Research Report Series (2006): HIV/AIDS

2006·0.75 MB·English

by  Volkow, Nora D. (NIDA Director)

N A T I O N A L I N S T I T U T E O N D R U G A B U S E
Research Report
S E R I E S
It is hard to believe that the
HIV/AIDS
human immunodeficiency virus
(HIV)/acquired immune deficiency
syndrome (AIDS) epidemic has been
with us for a quarter of a century
now. Today, an entire generation
of young adults has never known a
world without HIV/AIDS. How Does Drug Drug abuse and addiction
Early in the epidemic, drug abuse can also worsen the progression
and HIV were typically connected in Abuse Impact the
of HIV and its consequences,
people’s minds with injection drug
use and needle sharing. However, HIV/AIDS Epidemic? especially in the brain. In animal
this view greatly underestimates the studies, methamphetamine
impact that drug abuse can have on Drug abuse and addiction increased HIV viral replication;2
the spread of HIV and AIDS through
have been inextricably in human methamphetamine
the dangerous risk behaviors it
engenders. Drug and alcohol intox- linked with HIV/AIDS abusers, HIV caused greater
ication affect judgment and can since the beginning of the neuronal injury and cognitive
lead to risky sexual behaviors that
epidemic. While intravenous impairment compared with
put people in danger of contracting
or transmitting HIV. In addition, drug use is well known in this nondrug users.3,4
r
substance abuse may facilitate regard, less recognized is the
o the progression of HIV infections role that drug abuse plays more Who Is At Risk
by further compromising the
generally in the spread of HIV—
immune system.
t for HIV Infection
Initially characterized by relatively the virus that causes AIDS—by
c localized outbreaks, HIV/AIDS has increasing the likelihood of high- and How Does
now become a pandemic that
e has literally put the world at risk, risk sex with infected partners.1 HIV Become AIDS?
affecting diverse populations in This is because of the addictive
r different ways. And while all and intoxicating effects of many Anyone is vulnerable to
nations are affected by HIV/AIDS,
drugs, which can alter judgment contracting HIV. And
i each faces differing underlying
d causes requiring customized and inhibition and lead people while injecting drug users
prevention and treatment strategies. to engage in impulsive and (IDUs) are still at great risk of
NIDA’s response to the ongoing
unsafe behaviors. contracting HIV/AIDS, anyone
epidemic of HIV/AIDS is multifaceted.
e We support research to learn more
about the pivotal role of drug abuse
h in the spread of HIV/AIDS and to
develop effective strategies to prevent
and treat this disease. NIDA has
t
established that drug abuse
treatment is HIV prevention.
m This Research Reportis designed
to highlight the state of the science
and raise awareness of the linkages
between drug abuse and HIV/AIDS.
o
Nora D.Volkow,M.D.
r Director
National Institute on Drug Abuse
f Approximately 4 out of 10 U.S.AIDS deaths are related to drug abuse.
•
U.S. Department of Health and Human Services National Institutes of Health
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NIDA RESEARCH REPORT SERIES
under the influence of drugs or AIDS. Recent developments have The number of HIV infections
alcohol is at heightened risk. led to better treatments for HIV is harder to confirm given that,
This includes IDUs who share infection, the most effective being unlike AIDS reporting, HIV
contaminated syringes or injection a strategy known as highly active reporting is not mandatory.
paraphernalia, as well as anyone antiretroviral therapy (HAART). Currently, only about two-thirds
who engages in unsafe sex (e.g., of States report HIV infections;
multiple partners, unprotected What Is the Scope from these data, it is estimated
sex) or “transactional” sex that 40,000 new HIV infections
(e.g., trading sex for drugs or of HIV/AIDS in the have been occurring annually
money) that could expose them United States? since the early 1990s, down from
to infection.
the peak of 160,000 new infec-
A person infected with Currently, an estimated tions per year in the mid-1980s.
HIV has a virus that lives and
1 million people in the Nonetheless, the persistence of
multiplies primarily in the white
United States are living with this rate for more than a decade
blood cells, which are part of
HIV/AIDS. In this country, annual indicates that much remains to
the immune system. An infected
reported AIDS cases peaked in be done to improve the effective-
person may look and feel fine
1993 at approximately 80,000. ness of HIV prevention.
for many years and may not
Between 1993 and 1998, the
even be aware of the infection.
incidence of new cases declined What Is HAART?
