HOW DOES DRUG USE RELATE TO HIV?
Drug use is a major factor in the spread of HIV infection. Shared equipment
for injecting drugs can carry HIV and hepatitis, and drug use is linked
with unsafe sexual activity.
Drug use can also be dangerous for people who are taking anti-HIV medications.
Drug users are less likely to take all of their medications, and street
drugs may have dangerous interactions with HIV medications.
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INJECTION AND INFECTION
HIV infection spreads easily when people share equipment to inject
drugs. Sharing equipment also spreads hepatitis B, hepatitis C, and other
serious diseases.
Infected blood can be drawn up into a syringe and then get injected along with the drug by the next user of the syringe. This is the easiest way to transmit HIV during drug use because infected blood goes directly into someone's bloodstream.
Even small amounts of blood on cookers, filters, tourniquets, or in rinse water can be enough to infect another user. Blood on your hands - even small amounts - can also be dangerous when you help someone else find a vein, steady their arm, or when you pass equipment.
To reduce the risk of HIV and hepatitis infection, never share any equipment used with injection drugs, and keep washing your hands. Carefully clean your cookers and the site you will use for injection.
A recent study showed that HIV can survive in a used syringe for at least 4 weeks. If you have to re-use equipment, you can reduce the risk of infection by cleaning it between users. If possible, re-use your own syringe. It still should be cleaned because bacteria can grow in it.
The most effective way to clean a syringe is to use water first, then
bleach and a final water rinse. Try to get all blood out of the syringe
by shaking vigorously for 30 seconds. Use cold water because hot water
can make the blood form clots. To kill most HIV and hepatitis C virus,
leave bleach in the syringe for two full minutes. Cleaning does not always
kill HIV or hepatitis. Always use a new syringe if possible.
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NEEDLE EXCHANGE PROGRAMS
Some communities have started needle exchange programs to give free,
clean syringes to people so they won't need to share. These programs are
controversial because some people think they promote drug use. But research
on needle exchange shows that this is not true. Rates of HIV infection
go down where there are needle exchange programs, and more drug users sign
up for treatment programs.
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DRUG USE AND UNSAFE 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. 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. The ONLY thing left to say here is condoms
can save your LIFE.
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MEDICATIONS AND DRUGS
It is very important to take every dose of anti-HIV medications. People
who are not adherent (miss doses) are more likely to have higher levels
of HIV in their blood, and to develop resistance to their medications.
Drug use is linked with poor adherence, which can lead to treatment failure.
Some street drugs interact with medications. The liver breaks down some medications used to fight HIV, especially the protease inhibitors. It also breaks down some recreational drugs, including alcohol. When drugs and medications are both "in line" to use the liver, they might both be processed much more slowly. This can lead to a serious overdose of the medication or of the recreational drug.
An overdose of a medication can cause more serious side effects. An
overdose of a recreational drug can be deadly. At least one death of a
person with HIV has been blamed on mixing a protease inhibitor with the
recreational drug Ecstasy.
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THE BOTTOM LINE
Drug use is a major cause of new HIV infections. Shared equipment can
spread HIV, hepatitis and other diseases. Recreational drug use, including
alcohol, contributes to unsafe sexual activities.
To protect yourself from infection, never re-use any equipment for injecting drugs. Even if you re-use your own syringes, clean them thoroughly between times. Cleaning is only partly effective.
In some communities, needle exchange programs provide free, new syringes. These programs reduce the rate of new HIV infections.
Drug use can lead to missed doses of anti-HIV medications. This increases the chances of treatment failure and resistance to medications.
Mixing recreational drugs and anti-HIV medications can be dangerous. Drug interactions can cause serious side effects or dangerous overdoses. See below.
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Antiretroviral Medications and Recreational Drugs:
Understanding Potential Complications and Interactions
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Jennifer Devinney, RPh. HIV Clinical Pharmacist
Since the beginning of the HIV/AIDS epidemic there have been concerns about how recreational drug use may impact HIV infection and antiretroviral therapy. Some of the specific concerns are the potential effects that recreational drug use may have on disease progression and adherence to treatment regimens, as well as potential interactions between antiretroviral medications and recreational drugs. Unfortunately, these issues are very difficult to evaluate due to legal and ethical considerations. At this time, there are very few documented case studies addressing the outcome of recreational drug use by HIV-positive patients. The following paragraphs discuss some of the currently available information regarding these topics, including potentially harmful interactions between recreational drugs and HIV/AIDS therapies.
Because of the lack of information associated with this topic and the unpredictable actions of drugs in the body, we cannot predict with certainty the occurrence and type of adverse reactions secondary to the use of recreational drugs in combination with antiretroviral therapy. The best way to avoid a potentially serious interaction is to not use recreational drugs in combination with antiretroviral therapy. However, if you are using recreational drugs in combination with antiretroviral or other types of medications, it is important to be educated about all potential interactions and complications.
It is important to keep the following factors in mind:
Every person reacts differently to medications and recreational drugs.
There are also differences in how individuals absorb and metabolize medications.
