Substance use and HIV disease progression in the HAART era: implications for the primary prevention of HIV

HIV treatment as prevention among people who inject drugs - a re-evaluation of the evidence

Background

Population-level associations between community measures of HIV viral load and HIV incidence have been interpreted as evidence for HIV anti-retroviral treatment (ART) as prevention among people who inject drugs (PWID). However, investigation of concurrent HCV and HIV incidence trends allows examination of alternative explanations for the fall in HIV incidence. We estimate the contribution of ART and reductions in injecting risk for reducing HIV incidence in Vancouver between 1996 and 2007.

Methods

A deterministic model of HIV and HCV transmission among PWID was calibrated to the baseline (1996) HIV and HCV epidemic among PWID in Vancouver. While incorporating parameter uncertainty, the model projected what levels of ART protection and decreases in injecting risk could reproduce the observed reduction in HIV and HCV incidence for 1996-2007, and so what impact would have been achieved with just ART or just reductions in injecting risk.

Results

Model predictions suggest the estimated reduction (84%) in HCV incidence for 1996-2007 required a 59% (2.5-97.5 percentile range 49-76%) reduction in injecting risk, which accounted for nine-tenths of the observed decrease in HIV incidence; the remainder was achieved with a moderate ART efficacy for reducing sexual HIV infectivity (70%, 51-89%) and an uncertain ART efficacy for reducing injection-related HIV infectivity (44%, 0-96%). Despite this uncertainty, projections suggest that the decrease in injecting risk reduced HIV incidence by 76% (63-85%) and ART further reduced HIV incidence by 8% (2-19%), or on its own by 3% (-34-37%).

Conclusions

Observed declines in HIV incidence in Vancouver between 1996 and 2007 should be seen as a success for intensive harm reduction, whereas ART probably played a small role.

Substance-associated elevations in monocyte activation among methamphetamine users with treated HIV infection

OBJECTIVE

Microbial translocation and monocyte activation predict mortality in treated HIV. We examined whether substance use independently contributes to these pathophysiologic processes.

DESIGN

Cross-sectional study at baseline for a randomized controlled trial.

METHODS

HIV-positive, methamphetamine-using MSM with undetectable HIV viral load (less than 40 copies/ml) were enrolled. We examined if plasma biomarkers of monocyte activation and intestinal barrier integrity were associated with the following: reactive urine toxicology results (Tox+) for stimulants (i.e., methamphetamine or cocaine) and substance use severity measured by the Addiction Severity Index. Multiple linear regression models adjusted for age, antiretroviral therapy regimen, CD4 T-cell count, interleukin-6, and alcohol use severity.

RESULTS

The sample of 84 virally suppressed MSM had a median CD4 T-cell count of 645 cells/μl. Those who were Tox+ for stimulants displayed higher soluble CD14 (sCD14) levels (2087 versus 1801 ng/ml; P = 0.009), and this difference remained significant after adjusting for covariates (standardized beta = 0.23, P = 0.026). Greater substance use severity was also independently associated with higher sCD14 after adjusting for covariates (standardized beta = 0.29, P = 0.013). Being Tox+ for stimulants and substance use severity were not associated with soluble CD163 (sCD163) or intestinal fatty acid binding protein (iFABP) levels (P > 0.05).

CONCLUSIONS

Monocyte activation is one plausible mechanism by which stimulant use may increase clinical HIV progression.

Substance Use, Violence, and Antiretroviral Adherence: A Latent Class Analysis of Women Living with HIV in Canada

We used latent class analysis to identify substance use patterns for 1363 women living with HIV in Canada and assessed associations with socio-economic marginalization, violence, and sub-optimal adherence to combination antiretroviral therapy (cART). A six-class model was identified consisting of: abstainers (26.3%), Tobacco Users (8.81%), Alcohol Users (31.9%), 'Socially Acceptable' Poly-substance Users (13.9%), Illicit Poly-substance Users (9.81%) and Illicit Poly-substance Users of All Types (9.27%). Multinomial logistic regression showed that women experiencing recent violence had significantly higher odds of membership in all substance use latent classes, relative to Abstainers, while those reporting sub-optimal cART adherence had higher odds of being members of the poly-substance use classes only. Factors significantly associated with Illicit Poly-substance Users of All Types were sexual minority status, lower income, and lower resiliency. Findings underline a need for increased social and structural supports for women who use substances to support them in leading safe and healthy lives with HIV.

