Substance abuse and HIV

BACKGROUND

The human immunodeficiency virus, also known as HIV infection, is a retrovirus that causes AIDS (acquired immune deficiency syndrome). The retrovirus primarily attacks the body's immune system, making the body extremely vulnerable to opportunistic infections (infections that occur in immunocompromised individuals).

HIV is transmitted from person to person via bodily fluids, including blood, semen, vaginal discharge and breast milk. It can be spread by sexual contact with an infected person, by sharing needles/syringes with someone who is infected, or, less commonly (and rare in countries where blood is screened for HIV antibodies), through transfusions with infected blood. HIV has been found in saliva and tears in very low quantities and concentrations in some AIDS patients. However, contact with saliva, tears, or sweat has never been shown to result in transmission of HIV.

Since the AIDS epidemic began, injection drug use (IDU) has directly and indirectly accounted for more than one-third of AIDS cases in the United States. In the year 2000, out of the 42,156 new cases of AIDS reported 11,635 were IDU-associated.

Injection drug use is more common among racial and ethnic minorities in the United States, which makes them more likely to acquire HIV through IDU. In 2000, IDU accounted for 26% of all AIDS cases among African American adults and 31% among Hispanic adults and adolescents, compared to 19% of all cases among white adults and adolescents

In addition, women are more likely than men to acquire HIV through IDU. Fifty-seven percent of all AIDS cases reported among women have been attributed to injection drug use or sex with partners who inject drugs, compared to 31% of cases among men.

The use of non-injection drugs also contributes to the spread of HIV. Drug users typically engage in riskier behaviors than non-drug users. For instance, users may trade sex for drugs or money, or they may engage in behaviors that put them at risk for developing the infection while under the influence of drugs.

Currently, there is no cure for HIV infection or AIDS. Highly active antiretroviral therapy (HAART) can suppress the virus, even to undetectable levels, but the medications cannot completely eliminate HIV/AIDS.

DRUG ADDICTION

Drug addiction is considered a treatable disease. Addiction causes compulsive drug cravings, and addicts will continue to seek the drug, even in the face of severe adverse consequences. For many people, drug addiction is chronic, and it may last for years.

Relapses are possible, even after long periods of abstinence from the drug. As a chronic, recurring illness, addiction may require repeated treatments to increase the intervals between relapses until long-term abstinence is achieved.

Rehabilitation treatment programs are tailored to each individual's specific needs. People with drug addictions can achieve full recovery and lead healthy, productive lives.

INJECTION DRUG USE

Many drugs, including cocaine and heroin, can be injected directly into the bloodstream. Injection drug users (IDUs) may become infected with HIV, hepatitis C and other infectious diseases after sharing syringes and injection paraphernalia that have been used by infected individuals.

In 2003, exposure to injection drugs was responsible for 20% of new AIDS cases reported in men in the United States. In the same year, 5.9% of new AIDS cases resulted from sexual contact with men who had sex with men and injected drugs. Twenty-two percent of all men living with AIDS in the end of 2003 acquired the disease through IDU. The rate was higher, (30%) among African American and Hispanic males.

In 2003, exposure to injection drugs was responsible for 26.9% of new AIDS cases in women in the United States. At the end of 2003, it was estimated that 35% of all women living with AIDS acquired the disease from exposure to injection drugs or injection drug users. The rate was higher among American Indian/Alaskan Native women (41%) and Whites (40%). The rates were lower among female African Americans and Hispanics (33%) and Asian/Pacific Islanders (16%).

From 1998 (when HAART became widely available) to 2003, AIDS mortality among people who acquired the disease from IDU declined an average of seven percent. However, the rate increased 4.4% among women alone.

NON-INJECTION DRUG USE

Risky behavior: The use of non-injection drugs also contributes to the spread of HIV. Drug users typically engage in riskier behaviors than non-drug users. For instance, users may trade sex for drugs or money, or they may engage in behaviors that put them at risk for developing the infection while under the influence of drugs.

Recent studies suggest that trauma, substance abuse and sexual risk behaviors are all related. For instance, women who have experienced sexual abuse (as a child or as an adult) may have a hard time refusing unwanted sex, may use drugs as a coping mechanism or may engage in sexual activities with strangers more frequently than other women. According to research, past trauma may also cause women to be less assertive with birth control (including condoms), and they may have a greater number of sexual partners during their lifetime, which increases the risk for HIV.

