For HIV and Addiction, the Time to Act Is Now
These are exciting times for those of us working and living with HIV. There are promising new treatments in development, pre-exposure prophylaxis (PrEP) has added a significant additional resource to our prevention arsenal, and there is talk of seeing the end of the epidemic in our lifetimes. This optimism is reflected in major worldwide goals. UNAIDS, for example, has endorsed 90-90-90. That is, by 2020 at least 90% of people will know their status, 90% will receive sustained antiretroviral medication, and 90% will achieve a suppressed viral load. Policy reforms such as the National HIV/AIDS Policy acknowledge the role of stigma, mental health concerns, and health disparities.
All of this is certainly heady and represents more progress than I ever thought I would witness. Yet new HIV infection rates remain stubbornly consistent. Certain populations, especially gay men, women of color, and transsexuals, continue to see high, and in some cases increasing, rates of HIV while levels of viral suppression remain discouragingly low.
Indeed, the time to act is now, but we need to broaden our understanding of HIV/AIDS. There are epidemics within epidemics at work, and I believe that if they remain unaddressed we will never achieve our lofty goals. Biomedical advances are certainly essential, but so is recognition of the social and behavioral issues that directly impact new infection and medication adherence. First and foremost, among these is the high (and increasing) rate of addiction, which is directly tied to the HIV epidemic.
Most states in the U.S. now lose more citizens to drug overdoses than car accidents, and overdoses are the leading cause of death among certain age groups. Entire regions are experiencing a crisis of heroin, one that crosses all lines of race, ethnicity, and income. This trend has been developing for a decade. The CDC reports that between 2002 and 2013, the rate of heroin-related overdose deaths nearly quadrupled. For many, addiction to heroin began with a prescription for pain medications from their doctor. Dependence on such drugs occurs quickly and many turn to heroin when their prescription runs out, evidenced by a CDC report that 45% of people using heroin are also addicted to pain meds. Significantly, the heroin we see on the street today is not the "old-fashioned" version of times past. The heroin flooding our nation from Mexico is much more powerful, cheap, and accessible.
How is this relevant to HIV? Simply stated, injection drug use (IDU). Higher rates of IDU translate into higher risk for HIV. While only a small portion of new HIV infections are related to IDU, that number is growing. Injection drug use remains the most effective way to get not only HIV, but hepatitis B and hepatitis C as well. The heroin epidemic will only fuel HIV.
Another very different kind of drug is back with a vengeance: meth. Last seen at such levels over a decade ago, meth today, like heroin, has higher purity and cheaper prices. Hospital admissions and deaths from methamphetamine are on the rise across the country for all populations, but one group is at especially high risk for meth-related HIV: gay men. The prevalence of meth in the gay community, and its association with high-risk sexual behavior, represents a significant challenge to controlling the HIV epidemic.
Meth is destructive for several reasons. When used as a drug for sexual enhancement it commandeers the reward center of the brain, pushing sexual desire into overdrive. At the same time, it disinhibits and impairs judgment, all of which lead to high-risk sex. Meth-sex is nearly always condomless and users often party for days with multiple partners. In my new book, Lust, Men, and Meth: A Gay Man's Guide to Sex and Recovery, I document this perfect storm of drug use, high-risk sex, and HIV. Meth is wreaking havoc for many gay men and represents a crisis for our community. Many remain discouraged about meth, but it is important to note that, contrary to popular misconception, it is possible to achieve sobriety from methamphetamine and to reclaim healthy sex and intimacy. A roadmap for this recovery process is also provided in my book.
What can be done?
HIV and drug abuse are not two separate epidemics; they are integrally related. We must approach them syndemically, that is, as simultaneous epidemics that affect one another and which have an unfortunate synergy to make each one worse. In addition to understanding how addiction and HIV are related, we must address stigma, which remains a devastating problem. As with HIV, drug abusers experience powerful stigma that prevents them from acknowledging the problem, asking for help, or getting engaged in treatment. Stigma is embodied in many institutions and policies: criminalizing drug use, prohibiting harm reduction methods such as needle exchange, and providing adequate funding for evidenced-based treatment.
Addiction is not a moral issue, it is a medical problem, and one that directly impacts our ability to end the HIV/AIDS epidemic. The time to act is now, but we must broaden our actions to include not only the HIV virus but its behaviorally-based cousin, addiction. For many, the time to act has nearly run out.
Follow David Fawcett on Twitter at @drdavidfawcett.