The impact of prescribed opioids on CD4 cell count recovery among HIV-infected patients newly initiating antiretroviral therapy

OBJECTIVES

Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied.

METHODS

Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (< 90 days) and long-term (≥ 90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity [ascertained with the Veterans Aging Cohort Study (VACS) Index]. Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e. dose and known immunosuppressive properties).

RESULTS

Compared to those with none, patients with short-term opioids had a similar increase in CD4 cell count (mean rise per year: 74 vs. 68 cells/μL; P = 0.11), as did those with long-term prescribed opioids (mean rise per year: 74 vs. 75 cells/μL; P = 0.98). In sensitivity analysis, compared with no opioids, the effects of short-term prescribed opioids were statistically significant among those with a baseline CD4 cell count ≥ 500 cells/μL (mean rise per year: 52 cells/μL for no opioids vs. 20 cells/μL for short-term opioids; P = 0.04); findings were otherwise unchanged.

CONCLUSIONS

Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating ART.

Effects of Heavy Drinking on T-Cell Phenotypes Consistent with Immunosenescence in Untreated HIV Infection

BACKGROUND

The role of alcohol consumption in HIV-related adaptive immune dysfunction is debated. We hypothesized that heavy drinking would be associated with greater evidence of immunosenescence (i.e., aging-related decline of adaptive immune function) among antiretroviral therapy (ART)-naïve HIV-infected individuals.

METHODS

Using data from the Russia ARCH cohort study, we conducted a cross-sectional analysis of ART-naïve HIV-infected individuals recruited between 2012 and 2014.

INDEPENDENT VARIABLE

Heavy drinking defined as >4 standard drinks in a day (or >14 standard drinks per week) for men and >3 per day (or >7 per week) for women, respectively.

DEPENDENT VARIABLES

Percentage of CD8+ and CD4+ T-cells with a phenotype consistent with immunosenescence (i.e., expressing CD28- CD57+, or memory [CD45RO+ CD45RA+] phenotype and not the naïve [CD45RO- CD45RA+] phenotype).

STATISTICAL ANALYSIS

Multiple linear regression adjusted for confounders.

RESULTS

Of 214 eligible participants, 61% were heavy drinkers. Mean age was 33 years and the cohort was predominantly male (72%). Hepatitis C prevalence was high (87%) and mean log10 HIV-1 RNA copies/ml was 4.6. We found no significant differences by drinking status in the percentage of immunosenescent, memory, or naïve CD8+ or CD4+ T-cells.

CONCLUSIONS

In this cross-sectional analysis, heavy drinking in the setting of untreated HIV infection did not appear to be associated with alterations in T-cell phenotypes consistent with immunosenescence. To substantiate these findings, longitudinal studies should assess whether changes in alcohol consumption are associated with changes in these and other immunosenescent T-cell phenotypes.

Pharmacologic and non-pharmacologic treatments for chronic pain in individuals with HIV: a systematic review

Chronic pain occurs in as many as 85% of individuals with HIV and is associated with substantial functional impairment. Little guidance is available for HIV providers seeking to address their patients' chronic pain. We conducted a systematic review to identify clinical trials and observational studies that examined the impact of pharmacologic or non-pharmacologic interventions on pain and/or functional outcomes among HIV-infected individuals with chronic pain in high-development countries. Eleven studies met inclusion criteria and were mostly low or very low quality. Seven examined pharmacologic interventions (gabapentin, pregabalin, capsaicin, analgesics including opioids) and four examined non-pharmacologic interventions (cognitive behavioral therapy, self-hypnosis, smoked cannabis). The only controlled studies with positive results were of capsaicin and cannabis, and had short-term follow-up (≤12 weeks). Among the seven studies of pharmacologic interventions, five had substantial pharmaceutical industry sponsorship. These findings highlight several important gaps in the HIV/chronic pain literature that require further research.

