Comparison of drug abuse in Germany and China

Drug abuse has a long, but also different history in Germany and China. The Opium War largely influenced the history of China in 19th century; however, China was once recognized as a drug-free nation for 3 decades from the 1950s to the 1980s. Drug abuse has spread quickly since re-emerging as a national problem in China in the late 1980s. The number of registered drug abusers increased from 70 000 in 1990 to more than 1 million by the end of 2005. In past decades, illicit drug trafficking and production have swept most provinces in China, and drug abuse has caused many problems for both abusers and the community. One major drug-related problem is the spread of HIV, which has caused major social and economic damage in China. Germany, the largest developed European country, also faces the drug and addiction problem. Germany has about 150 000 heroin addicts, for whom HIV/AIDS has become a serious threat since the mid 1980s. To control the drug problem, the German Government adopted the “Action Plan on Drugs and Addiction” in 2003; the China Central Government approved a similar regulation in the antidrug campaign in 2005. Germany has experience in reducing drug-related harm. The methadone maintenance treatment (MMT) program has run for more than 20 years and the public has become more tolerant of addicts. In 2003, China began the MMT program for controlling the spread of HIV/AIDS. It is necessary for China to learn from developed countries to acquire success in its antidrug campaign. In this review, we will go over the differences and similarities in drug abuse between Germany and China. The differences are related to history, population and economics, drug policy context, drug laws, HIV/hepatitis C virus infection, the MMT program and so on. These 2 nations have drug abuse problems with different histories and currently use different approaches to handle illicit drug marketing and use. The legal penalties for illicit drug offences reflect the social differences of these 2 nations with respect to the seriousness of particular types of crimes. The characteristics of the MMT program may also influence patterns of drug abuse in these 2 nations and China should improve the MMT program based on the successful model in Europe, the USA, and Australia. We recommend more dialogue and collaboration between Germany and China.

Training HIV physicians to prescribe buprenorphine for opioid dependence

Few HIV physicians are trained to provide buprenorphine treatment. We conducted a cross-sectional survey to assess the impact of an eight-hour course on the treatment of opioid dependence on HIV physicians' preparedness to prescribe buprenorphine. 113 of 257 trained physicians (44%) provided HIV care. Post-course, the majority of both HIV physicians and non-HIV physicians (66% vs. 67%, P = .8) planned to pursue a registration to prescribe buprenorphine. The most common reason for not planning to do so was lack of experience (9% vs. 15%, P = .19). 52 of the 113 (46%) HIV physicians had concerns about prescribing buprenorphine. 30 of the 52 (58%) indicated that interactions between buprenorphine and HAART was their primary concern. Following training, most physicians feel prepared and plan to obtain a registration to prescribe buprenorphine. HIV physicians' concerns regarding interactions between buprenorphine and HAART need to be addressed in future training efforts.

Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network

OBJECTIVE

To examine the safety and effectiveness of assisted reproduction using sperm washing for HIV-1-serodiscordant couples wishing to procreate where the male partner is infected.

DESIGN AND METHODS

A retrospective multicentre study at eight centres adhering on the European network CREAThE and involving 1036 serodiscordant couples wishing to procreate. Sperm washing was used to obtain motile spermatozoa for 3390 assisted reproduction cycles (2840 intrauterine inseminations, 107 in-vitro fertilizations, 394 intra-cytoplasmic sperm injections and 49 frozen embryo transfers). An HIV test was performed in female partners at least 6 months after assisted reproduction attempt. The outcome measures recorded were number of assisted reproduction cycles, pregnancy outcome and HIV test on women post-treatment.

RESULTS

A total of 580 pregnancies were obtained from 3315 cycles. Pregnancy outcome was unknown in 47 cases. The 533 pregnancies resulted in 410 deliveries and 463 live births. The result of female HIV testing after assisted reproduction was known in 967 out of 1036 woman (7.1% lost to follow-up). All tests recorded were negative. The calculated probability of contamination was equal to zero (95% confidence interval, 0-0.09%).

