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How do prescription pain pills (opioids) affect HIV?

Prepared by Kathleen Clanon, MD and Pamela DeCarlo Community Engagement (CE) Core | July 2017

Are prescription opioids a concern?

Yes. Prescription pain pills (opioids) such as oxycodone, hydrocodone and methadone have helped millions of people effectively manage chronic pain. But for some, opioids have become a complex, tangled web of misuse and abuse that has led to dramatic increases in addiction, overdose, hepatitis B and C infection, and potentially, HIV infection in the US.[1] Prescription opioids sold in the US more than doubled from 2001 to 2015, yet there has not been a decrease in the amount of pain reported. The amount of oxycodone and hydrocodone alone tripled from 2000 to 2015. Healthcare providers wrote 259 million prescriptions for opioid painkillers in 2012—enough for every adult in the US.[2] The CDC recommends that prescription opioids should not be considered first-line or routine therapy for chronic pain.[3]

Why are prescription opioids a concern?

People often don’t know the risk involved in taking prescribed opioids. Opioids make people feel good, the side effects often are not bothersome, and patients tend to think that doctors would not prescribe something that is dangerous. Patients may not understand they can become physically dependent on them, and providers may not understand or adequately explain this. People being prescribed opioids should ask their providers if opioids are really the safest way to manage their pain.

Overdose. From 2000 to 2014, nearly half a million people died from drug overdoses, and more than 60% of drug overdose deaths involve an opioid. Every day, 46 people in the US die from prescription opioid overdose.[2]

Opioids are highly addictive. As many as 25% of people using opioids long-term struggle with opioid dependence.[4] And people become dependent on them extremely quickly. The chances of chronic use begin to increase as early as after the third day taken, and rise rapidly with each day after.[5]

What is their effect on HIV?

Potential negative effects on PLWH. For people living with HIV (PLWH), long-term opioid use may lead to depression, can trigger relapse, and actually can increase chronic pain.[6]

Increased risk behavior. Like alcohol and other drugs, prescription opioids can interfere with judgment and decision-making, and can result in users doing things they wouldn’t do when not in an altered state. People using opioids may have lowered inhibitions and be less likely to use condoms and more likely to share syringes, behaviors that increase the risk of transmitting and acquiring HIV as well as hepatitis C (HCV) and hepatitis B.[7]

Transition to injecting and heroin. The epidemic of prescription opioid misuse has resulted in a large population of people who are new to injecting. Almost 80% of new heroin users report using prescription opioids prior to heroin.[8]

What are concerns for PLWH?

Long-term opioid use. Chronic pain occurs in as many as 85% of PLWH and many use prescription opioids to manage their pain. Side effects from long-term and regular use of opioids include: decreased libido and testosterone, depression, neurological and heart rhythm problems. Repeated use of opiate pain medicines can, in fact, heighten—instead of alleviate—chronic pain in PLWH.[6]

Opioid misuse. Problematic prescription opioid use may be common among PLWH especially persons with a history of substance use, mental health issues, and poor adherence to ART. One study of PLWH prescribed opioids found that 62% had problematic use.[9]

Relapse and overdose. For PLWH with a history of alcohol and drug abuse, opioids may cause relapse. Accidental overdose is common, especially when opioids are combined with alcohol or benzodiazepines (such as Valium and Xanax), or with anti-depression and seizure medications.[3]

HIV healthcare. For many HIV providers, the unique factors in HIV care can influence whether they adopt federal guidelines for prescribing opioids. For example, goals such as retaining patients in HIV care or being an ally with patients, may be seen as more important than conservative opioid prescribing guidelines. Specialized training on opioid prescribing may be warranted for HIV providers.[10]

What are concerns for person at risk for HIV?

Lack of safer injecting knowledge and programs. The opioid epidemic has led to an increase in people who inject drugs (PWID). These new injectors tend to be mostly White, live in rural and suburban areas, have little knowledge of safe injecting practices or HCV and HIV risks, and have little or no access to education or services for injectors, such as syringe access programs.[11] This creates the potential for rapid spread of HIV once introduced into communities.

