Elsevier

The Lancet

Volume 376, Issue 9738, 31 July–6 August 2010, Pages 367-387
The Lancet

Series
Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs

https://doi.org/10.1016/S0140-6736(10)60829-XGet rights and content

Summary

HIV-infected drug users have increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. Substance-use disorders negatively affect the health of HIV-infected drug users, who also have frequent medical and psychiatric comorbidities that complicate HIV treatment and prevention. Evidence-based treatments are available for the management of substance-use disorders, mental illness, HIV and other infectious complications such as viral hepatitis and tuberculosis, and many non-HIV-associated comorbidities. Tuberculosis co-infection in HIV-infected drug users, including disease caused by drug-resistant strains, is acquired and transmitted as a consequence of inadequate prescription of antiretroviral therapy, poor adherence, and repeated interfaces with congregate settings such as prisons. Medication-assisted therapies provide the strongest evidence for HIV treatment and prevention efforts, yet are often not available where they are needed most. Antiretroviral therapy, when prescribed and adherence is at an optimum, improves health-related outcomes for HIV infection and many of its comorbidities, including tuberculosis, viral hepatitis, and renal and cardiovascular disease. Simultaneous clinical management of multiple comorbidities in HIV-infected drug users might result in complex pharmacokinetic drug interactions that must be adequately addressed. Moreover, interventions to improve adherence to treatment, including integration of health services delivery, are needed. Multifaceted, interdisciplinary approaches are urgently needed to achieve parity in health outcomes in HIV-infected drug users.

Introduction

Drug use, especially the injection of drugs, has been associated with some of the most severe HIV epidemics worldwide. HIV-infected drug users have increased prevalence and frequency of medical, psychiatric, and substance-use disorders that result in increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. The number and range of these comorbid disorders complicates diagnosis and treatment, resulting in several challenges in the provision of comprehensive care. HIV-infected drug users accessing antiretroviral therapy (ART) have worse clinical outcomes than do matched people living with HIV/AIDS who do not use drugs.1 Medical, psychiatric, and substance-use disorder comorbidities complicate care and must be simultaneously addressed to achieve health outcome parity. We describe some of the comorbidities affecting HIV-infected drug users and discuss adherence interventions and continuity of care issues that can be used to achieve the best possible care for this group.

Section snippets

Substance-use disorders

Drug and alcohol dependence, comorbidities that are highly prevalent in HIV-infected drug users, can each contribute to poor health outcomes. They are associated with decreased access to and use of health care, reduced likelihood of being prescribed ART, and once prescribed it, reduced adherence.2 Table 1 lists commonly used illicit drugs and their evidence-based treatments.

Key messages

  • HIV-infected drug users are at increased risk for several medical and psychiatric

Evidence-based treatment for chemical dependence

Chemical dependence is a chronic, relapsing, and treatable disease, characterised by compulsive drug-seeking behaviour and drug use. Although exposure to addictive substances is widespread in society, high vulnerability to addiction is more limited and is the product of biological, psychological, and environmental factors. Thus, identification of addictive disease and provision of and referral to appropriate treatment services are essential parts of the clinical management of HIV-infected drug

Viral hepatitis

Chronic hepatitis B and C are the most prevalent viral infections in IDUs, especially in those with HIV infection. Hepatitis B virus (HBV) and HCV share common routes of transmission with HIV, and therefore co-infection is frequent. Chronic HCV infection is the most common comorbidity in HIV-infected drug users, occurring in approximately 20% of all people living with HIV/AIDS and 60–90% of HIV-infected drug users. Transmission of HCV, however, is mainly parenteral because of its less efficient

Pharmacokinetic drug interactions between treatments for HIV infection, HIV-related comorbidities, and substance-use disorders

As the number of HIV-infected drug users enrolled in medication-assisted therapy expands, so too must the knowledge of drug interactions that occur between medication-assisted therapy, ART, and medications to treat comorbidities (table 4).11, 29 This knowledge is crucial because medication-assisted therapy might alter metabolism of antiretroviral drugs and other medications, resulting in increased toxicity or reduced effectiveness. Alternatively, these other medications might alter the

Improving adherence to treatment in HIV-infected drug users

Table 5 provides an overview of 13 interventions that examine adherence to treatment in IDUs. The range of interventions is diverse and includes cues and reminders, adherence counselling, contingency management, supervised therapy, medication-assisted therapy, and integrated health services delivery.

Several aids and reminders have been developed to improve adherence to pharmacotherapeutics: beepers and alarms, blister packs, pill boxes, and calendars.113, 114 Although they provide only a modest

The criminal justice system and HIV-related comorbidity

The high rate of HIV infection in prisoners worldwide is directly associated with society's approach to controlling illicit drug use. Mass incarceration of drug users has resulted in high rates of HIV/AIDS, tuberculosis, and other comorbidities in prisons compared with surrounding communities.146 Although the single most important strategy in controlling HIV in prison is to reduce the rate of incarceration,147 ample evidence suggests that the criminal justice system can be an effective place to

Conclusions

HIV-infected drug users have substantial HIV-related and non-HIV-related medical and psychiatric comorbidities. As a result, care is often complicated for the individual and for the health-care system. Several evidence-based interventions are available to improve treatment outcomes for this vulnerable population, but parity in treatment outcomes to reduce morbidity and mortality in HIV-infected drug users will be achieved only with further resources, expertise, political will, and commitment by

Search strategy and selection criteria

We searched PubMed, Google Scholar, PsychInfo, Ovid, and Scopus databases for publications on substance-use disorders using MeSH terms “HIV” or “AIDS” combined with “substance abuse”, “drug dependence”, “drug user”, “addiction”, “opioids/opiates”, “stimulants”, “cocaine”, “amphetamine”, “alcohol or injection drug use (IDU)” or “intravenous drug use/abuse (IVDU/IVDA)”. Additional details of the literature search and supplemental references are available in the webappendix.

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