CONCLUSION

This first multicentre retrospective study of assisted reproduction following sperm washing demonstrates the method to be effective and to significantly reduce HIV-1 transmission risk to the uninfected female partner. These results support the view that assisted reproduction with sperm washing could not be denied to serodiscordant couples in developed countries and, where possible, could perhaps be integrated into a global public health initiative against HIV in developing countries.

A hospital-based exercise program to improve body composition, strength, and abdominal adiposity in 2 HIV-infected children

Two girls, aged 10 and 17 years, both with perinatally acquired HIV infection, participated in a 12-week, hospital-based exercise rehabilitation program of progressive resistance exercise training with an aerobic component. Weight, height, skin-fold thickness (4 sites), lean body and fat mass (assessed by dual-energy x-ray absorptiometry), and visceral adiposity (assessed by single-slice CT scan) were measured at the start and at the competition of the training program. After 12 weeks of training, both girls showed improved muscle strength (up to 64% increase in some muscle groups) and decreased visceral adipose tissue (up to 23%) and subcutaneous adipose tissue (up to 21%). One child decreased her total body fat by 9%. No adverse effects of the program were seen. These preliminary data suggest that progressive resistance exercise training in a medically supervised environment is safe and feasible for children with HIV infection. Most of these improvements were sustained or had increased at follow-up after home-based training.

A perfect platform: combining contingency management with medications for drug abuse

Contingency management (CM) procedures, which provide concrete reinforcers or rewards contingent on verification of discrete targeted behaviors, such as drug-free urines, have been demonstrated to be effective in a number of clinical trials. However, to date there have been only a few that have capitalized on the unique strengths and capabilities of CM as an ideal platform to improve response to or address weaknesses of many pharmacotherapies used in the treatment of drug abuse. In this review, we describe the multiple potential uses of CM as a platform for pharmacotherapy, including reducing illicit drug use in the context of agonist therapies; fostering medication compliance with antagonists, aversive agents and HIV medications; fostering a period of abstinence prior to initiation of agents used to treat comorbid psychiatric conditions or in the context of vaccines to foster adequate periods of abstinence while titer levels are building; and to enhance the effectiveness of anticraving agents through additive or synergistic effects. Although its multiple strengths render it an almost perfect platform, CM does have some weaknesses that have limited its use to date, including cost, the short-term nature of its effects, and need for training. Future treatment development of CM as a medication platform needs to counter these issues by focusing on CM applications with large potential benefit, developing simple or automated methods for CM delivery and placing greater emphasis on the process of transitioning away from formal CM treatment.

The impact of ongoing illicit drug use on methadone adherence in illicit drug users receiving treatment for HIV in a directly observed therapy program

INTRODUCTION

Studies evaluating the effectiveness of opioid agonist therapy programs typically evaluate drug abstinence or treatment retention as their primary outcomes. However, in many circumstances (e.g. directly observed therapy (DOT) programs within methadone maintenance programs), methadone adherence is an extremely relevant clinical outcome. We sought to evaluate the impact of ongoing illicit drug use on methadone adherence within a DOT program for the treatment of HIV-infection.

METHODS

Patients were enrolled in a DOT program, where methadone and HIV medication are co-administered by a community pharmacist. Drug use (amphetamines, benzodiazepines, cocaine, and opiates) was assessed by repeated urinalysis results. Methadone adherence was calculated as the fraction of days methadone was administered.

RESULTS

Ongoing drug use, and poly-substance use was common, with only 4 of 60 patients abstaining from all illicit drug use. Overall methadone adherence was 84.5%. Amphetamine use (without benzodiazepine and cocaine use), benzodiazepine use (without amphetamines) and higher methadone doses were associated with higher methadone adherence. When patients used benzodiazepines or cocaine, any positive effect associated with amphetamine use was negated. In addition, opiate use was associated with decreased methadone adherence.

