Risk-taking behaviour

Being under the influence of drugs or alcohol may increase risk-taking behaviour.

Sex

For a lot of people, drugs and sex go together. Drug users might trade sex for drugs. Some people think that sexual activity is more enjoyable when they are using drugs.

Drug use, including alcohol, increases the chance that people will not protect themselves during sexual activity or will engage in high-risk sexual activities. Someone who is trading sex for drugs might find it difficult to set limits on what they are willing to do. Anyone using drugs is less likely to remember about using protection, or to care about it, thereby increasing their risk of contracting and transmitting HIV (AIDS.org Fact Sheet: Drug Use and HIV).

For the link between unprotected sex and crystal meth (methamphetamine), see under crystal meth above.

Drugs

Being under the influence of alcohol or drugs also increases the likelihood of using other drugs which can have an effect on the immune system, as well as the users’ ability to make informed choices. It has been shown that alcohol and other substance use can increase the likelihood of injecting, sharing needles and other drug use paraphernalia such as injecting equipment or sharing pipes or bank notes when snorting. This places individuals at a risk of transmission and/or re-infection of blood-borne viruses such as Hepatitis B&C and a risk of re-infection with other strains of HIV including drug resistant strains which can have an impact on treatment options (www.thebody.com/cdc/factdrug.html).

Lifestyle

Drug use, whether occasional / recreational or dependent can have an impact on the users lifestyle. During periods of drug use, an individual’s lifestyle can become more chaotic, due to a change in patterns of behaviour, such as being away from home and this can have an impact on adherence.

Good nutrition helps keep your immune system strong, enabling you to better fight disease. A healthy diet improves quality of life. However, drug use may also interrupt eating patterns, leading to ill health and can affect medication absorption if it needs to be taken with or after food. Good nutrition helps the body process the many medications taken by people with HIV.

Weight loss, wasting, and malnutrition continue to be common problems in HIV, despite more effective antiretroviral medications, and can contribute to HIV disease progression. Diet (and exercise) may help with symptoms such as diarrhoea, nausea, and fatigue, and with fat redistribution and metabolic abnormalities such as high blood sugar, cholesterol, and triglycerides (www.tufts.edu/med/nutrition-infection/hiv/health.html).

Smoking tends to go hand in hand with other drug use, including drinking and so-called ‘recreational drug’ use. People with HIV disease are more likely to smoke than HIV-negative people. Smoking can interfere with normal lung function in healthy people. In people with HIV, smoking weakens the immune system and can make it more difficult to fight off HIV-related infections, especially infections relating to the lungs. Having HIV increases the risk of chronic lung disease. This is a risk for smoking marijuana as well as tobacco. Smoking can interfere with processing of medications by the liver and people with HIV who smoke are more likely to suffer complications from HIV medication than those who don't. It can also worsen liver problems like hepatitis.

Smoking increases the risk of some long-term side effects of HIV disease and treatment. These include osteoporosis (weak bones that can lead to fractures). HIV treatment slightly increases the risk of heart attack, but smoking is the major controllable risk factor for heart attacks or strokes.

People with HIV disease who smoke are more likely to develop several opportunistic infections related to HIV, including thrush, oral hairy leukoplakia (whitish mouth sores), bacterial pneumonia and pneumocystis pneumonia (PCP).

For women, smoking can increase the risk and severity of infection with human papillomavirus (HPV). This increases the risk of cervical disease. (http://www.thebody.com/nmai/smoking.html)

Medication compliance

Alcohol / illicit drug use is a risk factor for poorer compliance as use can make adherence more difficult, which may lead to viral resistance and reduce effectiveness of treatment. This includes missed doses as well as not taking medication on time (http://www.aidsmap.com/prediction non-adherent patients).

Medication interactions

A number of anti-retroviral drugs interact with methadone and illicit drugs which can make both more or less potent. An opiate drug user may be unwilling to take any medication if they find that they experience opiate withdrawals due to interactions. It is therefore important that the HIV team and drug service communicates in order to ensure that methadone dose can be increased or decreased according to the anti-retroviral drugs that are being prescribed. All drug users need to be informed of the possible interactions between their prescribed drugs and any recreational drugs that they use so that they can be given appropriate harm reduction advice. It is therefore important that HIV healthcare professionals ask patients about any drugs that they use and create an environment where patients feel they can disclose drug use without any fear of discrimination. (see section on drug interactions later and under ecstasy and GHB above.)

