Injecting drug and HIV transmissions

Injecting drug use is the main route of HIV transmission in many countries

Transmission of HIV through injecting drug use accounts for the majority of new infections in Russia, Ukraine, Central Asia, some of Eastern Europe, South East Asia, North Africa, Iran, Afghanistan, Pakistan, Nepal, Indonesia, Portugal and the Southern Cone of Latin America. People at risk of becoming infected through injection drug use are often among the poorest and most marginalised sections of society: ethnic minorities, unemployed, youth, migrants, and sex workers.

Recreational drugs and interactions with ART There are potential interactions between injection and non-injection recreational drugs, substitution therapies and HIV treatment (ART). There is little or no research to address this.

Drug users sometimes excluded from ART programmes In many countries drug users are routinely excluded from ART. This is because of a widespread belief that they are less likely to adhere and less liable to have a good response to treatment. Reluctance to offer ART to people who inject drugs (PWIDs) includes not only injecting drug users (IDUs), but also those on medically prescribed substitution treatment such as methadone, users of non-injection drugs, and former drug users.

Excluding drug addicts from ART is unjustified Beliefs that drug users are non-adherent and untreatable are based on prejudice rather than science. Several studies suggest drug users can achieve high levels of adherence and that they benefit from treatment just like any other group of people with HIV. This is particularly when ART is provided with adherence, social and medical support.

  • A large Western European study of people receiving ART found no significant difference between IDUs and non-drug users in rising in CD4 count or treatment response.
  • Another study in Canada found that drug users who were adherent to treatment gained the same increases in CD4 count as adherent non-drug users.
  • In an American mobile needle exchange programme, 77% of drug users offered peer support along with ARVs achieved reduction of viral load to less than 400 copies/ mL and a 25% increase in CD4 count after six months. • A French study of people receiving ARVs found that those also receiving buprenorphine achieved higher levels of adherence (78.1%) than either former drug users (65.5%) or active IDUs not on buprenorphine (42.1%).
  • A French study of people receiving ARVs found that those also receiving buprenorphine achieved higher levels of adherence (78.1%) than either former drug users (65.5%) or active IDUs not on buprenorphine (42.1%).
  • A French study of people receiving ARVs found that those also receiving buprenorphine achieved higher levels of adherence (78.1%) than either former drug users (65.5%) or active IDUs not on buprenorphine (42.1%).

HIV i-Base: basic training for advocates
Comprehensive and accessible care Including as many health and social services as possible at a single site improves both adherence and treatment outcomes for people who inject drugs (PWID). Drug users are often reluctant to come forward for treatment and care. Services need to be located somewhere accessible to PWID and within the HIV clinic setting. Comprehensive, multidisciplinary services should include:

  • • Access to ART.
  • • Access to substitution therapy: methadone or buprenorphine.• Opportunistic infection prophylaxis and treatment.
  • • Accessible, non-judgemental healthcare team.
  • • Needle exchange. • Adherence support and counselling.
  • • Strong links with community-based programmes.
  • • Food plans and public transport.
  • • Outreach.

ART and recreational drug interactions: Overview There is considerable research about interactions between ART and other prescribed medications. There is much less information about interactions between ART and recreational drugs.

Theoretical information is not as useful as studies on humans Theoretical interactions proposed by scientists do not always match real interactions in people. Because these drugs are illegal, predicted interactions are not based on studies in humans but on theory, experiments in test tubes (in vitro) or tests on animals. There are difficulties both with conducting studies and using theoretical information:

  • Clinical trials using illegal drugs would require permission from the (American) government. The government is reluctant to allow studies because it may be seen as ‘soft on drugs’.
  • Illegal drugs are seldom pure. Other substances often contaminate them. They may contain little or no active ingredient. Finding supplies of pure drugs would, in some cases, be difficult. There are no approved versions of drugs like cocaine. Pharmaceutical companies are unwilling to manufacture test versions for medicinal products in their laboratories for legal and ethical reasons, even if the government granted permission.
  • Illegal drugs rarely have standard doses. What could be a relatively minor interaction at one dose could be severe at another.
  • There is little financial incentive for drug companies to do this work.
  • Manufacturers are concerned about legal liability should they offer advice based on
  • Clinical trials using illegal drugs would require permission from the (American) government. The government is reluctant to allow studies because it may be seen as ‘soft on drugs’.
  • Illegal drugs are seldom pure. Other substances often contaminate them. They may contain little or no active ingredient. Finding supplies of pure drugs would, in some cases, be difficult. There are no approved versions of drugs like cocaine. Pharmaceutical companies are unwilling to manufacture test versions for medicinal products in their laboratories for legal and ethical reasons, even if the government granted permission.
  • Illegal drugs rarely have standard doses. What could be a relatively minor interaction at one dose could be severe at another.
  • There is little financial incentive for drug companies to do this work.
  • Manufacturers are concerned about legal liability should they offer advice based on
  • Illegal drugs rarely have standard doses. What could be a relatively minor interaction at one dose could be severe at another. • There is little financial incentive for pharmaceutical companies to do this work. • Manufacturers are concerned about legal liability should they offer advice based on
  • There is little financial incentive for drug companies to do this work. • Manufacturers are concerned about legal liability should they offer advice based on
  • Manufacturers are concerned about legal liability should they offer advice based on
  • Clinical trials using illegal drugs would require permission from the (American) government. The government is reluctant to allow studies because it may be seen as ‘soft on drugs’.
  • Illegal drugs are seldom pure. Other substances often contaminate them. They may contain little or no active ingredient. Finding supplies of pure drugs would, in some cases, be difficult. There are no approved versions of drugs like cocaine. Drug companies are unwilling to manufacture test versions for medicinal products in their laboratories for legal and ethical reasons, even if the government granted permission.
  • Illegal drugs rarely have standard doses. What could be a relatively minor interaction at one dose could be serious at another.
  • There is little financial incentive for drug companies to do this work.
  • Manufacturers are concerned about legal liability should they offer advice based on
  • Illegal drugs are seldom pure. Other substances often contaminate them. They may contain little or no active ingredient. Finding supplies of pure drugs would, in some cases, be difficult. There are no approved versions of drugs like cocaine. Drug companies are unwilling to manufacture test versions for medicinal products in their laboratories for legal and ethical reasons, even if the government granted permission.
  • Illegal drugs rarely have standard doses. What could be a relatively minor interaction at one dose could be severe at another.
  • There is little financial incentive for drug companies to do this work. • Manufacturers are concerned about legal liability should they offer advice based on uncertain or incomplete information.