Correlates of Self-Reported Viral Suppression Among HIV-Positive, Young, Black Men Who Have Sex With Men Participating in a Randomized Controlled Trial of An Internet-Based HIV Prevention Intervention

BACKGROUND

Young, black men who have sex with men are disproportionately impacted by the US HIV epidemic, and HIV-positive, young, black men who have sex with men face stark disparities in HIV clinical outcomes.

METHODS

We performed an observational analysis of the 199 HIV-positive black men aged 18 to 30 years followed up for 12 months in healthMpowerment, a randomized controlled trial of an Internet-based HIV prevention intervention, to identify time-varying correlates of self-reported viral suppression using relative risk (RR) regression.

RESULTS

Retention at the 12-month visit was 84%. One hundred five (65%) of 162 participants reported being undetectable at baseline. At 3, 6, and 12 months, 83 (72%) of 115, 84 (82%) of 103, and 101 (86%) of 117 reported an undetectable viral load, respectively. In a multivariable model, participants who reported homelessness (RR, 0.85; 95% confidence interval [CI], 0.72-0.99), who had clinically significant depressive symptoms (RR, 0.88; 95% CI, 0.79-0.98), and who used methamphetamine or crack (RR, 0.61; 95% CI, 0.38-0.96) were less likely to report an undetectable viral load. Young men who engaged in condomless insertive anal intercourse were more likely to report viral suppression (RR, 1.14; 95% CI, 1.04-1.24).

CONCLUSION

HIV care for young, black men who have sex with men must be multidimensional to address medical needs in the context of mental health, substance use, and housing insecurity.

Role of substance use in HIV care cascade outcomes among people who inject drugs in Russia

Background

Engaging people who drink alcohol or inject drugs in HIV care can be challenging, particularly in Eastern Europe. Healthcare facilities in Russia are organized by specialty; therefore linking patients from addiction care to HIV hospitals has been difficult. The HIV care cascade outlines stages of HIV care (e.g., linkage to care, prescribed antiretroviral therapy [ART], and achieving HIV viral suppression). We hypothesized that unhealthy alcohol use, injection drug use, and opioid craving are associated with unfavorable HIV care cascade outcomes.

Methods

We analyzed data from a cohort (n = 249) of HIV-positive Russians who have been in addiction hospital treatment in the past year and had a lifetime history of injection drug use (IDU). We evaluated the association between unhealthy alcohol use (AUDIT score > 7 [both hazardous drinking and dependence]), past-month injection drug use (IDU), and opioid craving (visual analogue scale from 1 to 100) with HIV care cascade outcomes. The primary outcome was linkage to HIV care within 12 months. Other outcomes were prescription of ART (secondary) and achievement of undetectable HIV viral load (HVL < 500 copies/mL) within 12 months (exploratory); the latter was analyzed on a subset in which HVL was measured (n = 48). We assessed outcomes via medical record review (linkage, ART) and serum tests (HVL). To examine the primary outcome, we used multiple logistic regression models controlling for potential confounders.

Results

Among 249 study participants, unhealthy alcohol use (n = 148 [59%]) and past-month IDU (n = 130 [52%]) were common. The mean opioid craving score was 49 (SD: 38). We were unable to detect significant associations between the independent variables (i.e., unhealthy alcohol use, IDU and opioid craving) and any HIV care cascade outcomes in unadjusted and adjusted analyses.

Conclusion

In this cohort of HIV-positive Russians with a history of IDU, individual substance use factors were not significantly associated with achieving HIV care cascade milestones (i.e., linkage to HIV care; prescription for ART; or suppressed viral load). Given no detection of an association of cascade outcomes with recent unhealthy use of alcohol or injection drugs in this cohort, examining systemic factors to understand determinants of HIV care engagement for people with drug use would be important.

Alcohol and substance use diagnoses among HIV-positive patients receiving care in NYC clinic settings

BACKGROUND

Substance use among HIV-positive persons exacerbates health problems. This study sought to estimate the prevalence of alcohol and drug-use diagnoses and examined hypothesized predictors associated with alcohol and drug-use diagnoses among HIV-positive patients in New York City (NYC).

METHODS

This cohort study reviewed electronic medical records (EMRs) of 4965 HIV-positive patients based on diagnostic codes. These patients attended a comprehensive care clinic in NYC in 2012. Multinomial logistic regression was used to predict the odds of classification into substance use diagnosis grouping.

RESULTS

Of the full sample, only 12.7% of patients had an alcohol use diagnosis documented in their EMR compared with more than one-quarter (26.4%) of patients having a recorded drug use diagnosis (p<0.001). Compared with the No Alcohol or Drugs group, the regression model showed that older age and having a recent inpatient hospital stay independently predicted being in the Alcohol Only group; years living with HIV, having an unsuppressed viral load, and having a recent inpatient hospital stay were associated with higher odds of being in the Drugs Only and Alcohol and Drugs groups; and being women and men who have sex with men (MSM) were associated with decreased odds of being in the Drugs Only and Alcohol and Drugs groups.