Hepatic Safety of Buprenorphine in HIV-Infected and Uninfected Patients With Opioid Use Disorder: The Role of HCV-Infection

INTRODUCTION

Individuals with HIV and hepatitis C (HCV) infection, alcohol use disorder, or who are prescribed potentially hepatotoxic medications may be at increased risk for buprenorphine (BUP) associated hepatotoxicity.

MATERIALS AND METHODS

We examined a cohort of HIV-infected and uninfected patients receiving an initial BUP prescription between 2003 and 2012. We compared changes in alanine and aspartate aminotransferases (ALT and AST) and total bilirubin (TB) stratified by HIV status. We identified cases of liver enzyme elevation (LEE), TB elevation (TBE), and conducted chart review to assess for cases of drug induced liver injury (DILI) and death. We examined associations between age, sex, race, HIV-infection, HCV-infection, alcohol use disorder, and prescription of other potentially heptatotoxic medications with the composite endpoint of LEE, TBE, and DILI.

RESULTS

Of 666 patients prescribed BUP, 36% were HIV-infected, 98% were male, 60% had RNA-confirmed HCV infection, 50% had a recent diagnosis of alcohol use disorder, and 64% were prescribed other potentially hepatotoxic medications. No clinically significant changes were observed in median ALT, AST and TB and these changes did not differ between HIV-infected and uninfected patients. Compared with uninfected patients, HIV-infected (OR 7.3, 95% CI 2.1-26.1, p=0.002), HCV-infected (OR 4.9 95% CI 1.6-15.2, p=0.007) or HIV/HCV co-infected patients (OR 6.9, 95%CI 2.1-22.2, p=0.001) were more likely to have the composite endpoint of LEE, TB elevation or DILI, in analyses that excluded 60 patients with evidence of pre-existing liver injury. 31 patients had LEE, 14/187 HIV-infected and 17/340 uninfected (p=0.25); 11 had TBE, including 9/186 HIV-infected and 2/329 uninfected (p=0.002); 8 experienced DILI, 4/202 HIV-infected and 4/204 uninfected (p=0.45). There were no significant associations with alcohol use disorder or prescription of other potentially hepatotoxic medications after adjustment for HIV/HCV status.

CONCLUSIONS

Liver enzymes and TB are rarely elevated in HIV-infected and uninfected patients receiving BUP. Risk of hepatotoxicity was greater in individuals infected with HIV, HCV, or HIV/HCV co-infection, who may benefit from increased monitoring.

Management of problematic behaviours among individuals on long-term opioid therapy: protocol for a Delphi study

INTRODUCTION

Given the sharp rise in opioid prescribing and heightened recognition of opioid addiction and overdose, opioid safety has become a priority. Clinical guidelines on long-term opioid therapy (LTOT) for chronic pain consistently recommend routine monitoring and screening for problematic behaviours. Yet, there is no consensus definition regarding what constitutes a problematic behaviour, and recommendations for appropriate management to inform front-line providers, researchers and policymakers are lacking. This creates a barrier to effective guideline implementation. Thus, our objective is to present the protocol for a Delphi study designed to: (1) elicit expert opinion to identify the most important problematic behaviours seen in clinical practice and (2) develop consensus on how these behaviours should be managed in the context of routine clinical care.

METHODS/ANALYSIS

We will include clinical experts, defined as individuals who provide direct patient care to adults with chronic pain who are on LTOT in an ambulatory setting, and for whom opioid prescribing for chronic non-malignant pain is an area of expertise. The Delphi study will be conducted online in 4 consecutive rounds. Participants will be asked to list problematic behaviours and identify which behaviours are most common and challenging. They will then describe how they would manage the most frequently occurring common and challenging behaviours, rating the importance of each management strategy. Qualitative analysis will be used to categorise behaviours and management strategies, and consensus will be based on a definition established a priori.

ETHICS/DISSEMINATION

This study has been approved by the Institutional Review Board (IRB) of the University of Alabama at Birmingham (UAB). This study will generate Delphi-based expert consensus on the management of problematic behaviours that arise in individuals on LTOT, which we will publish and disseminate to appropriate professional societies. Ultimately, our findings will provide guidance to front-line providers, researchers and policymakers.