Recreational drugs are not standardized, so the exact contents and
concentrations of the products are not known. This complicates our ability
to accurately predict the occurrence and extent of an interaction. Also,
if an interaction does not occur with one batch of a product, this does
not rule out the occurrence of an interaction with other batches of the
same product.
Because an interaction is not observed in one person does not mean
that an interaction may not occur in a different person, or in the same
person at another point in time.
Drug interactions involving recreational drugs are not limited to antiretroviral
medications.
Interactions can also occur with other types of prescription and non-prescription
products. Like prescription and over-the-counter medications, recreational
drugs can be associated with drug interactions. This has been illustrated
by several cases in the literature. In 1996, the death of an HIV patient
in London, England taking the protease inhibitor (PI) ritonavir (Norvir®)
and methylenedioxymetamphetamine (MDMA or Esctasy) highlighted this issue.1
The level of ecstasy in this patient's blood was as high as that of an
individual who has taken 22 MDMA tablets. This case is an indication that
interactions between antiretroviral medications, especially protease inhibitors,
and recreational drugs are possible and can be deadly. Earlier this year,
a case report was published describing a 29-year-old HIV-positive male
who experienced serious and almost fatal reactions to MDMA and gamma-hydroxybutyrate
(GHB) when used in combination with PI therapy.2 The patient was admitted
to the hospital after becoming unresponsive and experiencing involuntary
muscle contractions in his legs and left side of the body. The patient's
PI therapy at the time of the incident consisted of ritonavir and saquinavir
soft gelatin capsules (Fortovase®).
Since their introduction to the market in 1995, PIs have revolutionized the treatment of HIV/AIDS infection from the standpoint of decreased morbidity and mortality.3 However, PI therapy is not without its limitations, and drug interactions are perhaps the most challenging of these. From a health care provider perspective, one of the most complicated aspects of HIV therapy is managing drug interactions between antiretroviral medications and other therapies.
As a class, all of the currently available PIs are highly metabolized in the liver by the same group of enzymes. Aside from being metabolized by these enzymes, PIs can also act as enzyme inhibitors, meaning they are capable of inhibiting the activity of select enzymes in the liver. Inhibiting the activity of an enzyme can potentially slow the metabolism and elimination of medications that are metabolized by this enzyme. The result of this slowed metabolism is an increase in the blood levels of the medication and prolonged effects of the drug in the body, potentially causing toxicity or an increase in the incidence of adverse effects. It is through this mechanism of enzyme inhibition that the PIs may interact with MDMA and GHB.1,2,4 Clinical research focussing on the metabolism of three commonly used amphetamines [amphetamine, MDMA, and methamphetamine (commonly known as crystal meth)] suggested that all three of these products are metabolized in the liver by an enzyme that ritonavir has been shown to inhibit.1,2,4 Meaning, it is possible that ritonavir may slow the metabolism of MDMA, resulting in higher blood concentrations and prolonged effects of the drug. Some reports have estimated that ritonavir may increase MDMA levels in the body up to three times what they may normally be.1 The metabolism of GHB has not been completely determined, but it is thought to be at least partly metabolized through enzymes that the PIs are capable of inhibiting.2 Marijuana has the same concerns as MDMA and GHB.4
Aside from direct interactions involving the metabolism of antiretroviral and recreational drugs, there has been information suggesting that certain drugs may affect the immune system. For example, opiates may suppress the immune system and possibly contribute to the immune suppressing effects of the HIV virus.5 Others have suggested that substances which stimulate the immune system, one example being cocaine, may stimulate the replication of the HIV-virus.5,6 The introduction of bacteria through a non-sterile injection may also stimulate the immune system to fight off the new bacteria.6 This stimulation of immune system factors may also stimulate the production of the HIV virus in the body. In addition, it has been suggested that prolonged stimulation of the immune system may end up weakening the immune system which can possibly contribute to the immune suppressing effects of the HIV virus. As previously mentioned, these theories have not been extensively studied, so while they are potential concerns, the true risks are not known.
For additional questions related to this topic or the treatment of HIV
infection, please contact your physician, health care provider, or pharmacist.
References:
1. Concar D. Deadly Combination. New Scientist, July 12, 1997.
2. Harrington RD, Woodward JA, Hooten TM, Horn JR. Life Threatening
Interactions Between HIV-1 Protease Inhibitors and the Illicit Drugs MDMA
and Gamma-Hydroxybutyrate. Archives of Internal Medicine 1999;159(18):2221-2224.
3. Bartlett JG. Natural History and Classification. In: 1998 Medical
Management of HIV Infection. Baltimore: Johns Hopkins University, Department
of Infectious Disease ;1998:1-15.
4. Tseng A, Antoniou T. Postulated Interactions with Recreational Drugs
[Posted on the World Wide Web]. Retrieved December 1999 from the World
Wide Web: http://www.tthhivclinic.com/recreation.htm.
5. Des Jarlais DC. Psychoactive Drug Use and Progression of HIV Infection.
Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology
1999;20:272-274.
6. Hoyt G. Living Well - To Party or Nor to Party [Posted on the World
Wide Web]. Retrieved December 1999 from the World Wide Web: http://www.thebody.com/asp/nov98/party.html.