Addressing Methamphetamine Abuse and Dependence in the President�s

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					    Addressing Methamphetamine Abuse and
Dependence in the President’s Emergency Plan
                     for AIDS Relief (PEPFAR)

                                             Thomas F. Kresina, PhD
                SAMHSA/CSAT Division of Pharmacologic Therapies
                             Billy Pick, JD Office of HIV/AIDS, USAID
                  Karen A. Kroeger, PhD CDC Global AIDS Program
PEPFAR
• The Emergency Plan is the largest commitment ever
  by any nation for an international health initiative
  dedicated to a single disease – originally a five-year,
  $15 billion, multifaceted approach to combating
  HIV/AIDS around the world. Reauthorized for 5 years
  at $48 billion to address HIV/AIDS, TB and malaria.




                                                            2
    FY09-FY14 The New Plan Emphasizes Continuation And Expansion


•     Continuation – HIV/AIDS treatment, prevention and care are life-long
      needs, continued to support those served during PEPFAR’s first five
      years.
•     Expansion– PEPFAR will further expand efforts to strengthen health
      systems and to leverage programs that address malaria, tuberculosis,
      child and maternal health, clean water, food and nutrition, education,
      and other needs. The Plan will emphasize transitioning from an
      emergency response to a sustainable response for treatment,
      prevention and care.




                                                                               3
  To tal Care
                                                                                                        To tal
   Funding
 (Includ ing Orp hans
                                                                                                      Tre atme nt
          and                                                                                          Funding
Vulnerab le Child ren)                                                                                   50%
       28%




        Preventio n o f M o ther-                                                   Co nd o ms and Related
                  to -                                         Ab s tinence/Be       Preventio n Activities
                              Injectio n Safety Blo o d Safety
         Child Trans mis s io n                                    Faithful
                                  Activities      Activities                                  6%
              (PM TCT)                                           Activities
                                      2%              2%
                   5%                                                  7%

                            P re ve ntio n o f           To tal                  P re ve ntio n o f
                             No n-S e xua l          P re ve ntio n                   S e xua l
                            Tra ns m is s io n         Funding                   Tra ns m is s io n
                                   9%                     22%                           13%


                                                                                                                    4
  Operationalizing PEPFAR


• Unified across all USG agencies –The “New way of Doing
  Business” means:
   • Cross agency collaboration
   • Deputy Principals-major decision making body
   • Interagency Working Groups
   • Country Core Teams
   • In-country inter-agency US Government teams
      – Led by US Ambassador in each country
      – Develop and execute Country Operational Plans (COP) for an
        integrated HIV/AIDS program
      – One program, one reporting system


                                                                     5
            PEPFAR Interagency Implementation



                                                     Office of the
                                                     Global AIDS
                                                  Coordinator (OGAC)




                                       Implementing Departments/Agencies


     HHS-
CDC, HRSA, NIH,
                          USAID            DOD       Peace Corps       DOL   DOC   Other Agencies
     FDA,
 SAMHSA, others




             SAMHSA provides all
             agencies expertise on
             prevention, care &
             treatment of drug abuse
                                                                                                    6
PEPFAR Worldwide Activities




                              7
Changes in the use of methamphetamines, amphetamines and related substances, 2005 or latest year available




          Changes in the use of methamphetamines, amphetamines and related
          substances, 2005 or latest year available




                                      Source: UNODC Work Drug Report, 2007
                                                                                                         8
Building a Methamphetamine
Prevention, Care and Treatment
Toolkit




                                 9
Methamphetamine Prevention, Care
and Treatment Toolkit
• PEPFAR Policy
  – HIV Prevention Among Drug Users Guidance: Injection Drug
    Use. March 2006
     • Policy guidance on the development of HIV/AIDS prevention-
       focused programs aimed at users of intravenous drugs and
       substance abusers
         – Tailoring HIV prevention programs to substance abusers
         – Supporting substance abuse programs as an HIV prevention
           measure
         – Offering HIV-infected drug users a comprehensive program to
           reduce their risk of HIV transmission

                                                                         10
    Research Data: Showing Relationship Between
    Drug Use and HIV Transmission
•    Research studies show the physiological and psychological
     properties of methamphetamine facilitate behaviors that increase
     the likelihood of HIV/STI transmission
      – Increases sexual drive, enhances sex, and decreases inhibitions 
         high risk sex
           • high number of sexual partners possibly with unknown HIV
             serostatus, limited condom use
      – Inexpensive and has long life enabling long sexual episodes
           • physical trauma


Shoptaw S & Reback CJ. Meth use and infectious disease-related behaviors in MSM: implications
   and interventions. Addiction 2007, 102(Suppl. 1): 130-5.
Reback CJ, Larkins S, Shoptaw S. Changes in the meaning of sexual risk behaviors among gay
   and bisexual male meth abusers before and after drug treatment. AIDS Behav 2004, 8: 87-98.