The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality

PURPOSE

For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality.

METHODS

Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality.

RESULTS

Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67).

CONCLUSIONS

Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.

Risk of mortality and physiologic injury evident with lower alcohol exposure among HIV infected compared with uninfected men

BACKGROUND

HIV infected (HIV+) individuals may be more susceptible to alcohol-related harm than uninfected individuals.

METHODS

We analyzed data on HIV+ and uninfected individuals in the Veterans Aging Cohort Study (VACS) with an Alcohol Use Disorders Identification Test-Consumption AUDIT-C score from 2008 to 2012. We used Cox proportional hazards models to examine the association between alcohol exposure and mortality through July, 2014; and linear regression models to assess the association between alcohol exposure and physiologic injury based on VACS Index Scores. Models were adjusted for age, race/ethnicity, smoking, and hepatitis C infection.

RESULTS

The sample included 18,145 HIV+ and 42,228 uninfected individuals. Among HIV+ individuals, 76% had undetectable HIV-1 RNA (<500 copies/ml). The threshold for an association of alcohol use with mortality and physiologic injury differed by HIV status. Among HIV+ individuals, AUDIT-C score ≥4 (hazard ratio [HR] 1.25, 95% CI 1.09-1.44) and ≥30 drinks per month (HR, 1.30, 95% CI 1.14-1.50) were associated with increased risk of mortality. Among uninfected individuals, AUDIT-C score ≥5 (HR, 1.19, 95% CI 1.07-1.32) and ≥70 drinks per month (HR 1.13, 95% CI 1.00-1.28) were associated with increased risk. Similarly, AUDIT-C threshold scores of 5-7 were associated with physiologic injury among HIV+ individuals (beta 0.47, 95% CI 0.22, 0.73) and a score of 8 or more was associated with injury in uninfected (beta 0.29, 95% CI 0.16, 0.42) individuals.

CONCLUSIONS

Despite antiretroviral therapy, HIV+ individuals experienced increased mortality and physiologic injury at lower levels of alcohol use compared with uninfected individuals. Alcohol consumption limits should be lower among HIV+ individuals.

Stigma, substance use and sexual risk behaviors among HIV-infected men who have sex with men: A qualitative study

Background

Public health HIV-service providers, including Medical Case Managers (case managers) and Disease Intervention Specialists (DIS) have a key role to play in identifying and addressing clients' complex mental health needs and substance use which contribute to sexual risk behaviors, yet their understanding and its consensus with HIV-infected men who have sex with men (MSM) have not been well characterized.

Methods

Together with an AIDS Service Organization and the Connecticut State Department of Public Health in 2011–2012, we conducted a focus group of case managers (n = 14) and interviewed DIS (n = 7) and HIV-infected MSM (n = 17) in Connecticut. We used the constant comparison method, grounded theory, and a community-based participatory approach to guide analysis.

Results

We identified three themes characterizing public health HIV-service providers' and MSM's perspectives regarding factors contributing to substance use and sexual risk behaviors in the context of HIV infection: 1) While both MSM and providers described a co-occurrence of HIV, stigma, substance use, and sexual risk behaviors, only MSM identified a causal relationship between these factors; 2) MSM and providers both described varying levels of self-efficacy in readiness to decrease substance use and sexual risk behaviors among MSM; both identified the social network as the key barrier to overcome; 3) Providers described how the co-occurrence of HIV, stigma and sexual risk behaviors leads to multi-faceted client needs for which they lacked sufficient training and collaboration.

Conclusions

Provider education, skills-based training, and interventions targeting social networks may decrease sexual risk behaviors among HIV-infected MSM.

•

MSM recognize that HIV diagnosis may trigger substance use and sexual risk behaviors.

