Adapting HIV Treatment for People With Substance Use Disorder

Chair, Monica Gandhi, MD, MPH, prepared useful Practice Aids pertaining to HIV for this CME/MOC/CE/AAPA activity titled “Adapting HIV Treatment for People With Substance Use Disorder.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/CE/AAPA information, and to apply for credit, please visit us at https://bit.ly/49hgPxT. CME/MOC/CE/AAPA credit will be available until June 4, 2025.

1. T
rauma-Informed Care
1-4

F
ull abbreviations, accreditation, and disclosure information available at PeerView.com/VCQ40 Six Guiding Principles of Trauma-Informed Care
Recognizing symptoms
of trauma and reinforcing
patients’ resilience
Being aware that many patients
with HIV and SUD
have a history of trauma Responding to agitated patients
in a nonjudgmental,
supportive way
Ensuring physical and emotional
safety for staff and patients
Promoting recovery and healing
for those who have
experienced trauma
Being trustworthy and
transparent with patients,
family members, and staff
Making decisions in partnership
with patients and avoiding
a power imbalance in interactions
Empowering patients and
giving them choice and control
over the care they receive
Promoting self-care
among staff and clinicians
What Is
Trauma-Informed
Care?
1. Safety2. Trustworthiness
and Transparency
3. Peer
Support
4. Collaboration
and Mutuality
5. Empowerment,
Voice, and Choice
6. Cultural,
Historical, and
Gender Issues
1. Kuehn BM. JAMA . 2020;323:595-597. 2. https://www.cdc.gov/orr/index.html. 3. https://blogs.cdc.gov/publichealthmatters/2022/05/trauma-informed. 4. https://store.samhsa.gov/sites/default/files/sma14-4884.pdf.

2. Sex-Positive Communication and Taking a Sexual History
1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/VCQ40 Sex-Positive Communication About HIV Transmission
Assess your own comfort by discussing sex with various patient groups
Avoid making assumptions about your patient based on age, appearance, marital status, or any other factor
Gather your patient’s basic information during the initial clinical assessment
• This includes their name, pronouns, sexual orientation, and gender identity
For gender identity, incorporate a two-step method into the assessment
• Ask for their sex assigned at birth (female, male, or decline to answer) and then current gender (female, male, transgender
female, transgender male, gender diverse, additional gender category, or decline to answer)
Ask for correct pronouns and terminology
• Identify any biases that you may have
• If you are uncomfortable talking about sex and sexuality, your patient will be too
• Use the pronouns they share and support that patient’s current gender identity, even if their anatomy does not match
that identity
Use neutral and inclusive terms, such as “partner”
Make your patient feel comfortable by establishing a rapport before asking sensitive questions
Ask other people to step into the waiting room while you talk to your patient
• These people may include partners, relatives, or care partners
• They can be invited back after the examination

3. Sex-Positive Communication and Taking a Sexual History
1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/VCQ40 • Have you ever been tested for STIs and HIV? Would
you like to be tested?
• Have you been diagnosed with an STI in the past?
When?
• Did you get treatment?
• Has (have) your current partner(s) or any former
partners ever been diagnosed or treated for an STI?
Were you tested for the same STI(s)? Do you know
your partner’s (or partners’) HIV status?
History
of STIs
• Do you think you would like to have (more) children
at some point?
• When do you think that might be?
• How important is it to you to prevent?
• Are you or your partner(s) using contraception or
practicing any form of birth control? Would you like
to talk about ways to prevent pregnancy? Do you
need any information on birth control?
Pregnancy
intention
• Do you and your partner(s) discuss STI prevention?
• What prevention methods do you use?
• How often do you use this/these method(s)?
• Have you received human papilloma virus (HPV),
hepatitis A, and/or hepatitis B shots?
• Are you aware of pre-exposure prophylaxis or PrEP?
Have you ever used it or considered using it?
Protection
From STIs
• Are you currently having sex of any kind—oral,
vaginal, or anal—with anyone? (Are you having sex?)
If no, have you ever had sex of any kind with another
person?
• In recent months, how many sex partners have
you had?
• What is/are the gender(s) of your sex partner(s)?
• Do you or your partner(s) currently have other
sex partners?
Partners
• I need to ask some more specific questions. Would
that be OK?
• What kinds of sexual contact do you have/have
you had?
• Do you have genital/anal/oral sex?
• Are you a top and/or bottom?
• Have you or any of your partners used drugs?
• Have you exchanged sex for your needs (eg, money,
housing, drugs)?
Practices
Five Ps Approach to Taking a Sexual History
1. https://www.cdc.gov/hiv/clinicians/screening/sexual-health.html.