Hepatitis C. Currently, HCV infection is a major concern for injectors, especially among young adults and those living in small towns and rural areas in the US who inject opioids. In 2013, 30,000 new cases of HCV occurred, and 28 states reported increases in HCV infections. This was an increase of more than 150% from 2010 to 2013.[11]

Potential rapid spread of HIV. In 2015, the first HIV outbreak associated with injecting prescription opioids occurred in rural Indiana. HIV infection spread quickly in this small community, with 135 people testing positive, and 80% of those reporting dissolving and injecting tablets of oxymorphone.[12]

What needs to be done?

While opioid prescriptions, use, addiction and overdose have skyrocketed in the past few years, federal, state and local agencies have responded with guidelines, regulations and programs to promote safety. In 2016, the CDC issued guidelines intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, to improve the safety and effectiveness of pain treatment, and to reduce the risks associated with long-term opioid therapy, including addiction, overdose, and death.[3]

Healthcare providers Non-opioid pain management. Providers working with PLWH should consider age, gender, socioeconomic status, current mental health, and substance use, as addressing pain without looking at these may have limited success. As the CDC recommends that opioids should not be a first-line therapy for chronic pain, providers should consider non-opioid means of managing pain. PLWH may get relief from pain with cognitive behavioral therapy, physical therapy, hypnosis or medical marijuana.[13] Overdose prevention. If providers and patients wish to use opioids, providers should discuss and provide written materials on the risks of dependence and overdose, and consider co-prescribing naloxone to reverse potentially fatal overdose.

People living with HIV PLWH who are prescribed opioids by their doctor should discuss any concerns and ask about non-opioid pain relief methods. If prescribed an opioid, they should use it for shortest period of time possible and be aware that dependence can happen right away, within 3 days of use.[5] PLWH who have been taking opioids for a long time should talk to their doctor about weaning off, or reducing their use.

Policymakers We know how to prevent HIV, and we have multiple effective HIV prevention interventions. The HIV outbreak among rural PWID in Indiana has shown what can happen when states and local communities do not invest in prevention. We need to make a serious commitment to expanding education; harm reduction services such as syringe access programs; overdose prevention including access to naloxone; and drug treatment.[14] Despite years of scientific evidence of their need, cost-effectiveness and effectiveness, there exist political and legislative barriers to implementing programs for PWID. We need to support, protect and expand existing laws and programs for the health and wellbeing of people who use and misuse prescription opioids, including PWID and their partners.

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Says Who?

1. RTI International. Opioids In America: A complex crisis. A comprehensive response. www.rti.org/sites/default/files/brochures/rti_opioids_in_america.pdf
2. CDC. Opioid painkiller prescribing: Where you live makes a difference. CDC Vital Signs. July 2014. www.cdc.gov/vitalsigns/opioid-prescribing
3. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR. 2016;65:1-49.
4. CDC. Injury prevention and control: Opioid overdose. Drug overdose deaths in the United States continue to increase in 2015. www.cdc.gov/drugoverdose/epidemic/
5. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use — United States, 2006–2015. MMWR. 2017;66:265–269. http://dx.doi.org/10.15585/mmwr.mm6610a1
6. Liu B, Liu X, Tang SJ. Interactions of opioids and HIV infection in the pathogenesis of chronic pain. Front Microbiol. 2016;7:103.
7. Zule WA, Oramasionwu C, Evon D, et al. Event-level analyses of sex-risk and injection-risk behaviors among nonmedical prescription opioid users. Am J Drug Alcohol Abuse. 2016;42:689-697.
8. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.
9. Turner AN, Maierhofer C, Funderburg NT, et al. High levels of self-reported prescription opioid use by HIV-positive individuals. AIDS Care. 2016;28:1559-1565.
10. Starrels JL, Peyser D, Haughton L, et al. When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers. Subst Abus. 2016;37:148-153.
11. National Institute on Drug Abuse. Prescription opioids and heroin. NIDA Research Report Series. 2015. www.drugabuse.gov/publications/research-reports/prescription-opioids-heroin
12. Conrad C,  Bradley HM,  Broz D, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone — Indiana, 2015. MMWR. 2015;64:443-444. www.cdc.gov/mmWr/preview/mmwrhtml/mm6416a4.htm
13. Merlin JS. Chronic pain in patients with HIV infection: What clinicians need to know. Topics in Antiviral Medicine. 2015;23:120-124.
14. Raymond D. Injecting opana: Indiana’s HIV outbreak and America’s opioid epidemic. Harm Reduction Coalition. March 2015. https://medium.com/addiction-unscripted/injecting-opana-indiana-s-hiv-outbreak-and-america-s-opioid-epidemic-65501f9aa6c8