Biological impact: Researchers have found that both methamphetamine abuse and HIV infection can cause impaired cognitive (mental) functions. Patients may experience difficulties learning new information, solving problems, concentrating and quickly processing information. The researchers suggest that methamphetamine abuse and HIV infection significantly reduce the size of certain brain structures, which may be associated with impaired cognitive functions. Co-occurring methamphetamine abuse and HIV infection has shown to cause a greater impairment than each condition alone.

Alcohol: Alcohol abuse appears to be prevalent among HIV patients. One study found that 41% of HIV-infected patients met the criteria for alcoholism, as defined by a score of five or higher on the Michigan Alcoholism Screening Test (MAST) survey.

Recent studies have shown that HIV-infected patients with a history of alcohol problems, who are receiving HAART and are currently drinking, have greater HIV progression than those who do not drink.

In addition, one animal study found that alcohol consumption might increase an individual's risk of developing HIV. The researchers studied rhesus monkeys that were infected with simian immunodeficiency virus (SIV). Alcohol was administered four consecutive days a week by an intragastric catheter, until an alcohol concentration of 50-60mM was reached. The researchers found that during the early stages of infection, the monkeys who received alcohol had 64 times the amount of virus in their blood than the control monkeys. The researchers concluded that the alcohol either increased infectivity of cells or increased the number of susceptible cells.

Also, several studies suggest that HIV/AIDS patients who drink, especially those who drink heavily, are less likely to adhere to treatment regimens. Researchers have found that up to half of HIV/AIDS patients who drank heavily reported taking antiretroviral medication off schedule. Taking antiretrovirals off schedule may allow HIV to replicate more rapidly, causing increased mutations in the virus. When HIV mutates, it may become resistant to treatment.

SIGNS AND SYMPTOMS

Early symptoms: Many people are asymptomatic (experience no symptoms) when they first become infected with HIV. After one or two months, it is common for individuals to experience flu-like symptoms, including, headache, fever, fatigue and enlarged lymph nodes.

These symptoms usually disappear after one week to one month and are often mistaken for another viral infection. Despite having minimal or no symptoms during this stage, individuals are very infectious, and the virus is present in large quantities in bodily fluids, including blood, semen, vaginal discharge and breast milk.

The most obvious sign of HIV infection is a decrease in the number of CD4 cells (helper T-cells), which fight infection and are found in the blood. The virus slowly kills these cells without causing symptoms. Even when the infected individual is asymptomatic, the virus is multiplying, infecting and destroying cells in the immune system.

Clinical latency symptoms: During the next stage, known as clinical latency, more serious symptoms arise. Once infected with HIV, it may take 10 or more years for more severe symptoms to appear in adults, or up to two years in children who are born with HIV infection. The length of this asymptomatic period varies in individuals. Some people may start to experience more serious symptoms within a few months, while others may be symptom-free for several years. The virus can also lay dormant (hide within infected cells).

As the immune system continues to weaken, many symptoms appear, including inflamed lymph nodes (swollen glands) that may be enlarged for more than three months. Other symptoms often experienced months to years before the onset of AIDS include fatigue, weight loss, frequent fevers and sweats, persistent or frequent yeast infections (oral or vaginal), persistent skin rashes or flaky skin, pelvic inflammatory disease (PID) in women and short-term memory loss.

In addition, some individuals develop shingles (painful nerve disease) or frequent and severe herpes infections that causes sores on the mouth, genitals, or anus. Infected children may grow slowly or be sick often.

AIDS symptoms: Once the patient's CD4 T-cell count is lower than 200 cells per microliter of blood, the infection has progress to AIDS. Since the patient is no longer capable of cell-mediated immunity, the individual experiences opportunistic infections and tumors like Mycobacterium tuberculosis, thrush, herpes viruses, cytomegalovirus, shingles, Epstein-Barr virus, Kaposi's sarcoma and pneumonia.

The first symptoms of AIDS often include moderate and unexplained weight loss, recurring respiratory tract infections and oral ulcerations.

DIAGNOSIS

As soon as the virus enters the body, the immune system produces antibodies, which are chemicals that locate invaders and fight off infections. While these antibodies cannot successfully destroy the virus, their presence can be used to detect whether HIV is in the body.