Access to medical care

Alcohol problems have been shown to be significantly associated with a delay for men in presenting to services for HIV. A similar pattern has also been observed with users of other drugs. Drug users also tend to be poor attenders' to their HIV clinic, which can be the result of past experiences within the medical setting.

Assumptions and judgements are made about alcohol and drug misusers, especially IV drug users. They can experience a lack of sympathy to general medical ailments as professionals may believe that the user ‘brought it on themselves and if didn’t use drugs, they won’t have the problem’. Some professionals may hold attitudes regarding the individuals’ lifestyle and therefore believe that if the user has contracted HIV and another blood borne virus then it ‘serves them right’. Receptionists, doctors, nurses and A&E staff may therefore discriminate against drug / alcohol users. In addition, many dentists refuse to treat drug users due to fears around Hepatitis C transmission, or discriminate against people who are HIV or Hepatitis C positive.

Most medical practitioners receive very little training on illicit drug use and don’t feel very knowledgeable around drug-related issues or very confident working with drug users. As with the general population, they get their messages from the media and are susceptible to the same images as the rest of the population. Some may be fearful of being manipulated or may have had a bad experience with a drug user in the past and this influences their attitudes to all drug users. In addition, a lack of understanding of drug user and their difficulties may lead them to become frustrated by a lack of behaviour change amongst users.

The structure of the health service can also make it difficult for some drug users to access services. For example an individual’s chaotic lifestyle can make it difficult for them to keep appointment times. If the appointment is early in the morning dependent drug users may not be able to attend as they may need to get score drugs to prevent withdrawals. Furthermore, clinic times generally do not fit in with a drug user’s lifestyle, and often they may not be able to make it to the clinic before it shuts. The hospital or clinic might be some distance away and they may not be able to afford to get there. Also, long waiting times in clinics or A&E may mean that many drug users can’t wait to be seen because they will need to go out use again.

Referral to specialist care has long waiting lists. As many drug users may be homeless or in unstable accommodation they may not find out that they have an appointment or the appointment may be so far in the future that they have forgotten about it when they are due to attend.

The ability to provide an array of social services, along with comprehensive medical care is a crucial, inseparable component in successfully providing treatment for HIV-positive alcohol and drug users. This is a population that has been disenfranchised and marginalized. Providing a warm and non-judgmental medical team is key. If clinicians are going to provide care for them they must first accept their life style, which for most may not be abstinence. Whether individuals are using drugs intravenously or not, they should still be able to receive treatments.

Adherence to medication

Problems with adherence to HAART have also been found in studies on recreational drug and alcohol users, which can affect T-cell counts and viral loads.

Halikitis et al. (2002) found that 51.9% of gay and bisexual men missed one dose of their medicines in the two-month period prior to assessment and 47.5% missed one dose in the last two weeks. Substance users reported more doses missed than non-drug users. Individuals who used club drugs were less adherent than those reporting no substance use and less adherent than those individuals who abused drugs other than club drugs. Reasons given for missing medication included being under the influence (56%), forgot (54%), busy with other things (53%), fell asleep (42%), being away from home (41%) and change in routine (40%). The researchers concluded that club drug use impacted adherence to HAART and needs to be addressed.

Lucas et al. (2001) studied 764 HIV-1 infected patients found that active drug users were more likely to report non-adherence to medication and to have smaller median reductions in HIV-1 RNA from baseline and smaller median increases in CD4 counts from baseline than patients who were non-users and former drug users. The reasons for these effects are unclear, however they may relate to psychological and social problems stemming from drug use.