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Special thanks to the following reviewers of this Fact Sheet: Rachel Anderson, Emily Behar, Neisha Becton, Holvis Delgadillo, Linda Gowing, Barbara Green-Ajufo, Renata Henry, Daryl Mangosing, Savannah O’Neill. Kathleen Clanon is affiliated with the Alameda County Health Care Services Agency. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Many Fact Sheets are available in Spanish.

©2017, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. 

This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 5U48DP004998 from the Centers for Disease Control and Prevention.

This brochure lists research focusing on HIV testing and helpful resources produced by CAPS/PRC. You might use it to:

• Stay up-to-date on research and learn what we found out from research
• Use the materials in trainings/presentations
• Advocate for services/funding
• Write grants
• Develop new or modify existing HIV prevention programs
• Evaluate current programs
• Connect with CAPS/PRC to develop new projects.

Lead researchers (PIs) are listed for each study. Questions? Comments? Contact Daryl Mangosing at 415 502-1000 ext. 44590 (vm only) or [email protected] This brochure was prepared by the Community Engagement (CE) Core, previously known as the Technology and Information Exchange (TIE) Core: “Tying research and community together.”

Health disparities and HIV/AIDS

Health disparities exist across race/ethnic, gender, sexual orientation, socioeconomic and/or geographically defined population groups. This e-newsletter features CAPS/PRC research that discusses and addresses health disparities among impacted groups that are living with or at risk of acquiring HIV/AIDS. Shout out to our Visiting Professors for summer 2017 ! We welcomed two first-year professors and welcomed back eight returning professors who all improved their programs of HIV-related health disparities research.

1. Local projects
2. National projects
3. International projects
4. Fact sheets on PrEP and Opioid Use
5. National HIV/AIDS Awareness Days: Research and Resources booklets
6. Announcements

What Are Heterosexual Men’s HIV Prevention Needs?

Prepared by Joshua Middleton and Reverend William Francis Community Engagement (CE) Core | March 2018

Heterosexual men are affected by HIV

HIV is a concern for heterosexual men, as almost 14% of new male HIV cases in 2016 occurred among heterosexuals, through sex with a woman (9.5%) and injecting drug use (3.9%). Most of those cases were among Black (63%) and Latino (22%) men, and men living in the Southeast (62%) and Northeast (19%) of the US.[1] These statistics, however, may not give us an accurate picture of HIV among heterosexual men. Because sexuality is complex, some heterosexually-identified men may have sex with men, but still identify as straight.[2] The CDC tracks HIV infections through means of infection, not by a person’s identity. Therefore, a heterosexual man who tells his healthcare provider he ever had a sexual encounter with a man is categorized under “men who have sex with men,” and if he says he has ever injected a drug, is categorized under “people who inject drugs (PWID).” Because of this, heterosexual men are seldom mentioned or addressed in the world of HIV prevention, care and research—where men are classified based on federal guidance and misconceptions, and not on men’s own identity.[3] This may be helpful for tracking the HIV epidemic, but it hampers service organizations who want to serve straight men who are at risk for or living with HIV, because funding for programs is linked to mode of transmission.

Fighting stigma

Misunderstanding, discrimination and HIV stigma. Heterosexual men may be reluctant to access testing and education programs at HIV-related organizations because they are concerned they might be labeled as gay or in the closet. Heterosexual men living with HIV can feel excluded from HIV clinics that brand their sites as safe and inclusive spaces for gay and bisexual men, which may be less about homophobia, and more about wanting a safe space for connection with and support from their community.[4] HIV criminalization. Straight men often are blamed for the HIV epidemic among heterosexual women, and may carry guilt, shame and fear of criminal charges. Between 2008 and 2016 in the US, there were 279 cases of HIV criminalization. This occurs when a person is prosecuted for not disclosing their HIV status to a partner. The majority of prosecutions are of heterosexual men.[5] Religion. Religion is an important part of many heterosexual men’s lives, yet sometimes the church may be the place where they are exposed to the beliefs that HIV is a punishment from God, and homosexuality and sex outside of marriage are sins.[6] These religious views may deter open dialogue around HIV, such as HIV testing and prevention, or disclosing HIV status.