It can take some time for the immune system to produce enough antibodies for the antibody test to detect them. This time period, known as the "window period," varies greatly from person to person. Most people will develop detectable antibodies within two to eight weeks. However, some individuals might take longer to develop detectable antibodies. Ninety seven percent of people develop antibodies in the first three months following the initiation of their infection. In very rare cases, it can take up to six months to develop antibodies to HIV. Therefore, if the initial negative HIV test was conducted within the first three months after possible exposure, repeat testing should be considered longer than three months after the exposure.

Enzyme immunoassay (EIA): The most common HIV tests use blood to detect HIV infection. In most cases the enzyme immunoassay (EIA) is used to look for antibodies to HIV. A positive (reactive) EIA must be used with a follow-up (confirmatory) test such as the Western blot to make a positive diagnosis.

Western blot test: A Western blot test is typically used to confirm a positive HIV diagnosis. During the test a small sample of blood is taken, and it is used to detect HIV antibodies, not the HIV virus itself.

Oral fluid test: Oral fluid (not saliva) is collected from the patient's gums. An EIA antibody test is then performed on the sample. A follow-up confirmatory Western Blot test is required if the results are positive.

RNA test: RNA tests look for the genetic material of HIV in the patient's blood. These tests can be used to screen the donated blood supply and to detect very early infections in rare cases when antibody tests are unable to detect antibodies to HIV.

Rapid test: A rapid test produces results in about 20 minutes. Rapid tests use blood (from a vein or finger stick) or oral fluid to look for HIV antibodies. A positive HIV test should be confirmed with a Western blot test before a final diagnosis of infection can be made. These tests have similar accuracy rates as the traditional EIA screening tests.

Home testing kit: Consumer-controlled test kits (popularly known as "home testing kits") were first licensed in 1997. The Home Access© HIV-1 Test System is the only home kit that is approved by the U.S. Food and Drug Administration (FDA). The Home Access© HIV-1 Test System is sold at most local drug stores. It is not a true home test, but rather a home collection kit. The test involves pricking a finger with a special device, placing drops of blood on a specially treated card and then mailing the card to be tested at a licensed laboratory. Customers receive an identification number to use when calling for the results. Callers may talk to a counselor before taking the test, while waiting for the test results and/or after the results are given. All individuals who receive a positive test result are given referrals for a follow-up confirmatory test, as well as information and resources on treatment and support services.

TREATMENT

General: HIV patients who are drug users should discontinue illicit drug use. Rehabilitation programs are available to help drug users overcome addictions. Currently, there is no cure for HIV infection or AIDS. Highly active antiretroviral therapy (HAART) can suppress the virus, even to undetectable levels, but they cannot completely eliminate HIV/AIDS.

Highly active antiretroviral therapy (HAART): When HIV reproduces, different strains of the virus emerge, and some are resistant to antiretroviral drugs. Therefore, it is common for healthcare providers to recommend a combination of antiretroviral drugs known as highly active antiretroviral therapy (HAART). This therapy usually combines drugs from at least two different classes of antiretroviral drugs, and it has been shown to suppress the virus. While these drugs cannot cure HIV infection or AIDS, they can suppress the virus.

Currently, the FDA has approved 28 antiretroviral drugs to treat HIV. These drugs fall into three major classes - reverse transcriptase (RT) inhibitors, fusion inhibitors and protease inhibitors. In July 2006, the FDA approved a multi-class combination called Atripla©.

Reverse transcriptase (RT) inhibitors disrupt the reverse transcription stage in the HIV lifecycle. During this stage, an HIV enzyme, known as reverse transcriptase, converts HIV RNA to HIV DNA. There are two main types of RT inhibitors - non-nucleoside RT inhibitors and nucleoside/nucleotide RT inhibitors. Non-nucleoside RT inhibitors bind to reverse transcriptase, preventing HIV from converting the HIV RNA into HIV DNA. Approved non-nucleoside RT inhibitors include Rescriptor©, Sustiva© and Viramune©.

Nucleoside/nucleotide RT inhibitors serve as faulty DNA building blocks. Once they are incorporated into the HIV DNA, the DNA chain cannot be completed. Therefore, the drugs prevent HIV from replicating inside a cell. Approved drugs include Combivir©, Emtriva©, Epivir©, Epzicom©, Hivid©, Retrovir©, Trizivir©, Truvada©, Videx EC©, Videx©, Viread©, Zerit© and Ziagen©.