•

HIV-service providers inconsistently prepared to facilitate behavior change among MSM

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Need social network-based interventions to decrease MSM's risk behaviors

•

Provider training on interventions & stages of change theory to address risk behaviors warranted

Trends in Any and High-Dose Opioid Analgesic Receipt Among Aging Patients With and Without HIV

Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and older age, are increasingly recognized. However, trends in opioid receipt among HIV-infected patients are not well characterized. We examined trends, from 1999 to 2010, in any and high-dose (≥120 mg/day) opioid receipt among patients with and without HIV, by age strata, controlling for demographic and clinical correlates. Of 127,216 patients, 64 % received at least one opioid prescription. Opioid receipt increased substantially among HIV-infected and uninfected patients over the study; high-dose therapy was more prevalent among HIV-infected patients. Trends in high-dose receipt stratified by three age groups revealed an increasing trend in each age strata, higher among HIV-infected patients. Correlates of any opioid receipt included HIV, PTSD and major depression. Correlates of high-dose receipt included HIV, PTSD, major depression and drug use disorders. These findings suggest a need for appropriate balance of risks and benefits, especially as these populations age.

Implementation of integrated stepped care for unhealthy alcohol use in HIV clinics

Background

Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists.

Methods

We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes.

Results

From the providers’ perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention.

Conclusions

Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).

In the Clinic. Alcohol Use

This issue provides a clinical overview of alcohol use, focusing on health benefits, harms, prevention, screening, diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

The epidemiology of substance use disorders in US Veterans: A systematic review and analysis of assessment methods

BACKGROUND

Substance use disorders (SUDs), which encompass alcohol and drug use disorders (AUDs, DUDs), constitute a major public health challenge among US veterans. SUDs are among the most common and costly of all health conditions among veterans.

OBJECTIVES

This study sought to examine the epidemiology of SUDs among US veterans, compare the prevalence of SUDs in studies using diagnostic and administrative criteria assessment methods, and summarize trends in the prevalence of SUDs reported in studies sampling US veterans over time.

METHODS

Comprehensive electronic database searches were conducted. A total of 3,490 studies were identified. We analyzed studies sampling US veterans and reporting prevalence, distribution, and examining AUDs and DUDs.

RESULTS

Of the studies identified, 72 met inclusion criteria. The studies were published between 1995 and 2013. Studies using diagnostic criteria reported higher prevalence of AUDs (32% vs. 10%) and DUDs (20% vs. 5%) than administrative criteria, respectively. Regardless of assessment method, both the lifetime and past year prevalence of AUDs in studies sampling US veterans has declined gradually over time.

CONCLUSION

The prevalence of SUDs reported in studies sampling US veterans are affected by assessment method. Given the significant public health problems of SUDs among US veterans, improved guidelines for clinical screening using validated diagnostic criteria to assess AUDs and DUDs in US veteran populations are needed.

SCIENTIFIC SIGNIFICANCE

These findings may inform VA and other healthcare systems in prevention, diagnosis, and intervention for SUDs among US veterans.

Impact of defined clinical population and missing data on temporal trends in HIV viral load estimation within a health care system

OBJECTIVES

Community viral load (CVL) estimates vary based on analytic methods. We extended the CVL concept and used data from the Veterans Health Administration (VA) to determine trends in the health care system viral load (HSVL) and its sensitivity to varying definitions of the clinical population and assumptions regarding missing data.

METHODS

We included HIV-infected patients in the Veterans Aging Cohort Study, 2000-2010, with at least one documented CD4 count, HIV-1 RNA or antiretroviral prescription (n = 37 318). We created 6-month intervals including patients with at least one visit in the past 2 years. We assessed temporal trends in clinical population size, patient clinical status and mean HSVL and explored the impact of varying definitions of the clinical population and assumptions about missing viral load.