However, as the immune system
steadily before leveling off
weakens, the individual becomes
between 1999 and 2001. However, The availability of HAART
more vulnerable to illnesses and
since 1996 has had a
common infections. Over time, since 2001, the number of new
dramatic effect on the face
the untreated HIV patient is cases has increased slightly each
of HIV/AIDS. HAART is a custo-
likely to succumb to multiple, year with approximately 42,500
mized combination of different
concurrent illnesses and develop new AIDS cases reported in 2004.
classes of medications that a
physician prescribes based on
Estimated Number of AIDS Cases and Deaths such factors as the patient’s viral
Among Adults and Adolescents with AIDS, load, CD4+ lymphocyte count,
and clinical symptoms. CD4+
1985–2003—United States
lymphocytes are white blood
cells that HIV infects and kills,
90
n AIDS leading to a weakened immune
s) 80 1993 Case Definition* n Deaths system and AIDS. Though not a
d
n
a cure, HAART controls viral load,
us 70
o helping to delay the onset of
h
n t 60 symptoms and achieve prolonged
s (i survival in people diagnosed
h 50
at with HIV/AIDS.5
e
d D 40 With HAART, the medical
n consequences associated with
a
es 30 HIV/AIDS have changed. New
s
Ca 20 diagnoses of HIV-associated
of infections and some neurological
o. 10 complications, such as HIV
N
dementia, have decreased since
0
‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 its introduction.5,6 However, other
Year of Diagnosis or Death neurological problems, such as
peripheral nerve damage, have
*CDC expands AIDS case definition. Source: CDC, U.S. Department of Health and Human Services.
increased with the use of this
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resulting from living longer with
Hepatitis C the disease.
Which Populations
HCVinfection, the leading cause of liver disease, is highly
Are Most Affected?
prevalent among IDUs and often co-occurs with HIV.
In fact, between 85 and 90 percent of HIV-infected IDUs may also
While all groups are
be infected with HCV.7 NIDA-funded studies have found that with-
affected by HIV/AIDS,
in 3 years of beginning injection drug use, a majority of IDUs
not all are affected
contract HCV.
equally. The first populations
to be affected by AIDS were
Approximately 4 million people in the United States are currently
primarily men who have sex
infected with HCV; of these, approximately 400,000 are co-infected
with men (MSM) and IDUs. In
with HIV, enhancing the risk of severe liver disease, especially
among drug addicts.8 Chronic HCV and HIV co-infection results in fact, injection drug use has been
an accelerated progression to end-stage liver disease and death associated directly or indirectly
when compared with individuals infected with HCV alone. (e.g., through sex with IDUs,
mother-child transmission) with
While the treatment of co-occurring HIV and HCV presents certain more than one-third of AIDS
challenges, treatment during the acute phase of HCV infection cases in the United States. IDUs
(i.e., within 6 to 12 months of detection) has shown promise.
continue to be at increased risk
Treatment thereafter significantly improves infected patients’ quality
of HIV and other infections
of life and should also be pursued.
associated with drug abuse,
including the hepatitis C virus
(HCV), hepatitis B virus (HBV),
therapy. HAART is also reported One of the challenges for endocarditis, skin infections, and
to be associated with increased patients treated with HAART is abscesses. Over the past several
lipid levels (including cholesterol) adhering to the medication years, however, the proportion
in the blood, abnormal glucose routine needed for maximum of AIDS cases attributable to
metabolism, and other clinical benefit from this therapy. injection drug use has declined,
complications such as heart Adherence can be particularly while AIDS cases attributable to
disease. problematic for drug abusers
heterosexual transmission have
Potential interactions between with chaotic lifestyles, which
increased. From 2000 through
HAART and medications used to can interfere with their ability to
2004, the annual number of
treat drug addiction may decrease follow prescribed regimens. In
AIDS diagnoses attributable to
the effectiveness of either or addition, because HAART reduces
heterosexual contact increased
both treatments. For instance, viral load, some patients mistak-
18 percent among women and
when methadone, a treatment enly believe that they do not
24 percent among men. In 2003,
for heroin and other opioid need to adhere to the treatment
MSM and those exposed through
addictions, is administered with regimen or that reduced viral
heterosexual contact together
certain antiretroviral medications load means elimination of the
accounted for approximately
that are components of HAART risk of transmitting HIV.10,11,12 This
77 percent of cases, with MSM
therapy, the concentration of belief can, in turn, lead to com-
accounting for roughly 46 percent
methadone in the blood is signif- placency about risk behaviors
icantly decreased,9 potentially and resumption of unsafe sex of the total cases.14
compromising its effectiveness. and injection practices.13 NIDA- African-Americans experience
Research is under way to deter- supported research has helped to striking disparities in HIV-infection
mine if buprenorphine, a newer improve HIV outcomes among rates compared with other
medication for the treatment of IDUs and has advanced new populations, and they are at
opioid addictions, has similar discoveries and approaches for particularly high risk for develop-
liabilities. treating medical consequences ing AIDS. To illustrate, while