Fusion inhibitors prevent the virus from fusing with the cellular membrane, thus blocking entry into the cell. Only one fusion inhibitor, Fuzeon©, is FDA-approved.

Protease inhibitors (PIs) interfere with the protease enzyme that HIV uses to produce infectious viral particles. PIs prevent viral replication by inhibiting the activity of protease, an enzyme used by the virus to cleave nascent proteins for final assembly of new virons. FDA-approved protease inhibitors include Agenerase©, Aptivus©, Crixivan©, Invirase©, Kaletra©, Lexiva©, Norvir©, Prezista©, Reyataz© and Viracept©.

Drug abuse treatment and rehabilitation: Long-term drug use can cause permanent damage to the body and may cause liver damage or heart failure. In addition, drug users are more likely to develop other infectious disease, such as hepatitis. While all individuals are encouraged to discontinue drug use, HIV/AIDS patients are especially encouraged to do so because they are extremely vulnerable to infectious diseases and complications.

Studies have shown that treating drug abuse can effectively reduce the spread of HIV. According to research, drug abusers who complete treatment successfully no longer engage in high-risk behaviors, including drug injection and unsafe sexual practices. Drug treatment programs also provide current information about HIV/AIDS and related diseases. Many treatment centers also provide HIV/AIDS counseling, testing services and referrals for medical and social services.

Addiction can be difficult to overcome without help. Rehabilitation treatment programs are available to help patients recover from addiction. Programs are tailored to specific individuals. Treatment may include group therapy, motivational interviewing, family therapy and one-on-one counseling. Medication like buprenorphine may be prescribed to overcome withdrawal symptoms of opiate addictions. The duration of rehabilitation treatment usually lasts several months. However, treatment varies among individuals. Support groups, like Alcoholics Anonymous (AA), may help individuals stay sober once they have completed a rehabilitation program.

Syringe Exchange Programs (SEPs): Syringe exchange programs (SEPs) provide sterile syringes (needles) in exchange for used syringes to reduce transmission of HIV and other blood-borne infections associated with reuse of contaminated syringes by injection drug users. Often, programs also provide other public health services, such as HIV testing, risk-reduction education and referrals for substance-abuse treatment.

According to the results of a recent study, SEPs may be able to effectively reduce the number of new HIV infections. The global study examined injection drug use and HIV infection in 99 cities. Researchers found that HIV prevalence decreased (by 19% a year) in cities that introduced needle exchange programs, but increased (by 8% a year) in cities that never had needle exchanges.

However, the U.S. government prohibits federal funding for SEPs.

INTEGRATIVE THERAPIES

Good scientific evidence :

Thiamin (vitamin B1) : Patients with chronic alcoholism or experiencing alcohol withdrawal are at risk of thiamin deficiency and associated complications. These individuals should receive thiamin supplements.

Thiamin is generally considered safe and relatively nontoxic, even at high doses. Avoid if allergic or hypersensitive to thiamin. Thiamin appears safe if pregnant or breastfeeding. The U.S. Recommended Daily Allowance (RDA) for pregnant or breastfeeding women is 1.4mg taken by mouth.

Unclear or conflicting scientific evidence :

Acupressure, shiatsu : Preliminary evidence suggests that acupressure may be a helpful adjunct therapy to help prevent relapse, withdrawal or dependence. Further research is necessary to confirm these findings.

Acupuncture : Acupuncture has been suggested as a possible treatment for alcoholism. However, the results of scientific studies are mixed. More research is needed to evaluate use of acupuncture in this application.

More studies are needed before a recommendation can be made for or against the use of acupuncture in cocaine/opiate addiction.

Colon therapy/colonic irrigation : One small study of unclear methodology suggested that colonic irrigation employing Chinese herbs may augment dihydroetorphine (DHE) and methadone therapy in heroin addicts going through withdrawal, possibly resulting in more rapid detoxification. However, the data provided are insufficient for making any definitive conclusions. More studies are needed.

DHEA (dehydroepiandrosterone) : Preliminary study shows that DHEA is not beneficial in treating cocaine dependence. However, further research is needed before a firm conclusion can be drawn.