RESULTS

The clinical population size varied by definition, increasing from 16 000-19 000 patients in 2000 to 23 000-26 000 in 2010. The proportion of patients with suppressed HIV-1 RNA increased over time. Over 20% of patients had no viral load measured in a given interval or the past 2 years. Among patients with a current HIV-1 RNA, mean HSVL decreased from 97 800 HIV-1 RNA copies/mL in 2000 to 2000 copies/mL in 2010. When current HIV-1 RNA data were unavailable and the HSVL was recalculated using the last available HIV-1 RNA, HSVL decreased from 322 300 to 9900 copies/mL. HSVL was underestimated when using only current data in each interval.

CONCLUSIONS

The CVL concept can be applied to a health care system, providing a measure of health care quality. Like CVL, HSVL estimates depend on definitions of the clinical population and assumptions about missing data.

Heroin Use and HIV Disease Progression: Results from a Pilot Study of a Russian Cohort

Opioids have immunosuppressive properties, yet their impact on HIV disease progression remains unclear. Using longitudinal data from HIV-infected antiretroviral therapy-naïve Russian individuals (n = 77), we conducted a pilot study to estimate the effect of heroin use on HIV disease progression. Heroin use was categorized based on past 30 days self-reported use at baseline, 6 and 12 months as none, intermittent or persistent. We estimated the effect of heroin use on HIV disease progression, measured as change in CD4 count from baseline to 12 months, using multivariable linear regression. Those with intermittent (n = 21) and no heroin use (n = 39) experienced mean decreases in CD4 count from baseline to 12 months (-103 and -10 cells/mm(3), respectively; adjusted mean difference (AMD) -93; 95 % CI -245, 58). Those with persistent use (n = 17) showed a mean increase of 53 cells/mm(3) (AMD 63; 95 % CI -95, 220). Future studies exploring the effects of heroin withdrawal on HIV disease progression are warranted.

Drinking trajectories among HIV-infected men who have sex with men: a cohort study of United States veterans

BACKGROUND

Although high rates of alcohol consumption and related problems have been observed among HIV-infected men who have sex with men (MSM), little is known about the long-term patterns of and factors associated with hazardous alcohol use in this population. We sought to identify alcohol use trajectories and correlates of hazardous alcohol use among HIV-infected MSM.

METHODS

Sexually active, HIV-infected MSM participating in the Veterans Aging Cohort Study were eligible for inclusion. Participants were recruited from VA infectious disease clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh, and Washington, DC. Data from annual self-reported assessments and group-based trajectory models were used to identify distinct alcohol use trajectories over an eight-year study period (2002-2010). We then used generalized estimate equations (GEE) to examine longitudinal correlates of hazardous alcohol use (defined as an AUDIT-C score ≥4).

RESULTS

Among 1065 participants, the mean age was 45.5 (SD=9.2) and 606 (58.2%) were African American. Baseline hazardous alcohol use was reported by 309 (29.3%). Group-based trajectory modeling revealed a distinct group (12.5% of the sample) with consistently hazardous alcohol use, characterized by a mean AUDIT-C score of >5 at every time point. In a GEE-based multivariable model, hazardous alcohol use was associated with earning <$6000 annually, having an alcohol-related diagnosis, using cannabis, and using cocaine.

CONCLUSIONS

More than 1 in 10 HIV-infected MSM US veterans reported consistent, long-term hazardous alcohol use. Financial insecurity and concurrent substance use were predictors of consistently hazardous alcohol use, and may be modifiable targets for intervention.

Incarceration and health outcomes in HIV-infected patients: the impact of substance use, primary care engagement, and antiretroviral adherence

BACKGROUND AND OBJECTIVES

One in seven HIV-infected individuals is incarcerated each year. We used data from the Veterans Aging Cohort Study (VACS) to explore the relationship between incarceration and HIV disease outcomes and evaluate potential mediators of this relationship.

METHODS

HIV disease outcomes included: low CD4 counts (<200 cells/mL), detectable viral RNA loads (>500 copies/mL), and the VACS Index score. We performed a mediation analysis among 1,591 HIV-infected patients to examine whether unhealthy alcohol use, drug use, primary care engagement, or antiretroviral adherence mediated observed associations.