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African-Americans make up just for 68 percent of the female ages 13–19 represent only 15
13 percent of the U.S. population, HIV/AIDS diagnoses from 2001 percent of U.S. teenagers, they
they accounted for more than half through 2004 while White females accounted for 66 percent of new
of the total AIDS cases diagnosed accounted for 16 percent and AIDS cases reported among
in 2004. Moreover, African- Hispanic females 15 percent.15 teens in 2003.16
American females accounted And although African-Americans Young people (ages 13 to 24)
are also at risk for HIV/AIDS,
with minority youth at particularly
high risk. According to the
HIV/AIDS: The Differential Experience
Centers for Disease Control and
of African-Americans Prevention (CDC), an estimated
40,000 young people in the
United States had been diagnosed
Disproportionate rates of HIV infection among African- with AIDS. This number repre-
Americans have increased steadily over time. By the end of sents approximately 4 percent
2004, an estimated 178,000 African-Americans were living with of the cumulative AIDS cases
AIDS, the highest proportion of any racial/ethnic group. African- through 2004. Moreover, between
Americans also represent 43 percent of AIDS cases diagnosed 2000 and 2004, the proportion
since the start of the epidemic, which has disproportionately of young people diagnosed with
affected subgroups of African-Americans as well, including women, AIDS increased from 4.3 percent
youth, and MSM. to 5.1 percent. Particular HIV risk
behaviors of this group, including
HIV/AIDS is now the leading cause of death among all African- sexual experimentation and drug
Americans ages 25–44, ahead of heart disease, accidents, abuse, are often influenced by
cancer, and homicide.17 The disproportionate rates of HIV infection strong peer group relationships
among African-Americans is not due to higher rates of injection and diminished parental involve-
drug use or addiction in this population. Recent research suggests, ment that can occur during
in fact, that African-Americans have lower rates of addiction than adolescence.
Whites (8.3 percent vs. 9.6 percent of drug or alcohol abuse or Compounding this adolescent
dependence),18 but the two groups do not differ significantly in vulnerability today is the notion
their rates of injection drug use. The noted disparities may in part of “generational forgetting,”
reflect data showing that African-Americans are predominant which is a diminished view of
among those who become aware of their infection at later the dangers of HIV/AIDS among
stages in the disease process, and who therefore represent lost certain members of today’s
generations. Studies show that
opportunities for treatment.
today’s youth may be more
To address these disparities, NIDA is encouraging research that likely to hold this view than
examines the relationship between drug abuse and prevalence older Americans who witnessed
of HIV- and AIDS-related morbidity and mortality among African- a higher AIDS mortality rate
Americans, as well as studies that measure the effectiveness of associated with the rapid pro-
HIV prevention and treatment programs within these populations. gression from HIV to AIDS early
NIDA also is encouraging studies that focus on the nexus of in the epidemic. In addition,
drug abuse, HIV/AIDS, and criminal justice involvement among one study comparing youth
living with HIV before and after
African-Americans to determine when the risk for contracting
the era of HAART found that
and transmitting HIV is greatest (e.g., during community-based
post-HAART youth were more
supervision, in prison/jail, or during re-entry into society).
likely to engage in unprotected
Additional studies are needed that characterize risk and pro-
sex and substance abuse; how-
tective factors in order to develop culturally sensitive prevention
ever, whether this outcome is a
interventions to reduce HIV infection and minimize associated
direct result of the availability of
health consequences and co-occurring conditions such as HCV.
HAART is not known.19
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NIDA RESEARCH REPORT SERIES
to 1 day per month at 6-month
How Does
followup among noninjection
Treating Drug cocaine abusers. Reduction in
cocaine use was associated with
Abuse Affect
an average 40 percent decrease
the HIV/AIDS in HIV risk across gender and
ethnic groups, mainly as a result
Epidemic?
of fewer sexual partners and less
unprotected sex.5 Among gay
Since the late 1980s, research
and bisexual men who abused
has shown that drug abuse
methamphetamine, compre-
treatment is effective HIV
hensive behavioral treatment
prevention. Drug abusers in
reduced sexual risk behaviors
treatment stop or reduce their
and sustained those reductions
drug use and related risk behav-
for at least 1 year following
iors, including risky injection shows that comprehensive HIV
substance abuse treatment.22
practices and unsafe sex.20 Drug prevention strategies can be cost-
Behavioral treatments have
treatment programs also serve effective and reliable in prevent-
also shown promise for enhanc-
an important role in providing ing new HIV infections among
ing adherence to antiretroviral
current information on HIV/AIDS diverse populations of drug
therapy. Interventions aimed
and related diseases, counseling abusers and their communities.23
at increasing HIV treatment
and testing services, and referrals Recent research confirms these
adherence are crucial to treat-
for medical and social services. findings, demonstrating that
ment success, but usually require
Combined pharmacological school- and community-based
dramatic lifestyle changes.