ART and recreational drug interactions: ritonavir

  • Ritonavir and street drugs are Predicted interactions based on using full dose (1,200mg a day). Ritonavir is now most commonly used to boost other protease inhibitors at a low dose (100-400mg a day).
  • 2 to 3 fold increase in ecstasy levels.
  • 2 to 3 fold increase in levels of amphetamines. About 50% decrease in blood levels of heroin – 36% decrease in methadone. No serious interactions with cocaine. Significant increase in levels of sildenafil (Viagra) and similar drugs. About 50% decrease in blood levels of heroin – 36% decrease in methadone.
  • No serious interactions with cocaine. • Significant increase in levels of sildenafil (Viagra) and similar drugs.All protease inhibitors are processed by the body in a similar way to ritonavir, as is the non-nuke efavirenz, so there is potential for interaction with any of these drugs.
  • Ritonavir and the liver Ritonavir makes the liver process many drugs more slowly (inhibition). This means that the drugs stay in the body longer times and/or at higher levels. This includes PIs – which is why ritonavir is used at low dose to make PIs more effective. It also includes amphetamines and many prescription drugs.
  • Ritonavir makes the liver process some drugs more quickly (induction). This means that the drugs stay in the body for shorter times and/or at lower levels. This includes heroin and other opiates, methadone plus some prescription drugs.

History In1996 a young HIV-positive British man died after taking ecstasy while using ritonavir. His death was caused by an overdose. The level of ecstasy in his blood was nearly ten times the level that is expected to cause serious toxic effects, i.e., roughly the same as taking 22 ecstasy tablets. This man had taken ecstasy previously with no such ill effects. This was the first time that he had taken ecstasy since adding full-dose ritonavir to his ART combination, which is why his doctors concluded that this interaction was the culprit. Following interventions by activists, the company (Abbott) produced some theoretical information for ritonavir’s interaction with common recreational drugs.

  • ART and recreational drug interactions: street drugs
  • Ecstasy Potential for an interaction with PIs or efavirenz.
    Other amphetamines Potentially dangerous interactions with ritonavir. This combination should be avoided if possible.
  • GHB Potential interaction with PIs (especially ritonavir) and possibly efavirenz.
  • Ketamine There are no studies describing interactions between ketamine and ARVs. People on PIs may be at risk of ketamine toxicity because of drug accumulation. Ritonavir may increase levels of ketamine.
  • PCP (angel dust) Potential interaction with PIs, and possibly efavirenz. May result in elevated PCP concentrations and toxicity.
  • LSD It is not clear how this drug works, therefore anticipating drug interactions with LSD is extremely difficult. People on ARVs who use LSD should be warned about the possibility of an interaction, be aware of signs of LSD toxicity.
  • Cocaine Suggested that interactions with nevirapine or efavirenz may possibly increase risk of liver toxicity, but there is no research to support this.
  • Heroin May be processed faster when used with PIs and efavirenz, producing symptoms of withdrawal.
  • Interactions between ARVs and street drugs: http://www.natap.org/2003/Jan/010703_3htm is an excellent paper from 2003 describing scientific aspects of interactions.
  • afrer drug use In most cases, problems arise because ART stops the liver processing recreational drugs in the normal way. This means they stay in the body for longer and/or at higher levels.
    Take less. . . Especially the first time after starting ART. Take less of the recreational drug and take them less often.

HIV i-Base: basic training for advocates
Drug users and ARVs
Know the danger signs. . . Be aware of signs of overdose. ART side effects are similar to signs of recreational drug toxicity. The after-effects of recreational drugs can seem like ART side effects. ART side effects may reappear or get worse.If you are dancing. . . Stay cool. Take breaks. Check whether there is medical help on site. Have a friend with you. Drink water regularly. Avoid alcohol.