This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. Injection drug users (DUs) constitute 31% of HIV-infected individuals in the U.S. and account for a majority of HIV-positive patients in many poor urban areas. The Johns Hopkins HIV clinic currently provides care to 3,000 individuals, of whom 51% have a history of injection drug use. Relative to other HIV risk groups, active DUs underutilize highly active antiretroviral therapy (HAART), experience higher rates of HIV disease progression and death, and remain at high risk for transmitting HIV to others through needle sharing and other behaviors. Integrated models of HIV care and substance abuse treatment are needed. Research overwhelmingly indicates that treatment of opioid dependence with replacement therapy is superior to detoxification and non-pharmacologic interventions alone in reducing illicit drug, keeping patients in treatment, and improving medical outcomes (1-3). However, access to effective opioid addiction treatment has historically been limited. Recent legislation and the FDA approval of buprenorphine (BPN) have opened the door to treatment of opioid dependence in primary care settings by licensed physicians who have completed an 8-hour training module (4-7) and received a waiver from the Drug Enforcement Administration. Many regard this initiative as the most important advance in substance abuse care in decades, an advance that is particularly germane to the HIV epidemic. Given the high burden of opioid addiction encountered in the Johns Hopkins HIV Clinic, we are uniquely situated to spearhead this research endeavor. Our multidisciplinary working group proposes to develop and pilot an integrated care model that incorporates medical HIV management, behavioral counseling, psychiatric care, and opioid replacement therapy with BPN. The integration of HIV care and substance abuse treatment has direct relevance to the CFAR themes of treatment (improving outcomes) and prevention (minimizing transmission risky behavior in HIV-positive individuals).
Specific aim We propose to conduct a pilot study of an on-site BPN maintenance therapy program in 30 opioid-dependent or -abusing adults receiving medical care in the Johns Hopkins HIV Clinic. We will assess the effectiveness of this program with regard to the following outcomes: 1) Retention to BPN treatment, 2) Utilization of and adherence to HAART, 3) HIV RNA levels and CD4 cell counts, 4) Urine drug screens, 5) Self-reported frequency of drug use and injection equipment sharing, 7) Measurements of addiction severity and associated psychosocial domains. We hypothesize that the integration of HIV care and BPN-based treatment of opioid addiction will lead to improved utilization of HIV care and treatment outcomes, reductions in illicit drug use, and reductions in HIV transmission risk behaviors in HIV-infected DUs. Our working group includes a new collaboration of junior faculty in infectious diseases, psychiatry, and general internal medicine. This proposed project will provide the preliminary experience and data needed to launch a long-range multi-disciplinary research program including infectious diseases, psychiatry, substance abuse, and clinical pharmacology. The National Institute on Drug Abuse (NIDA) has expressed particular interest in funding research on BPN in HIV treatment settings, and specifically requested submissions from Johns Hopkins.
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