DISCUSSION

The effect of many illicit drugs on methadone adherence may differ from reports using other treatment outcomes.

Occupational therapy for advanced HIV patients at a home care facility: a pilot study

Occupational therapy holds promise to increase quality of life and social functioning in patients with HIV infection. Since 2000 through 2005, we experimented a complex structured intervention including directly administered HAART, psychiatric support and occupational therapy for 14 patients with advanced HIV infection and multiple disabilities, cared for at an Italian home care facility. Social and occupational abilities were evaluated using the Axis V of DMS-IV, as assessed by the Global Assessment of Functioning Scale. Patients' abilities in coping with stressful situations were examined using the Social Dysfunction Rating Scale. Both outcomes were evaluated in interviews at study entrance and yearly thereafter. As compared to baseline, social function mean score significantly increased by 42% after one year of follow-up, and social stress mean score was significantly reduced by 11%. Both outcomes continued to improve constantly during the entire follow-up. Acceptance of the intervention was high, and three patients got outdoor job positions. The findings from this pilot study suggest that occupational therapy could be integrated with success in the treatment of severely disabled patients with advanced HIV infection. Confirmation from further research is required.

The disjunction between policy and practice: HIV discrimination in health care and employment in Indonesia

Through the areas of health and employment, this study examined the disjunction between policy and practice with regards to HIV/AIDS-related discrimination in Indonesia. The primary centres for data collection were Jakarta and Bali, where it was found that the contradictions between international commitments and written internal policies supported for forms of arbitrary discrimination against People Living with HIV/AIDS (PLWHA). This paper argues that for effective change to occur, the cultural mindset of service providers in the health care and employment sectors need to be changed through integrating institutional support and educational training.

Living and working with HIV in France in 2003: results from the ANRS-EN12-VESPA Study

OBJECTIVES

The employment rate of people living with HIV in France remains lower than in the general population despite HAART (highly active antiretroviral therapy) availability, translating into a high disease-related socioeconomic burden. Our objective was to investigate the relationships between HIV disease and employment status.

DESIGN

We used data from the ANRS-EN12-VESPA Study.

METHODS

Analyses were restricted to the 2750 working-aged (<60 years) participants. Individuals' health characteristics were compared according to employment status and plans of access/return to work, using logistic regression models to account for sociodemographic/occupational and health characteristics.

RESULTS

The employment rate was 56.5%; 44.9% of participants had remained employed since diagnosis and 11.6% had accessed employment after diagnosis. Compared with unemployed participants, those who had maintained employment were less likely to be of fair/poor health and have a history of AIDS and hepatitis C virus co-infection, were more likely to have been diagnosed with HIV after 1996, have a history of HIV-related hospitalization and a CD4 cell count of 200 cells/microl or less. Among employed participants, 70.1% had not disclosed their HIV status at the workplace and 8.5% reported HIV-related adjustments in their working conditions. Among the unemployed, 64.5% reported plans of access/return to work and 58.2% of those had attempted to do so. Motivations for access/return to work were mainly of a social, psychological and financial nature.

CONCLUSION

The employment status of people living with HIV/AIDS is associated with sociodemographic/occupational factors in addition to health characteristics. Management of HIV infection at work remains a challenge in the HAART era.

Factors distinguishing employed from unemployed people in the Positive Health Study

OBJECTIVE

To identify predictors of unemployment among Australian people living with HIV/AIDS.

DESIGN

A longitudinal cohort of Australian men living with HIV/AIDS.

METHODS

Participants were separated into two groups, currently working versus currently unemployed. The two groups were compared on a range of factors related to physical health, mental health and sociodemographic variables. Each family of variables was reduced to a set of best predictors, and multivariate log binomial regression was used to identify the predictors of unemployment.

RESULTS

Unemployment was more likely among those who experienced HIV/AIDS-related illness, scored higher on the Kessler scale of psychological distress and were older. There was a lower likelihood of unemployment among those who had better self-rated health, had been living with HIV/AIDS for a shorter period and who had a tertiary education.