Holistic approach

Addressing issues that impact heterosexual men as a whole person—body, mind and spirit—can be more effective than addressing HIV transmission mode. Health inequalities and structural barriers, not necessarily sexual risk taking behaviors, make men more likely to contract HIV and less likely to seek and have access to HIV programs.[3] Family, relationships and intimacy. It is important for heterosexual men to explore their identity as a father, a romantic partner and a member of a family unit.[7] Men view intimacy in many different ways, including being able to communicate with their partner, being transparent and comfortable expressing their feelings, spending quality time with their partners, and having healthy and satisfying sexual lives.[8] Men and boys may need support developing communication skills with their partners. Social injustice and resilience. The largest proportion of heterosexual HIV cases occur among Black men in the Southeast. This is also true for other race/ethnic groups except American Indian/Alaska Native where the largest number is in the West. The second largest number of cases among Black, Latino, and White men occur in the Northeast US. Latino men, the second largest race/ethnic group with HIV also are most affected in the South and Northeast US. Black and Latino men also face disproportionate rates of unemployment, racism, incarceration and lack of education, which can be more pressing issues to contend with than HIV and healthcare. Despite these challenges, many Black men have supportive communities, are highly resilient and persevere. HIV prevention and care services can support Black men by partnering with educational and vocational services to bolster men’s efforts to survive and thrive amid their adversities.[8] Incarceration and post-incarceration services. Programs for heterosexual men should address the impact of incarceration on men, their partners, family and community. Sex with men, sexual assault and injection drug use are risks while incarcerated. People living with HIV (PLWH) may face treatment interruption both in prison and jail, and upon release—which can increase their viral loads and infectivity. Programs can provide education and risk reduction for men affected by incarceration,[9] as well as support finding employment, healthcare and housing upon release.[3]

Quality healthcare

Talking about health. Many men don’t feel comfortable talking about their sexual health and behaviors with their doctors, and doctors typically don’t ask these questions. Cultural male stereotypes and seeing the bulk of health services and promotions focused on women, hamper men’s willingness to seek out health care services, including HIV testing.[10] Healthcare providers need to take a proactive role engaging men, and provide a non-judgmental, safe environment where men can feel free and safe to talk about their sexual health. HIV testing. Providers and clinics need greater awareness that heterosexual men can be at risk for HIV, and should offer all men HIV testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Half of heterosexual men living with HIV were diagnosed 5 years or more after they were infected, later than any other population. Providers should talk to men of every age about HIV and HIV risk reduction, and let them know that HIV testing is a part of routine healthcare.[11] HIV treatment and PrEP. PLWH who are on antiretroviral treatment and have undetectable viral loads do not transmit the virus to their partners.[5] PrEP, a medication for people who do not have HIV, can be used by men and women to protect themselves from HIV safely. These medical breakthroughs can help heterosexual men avoid HIV transmission, safely have children, reduce stress and worry, and increase trust and sexual pleasure in relationships.

Resources and programs

There has been resistance in the HIV community to track, fund, research and provide HIV services for heterosexual men, perhaps due to the focus on the mode of transmission and reluctance to acknowledge men’s own heterosexual identity.[3] For example, for the past five years there have been more new HIV cases from heterosexual transmission than from injecting drug use transmission among men,[1] yet programs and services for PWID far outnumber those for straight men. Programs for heterosexual men should collaborate with mainstream organizations, as straight men are less likely to use HIV-specific services. Programs should reach out to places where straight men go, such as the grocery store, gym, barbershops, sporting events, clubs, churches, colleges, vocational services. Heterosexual men prefer to hear messages from other straight men in community locations.[12] Programs, providers and researchers can do a better job of supporting Black men’s strengths and stop highlighting weaknesses. Increasing HIV testing, education, care and treatment, including PrEP for heterosexual men, can help address HIV. Increasing quality education, job and housing opportunities, as well as providing safe spaces for Black men that foster social support can also address HIV.[7]

