectious diseases such
as sexually transmitted infections,
hepatitis B and C, and TB at the point of
contact is feasible and acceptable.
7. Behavioural interventions aimed
at reducing the risk of HIV
transmission
• No study has shown reductions of HIV
transmissions or reductions in sexual risk
behaviours that correspond with
reductions in stimulant use. Behavioural
treatments may or may not be effective in
reducing stimulant consumption but should
not be relied upon to reduce HIV
transmission.
Targeted IEC
•
Targeted information, education and
communication programmes delivered at the
community level can act as a structural
prevention intervention to increase awareness
of links between stimulant use and HIV and
promote positive behaviour change such as
HIV testing, condom use and other safer sex
practices and can provide useful information
about HIV and harm reduction appropriate to
people who use stimulants.
Factors to consider when planning,
implementing and evaluating HIV
interventions
Stimulant switching
• People who use stimulants exhibit certain
preferences for specific psycho-stimulants.
The proximity of a diverse drug market
that offers a wide range of stimulant
choices will facilitate an environment
conducive to “stimulant switching”[1].
•
[1] World Drug Report 2012
“Polydrug” use
• Due to its ease of availability, alcohol
consumption is obtainable to those who wish to
use it concurrently with their stimulants.
• Each type of polydrug use may present unique
challenges to developing specific interventions
that address the myriad of factors that result
from substance mixing.
• Factors that affect preference include “halflives”. Cocaine and crack have short half-lives
(30-45 minutes for powder cocaine; 2-10
minutes for crack); compared with ATS (9-12
hours for amphetamine and methamphetamine;
4-5 hours for ecstasy).
People who inject stimulants
• Given the “half life” issues as discussed, some
people who inject stimulant such as cocaine or
ATS may inject more often than a person who is
injecting opioids and require more sterile
syringes than the service user who injects
opioids exclusively. In order to serve the needs
of this sub group of people who inject drugs it is
important for sterile syringe programmes to
adapt the information and education they
provide to emphasize the need for safe injecting
and safe sexual practices.
Sexual risk behaviours
concomitant to stimulant use
• Stimulant use has been shown to increase
frequency of sexual intercourse and thereby
increasing the vulnerability to HIV
• Stimulant-associated unprotected sex in the
context of concurrent sexual partnerships
increase the probability of HIV transmission
• Stimulant use reduces inhibitions sufficiently to
facilitate sex work, to promote sexual exploration
and/or to overcome feelings of stigma and
internalized homonegativity
Women
• Women who use stimulants face additional and unique
challenges. One of the main challenges is the crosscultural stigma associated with their vacating gender
roles such as caring for their family and being pregnant
or mothers of infants and children
• Women face power dynamics in relationships and higher
rates of poverty; those factors interfere with their ability
to access reproductive health supplies, including
condoms and other contraceptives. Such situations are
particularly common among women who use drugs.
Women who use stimulants have elevated risks for HIV
transmission, STI, and high rates of partner violence.
Thank you