CONCLUSION

These findings indicate that unemployment among people living with HIV/AIDS is best understood within a combined social and medical context. Interventions that acknowledge the differences in age and education that contribute to unemployment would improve employment prospects among people living with HIV/AIDS.

Health-related quality of life in French people living with HIV in 2003: results from the national ANRS-EN12-VESPA Study

OBJECTIVE

Since the advent of HAART, the assessment of health-related quality of life (HRQL) has become a major concern in the therapeutic follow-up of people living with HIV.

DESIGN

HRQL was evaluated for 2235 participants in the ANRS-EN12-VESPA Study. These participants completed the Medical Outcome Study 36-Item Short Form Health Survey (MOS SF-36) questionnaire. Anxiety and depression were assessed using the Hospital Anxiety and Depression (HAD) scale. Individuals were considered to have an 'acceptable' physical (and mental) HRQL if their MOS SF-36 scores were greater than the 25 percentile of the corresponding age-sex-specific distribution of scores in the French general population.

METHODS

Logistic regression models were used to identify factors associated with an 'acceptable' physical and mental HRQL among demographic, psychosocial and clinical characteristics. Potential selection bias caused by non-random missing responses to the MOS SF-36 questionnaire was statistically tested.

RESULTS

Physical and mental HRQL were 'acceptable' in 1176 (53%) and 1152 (51%) individuals, respectively. After adjusting for sociodemographic factors, HIV clinical status and hepatitis C co-infection, high HAD scores and the consumption of anxiolytic, antidepressant and hypnotic drugs were found to be negatively associated with normal physical and mental HRQL.

CONCLUSION

The role of disclosure and discrimination is determinant in HRQL, and the various cultural and psychological dimensions require further research. The presence of other infections or co-morbidities requires a comprehensive care system including medical staff and social worker teams. HIV should increasingly be regarded as a chronic disease characterized by different pathological conditions requiring a comprehensive and multidisciplinary approach.

Substance abuse treatment and receipt of liver specialty care among persons coinfected with HIV/HCV who have alcohol problems

We examined the association of substance abuse treatment with access to liver specialty care among 231 persons coinfected with HIV and hepatitis C virus (HCV) with a history of alcohol problems who were recruited and followed up in the HIV-Longitudinal Interrelationships of Viruses and Ethanol cohort study from 2001 to 2004. Variables regarding demographics, substance use, health service use, clinical variables, and substance abuse treatment were from a standardized research questionnaire administered biannually. We defined substance abuse treatment services as any of the following in the previous 6 months: 12 weeks in a halfway house or residential facility, 12 visits to a substance abuse counselor or mental health professional, day treatment for at least 30 days, or any participation in a methadone maintenance program. Liver specialty care was defined as a visit to a liver doctor, a hepatologist, or a specialist in treating hepatitis C in the past 6 months. At study entry, most of the 231 subjects (89%, n = 205) had seen a primary care physician, 50% had been exposed to substance abuse treatment, and 50 subjects (22%) had received liver specialty care. An additional 33 subjects (14%) reported receiving liver specialty care during the follow-up period. In the multivariable model, we observed a clinically important although not statistically significant association between having been in substance abuse treatment and receiving liver specialty care (adjusted odds ratio = 1.38; 95% confidence interval = 0.9-2.11). Substance abuse treatment systems should give attention to the need of patients to receive care for prevalent treatable diseases such as HIV/HCV coinfection and facilitate its medical care to improve the quality of care for individuals with substance use disorders. The data illustrate the need for clinical care models that give explicit attention to the coordination of primary health care with addiction and hepatitis C specialty care while providing ongoing support to engage and retain these patients with complex health needs.

Coping and burden among informal HIV caregivers

OBJECTIVE

The aim of this study was to examine the role of coping on caregiver burden among a heterogeneous group of caregivers of persons living with HIV during the era of highly active antiretroviral therapy.