                                                                                                11
 Epidemiology of Methamphetamine Use
•     Compared to general population in Thailand, meth users had:
       – Higher HIV rates: 3% vs. 1.5%
       – Higher STI prevalence: 8x higher
•     Rapid assessment of drug users in Cambodia found:
       – Over 97% used ATS for recreational purposes and for strength
       – ATS increased sex drive and prolonged sex
       – 40% reported irregular or no condom use while under the influence of
         drugs
•     Rapid assessment of drug users in South Africa found:
       – Frequent use of meth among MSM and moderate use among sex
         workers and IDUs in Cape Town
       – Risk behaviors included infrequent condom use, using drugs to enhance
         sex, and the exchange of sex for drugs.
German D, Sherman SG, Latkin CA, et al.. Interntl J Drug Policy 2008, 19: 122-9.
Celentano DD, Sirirojn B, Sutcliffe CG, et al., Thailand. STDs 2008, 34(4): 400-5.
O’Connell K. IRARE: Drug Use and Sexual HIV Risk Patterns among Non-Injecting and Injecting Drug Users in Phnom Penh and Poipet,
      Cambodia, 2006.
Parry, C, Carney, T, & Petersen, P. Drug use and sexual HIV risk patterns among injecting and non-injecting drug users in Cape Town, Pretoria,
      and Durban, SA. Technical Report

                                                                                                                                           12
SAMHSA Supported
Methamphetamine Treatment
Project Treatment Project (1999-2003) Standardized psychosocial
• Methamphetamine
  outpatient protocol developed at UCLA (Rawson & Ling)
   – Cognitive-behavioral & relapse prevention groups, family education groups,
      social support groups, individual counseling, and urine and breath testing
      delivered in a structured manner over a 16-week period. Approach is
      directive, non-confrontational -focuses on current issues & behavior change.
   – Compared Matrix Model and “Treatment as Usual” (TAU)
   – 3 Year randomized clinical trial
   – Results demonstrated that both the Matrix Model and Treatment as Usual
      had positive outcomes
   – KAP developed these study protocols into treatment manuals for wide
      distribution to the field so any provider can use the approach.




                                                                                     13
                     Knowledge Application Program (KAP)
 Established to synthesize, package, and transmit
 evidence-based knowledge to treatment providers.
Treatment Improvement Protocols (TIPs)
• Redesigned as a how-to document


Collateral products
• Short, concise documents based on TIPs, including Quick Guides, KAP
   Keys, screening tools


Treatment manuals
• For teens, adults, and older adults
• Topics: anger management, relapse prevention
   stimulant abuse (based on csat’s methamphetamine
   study), marijuana abuse (based on csat’s
   Cannabis Youth Treatment Study)
Methamphetamine Prevention, Care
and Treatment Toolkit
• Methamphetamine Treatment Project- Matrix
  Intensive Outpatient treatment for stimulant use
  disorders
   – Counselor’s Treatment Manual
   – Counselor’s Family Education Manual
   – Clients Handbook
   – Clients Handbook Treatment Companion
   – WWW.ncadi.samhsa.gov

                                                     15
Matrix Intensive Outpatient
Treatment- Treatment Reduces HIV
Risk Behaviors
 – Rawson & Methamphetamine Treatment Project authors- J Sub
   Abuse Treat 2008
     • HIV risk behaviors measured by AIDS Risk Assessment
     • Baseline, discharge 6,12,36 months after treatment
     • Baseline to treatment discharge and 3 yr follow-up showed both injection and
       sexual risk behavior decreased
         – number of injections, use of dirty needles and equipment, sex without
             condoms, sex while high, unsafe sex with an IDU or meth users

 – Introducing HIV prevention interventions to meth users in PEPFAR




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