Managing HIV/AIDS Therapy in Special Populations Are there any special issues in treating injection drug users with HIV/AIDS?
	Enlarged Version of Graphics Below	Dr. Kwakwa (OC): The main concern with us as clinicians when it comes to the injection drug user with HIV is the potential for adherence or nonadherence, and this refers to the person who is actively using. The person with past injection drug use is at no greater risk of nonadherence, and so that is the main challenge. Dr. Kwakwa (VO): Are we doing the patient more harm than good by treating them? Are they going to come back six months later with resistant virus because they have been unable to adhere to their medication, and have they perhaps transmitted the resistant virus in the interim?   See Slide Dr. Kwakwa (OC): I think that in general, providers are not very comfortable treating active drug users. We are more comfortable adhering to our script of: "Do not initiate therapy until the patient is ready," "ready" being "adherent," ready to be adherent with a therapy. The issue with the injection drug user, though, comes especially when the person has a fairly low CD4 count, and has expressed willingness to take antiretroviral therapy, but not willingness to stop the injection drug use... Dr. Kwakwa (VO): ...And, there, what we do in our practice with such a patient is really begin them on a therapeutic regimen, and keep a close eye on them. Have them coming back frequently to see the nutritionist, to see the social worker, to see the DNA counselor, to see the phlebotomist, to see the clinician. That really brings them in frequently enough that they stay in touch, and we have had fairly good success treating people, some of whom never stop the injection drug use, and some of whom do stop in the course of therapy. In that case, we tend to choose a regimen with a higher barrier to resistance, so that should the patient miss a dose here and there, they are less likely to come in with virus that is resistant.   See Slide Dr. Kwakwa (VO): With the non-nucleosides, specifically nevirapine/efavirenz, there has been shown to be a decrease in the level of methadone, and so, the dose may need to be increased with patients who are started on these drugs while they are on methadone specifically. Some of the protease inhibitors, such as fosamprenavir, such as tipranavir, also report a decrease in methadone levels, but it hasn't been shown to be of clinical significance-but patients certainly need to be monitored closely if they are on methadone when they are started on any of these antiretroviral therapies, and their dose adjusted accordingly should they have any symptoms of withdrawal.   See Slide Dr. Kwakwa (OC): The other issue in IV drug use-and this may be, perhaps, less for clinicians than for other members on the care team-would be really teaching how-the safe use of needles, and I speak of "safe" in the personal sense, as well as in the public health sense.
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