CONCLUSIONS

Substance use diagnosis was associated with viremia and low CD4 counts and hospital stays. This implies that providers should screen for substance use in HIV-positive patients with poor health. Further examination of the extent of such comorbidity is instrumental for intervention efforts.

HIV treatment cascade among female entertainment and sex workers in Cambodia: impact of amphetamine use and an HIV prevention program

BACKGROUND

HIV prevalence remains high in Cambodia among female entertainment and sex workers (FESW), and amphetamine-type stimulant (ATS) use significantly increases risk of infection. A successful continuum of care (CoC) is key to effective clinical care and prevention. This study aimed to describe the HIV CoC in HIV-positive FESW. We examined CoC outcomes among HIV-positive FESW participating in the Cambodia Integrated HIV and Drug Prevention Implementation (CIPI) study, being implemented in ten provinces. CIPI is a trial aimed at reducing ATS use concomitant with the SMARTgirl HIV prevention program.

METHODS

From 2013 to 2016, 1198 FESW ≥ 18 years old who reported multiple sex partners and/or transactional sex were recruited. We identified 88 HIV-positive women at baseline. We described linkage to care as 12-month retention and viral suppression (<1000 copies/mL). Logistic regression analyses were conducted to examine correlates of retention in care at 12 months, and viral suppression.

RESULTS

Median age of the 88 HIV-positive women was 32 years [interquartile range (IQR) 28, 35]; 50% were working in entertainment venues and 50% as freelance sex workers; 70% reported SMARTgirl membership. In the past 3 months, women reported a median of 15 sex partners, 38% reported unprotected sex, and 55% reported using ATS. Overall, 88% were receiving HIV care, 83% were on antiretroviral therapy, 39% were retained in care at 12 months, and 23% were virally suppressed. SMARTgirl membership was independently associated with fourfold greater odds of 12-month retention in care (AOR = 4.16, 95% CI 1.38, 12.56). Those at high risk for an ATS use disorder had 91% lower odds of 12-month retention in care (AOR = 0.09, 95% CI 0.01, 0.72). Viral suppression was independently associated with SMARTgirl membership, older age, reporting of STI symptoms, worse symptoms of psychological distress, and greater numbers of sex partners.

CONCLUSIONS

This is the first study to characterize the HIV CoC in Cambodian FESW. While most women were successfully linked to HIV care, retention and viral suppression were low. Tailored programs like SMARTgirl, targeting the broader population of HIV-positive FESW as well as interventions to reduce ATS use could optimize the clinical and population health benefits of HIV treatment. Trial registration This work reports data collected as part of a trial: NCT01835574. This work does not present trial results.

Cocaine dependence modulates the effect of HIV infection on brain activation during intertemporal decision making

BACKGROUND

Both HIV infection and chronic cocaine use alter the neural circuitry of decision making, but the interactive effects of these commonly comorbid conditions have not been adequately examined. This study tested how cocaine moderates HIV-related neural activation during an intertemporal decision-making task.

METHODS

The sample included 73 participants who differed on cocaine and HIV status (18 COC+/HIV+, 19 COC+/HIV-, 19 COC-/HIV+, 17 COC-/HIV-). Participants made choices between smaller, sooner and larger, delayed rewards while undergoing functional MRI. Choices varied in difficulty based on subjective value: hard (equivalently valued), easy (disparately valued), and control choices. A mixed-effects model controlling for education and smoking identified main and interactive effects of HIV and COC during hard relative to easy choices (difficulty contrast).

RESULTS

COC+ status was associated with lower activation in bilateral frontal gyri and right insular and posterior parietal cortices. HIV+ status was associated with higher activation in the visual cortex, but lower activation in bilateral prefrontal cortices and cerebellum and left posterior parietal cortex. COC moderated the effects of HIV in several clusters centered in the bilateral prefrontal cortices and cerebellum. In post-hoc analyses, there were significant effects of HIV status on activation for COC+, but not COC-, participants; interaction effects remained after controlling for polysubstance use.

CONCLUSION

Cocaine use may diminish the compensatory neural activation often seen among HIV+ samples during decision making. Our results highlight the importance of examining the neuropsychiatric effects of comorbid medical conditions to identify potential neural targets for cognitive remediation interventions.