and behavioral treatments for prevention programs designed
Effective treatment often includes
drug abuse have a demonstrated for inner-city African-American
providing a consistent medical
impact on HIV risk behaviors boys can be effective in reducing
regimen to counter the often
and incidence of HIV infection.20 high-risk behaviors, including
irregular lifestyle created by
For example, recent research drug abuse and risky sexual
drug abuse and addiction.
showed that when behavioral practices that can lead to HIV
therapies were combined with infection.24 This research also
Which HIV/AIDS
methadone treatment, approxi- underscores the importance of
mately half of study participants Prevention ensuring cultural relevancy for
who reported injection drug use specific populations.
Programs Work
at intake reported no such use at Early detection of HIV is
study exit, and over 90 percent another approach for preventing
Best?
of all participants reported no HIV transmission. Research indi-
needle sharing at study exit.21 Cumulative research has cates that routine HIV screening
While these findings show great shown that comprehensive in healthcare settings among
promise for achieving reductions HIV prevention—drug populations with a prevalence
in sexual and drug-related risk addiction treatment, community- rate as low as 1 percent is as
behaviors, studies are now based outreach, testing, and cost effective as screening for
needed to determine the long- counseling for HIV and other other conditions such as breast
term effectiveness of such infections—is the most effective cancer and high blood pressure.
interventions. way to reduce risk of blood- These findings suggest that HIV
Moreover, drug treatment has borne infections among drug- screening can lower healthcare
also been shown to decrease abusing individuals. NIDA’s costs by preventing high-risk
cocaine use from an average extensive prevention research practices and decreasing virus
of 10 days per month at baseline portfolio, begun in the 1980s, transmission.25,26
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NIDA RESEARCH REPORT SERIES
Heterosexual sex has now
How Has the How Can We
become a major transmission
HIV/AIDS Epidemic route for HIV and is a leading Counter These
cause of infection among women,
Changed Over the Trends?
especially within minority com-
Past 25 Years? munities. In fact, the proportion Scientific knowledge is the
best tool we have to address
of total AIDS cases attributed to
CDC surveillance data the disease of addiction and
heterosexual transmission has
reveal a notable shift in its consequences, including HIV.
increased sixfold since 1989 from
the HIV/AIDS epidemic in Research has taught us that drug
5 percent to 31 percent.
the United States, with a higher abuse is preventable and that
Emerging trends in HIV infec-
addiction is treatable. Promising
proportion of new AIDS diag-
tion include an increase in new
prevention and treatment strate-
noses today occurring among
infections among MSM, after
gies continue to emerge to
women, racial/ethnic minorities,
years of decline. This increase
address this devastating disease,
low-income groups, and young has been associated with a
yet much remains to be done.
MSM. Early in the HIV/AIDS resurgence of risky sexual
The greater proportion of HIV
epidemic, infections were mainly behavior linked to the use of infections associated with hetero-
seen among White, urban, MSM methamphetamine and other sexual contact requires additional
or male IDUs. However, over club drugs. While the link research to better unravel the
the past 25 years, the boundaries between HIV infection and dynamics behind how drug
between groups at greater and methamphetamine abuse is not abuse may be contributing to
lesser risk for contracting the established for heterosexuals, cases of new HIV infections. We
virus have been dissolving, with data show an association know that substance abuse may
the diversity of those potentially between methamphetamine affect judgment and decision-
at risk rapidly increasing. use and risky sexual behavior. making and lead to high-risk
sexual encounters and that sexu-
ally active drug abusers increase
the likelihood of HIV transmis-
Proportion of AIDS Cases Among Adults and Adolescents,
sion. However, we have not yet
by Transmission Category and Year of Diagnosis,
identified all of the behavioral,
1985–2003—United States
biological, and environmental
processes involved in the sexual
transmission of HIV among drug
70% n Male-to-male sexual contact
abusers. We now need to estab-
n Injection drug use (IDU)
60 n Heterosexual contact lish how an individual’s peers,
n Male-to-male sexual contact and IDU relationships, social networks,
50
and environment influence both
drug abuse and sexual risk taking.
40
s
e Linkages to drug diffusion, drug
s
a
C30 abuse practices, and HIV risk
behaviors are of particular interest.