Hypnotherapy : Hypnotherapy has been studied as a possible treatment for alcohol dependence. However, the results from preliminary studies are inconclusive. Additional research is needed before a firm conclusion can be drawn.

Hypnotherapy has also been studied as a possible treatment for drug addition. However, further research is warranted.

Kudzu : One animal study suggests that kudzu may be a useful treatment for alcoholism. However, other randomized controlled trials suggest that kudzu is not an effective treatment for alcoholism. Therefore, there is insufficient evidence to recommend for or against kudzu for the treatment of alcoholism.

L-carnitine : L-carnitine or acetyl-L-carnitine may help treat alcoholism. Additional research is needed to make a firm recommendation.

Massage : Massage shows promise as an adjunctive treatment to traditional medical detoxification for alcoholism. Further research is needed to confirm these results.

Prayer, distance healing : Initial research suggests that intercessory prayer has no effect on alcohol or drug dependency. Better research is necessary before a firm conclusion can be drawn.

Psychotherapy : Psychotherapy, especially cognitive behavioral therapy, may help patients abstain from drug use and reduce relapses. Combination treatment of psychotherapy and certain medications is sometimes more effective than psychotherapy alone. Group therapy may be more effective than individual therapy. Further research is warranted.

Qi gong : A recent study looked at the effectiveness of Qi gong therapy vs. medical and non-medical treatment in the detoxification of heroin addicts. Results showed that Qi gong may be beneficial in heroin detoxification without side effects, although the possibility of the placebo effect cannot be completely eliminated. Other treatments have been better studied for heroin detoxification and are recommended at this time. Qi gong may be used as an adjunct therapy.

Yoga : Preliminary research suggests that yoga may be beneficial when added to standard therapies for the treatment of heroin or alcohol abuse. Additional studies are needed before a recommendation can be made.

Fair negative scientific evidence :

Ginkgo biloba : One small study reports no benefit of ginkgo for cocaine dependence.

PREVENTION

Do not share needles or syringes.

Avoid sexual contact, including oral sex, with an infected person without using a condom or other latex barrier.

Avoid unprotected sexual contact with someone whose HIV status is unknown.

Wear gloves when in contact with blood or other body fluids that could possibly contain blood, such as urine, feces or vomit.

Cuts or breaks on the exposed skin of both the caregiver and patient should be covered with bandages.

Wash any body area that comes into contact with blood or other body fluids with soap and water. Surfaces that have been tainted with blood should be disinfected appropriately.

Practices that increase the likelihood of blood contact, such as sharing razors and toothbrushes, should be avoided.

Needles and other sharp instruments should be used only when medically necessary and handled appropriately.

In 1985, the CDC issued a list of routine precautions for all personal-service workers (such as hairdressers, barbers, cosmetologists and massage therapists) to take. Instruments that penetrate the skin (like tattoo and acupuncture needles or ear piercing guns) should either be used once and disposed of or thoroughly sterilized. Instruments that are not meant to penetrate the skin, but may come in contact with blood (like razors) should not be shared unless thoroughly sterilized.

Individuals, especially those who engage in high-risk behaviors that may lead to HIV infection, should be tested for HIV annually.

Antiviral therapy during pregnancy can significantly lower the chance that the virus will be passed to the infant before, during or after birth. The treatment is most effective if it is started as early as possible during pregnancy. However, there are still health benefits if treatment is begun during labor or shortly after the baby is born.

Infected mothers should not breastfeed their newborn(s).

Delivering the baby by cesarean section has shown to reduce the risk of transmission to the newborn. However, this is not the standard preventative care for HIV-infected pregnant women. It should only be considered in certain clinical circumstances (such as for patients who have a very high viral overload or for patients who do not adhere to antiretroviral therapy).

AUTHOR INFORMATION

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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• Lefevre F, O'Leary B, Moran M, Mossar M, Yarnold PR, Martin GJ, Glassroth J. Alcohol consumption among HIV-infect patients. J Gen Intern Med. 1995 Aug;10(8):458-60. View abstract
• National Institute on Drug Abuse. www.nida.nih.gov.
• Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.
• The Body: The Complete HIV/AIDS Resource. www.thebody.com.
• U.S. Department of Health and Human Services HIV/AIDS Program. http://hab.hrsa.gov.