RESULTS

Among 1,591 HIV-infected patients, 47% reported having a history of incarceration. In multivariate analyses, a history of incarceration was associated with a higher VACS Index score (β 2.47, 95% CI 0.52-4.43). Mediation analysis revealed that recent drug use attenuated the association by 22% (β 1.93, 95% CI -0.06, 3.91) while other proposed mediators did not.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Improving access to drug treatment when incarcerated and upon release may be an important target to improving the health of HIV-infected individuals with a history of incarceration. (Am J Addict 2015;24:178-184).

Sexual partner notification of HIV infection among a National United States-based sample of HIV-infected men

Limited data exist on whether sexual partner notification practices among HIV-infected men, particularly those who have sex with men (MSM), vary by HIV viral load. We examined factors associated with complete (all partners) versus incomplete partner notification in 760 HIV-infected individuals across the United States, 49 % of whom were MSM. Thirty-four percent reported incomplete partner notification. Incomplete partner notification was more likely among black men, MSM, and those reporting casual partners and non-condom use. Partner notification practices did not vary by HIV viral load except among those with casual partners in whom a detectable viral load was associated with incomplete partner notification. Increased sexual partner notification among HIV-infected men, especially MSM, is needed.

Opportunities for improving partner notification for HIV: results from a community-based participatory research study

To identify actionable opportunities for improving Partner Notification (PN) for HIV among men who have sex with men (MSM), we characterized the perspectives and experiences of PN among Medical Case Managers (case managers), Disease Intervention Specialists (DIS), and MSM. In partnership with an AIDS service organization and the Connecticut State Health Department, we conducted a focus group of case managers (n = 14) and in-depth interviews with DIS (n = 7) and MSM (n = 24). We found differences between MSM's and providers' (case managers and DIS) perspectives regarding (1) determinants of sexual risk behaviors; (2) considerations impacting HIV disclosure; and (3) barriers to trusting relationships between MSM and providers. Factors impacting MSM perspectives on PN were incompletely appreciated by both case managers and DIS. PN may be improved through improving provider understanding of the complexities for MSM regarding sexual risk behaviors and disclosure and transcending barriers to trusting relationships between MSM and providers.

Guideline-concordant management of opioid therapy among human immunodeficiency virus (HIV)-infected and uninfected veterans

Whether patients receive guideline-concordant opioid therapy (OT) is largely unknown and may vary based on provider and patient characteristics. We assessed the extent to which human immunodeficiency virus (HIV)-infected and uninfected patients initiating long-term (≥ 90 days) OT received care concordant with American Pain Society/American Academy of Pain Medicine and Department of Veterans Affairs/Department of Defense guidelines by measuring receipt of 17 indicators during the first 6 months of OT. Of 20,753 patients, HIV-infected patients (n = 6,604) were more likely than uninfected patients to receive a primary care provider visit within 1 month (52.0% vs 30.9%) and 6 months (90.7% vs 73.7%) and urine drug tests within 1 month (14.8% vs 11.5%) and 6 months (19.5% vs 15.4%; all P < .001). HIV-infected patients were also more likely to receive OT concurrent with sedatives (24.6% vs 19.6%) and a current substance use disorder (21.6% vs 17.2%). Among both patient groups, only modest changes in guideline concordance were observed over time: urine drug tests and OT concurrent with current substance use disorders increased, whereas sedative coprescriptions decreased (all Ps for trend < .001). Over a 10-year period, on average, patients received no more than 40% of recommended care. OT guideline-concordant care is rare in primary care, varies by patient/provider characteristics, and has undergone few changes over time.

PERSPECTIVE

The promulgation of OT clinical guidelines has not resulted in substantive changes over time in OT management, which falls well short of the standard recommended by leading medical societies. Strategies are needed to increase the provision of OT guideline-concordant care for all patients.

The impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected, opioid-dependent patients

BACKGROUND

Opioid dependence is a major risk factor for HIV infection, however, the impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected opioid-dependent patients is unknown.