METHODS

Burden and coping were examined among 176 caregivers of persons living with HIV. Three styles of coping were examined using a 7-item scale: active-approach (task), blame-withdrawal (emotion), and distancing (avoidance).

RESULTS

A total of 58.8% of the caregivers were women. They had a mean age of 42 years; 61.9% cohabited with the persons living with HIV who had a mean CD4 count of 401. All three styles of coping were significantly positively correlated with caregiver burden. After controlling for demographic variables and caregiver depression, active-approach coping and distancing coping independently moderated the relationship between perceived severity of HIV-related symptoms (stress) and caregiver burden; however, some caregivers experienced burden even at low levels of stress.

CONCLUSIONS

These results indicate that in the era of highly active antiretroviral therapy, coping mitigates the effect of stress on burden.

The SF-36 physical and mental health factors were confirmed in cancer and HIV/AIDS patients

BACKGROUND AND OBJECTIVE

This study assesses the extent to which the RAND-36/SF-36 items measure physical and mental health (PH and MH), as implied by existing summary scoring systems.

METHODS

A total of 1,714 heterogeneous cancer and HIV/AIDS patients were recruited from five institutions. Of these, 56% were women; 81% Caucasians; and about 10% were from each of the major cancer types and HIV/AIDS.

RESULTS

Analyses of the SF-36 confirmed the two dimensions of health namely physical and mental. However, item fit statistics and residual factor analysis revealed that some items intended to represent the PH dimension fit better with the MH dimension.

CONCLUSION

This paper demonstrated the value of Rasch residual factor analysis for understanding and enhancing interpretation of health.

Effects of a lifestyle modification program in HIV-infected patients with the metabolic syndrome

OBJECTIVES

A large percentage of HIV-infected patients receiving HAART develop the metabolic syndrome. In this study, we sought to determine whether lifestyle modification improves metabolic syndrome criteria, including waist circumference, blood pressure, fasting blood sugar, triglycerides, and HDL-cholesterol among HIV-infected patients with the metabolic syndrome.

DESIGN

We conducted a randomized, 6-month study in HIV-infected patients with metabolic syndrome as defined by the National Cholesterol Education Program. Subjects were randomly assigned to an intensive lifestyle modification program, which included weekly one-on-one counseling sessions with a registered dietician, or observation (control group).

METHODS

Metabolic syndrome criteria and cardiovascular parameters, including blood pressure, body composition, submaximal stress testing, lipids and other biochemical parameters were determined.

RESULTS

Thirty-four patients were randomly assigned and 28 subjects completed the study. Compared with the control group, subjects randomly assigned to the lifestyle modification program demonstrated significant decreases in waist circumference (-2.6 +/- 1.1 versus 1.2 +/- 1.0 cm, P = 0.022), systolic blood pressure (-13 +/- 4 versus 4 +/- 4 mmHg, P = 0.008), hemoglobin A1C (-0.1 +/- 0.1 versus 0.2 +/- 0.1%, P = 0.017), lipodystrophy score (-1.2 +/- 0.3 versus 0.9 +/- 0.6, P = 0.006) and increased activity (17.7 +/- 14.3 versus -33.1 +/- 12.7 metabolic equivalents, P = 0.014) as measured by the Modifiable Activity Questionnaire, but lipid levels did not improve.

CONCLUSION

These data demonstrate that intensive lifestyle modification significantly improved important cardiovascular risk indices in HIV-infected patients with the metabolic syndrome. Lifestyle modification may be a useful strategy to decrease cardiovascular risk in this population.

Impact of permanent supportive housing on the use of acute care health services by homeless adults

OBJECTIVE

This analysis examined the impact of permanent supportive housing on the use of acute care public health services by homeless people with mental illness, substance use disorder, and other disabilities.