4. Recommendations for the Treatment
of People With HIV and Substance Use Disorder
1

Full abbreviations, accreditation, and disclosure information available at PeerView.com/VCQ40 SUDs are prevalent among people with HIV and contribute to poor health outcomes;
screening for SUDs should be a routine part of clinical care
Healthcare providers should be nonjudgmental when addressing substance use with their patients
People with HIV and SUDs should be screened for additional mental health disorders
Ongoing substance use is not a contraindication to ART; people who use substances
can achieve and maintain viral suppression with ART
Selection of ARV regimens for individuals who practice unhealthy substance and alcohol use
should take into account potential adherence barriers, comorbidities that could impact care,
potential drug–drug interactions, and possible AEs associated with the medications
People with HIV and SUDs should be offered evidence-based pharmacotherapy (eg, opioid agonist
therapy, tobacco cessation treatment, alcohol use disorder treatment)
Substance use may increase the likelihood of risk-taking behaviors, the potential
for drug–drug interactions, and the risk or severity of substance-associated toxicities
ARV regimens with once-daily dosing of single-tablet regimens, high barriers to resistance,
low hepatotoxicity, and low potential for drug–drug interactions are preferred
Key
Considerations
and HHS
Recommendations
for People With
HIV (PWH) and
Substance Use
Disorder (SUD)

5. Recommendations for the Treatment
of People With HIV and Substance Use Disorder
1

Full abbreviations, accreditation, and disclosure information available at PeerView.com/VCQ40 Guideline-Recommended Strategies
to Improve Adherence to ART
• The approach taken to improve adherence should be tailored to each person’s needs and barriers to care
– Change ART to simplify dosing or to reduce adverse events
– Allow flexible appointment scheduling; offer extended appointment hours or telemedicine
– Provide resources to assist with treatment costs to maintain uninterrupted access to both ART and appointments
– Link patients to resources to assist with unmet social and economic needs, such as transportation, food, housing,
and support services
– Link patients to counseling to overcome stigma, substance use, or depression
• Multidisciplinary approaches, including collaborations with nursing, pharmacy, social work, and case management
are recommended
People with HIV having ART adherence problems should be placed on regimens
with high genetic barriers to resistance, such as dolutegravir, bictegravir, or boosted darunavir
Patient counseling and education should emphasize the importance of adherence,
help patients to identify their barriers to adherence and address those that are within their purview,
and link the patient to resources to overcome other barriers

6. Recommendations for the Treatment
of People With HIV and Substance Use Disorder
1

Full abbreviations, accreditation, and disclosure information available at PeerView.com/VCQ40 Considerations for Use of Long-Acting
Injectables for PWH and SUD
• Depressive disorders have been associated with cabotegravir and rilpivirine, so patients with SUD
should be screened for depressive disorders and treated for depression if indicated; if depressive
disorders worsen while on cabotegravir and rilpivirine, patients should be re-evaluated to determine
whether continued therapy with this regimen is advisable
• Consider the impact of using LAIs in the context of current or past substance use behaviors; some
people who either currently inject or previously injected substances may find that LAIs are a trigger
for the injection of illicit substances
• Consider what additional support may be needed to help people with SUDs be successful with LAIs;
administration of LAI in conjunction with substance use treatment, case management, patient navigators,
and/or peer navigators should be considered to help patients return for follow-up injections
• Discuss adherence with patients during multiple, nonjudgmental evaluations
• Given the often unpredictable lifestyles of people with SUDs, clinical care teams should be flexible
in scheduling patients for injections or accommodating walk-ins for injections
1. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/substance-use-disorders-and-hiv?view=full.

