HIV and Substance Abuse
Alcohol Abuse
About.com. 25 July 2006. 14 Oct. 2009
Virus Progresses Faster
For people who have already been infected with HIV, drinking alcohol can also accelerate their HIV disease progression, according to a study by Jeffrey H. Samet at Boston University. The reason for this is both HIV and alcohol suppress the body's immune system.
Samet's research found that HIV patients who were receiving highly active antiretroviral therapy (HAART), and were currently drinking, have greater HIV progression than those who do not drink. They found that HIV patients who drank moderately or at at-risk levels had higher HIV RNA levels and lower CD4 cell counts, compared with those who did not drink.
Drinking Affects Medication Adherence
Patients with HIV who drink, especially those who drinking heavily, or less likely to adhere to their prescribed medication schedule. Both the Samet study and research at the Center for Research on Health Care at the University of Pittsburgh School of Medicine found that nearly half of their patients who drank heavily reported taking medication off schedule.
The researchers said many of the heavy drinkers simply would forget to take their medications. This is potentially a big problem for healthcare providers due to the fact that alcohol dependence in those with HIV run at rates twice as high as the general population.
Drug Abuse and HIV
International AIDS Society Feb. 2003. 14 Oct. 2009
Among injection drug users in this country, some 40% to 45% are HIVinfected, 30% have a positive test result with tuberculin skin testing, 80% to 90% are hepatitis C virus (HCV)-seropositive, 40% are hepatitis B virus (HBV)-seropositive, and 60% use alcohol. The frequency of other sexually transmitted diseases (STDs) ranges from 0% to 80%, and STDs are more common in women than in men. Such data are known only for injection drug users, who account for approximately 10% of the estimated 6 million active drug users in the United States. Levels of such comorbidity in non-injection drug users are likely somewhere between those observed in injection drug users and those in the general population.
However, it is also believed that the drug-using population is larger than estimated and that significant comorbidity occurs in the unaccounted-for segments of this population. Comorbidity is the rule in substance abuse-drug users typically use more than 1 drug and have more than 1 disease-and it complicates patient management.
A third of addicts have overt psychiatric comorbidity; in others, psychiatric problems become evident during treatment, with psychosis emerging in response to drug treatment in some. Often, psychiatric illness must be managed before the patient can begin treatment for medical illness and substance abuse. Disease contracted as a result of risk behaviors also complicates management.
These diseases can be split into 2 conceptual categories: those that pose a public health threat, such as HIV disease, hepatitis, other STDs, and tuberculosis; and those that do not, such as cellulitis, endocarditis, and meningitis. In this latter context alone, billions of dollars are spent treating complications of drug abuse that could be prevented with rigorous adoption of a focus on treatment and prevention of drug abuse.
Additional management complications stem from problems with interactions between drugs used to treat substance dependence and those that treat medical and psychiatric illnesses. Further, many substance abusers appear to have increased tissue and organelle injury that can complicate drug treatment.
With regard to HIV infection in substance abusers, injection drug users have a high rate of HIV disease, as noted above. In addition, approximately 25% to 30% of noninjection drug users have HIV infection. Drug-sharing and sex networks frequently overlap. Transmission of HIV can occur through needle sharing and sex, and the use of some non-injection drugs, such as crack cocaine, is associated with frequent unsafe sex practices and increased risk of transmission of HIV infection and other STDs.
Transmission can also occur in the absence of needle sharing through reuse of the cotton wads that are used to filter injected heroin or cocaine solutions. Virus-containing blood from the reused syringe of one person is deposited in the cotton wad and then washed into the drug solution to be injected by another person when the solution is filtered through the reused cotton wad. Persons infected in this manner may believe that they are at no risk for HIV transmission and can subsequently infect others through unprotected sex, which they perceive as "safe" because they do not share needles.
As noted, the prevalence of other STDs among drug users is highly variable, with prevalence and incidence varying in part according to the substance of abuse. Notable associations include those of syphilis and crack cocaine use; trichomoniasis in injection drug-using women, which is associated with vaginal inflammation that may facilitate HIV transmission; and a high rate of sexual transmission of HBV (30%- 50%) in injection drug users. Approximately 60% of the 4 million cases of HCV infection are in injection drug users, with sexual transmission accounting for less than 20% of cases. HCV transmission among drug users can be blood-borne, as a result of sharing razors and the straws used to snort drugs, which can cut the nasal mucosa and draw blood. Infection occurs in 50% to 80% of injection drug users within the first 2 years of use. Coinfection with HBV and HCV dramatically accelerates HCV disease progression in the drug-using population, with progression to severe liver disease occurring in 2 or 3 years in some cases. HCV infection is emerging as a substantial problem in younger persons in association with abuse of injection drugs, including steroids.
Medical and psychiatric drug therapy can be complex in patients receiving methadone for opiate addictions. It should be noted that measurable changes in serum levels of methadone with coadministration of these agents are not always accompanied by clinically significant effects (eg, withdrawal symptoms). Clinical effects have been observed with nevirapine and efavirenz among the NNRTIs and with nelfinavir among the PIs.
In treating medical and psychiatric disease in substance abusers, both substance abuse and concomitant disease must be identified and treated. Substance abuse is a chronic disease requiring chronic treatment, beginning with identification of the disease, detoxification, and stabilization.
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