Making a difference

It is time to recognize and fully address HIV among heterosexual men. Organizations, health departments and clinics should consider the needs of heterosexual men when planning their budgets, and include men in program planning, service delivery, research and policymaking. Straight men can help fight stigma and invisibility by speaking up, disclosing their status, working in HIV organizations and taking their place at the table to advocate for funding and programs. "Until we all come together, HIV is not going to end." -Rev. Francis

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Says who?

1. Centers for Disease Control and Prevention. HIV Surveillance Report, 2016. November 2017; vol. 28. 2. Carrillo H, Hoffman A. From MSM to heteroflexibilities: Non-exclusive straight male identities and their implications for HIV prevention and health promotion. Global Public Health. 2016;11:923-36. 3. Bowleg L, Raj A. Shared communities, structural contexts, and HIV risk: prioritizing the HIV risk and prevention needs of Black heterosexual men. American Journal of Public Health. 2012;102:S173-S177. 4. Kou N, Djiometio JN, Agha A, et al. Examining the health and health service utilization of heterosexual men with HIV: a community-informed scoping review. AIDS Care. 2017;29:552-558. 5. Halkitis PM, Pomeranz JL. It’s time to repeal HIV criminalization laws. Huffington Post. August 1, 2017. 6. Wilson PA,  Wittlin NM, Muñoz-Laboy M, et al. Ideologies of Black churches in New York City and the public health crisis of HIV among Black men who have sex with men. Global Public Health. 2011;6: S227–S242. 7. Abrahams C, Jones D, Viera A, et al. The forgotten population in HIV prevention: Heterosexual Black/African American men: Key findings and strategies. Harm Reduction Coalition position paper. December 2009. 8. Teti M, Martin AE, Ranade R, et al. “I’m a keep rising. I’m a keep going forward, regardless”: Exploring Black men’s resilience amid sociostructural challenges and stressors. Qualitative Health Research. 2012; 22:524–533. 9. Valera P, Chang Y, Lian Z. HIV risk inside US prisons: A systematic review of risk reduction interventions conducted in US prisons. AIDS Care, 2017;29:943-952. 10. Marcell AV, Morgan AR, Sanders R. The socioecology of sexual and reproductive health care use among young urban minority males. Journal of Adolescent Health. 2017;60:402-410. 11. CDC. HIV testing. CDC National HIV Surveillance System, 2015. 12. Murray A, Toledo L, Brown EE, et al. “We as Black men have to encourage each other:» Facilitators and barriers associated with HIV testing among Black/African American men in rural Florida. Journal of Health Care for the Poor and Underserved. 2017;28:487-498.

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Special thanks to the following reviewers of this Fact Sheet: Tony Antoniou, Lisa Bowleg, Derek Canas, Hector Carrillo, Todd Genre, Barbara Green Ajufo, Davina Jones, Steve Kogan, Steven Lamm, Daryl Mangosing, Arik Marcell, Ashley Murray, Bob Siedle-Khan, Michelle Teti, Pamela Valera, Bill Woods Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. ©2018, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 5U48DP004998 from the Centers for Disease Control and Prevention.

Research & Resources

This brochure lists research projects with African Americans and helpful resources produced by CAPS/PRC. You might use it to:

• Stay up-to-date on research and learn what we found out from research
• Provide materials in trainings/presentations
• Advocate for services/funding
• Write grants
• Develop new or modify existing HIV prevention programs
• Evaluate current programs
• Connect with CAPS/PRC to develop new projects. Lead researchers (PIs) are listed for each study. Contact us below to connect.

Questions? Comments? Contact Daryl Mangosing at 415-502-1000 ext. 17163 (vm only) or [email protected] This brochure was prepared by the CAPS Community Engagement (CE) Core, which is previously known as the Technology and Information Exchange (TIE) Core.

Acronyms

MSM: Men who have sex with men PI: Principal Investigator (lead researcher on the study) CO-I: Co-Investigator (contributing researcher or research partner)