7. Treating Substance Use Disorders
in People With HIV
1-4

Full abbreviations, accreditation, and disclosure information available at
PeerView.com/VCQ40 SAMHSA Treatment of Alcohol Use Disorder Decision Grid
Medications for Treatment of Alcohol Use Disorder
Comments
Potential Interaction
With ARV Drugs
Dose and
Recommendations
Medication
Contraindicated in patients
with CrCl <30 mL/min
No significant interaction
with ARV drugs expected
666 mg PO 3x/day
or
333 mg PO 3x/day
for patients with
CrCl 30-50 mL/min
Acamprosate
Counsel patients regarding disulfiram
reaction when taken with alcohol;
symptoms for the reaction may include
flushing, tachycardia, nausea,
vomiting, or hypotension
Use with caution when prescribing
an ARV oral solution that contains
ethanol and/or propylene glycol
(eg, FPV, LPV/r, RTV)
250 mg PO once dailyDisulfiram
Has the greatest efficacy of all
FDA-approved medications
for alcohol use disorder
No significant interaction
with ARV drugs expected
50-100 mg PO once daily
Depot formulation
is a fixed-dose
monthly injection
Naltrexone
Medications
Pretreatment Indicators Injectable
Naltrexone
Oral
Naltrexone
DisulfiramAcamprosate
AAAXRenal failure
CCCASignificant liver disease
AACACoronary artery disease
CCAAChronic pain
XXAACurrent opioid use
AACAPsychosis
AAXAUnwilling or unable to sustain total abstinence
ACCCRisk factors for poor medication adherence
AACADiabetes
XAAAObesity that precludes IM injection
++AAFamily history of alcohol use disorders
CAAABleeding/other coagulation disorders
++AAHigh level of craving
++AAOpioid dependence in remission
AAA+History of postacute withdrawal syndrome
AAXACognitive impairment
Appropriate to use A Use with cautionC ContraindicatedX Particularly appropriate+

8. Treating Substance Use Disorders
in People With HIV
1-4

Full abbreviations, accreditation, and disclosure information available at
PeerView.com/VCQ40 Medications for Treatment of Nicotine Use Disorder
Comments
Potential Interaction
With ARV Drugs
Dose and RecommendationsMedication
Work with the patient
to identify the route of delivery
that the patient will use
and find most helpful
No significant interaction
with ARV drugs expected
FDA has approved a wide variety
of nicotine-replacement products;
all formulations are effective
Nicotine
replacement
therapy
Tobacco quit date ideally
should be 1 week
after starting therapy
Concentration may be
reduced when used
with ARV drugs that are
CYP2D6 inducers
Start at 150 mg PO daily for 3 days and
then increase to either 150 mg twice daily
or 300 mg once daily; use only formulations
that are approved for once-daily dosing
Bupropion
Tobacco quit date ideally
should be 1 week
after starting therapy
No significant interaction
with ARV drugs expected
Titrate the dose based on tolerability
until the desired effect is achieved;
the goal is to reach a dose of
1 mg PO twice daily
Requires dose adjustment in patients
with CrCl <30 mL/min
Varenicline
Medications for Treatment of Opioid Use Disorder
Comments
Potential Interaction
With ARV Drugs
Dose and RecommendationsMedication
Buprenorphine has 90% first-pass hepatic
metabolism; verify that the patient is using
the appropriate technique for sublingual
administration before adjusting the dose
because improper administration will result
in poor absorption and low drug levels
Potential interaction
with ARV drugs that
are CYP inhibitors
or inducers
Individualize buprenorphine
dosing based on a patient’s
opioid use; dose range is
4-24 mg sublingually
Dosing is once daily
or twice daily
Buprenorphine
QTc prolongation is a concern at higher
doses; methadone can be prescribed
for OUD only by a licensed OTP
Potential interaction
with ARV drugs that
are CYP inhibitors
or inducers
Individualize the dose;
patients who receive higher
doses (>100 mg) are
more likely to remain
in treatment
Methadone
Longer time of continuous abstinence
in those who received depot formulation
naltrexone compared with placebo after
transition from prison to community
No significant
interaction
with ARV drugs
expected
50-100 mg PO once daily
Depot formulation is a
fixed-dose monthly injection
Naltrexone

9. Treating Substance Use Disorders
in People With HIV
1-4

Full abbreviations, accreditation, and disclosure information available at
PeerView.com/VCQ40 1. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/substance-use-disorders-and-hiv?view=full. 2. https://store.samhsa.gov/sites/default/files/sma13-4380.pdf.
3. Batki S et al. J Addict Med . 2024;18(suppl 1):1-56. 4. https://eguideline.guidelinecentral.com/i/1519511-stimulant-use-disorder.
There are no FDA-approved pharmacotherapies
for the management of stimulant use disorders
Approach to Treatment of Stimulant Use Disorder
Use Reduction
Treatment supporting cocaine and methamphetamine use reduction
Contingency
management
Desire smoking cessation,
stimulating effect
Desire weight gain, sleep
improvement; okay if cardiac disease
Bupropion
Mirtazapine
(methamphetamine)
Response inadequate; desire
to treat alcohol use disorder
Response inadequate; desire
to treat alcohol use disorder
±
IM/PO naltrexone
(methamph)
Not tolerated/response inadequate
Consider addiction medicine consult
Desire to treat ADHD
Psychostimulants Topiramate