What Is HAART?

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The availability of HAART since 1996 has had a dramatic effect on the face of HIV/AIDS. HAART is a customized combination of different classes of medications that a physician prescribes based on such factors as the patient’s viral load, CD4⁺ lymphocyte count, and clinical symptoms. CD4⁺ lymphocytes are white blood cells that HIV infects and kills, leading to a weakened immune system and AIDS. Though not a cure, HAART controls viral load, helping to delay the onset of symptoms and achieve prolonged survival in people diagnosed with HIV/AIDS.⁵

With HAART, the medical consequences associated with HIV/AIDS have changed. New diagnoses of HIV-associated infections and some neurological complications, such as HIV dementia, have decreased since its introduction..^5,6 However, other neurological problems, such as peripheral nerve damage, have increased with the use of this therapy. HAART is also reported to be associated with increased lipid levels (including cholesterol) in the blood, abnormal glucose metabolism, and other clinical complications such as heart disease.

Potential interactions between HAART and medications used to treat drug addiction may decrease the effectiveness of either or both treatments. For instance, when methadone, a treatment for heroin and other opioid addictions, is administered with certain antiretroviral medications that are components of HAART therapy, the concentration of methadone in the blood is significantly decreased,⁹ potentially compromising its effectiveness. Research is under way to determine if buprenorphine, a newer medication for the treatment of opioid addictions, has similar liabilities.

One of the challenges for patients treated with HAART is adhering to the medication routine needed for maximum benefit from this therapy. Adherence can be particularly problematic for drug abusers with chaotic lifestyles, which can interfere with their ability to follow prescribed regimens. In addition, because HAART reduces viral load, some patients mistakenly believe that they do not need to adhere to the treatment regimen or that reduced viral load means elimination of the risk of transmitting HIV.^10,11,12 This belief can, in turn, lead to complacency about risk behaviors and resumption of unsafe sex and injection practices.¹³ NIDAsupported research has helped to improve HIV outcomes among IDUs and has advanced new discoveries and approaches for treating medical consequences resulting from living longer with the disease.

Hepatitis C

HCV infection, the leading cause of liver disease, is highly prevalent among IDUs and often co-occurs with HIV. In fact, between 85 and 90 percent of HIV-infected IDUs may also be infected with HCV.7 NIDA-funded studies have found that within 3 years of beginning injection drug use, a majority of IDUs contract HCV. Approximately 4 million people in the United States are currently infected with HCV; of these, approximately 400,000 are co-infected with HIV, enhancing the risk of severe liver disease, especially among drug addicts.8 Chronic HCV and HIV co-infection results in an accelerated progression to end-stage liver disease and death when compared with individuals infected with HCV alone. While the treatment of co-occurring HIV and HCV presents certain challenges, treatment during the acute phase of HCV infection (i.e., within 6 to 12 months of detection) has shown promise. Treatment thereafter significantly improves infected patients’ quality of life and should also be pursued.

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While all groups are affected by HIV/AIDS, not all are affected equally. The first populations to be affected by AIDS were primarily men who have sex with men (MSM) and IDUs. In fact, injection drug use has been associated directly or indirectly (e.g., through sex with IDUs, mother-child transmission) with more than one-third of AIDS cases in the United States. IDUs continue to be at increased risk of HIV and other infections associated with drug abuse, including the hepatitis C virus (HCV), hepatitis B virus (HBV), endocarditis, skin infections, and abscesses. Over the past several years, however, the proportion of AIDS cases attributable to injection drug use has declined, while AIDS cases attributable to heterosexual transmission have increased. From 2000 through 2004, the annual number of AIDS diagnoses attributable to heterosexual contact increased 18 percent among women and 24 percent among men. In 2003, MSM and those exposed through heterosexual contact together accounted for approximately 77 percent of cases, with MSM accounting for roughly 46 percent of the total cases.¹⁴

African-Americans experience striking disparities in HIV-infection rates compared with other populations, and they are at particularly high risk for developing AIDS. To illustrate, while African-Americans make up just 13 percent of the U.S. population, they accounted for more than half of the total AIDS cases diagnosed in 2004. Moreover, African- American females accounted for 68 percent of the female HIV/AIDS diagnoses from 2001 through 2004 while White females accounted for 16 percent and Hispanic females 15 percent.¹⁵ And although African-Americans ages 13–19 represent only 15 percent of U.S. teenagers, they accounted for 66 percent of new AIDS cases reported among teens in 2003.¹⁶

Young people (ages 13 to 24) are also at risk for HIV/AIDS, with minority youth at particularly high risk. According to the Centers for Disease Control and Prevention (CDC), an estimated 40,000 young people in the United States had been diagnosed with AIDS. This number represents approximately 4 percent of the cumulative AIDS cases through 2004. Moreover, between 2000 and 2004, the proportion of young people diagnosed with AIDS increased from 4.3 percent to 5.1 percent. Particular HIV risk behaviors of this group, including sexual experimentation and drug abuse, are often influenced by strong peer group relationships and diminished parental involvement that can occur during adolescence.

Compounding this adolescent vulnerability today is the notion of “generational forgetting,” which is a diminished view of the dangers of HIV/AIDS among certain members of today’s generations. Studies show that today’s youth may be more likely to hold this view than older Americans who witnessed a higher AIDS mortality rate associated with the rapid progression from HIV to AIDS early in the epidemic. In addition, one study comparing youth living with HIV before and after the era of HAART found that post-HAART youth were more likely to engage in unprotected sex and substance abuse; however, whether this outcome is a direct result of the availability of HAART is not known.¹⁹

HIV/AIDS: The Differential Experience of African-Americans

Disproportionate rates of HIV infection among African-Americans have increased steadily over time. By the end of 2004, an estimated 178,000 African-Americans were living with AIDS, the highest proportion of any racial/ethnic group. African- Americans also represent 43 percent of AIDS cases diagnosed since the start of the epidemic, which has disproportionately affected subgroups of African-Americans as well, including women, youth, and MSM. HIV/AIDS is now the leading cause of death among all African- Americans ages 25–44, ahead of heart disease, accidents, cancer, and homicide.17 The disproportionate rates of HIV infection among African-Americans is not due to higher rates of injection drug use or addiction in this population. Recent research suggests, in fact, that African-Americans have lower rates of addiction than Whites (8.3 percent vs. 9.6 percent of drug or alcohol abuse or dependence),18 but the two groups do not differ significantly in their rates of injection drug use. The noted disparities may in part reflect data showing that African-Americans are predominant among those who become aware of their infection at later stages in the disease process, and who therefore represent lost opportunities for treatment. To address these disparities, NIDA is encouraging research that examines the relationship between drug abuse and prevalence of HIV- and AIDS-related morbidity and mortality among African-Americans, as well as studies that measure the effectiveness of HIV prevention and treatment programs within these populations. NIDA also is encouraging studies that focus on the nexus of drug abuse, HIV/AIDS, and criminal justice involvement among African-Americans to determine when the risk for contracting and transmitting HIV is greatest (e.g., during community-based supervision, in prison/jail, or during re-entry into society). Additional studies are needed that characterize risk and protective factors in order to develop culturally sensitive prevention interventions to reduce HIV infection and minimize associated health consequences and co-occurring conditions such as HCV.