20
10 Next Steps
0 Research is also needed to
1985 1988 1991 1994 1997 2000 2003 understand the factors
Year of Diagnosis leading to disparities in
HIV infection and survival rates
Note: Data adjusted for reporting delays and for estimated proportional redistribution of
among racial and ethnic minori-
cases in persons initially reported without an identified risk factor.
ties, particularly among African-
Source: CDC, U.S. Department of Health and Human Services.
Americans. We can begin with
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NIDA RESEARCH REPORT SERIES
research that characterizes the
extent and nature of disparities Glossary
in the rates of HIV infection and
the occurrence of co-infections Acquired immune deficiency syndrome (AIDS):The most severe manifestation of infection with
HIV.An AIDS diagnosis is based on the presence of clinical symptoms, a patient’s HIV viral load, and a
and other conditions among
CD4+lymphocyte count at or below 200 cells per microliter in the presence of HIV infection. Persons
drug-abusing minorities, taking
living with AIDS often have infections of the lungs, brain, eyes, and other organs, and frequently
into account age, gender, educa-
suffer debilitating weight loss, diarrhea, and a type of cancer called Kaposi’s sarcoma.
tion, sexual identity, geographic
region, and socioeconomic status. Addiction:A chronic, relapsing disease characterized by compulsive drug seeking and abuse and by
Studies are also needed to char- long-lasting changes in the brain.
acterize risk and protective fac-
tors so as to develop culturally Antiretroviral drugs:Medications used to kill or inhibit the multiplication of retroviruses such as HIV.
sensitive prevention interventions.
Behavioral treatments:A set of treatments that focus on modifying thinking, motivation, coping
Research on HIV disease
mechanisms, and choices made by individuals.
progression and its relationship
to the use and availability of CD4+lymphocyte:A type of cell involved in protecting against viral, fungal, and protozoal
treatment services will help us infections. These cells normally stimulate the immune response, signaling other cells in the immune
develop better interventions. system to perform their special functions.
Finally, research is needed to
Cultural relevancy:The ability of an intended audience to view an intervention as applicable to
investigate the transmission of
their life circumstances.
treatment-resistant HIV strains
among drug abusers and to
Generational forgetting:Term to describe when knowledge of adverse consequences experienced
explore the extent to which
by a particular generation or population is lost by a younger cohort. In this report, it refers to the
drug abuse may contribute to diminished view of the dangers of HIV/AIDS among those 25 and younger.
the development of resistant
viral infections. Highly active antiretroviral therapy (HAART):A combination of three or more antiretroviral
drugs used in the treatment of HIV infection and AIDS.
Summary
Hepatitis C virus (HCV):A virus that causes liver inflammation and disease. Hepatitis is a general
While calls for more term for liver damage and hepatitis C is the most common type of hepatitis found among those with HIV.
research continue, impor-
Human immunodeficiency virus (HIV):HIV is the virus that causes AIDS.
tant discoveries made
possible by NIDA and others
Injection drug use:Act of administering drugs using a hypodermic needle and syringe.
have positioned the field to move
forward in developing effective Opioid:A compound or drug that binds to receptors in the brain involved in the control of pain and
prevention and treatment other functions (e.g., morphine, heroin, oxycodone).
approaches. Three key findings
Pharmacological treatment:Treatment using medications.
inform our approach, linking the
interactions of drug abuse and
Viral load:The quantity of HIV RNA (ribonucleic acid) in the blood. Research indicates that viral load
HIV/AIDS in ways that extend is a better predictor of the risk of HIV disease progression than the CD4+lymphocyte count. The lower
far beyond injection drug use. the viral load, the longer the time to AIDS diagnosis and the longer the survival time. Viral load testing
First, drug abuse impairs judg- for HIV infection is used to determine when to initiateor change therapy.
ment and good decisionmaking,
leaving people more prone to
engage in HIV risk behaviors,
Resources:
including risky sexual behavior
and nonadherence to HIV treat- a. Department of Health and Human Services AIDSinfoWeb site (www.aidsinfo.nih.gov)
ment. drug abuse
Second, b. Institute of Medicine Report “No Time to Lose” (www.nap.edu)
adversely affects health and may
c. National Institute of Allergy and Infectious Diseases (www.niaid.nih.gov)
exacerbate disease progression.
d. NIDA’s HIV Prevention Principles (www.drugabuse.gov/POHP/principles.html)
and most important,
Third,
because of these linkages, we e. The Centers for Disease Control and Prevention (www.cdc.gov)
must recognize that drug abuse f. U.S. Preventive Services Task Force (www.preventiveservices.ahrq.gov)
treatment is HIV prevention.
8
NIDA RESEARCH REPORT SERIES
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