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Management of HIV Infection in a Methadone Treatment Program

—Robert Maslansky, M.D., Medical Director, Addiction Rehabilitation Clinic, New York University (NYU)-Bellevue Medical Center, New York, New York

Human immunodeficiency virus (HIV) infection has changed the way we look at addiction to heroin. In certain communities it represents a death sentence in less than 10 years for fully 1/2 of all intravenous users. At NYU-Bellevue Methadone Maintenance Treatment Center, 52 percent of our patients tested between 1985-1991 were HIV positive. Before 1985, our program recorded a predictable 3 to 5 deaths per year, mostly attributable to infective endocarditis, liver failure secondary to chronic hepatitis B, trauma, and drug overdose. In 1990 we recorded 42 deaths. All this additional mortality is directly attributable to HIV disease. The concomitant morbidity of these patients adds immensely to the clinical burden. Patients have everything from tuberculosis (25 active cases, some with resistant strains) to toxoplasmosis and severe herpes zoster. Results like this oblige all of us to ask important questions about the urgency and availability of treatment for heroin addiction.

At our methadone center, we opted to test and provide treatment to patients with early and asymptomatic HIV infection. Our experience demonstrates that on-site treatment of HIV infection is both feasible and urgent in a methadone maintenance treatment program and, by inference, in drug-free programs as well. We have shown that methadone treatment works in preventing the spread of HIV infection in our setting. For those communities not yet beset with this problem, our experience may be a cautionary tale you would be wise to heed carefully.

The NYU-Bellevue experience

When we argued for funds to treat HIV-infected patients in our methadone program, we were attempting to pick up the pieces of a failed system that produces a 50 percent HIV infection rate among the estimated 250,000 intravenous drug misusers in New York City. This is a system which permits more than 150,000 patients to go untreated for their addiction, a system which has criminalized a needle exchange program, which has failed to fund drug treatment programs adequately. New York's 50 percent infection rate is in contrast to such places as Los Angeles, California with a 4 percent incidence of HIV infection among intravenous drug users or Melbourne, Australia with a rate of less than 5 percent.

This system, however, mobilized a sluggish bureaucracy on the issue of HIV treatment for methadone patients. Within 3 weeks after our request, we were assessing and treating minimally symptomatic and asymptomatic HIV-infected patients on site with the expensive drug zidovudine (AZT), with no complaints from anyone.

Between 1985 and 1991, we tested 623 (62 percent) of the 1,012 patients at risk for HIV infection. Of these, 321 (52 percent) tested positive. We were able to treat 94 HIV+ patients (29 percent) with AZT between 1988-91, of which 73 patients are still in treatment (6 patients have been hospitalized for a total of 10 admissions). No follow-up data is available on 2l patients, of whom 11 transferred elsewhere, 6 died, and 4 dropped out.

Providing on-site, directly observed therapy is a major benefit for methadone patients. Intravenous drug users tend to be less compliant than others in following through with any treatment regimen. Our provision of AZT along with methadone—in the same setting among familiar faces—is promoting a much higher degree of treatment compliance than these patients would otherwise achieve. This treatment reinforces the total ambiance of the clinic, where we provide such comprehensive care as a program for the many children of our patients. On a practical level, treating our patients with AZT greatly reduces the burden of new patients who would otherwise be treated in the hospital's infectious virology department.

Methadone treatment has been effective in preventing new cases of HIV infection. Among the 102 patients who tested negative for HIV and who have remained in methadone treatment, only 1 (less than 1 percent) has seroconverted to HIV positive. Of the 200 HIV-negative patients who left methadone treatment, 87 have been retested; 6 (approximately 7 percent) have become HIV positive.

What methadone treatment programs can do

When one asks, "What can be done?", the obvious answer is that, like our program, methadone clinics need to go beyond their mandate to treat addiction. Methadone programs can do the following:

• Provide treatment to patients with early and asymptomatic HIV infection. At NYU-Bellevue, we are doing the utmost for patients that can be done within the constraints of currently available treatment. Perhaps only about 5 percent of methadone patients nationally are receiving the kind of HIV management that we offer our patients; thousands more could benefit from such help. The criteria for providing AZT prophylaxis are listed in the sidebar.
• Provide education and counseling on HIV prevention. At our center, we provide intense and diligent AIDS awareness classes; we also give individual counseling on clean needle use and on condom use as well.
• Test and make patients aware of their HIV status. In New York City alone, it is estimated that there are more than 15,000 methadone-maintained patients who are HIV-seropositive. It is highly probable that 80 percent of the 15,000—that is 12,000 patients—are not even aware of their HIV status. Many of these in seropositive status are not informed (or even tested).
• Stress the importance of retaining patients in methadone treatment. Our program, as well as other research, demonstrates that retaining patients in methadone treatment helps to prevent new cases of HIV infection.

Mobilizing the system to a broader mandate

What else can be done? Public education may be necessary if the system is to be mobilized to go beyond its mandate to treat addiction. We in methadone clinics are crucially situated for helping to control the AIDS epidemic through prevention, identification, and early treatment of HIV infection among intravenous drug users. Most of the thousands of methadone patients who do not know their seropositive status are heterosexually active males, many with more than one partner. They represent the focal point of additional spread into the general community, particularly to women whose only risk factor is having sex with an infected man. And what is particularly troublesome is that these patients are in treatment for heroin addiction but the system cannot mobilize to do anything beyond its mandate to treat addiction.

Let us be very clear about the extent of HIV risk for both intravenous drug users and for their sexual partners and children. In 1991, the estimated AIDS/HIV infection risk for persons in New York City included:

• 44 percent of persons with HIV infection are intravenous drug abusers (IVDA)