It has been found that HIV-positive injecting drug users fail to derive the same virological benefit from HAART as either HIV-positive former intravenous drug users or people with HIV who have never injected drugs (Palepu et al. 2003). They compared the proportion of current IV drug users who achieved two successive viral load results below 500 copies/ml after starting HAART. Data on CD4 cell count and HIV viral load were obtained for 578 patients and participants were asked to complete a questionnaire concerning their demographic details and drug-taking risk behaviour. To establish levels of adherence, investigators obtained information on the number of prescriptions being refilled. Current IV drug use was reported by 78 (13%) of patients, a further 96 (17%) said they had used IV drugs and 404 (70%) said they had never used IV drugs.

Adherence was worst in current IV drug users (77%), followed by former users (81.5%) and people who had never used drugs (91.6%). Univariate analysis found that current and former drug users were less likely to achieve an undetectable viral load. They also had a higher baseline viral load (170,000 copies/ml versus 120,000 copies/ml) and receiving fewer months of therapy (14.5 versus 39). The investigators acknowledge that using prescription refill as a measure is unsatisfactory as patients in their study could by obtaining medication but then failing to take it. However, they conclude that when other prognostic variables were controlled for, current IV drug users were less likely to achieve a virological response to HAART. High adherence, longer duration of therapy, lower baseline viral load and NNRTI-based therapy were associated with “superior virological outcome for former and non-injection drug users.”

Those users who have a lack of organisation in their personal lives which can occur due to drug use at any level may need help developing a structure to which they can tailor their regimen. Interventions should help minimize or cope with the negative side effects of HAART, and emphasis the positive aspects of the regime. This can be difficult as many patients may not disclose their drug use to their HIV centre for fear of discrimination or because they don’t see themselves as being a drug user.

However, HIV-positive individuals on HAART who use alcohol or recreational drugs are in great need of adherence enhancing interventions to reduce their risk of developing drug resistant virus. This would include looking at the individual’s lifestyle, and identifying the times or activities that lead to poorer adherence and giving advice as appropriate. For example, advice may be specifically around ways of adhering at the weekend, when going out clubbing, such as forward planning if the person does not always go home and addressing concerns around drug interactions which may be contributing to the individuals’ non-adherence.

The data regarding adherence problems to HAART medication and alcohol and recreational drugs are not always consistent. For example, Saunders et al (2001) studied 78 subjects with varying use of alcohol and recreational drugs (heavy users, moderate users, non-users). In this small sample they found no relationship between alcohol and recreational drug use and adherence problems. The heavy users had reported few problems with adherence but this may have been due to motivation to exaggerate actual compliance.

There have been studies that suggest that HIV-positive drug users who continue to inject heroin may develop AIDS faster than those who use other drugs or give up drugs (Ronald et al, 1994)). However, a pre-HAART review of the literature, conducted in 1994, concluded that "there appears to be little convincing evidence that active drug injection is detrimental to the outcome of HIV infection" (Phillips et al. 1994). However, injecting drug use has been associated with the more rapid evolution of drug resistance, suggesting that active injecting may have implications for the long-term effectiveness of HAART (Carneiro 1999).

References

Carneiro M et al. The effect of drug-injection behaviour on genetic evolution of HIV-1. Journal of Infectious Diseases 180(4): 1025-1032, 1999.

Halkitis P.N., Kutnick A.H., Borkowski T., Parsons J.T. Adherence to HIV medications and club drug use among gay and bisexual men. 2002 XIV International AIDS Conference 2002.

Lucas G.M., Cheever L.W., Chaisson R.E., Moore R.D. Detrimental effects of continued illicit drug use on the treatment of HIV-1 infection. JAIDS 27: 251-259, 2001.

Palepu A et al. Impaired virologic response to highly active antiretroviral therapy associated with ongoing injection drug use. JAIDS 32: 522 - 526, 2003.

Phillips AN et al. Active drug injecting and progression of HIV infection. AIDS 8(3): 385-386, 1994.

Ronald PJM et al. Continued drug use and other cofactors for progression to AIDS among injecting drug users. AIDS 8: 339-343, 1994.

Saunders D.S., Lancee W.J., Rourke S.B. The effect of alcohol and drug use on HAART adherence. Source: http://www.pulsus.com/cahr/abs/abs222.htm.%20oral%20presentation.%202001.

Swanson & Cooper. Dangerous Liaison: Club Drug Use and HIV/AIDS. http://www.thebody.com/ 2002