METHODS

The sample consisted of 236 single adults who entered supportive housing at two San Francisco sites, Canon Kip Community House and the Lyric Hotel, between October 10, 1994, and June 30, 1998. Eighty percent had a diagnosis of dual psychiatric and substance use disorders. Administrative data from the city's public health system were used to construct a retrospective, longitudinal history of service use. Analyses compared service use during the two years before entry into supportive housing with service use during the two years after entry.

RESULTS

Eighty-one percent of residents remained in permanent supportive housing for at least one year. Housing placement significantly reduced the percentage of residents with an emergency department visit (53 to 37 percent), the average number of visits per person (1.94 to .86), and the total number of emergency department visits (56 percent decrease, from 457 to 202) for the sample as a whole. For hospitalizations, permanent supportive housing placement significantly reduced the likelihood of being hospitalized (19 to 11 percent) and the mean number of admissions per person (.34 to .19 admissions per resident).

CONCLUSIONS

Providing permanent supportive housing to homeless people with psychiatric and substance use disorders reduced their use of costly hospital emergency department and inpatient services, which are publicly provided.

Effect of long-cycle structured intermittent versus continuous HAART on quality of life in patients with chronic HIV infection

OBJECTIVE

To examine the effect of repeated, long-cycle structured intermittent versus continuous HAART on health-related quality of life (HRQL) and symptom distress in patients with chronic HIV infection and plasma HIV RNA of less than 50 copies/ml.

DESIGN

Prospective survey of adult patients (n = 46) enrolled in a randomized clinical trial evaluating intermittent versus continuous HAART on immunological and virologic parameters. Patients (n = 23) randomized to structured intermittent therapy received serial cycles of 4 weeks on/8 weeks off HAART.

OUTCOME MEASURES

HRQL was measured by the physical and mental health summary scores of the Medical Outcomes Study HIV Health Survey (MOS-HIV). Symptom distress was measured by the Symptom Distress Scale. Patients completed initial questionnaires prior to randomization and at weeks 4, 12, and 40 of the trial via a touch screen computer in an outpatient clinic.

RESULTS

Baseline demographic and clinical characteristics were equivalent in both treatment groups. Although the mental health summary score declined significantly over time for the structured intermittent group, linear mixed modeling ANOVA indicated no significant difference across time for MOS-HIV summary and Symptom Distress Scale scores between the two treatment arms.

CONCLUSION

In this small sample, repeated long-cycle structured intermittent therapy may not provide HRQL or symptom distress advantage compared to continuous HAART in patients with chronic HIV infection over 10 months of treatment. Further research in a heterogenous chronic HIV population and longer follow-up period is warranted.

[Rehabilitation, social medical evaluation and counselling in HIV-infected patients]

An inpatient rehabilitation programme for HIV-infected patients is described. Since the early nineties some 1,200 patients with HIV infection have been treated in our internal and orthopaedic rehabilitation clinic. Beside internal and orthopaedic diagnostics, supporting compliance with antiretroviral therapy, motivating the patients for regular moderate exercises and specific nutritional counselling are major issues of the programme. From the psychological point of view, the patients are offered to aquire relaxation and stress coping techniques, to take part in non-smoking courses and to use individual psychological counselling in case of depression or panic. In addition, all HIV-infected patients are offered individual advice on their disease and necessary changes in lifestyle. Finally, the programme includes social medical evaluation and counselling. As the majority of the patients are still working or are of working age, evaluating the capacity for work and potential introduction of occupational rehabilitation measures are prominent. Almost 70 percent of the HIV-infected patients who had been treated in our clinic over the last few years were fully capable of returning to their previous occupation. Our experiences demonstrate that statements such as rehabilitation of AIDS patients being useless because of its missing prospects of success, are not up-to-date any longer. Since introduction of combination antiretroviral therapy many patients with HIV infection are able to return to their previous occupation if they receive the necessary medical und psychosocial support.

