Technical Guide to HIV Prevention, Treatment and Care for People Who Use Stimulants

1. Technical Guide to HIV Prevention, Treatment and Care for People Who Use Stimulants CDARI Press March 2014 Dr Marcus Day, Director

2. 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 .

3. Take Home Messages • immuno-depressiveness of crack and cocaine • Efficacy of ART despite immuno-depressiveness • Prohibition and criminalisation compound the vulnerability

4. 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-and-analysis/WDR-2012.html

5. 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.

6. 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.

7. 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

8. 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.

9. Variability of Stimulant Use • wide range of variability in levels of stimulant use, from minimal to occasional to regular/daily use.

10. 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.

11. A comprehensive package of efficacious interventions for HIV prevention, treatment and care • 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

12. 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.

13. 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

14. Route of administration • Stimulants are most commonly used via non-injection methods such as • oral, • smoked, • snorted, • inserted anally • Injected

15. 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.

16. 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

17. 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.

18. 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.

19. 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. 15-32

20. 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

21. 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.

22. Immuno-depressiveness • There are indications of the immuno-depressiveness of crack and cocaine and that its use may impede the mechanisms that inhibit viral uptake and may enhance viral progression.

23. 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

24. 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

25. 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%2BANNUAL%2BREPORT.pdf

26. 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

27. Core interventions • A comprehensive package of efficacious interventions for HIV prevention, treatment and care among stimulant users (who are mostly non-injecting) include:

28. 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

29. 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

30. 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

31. 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.

32. 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

33. 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

34. 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.

35. 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.

36. 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

37. 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

38. 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

39. 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.

40. 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

41. STI Screening • Screening, prevention and treatment of STIs, hepatitis B, hepatitis C, and tuberculosis (TB)

42. 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.

43. 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.

44. 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.

45. Factors to consider when planning, implementing and evaluating HIV interventions

46. 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

47. “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 “half-lives”. 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).

48. 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.

49. 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

50. Women • Women who use stimulants face additional and unique challenges. One of the main challenges is the cross-cultural 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.