The clinical picture of HIV in drug using populations is significantly different from HIV in other populations. For example, there are almost no cases of Kaposi's Sarcoma in male IVDUs who are HIV positive but there is a five-fold risk of death from bacterial infections in HIV positive drug users vs. HIV-positive non-drug users. IVDUs seem to be more susceptible of bacterial pneumonia as a result of HIV infection. This condition and pulmonary tuberculosis, also common in the drug users, have both AIDS defining illnesses.

A database was established to look at particular manifestations of HIV in drug users. Many of the most common diseases are bacterial infections, pulmonary tuberculosis, sexually transmitted diseases, hepatitis, and malignancies other than KS and lymphomas. When IVDUs develop pneumonias, it is more often bacterial pneumonia, which requires a different course of treatment, or TB-related, rather not PCP.

Certain malignancies, not considered AIDS-defining but definitely life - threatening, are also occurring mostly in IVDUs. These include lung cancer and cancers of the GI tract. In HIV positive women, cervical diseases and superimposed HPV infection are important clinical conditions that must not be underestimated. Cervical cancer was added as an AIDS defining illness in 1993.
Some medical problems / symptoms will be as a result of the drug use and some due to the HIV. Alcohol / illicit drug use can precipitate or exacerbate medical conditions and result in an overlapping of symptoms. Certainly fever, infection and diarrhoea are quite common in drug users. Symptoms of HIV such as weight loss, diarrhoea, and fever may be caused either by drug use or withdrawal. Consequently, the clinical manifestations of HIV can be combined with, masked by, or mimicked by the effects of drugs and alcohol.

Often so-called behavioural problems associated with ‘problem drinkers and drug users’ are misdiagnosed disorders associated with brain lesions or central and peripheral nervous system toxicities. It is absolutely imperative that clinicians look beyond stereotypes and prejudices when treating drug addicts and recognize coexistent, parallel pathophysiology that may be occurring (Selwin 1996).

Pain management is another important issue to consider when treating heroin users, as they will need more narcotic, not less. Dosages that are considered dangerous for other people, may be required for drug users, because of their capacity and tolerance for narcotics. Former addicts and recovering addicts may also need slightly higher doses of pain medications. Just because a person may have a history of drug addiction doesn't mean that they shouldn't be given pain medication when they need it (Selwin 1996).

Hepatitis

It is estimated that between 15-40% of alcoholics are Hepatitis C positive (http://www.alcoholconcern.org.uk/). It is reported that between 50 - 80% of IVDUs are Hepatitis C positive and 20% are Hepatitis B positive. Rates of Hepatitis C in Crack users and amongst people who snort drugs (cocaine, amphetamines) are increasing due to sharing of, for example bank notes, for snorting or pipes for smoking crack.

Hepatitis, delta-hepatitis (which can accompany hepatitis-B) and hepatitis-C show serologic abnormalities in the presence of HIV. Whilst they don't become more active or severe in people with HIV, HIV-positive drug users are more likely to carry hepatitis longer and thus remain infectious for a longer period of time. (Selwin 1996)

Co-infection of HIV and Hepatitis can result in a more complex medical picture. It can accelerate the time course to cirrhosis. Alcohol can even in modest amounts be a major risk factor for the development of HCV infection-related cirrhosis.

Whilst Hepatitis B vaccination programmes are being offered in a number of drug services, take up is not high enough, resulting in an increased risk of rates. However, prognosis of Hepatitis B has not been shown to be adversely affected by co-infection with HIV.

Hepatitis C appears to have a more accelerated course to fibrosis, cirrhosis and hepatic failure in HIV-positive individuals. Some researchers believe that Hepatitis C may accelerate HIV progression. The hepatotoxicity of many antiretroviral medications complicates the treatment of HIV in hepatitis C carriers.

Pancreatitis

Pancreatitis is an inflammation of the pancreas, which can result as a consequence of chronic alcohol use and also an adverse effect of several HIV medications. (ddI & ddC)

Peripheral neuropathy

Peripheral neuropathy describes damage to the peripheral nervous system, the vast communications network that transmits information from the brain and spinal cord (the central nervous system) to every other part of the body. Peripheral neuropathy occurs most frequently in people who smoke, are over age 40, and have difficulty controlling their blood sugar levels. It can be caused as a consequence of chronic alcohol use, HIV medications (ddI, ddC, d4T) and HIV infection.

Dementia

Dementia is a progressive brain dysfunction, leads to a gradually increasing restriction of daily activities. Heavy alcohol use can have an adverse effect on the Central Nervous System, it exacerbates the detrimental effect of HIV infection on the brain and complicates the course of HIV associated dementia. Both alcohol-related dementia and HIV dementia are associated with frontal lobe pathology and neuronal loss.

Liver damage

Alcohol and Illicit drug use can put extra strain on the liver, leading to liver damage. Any drug can cause potential liver toxicity’s which are a concern to people with HIV as liver damage in itself can make people ill and it can stop the body from processing anti-HIV drugs properly.

Cardiomyopathy

Cardiomyopathy is a serious disease in which the heart muscle becomes inflamed and doesn't work as well as it should. There may be multiple causes including viral infections. Alcohol, cocaine and HIV infection may have additive or synergistic effects, and HIV infection and alcohol or cocaine independently can increase the risk of cardiomyopathy.

Bacterial pneumonia

Bacterial pneumonia is an infection that causes irritation, swelling, and congestion in the lungs. Alcohol and HIV infection may have additive or synergistic effects, and both HIV infection and alcohol independently can increase the risk of bacterial pneumonia. When IVDUs develop pneumonia, it is more often bacterial pneumonia or TB related, rather than PCP.

Bacterial infections caused by encapsulated organisms such as S. pneumoniae and H. influenza, especially pneumonia are common in HIV infected IDUs.

References

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Celetano DD et al. Self-reported ART in IDUs. JAMA 280: 544-546, 1998.

Chaisson, et al. Race, sex, drug use and progression of HIV disease. NEJM 333: 751-756, 1995.

Floris-Moore, et al. Gender and Hospitalization Patterns Among HIV-Infected Drug Users Before and After the Availability of Highly Active Antiretroviral Therapy Journal of Acquired Immune Deficiency Syndromes 2004.

Mannheimer SB, et al. Use of antiretroviral therapy by drug users with HIV infection. JAMA. 281(8): 699 [discussion 700-701], 1999.

Michaels SH, et al. Letter. JAMA. 281(8): 699-700, 1999.

O’Connor PG, et al. Medical progress: medical care for injection-drug users with HIV infection. NEJM. 331(7): 450-459, 1994.

Selwin, P. HIV and Drug Users: A Different Clinical Picture. Being Alive Newsletter, 1996.

Selwyn PA, et al. Clinical manifestations and predictors of disease progression in drug users with HIV infection. NEJM. 327(24): 1697-1703, 1992.

Strathdee SA, et al. Barriers to use of free ART in IDUs. JAMA. 280: 547-549, 1998.