Work-related abilities in schizophrenia and HIV infection

Schizophrenia and human immunodeficiency virus (HIV) infection both are associated with high rates of neurocognitive impairment. These impairments predict unemployment in both disorders, independent of other disease-related factors that may affect employment. In this study, we investigated work-related abilities and previous employment patterns in 27 unemployed patients with schizophrenia, 27 demographically matched unemployed HIV-infected participants, and 27 nonmatched employed HIV seropositive (HIV+) participants. All subjects were administered a computerized and hands-on assessment of vocational abilities and a comprehensive work history interview. Compared with the employed HIV+ group, the two unemployed groups had lower estimates of maximal lifetime job functioning. In terms of current vocational abilities, the employed HIV+ subjects generally performed best, followed by the unemployed HIV+ subjects and the patients with schizophrenia. Although the unemployed schizophrenia subjects had the most decline in vocational abilities (from estimated lifetime maximum level), the patterns of decline were similar in the two unemployed groups and were suggestive of parallel impairments in frontal-subcortical functioning.

Clinician-delivered intervention during routine clinical care reduces unprotected sexual behavior among HIV-infected patients

OBJECTIVE

To evaluate the effectiveness of a clinician-delivered intervention, implemented during routine clinical care, in reducing unprotected sexual behavior of HIV-infected patients.

DESIGN

A prospective clinical trial comparing the impact of a clinician-delivered intervention arm vs. a standard-of-care control arm on unprotected sexual behavior of HIV-infected patients.

SETTING

The 2 largest HIV clinics in Connecticut.

PARTICIPANTS

A total of 497 HIV-infected patients, aged > or =18 years, receiving HIV clinical care.

INTERVENTION

HIV clinical care providers conducted brief client-centered interventions at each clinical encounter that were designed to help HIV-infected patients reduce unprotected sexual behavior.

MAIN OUTCOME MEASURES

Unprotected insertive and receptive vaginal and anal intercourse and unprotected insertive oral sex; unprotected insertive and receptive vaginal and anal intercourse only.

RESULTS

HIV-infected patients who received the clinician-delivered intervention showed significantly reduced unprotected insertive and receptive vaginal and anal intercourse and insertive oral sex over a follow-up interval of 18 months (P < 0.05). These behaviors increased across the study interval for patients in the standard-of-care control arm (P < 0.01). For the measure of unprotected insertive and receptive vaginal and anal sex only, there was a trend toward a reduction in unprotected sex among intervention arm participants over time (P < 0.09), and a significant increase in unprotected sex in the standard-of-care control arm (P < 0.01).

CONCLUSIONS

A clinician-delivered HIV prevention intervention targeting HIV-infected patients resulted in reductions in unprotected sex. Interventions of this kind should be integrated into routine HIV clinical care.

Co-morbidity of infectious and addictive diseases in St. Petersburg and the Leningrad Region, Russia

The Russian health care system is organized around specific diseases, with relatively little focus on integration across specialties to address co-morbidities. This organizational structure presents new challenges in the context of the recent epidemics of injection drug use (IDU) and HIV. This paper uses existing and new data to examine the prevalence of reported new cases of drug dependence (heroin) and HIV over time as well as associations between drug dependence and alcoholism, hepatitis B and C, and tuberculosis in the City of St. Petersburg and the Leningrad region. We found a sharp rise in reported cases of IDU beginning in 1991 and continuing until 2002/2003, followed by a sharp rise in newly reported cases of HIV. These rises were followed by a drop in new cases of HIV and drug addiction in 2002/2003 and a drop in the proportion of HIV-positive individuals with IDU as a risk factor. Infection with hepatitis B and C were common, especially among injection drug users (38 and 85%, respectively), but also in alcoholics (7 and 14%). Tuberculosis was more common in alcoholics (53%) than in persons with alcoholism and drug dependence (10%), or with drug dependence alone (4%). Though these data have many limitations, they clearly demonstrate that drug dependence and/or alcoholism, HIV, hepatitis, and tuberculosis frequently co-occur in St. Petersburg and the Leningrad Region. Prevention and treatment services across medical specialties should be integrated to address the wide range of issues that are associated with these co-morbidities.