METHODS

We conducted a longitudinal analysis of 303 HIV-infected opioid-dependent patients initiating buprenorphine/naloxone treatment. Outcomes included self-reported past 90-day needle-sharing and non-condom use. We assessed trends over the 12 months using the Cochran-Armitage trend test. Using generalized estimating equations, after multiple imputation, we determined factors independently associated with needle-sharing and non-condom use, including time-updated variables. We then conducted a mediation analysis to determine whether substance use explained the relationship between time since treatment initiation and needle-sharing.

RESULTS

Needle-sharing decreased from baseline to the fourth quarter following initiation of buprenorphine/naloxone (9% vs. 3%, p<0.001), while non-condom use did not (23% vs. 21%, p=0.10). HIV risk behaviors did not vary based on the presence of a detectable HIV-1 RNA viral load. Patients who were homeless and used heroin, cocaine/amphetamines or marijuana were more likely to report needle-sharing. Heroin use fully mediated the relationship between time since treatment initiation and needle-sharing. Women, patients who identified as being gay/lesbian/bisexual, those married or living with a partner and who reported heroin or alcohol use were more likely to report non-condom use. Older patients were less likely to report non-condom use.

CONCLUSIONS

While buprenorphine/naloxone is associated with decreased needle-sharing among HIV-infected opioid-dependent patients, sexual risk behaviors persist regardless of viral load. Targeted interventions to address HIV risk behaviors among HIV-infected opioid-dependent populations receiving buprenorphine/naloxone are needed.

HIV testing and sexual risk reduction counseling in office-based buprenorphine/naloxone treatment

OBJECTIVES

We assessed the feasibility and preliminary efficacy of human immunodeficiency virus (HIV) testing with sexual risk reduction counseling for opioid-dependent patients initiating office-based buprenorphine/naloxone treatment.

METHODS

We conducted a 14-week randomized, controlled trial with 30 patients (original target of 114) assigned to receive buprenorphine/naloxone induction/stabilization and HIV testing with Brief Sexual Risk Management (BSRM) or Enhanced Sexual Risk Management (ESRM). We evaluated process measures and compared outcomes at baseline and during the 3-month follow-up.

RESULTS

Similar proportions of patients receiving BSRM and ESRM underwent HIV testing (93% vs 80%; P = 0.28) and completed counseling sessions (80% vs 67%; P = 0.40). Brief Sexual Risk Management sessions were shorter than ESRM sessions (15.4 vs 23.4 minutes), with comparable manual adherence (P = 0.80). Outcomes did not vary by BSRM versus ESRM.

CONCLUSIONS

Although the recruitment of opioid-dependent patients with sexual risk behaviors is challenging, HIV testing with sexual risk reduction counseling in office-based buprenorphine/naloxone treatment practice is feasible. Interventions to decrease sexual risk behaviors among a segment of this population are necessary.

The use of message framing to promote sexual risk reduction in young adolescents: a pilot exploratory study

Few studies have explored the application of message framing to promote health behaviors in adolescents. In this exploratory study, we examined young adolescents' selection of gain- versus loss-framed images and messages when designing an HIV-prevention intervention to promote delayed sexual initiation. Twenty-six adolescents (aged 10-14 years) participated in six focus groups and created and discussed posters to persuade their peers to delay the initiation of sexual activity. Focus groups were audio-recorded and transcribed. A five-person multidisciplinary team analyzed the posters and focus group transcripts using thematic analysis. The majority of the posters (18/26, 69%) contained both gain- and loss-framed content. Of the 93/170 (56%) images and messages with framing, similar proportions were gain- (48/93, 52%) and loss-framed (45/93, 48%). Most gain-framed content (23/48, 48%) focused on academic achievement, whereas loss-framed content focused on pregnancy (20/45, 44%) and HIV/AIDS (14/45, 31%). These preliminary data suggest that young adolescents may prefer a combination of gain- and loss-framing in health materials to promote reduction in sexual risk behaviors.