Predicting health-related quality of life in people living with HIV in Nepal: mental health disorders and substance use determinants

HIV-positive people often experience mental health disorders and engage in substance use. Such conditions tend to impair their health-related quality of life (QOL). Evidence, however, is limited about the influence of mental health disorders and substance use on QOL by gender. Also, little is known about the influences of anxiety and high levels of stress on QOL. We recruited 682 HIV-positive people in Nepal and measured their depression, anxiety, stress levels, substance use, and QOL. Multiple linear regressions assessed the association of mental health disorders and substance use with QOL. Presence of depressive symptoms was negatively associated with all domains of QOL including the physical (men: β = -0.68, p = 0.037; women: β = -1.37, p < 0.001) and the psychological (men: β = -1.08, p <  0.001; women: β = -1.13, p <  0.001). Those who experienced anxiety had lower scores in the physical (β = -0.89, p = 0.027) and psychological (β = -1.75, p = 0.018) QOL domains among men and in the spiritual QOL domain (β = -0.061, p = 0.043) among women. High stress levels were associated with lower scores across all QOL domains including the physical (men: β = -0.16, p < 0.001; women: β = -0.14, p <  0.001) and the psychological (men: β = -0.09, p < 0.001; women: β = -0.10, p < 0.001). Substance-using men were more likely to have lower scores in physical (β = -0.70, p = 0.039) and psychological (β = -0.073, p = 0.002) domains. Among women, meanwhile, substance use was negatively associated with the psychological domain only (β = -0.77, p = 0.005). In conclusion, mental health disorders and substance use had negative associations with QOL. Attention should be given to addressing the mental health care needs of HIV-positive people to improve their QOL.

HIV-infected individuals who use alcohol and other drugs, and virologic suppression

People living with HIV (PLWH) on antiretroviral therapy (ART) who use substances were examined to (a) describe those with virologic control and (b) determine which substance use-factors are associated with lack of virologic control. Participants were adult PLWH taking ART with either past 12-month DSM-IV substance dependence or past 30-day alcohol or illicit drug use. Substance use factors included number of DSM-IV alcohol or drug dependence criteria and past 30-day specific substance use. Associations with HIV viral load (HVL) (<200 vs. ≥200 copies/mL) were tested using logistic regression models. Multivariable analyses adjusted for age, sex, homelessness and anxiety or depression. Participants (n = 202) were median age 50 years, 66% male, 51% African American and 75% self-reported ≥90% past 30-day ART adherence. Though HVL suppression (HVL <200 copies/mL) was achieved in 78% (158/202), past 30-day substance use was common among this group: 77% cigarette use; 51% heavy alcohol use; 50% marijuana; 27% cocaine; 16% heroin; and 15% illicit prescription opioid use. After adjusting for covariates, specific substance use was not associated with a detectable HVL, however number of past 12-month DSM-IV drug dependence criteria was (adjusted odds ratio = 1.23 for each additional criterion, 95% CI: 1.04-1.46). Three-quarters of a substance-using cohort of PLWH receiving ART had virologic control and ≥90% ART adherence. Substance dependence criteria (particularly drug dependence), not specifically substance use, were associated with lack of virologic control. Optimal HIV outcomes can be achieved by individuals who use alcohol or drugs and addressing symptoms of substance dependence may improve HIV-related outcomes.

Impact of opioid substitution therapy on the HIV prevention benefit of antiretroviral therapy for people who inject drugs

OBJECTIVE

A recent meta-analysis suggested that opioid substitution therapy (OST) increased uptake of antiretroviral treatment (ART) and HIV viral suppression. We modelled whether OST could improve the HIV prevention benefit achieved by ART among people who inject drugs (PWID).

METHODS

We modelled how introducing OST could improve the coverage of ART across a PWID population for different baseline ART coverage levels. Using existing data on how yearly HIV-transmission risk is related to HIV plasma viral load, changes in the level of viral suppression across the population were used to project the relative reduction in yearly HIV-transmission risk achieved by ART, with or without OST, compared with if there was no ART - defined here as the prevention effectiveness of ART.

RESULTS

Owing to OST use increasing the chance of being on ART and achieving viral suppression if on ART, the prevention effectiveness of ART for PWID on OST (compared with PWID not on OST) increases by 44, 31, or 20% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively. Improvements in the population-level prevention effectiveness of ART are also achieved across all PWID, compared with if OST was not introduced. For instance, if OST is introduced at 40% coverage, the population-level prevention effectiveness of ART could increase by 27, 20, or 13% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively.

CONCLUSION

OST could improve the HIV prevention benefit of ART; supporting strategies that aim to concurrently scale-up OST with ART.

The association between symptoms of mental disorders and health risk behaviours in Vietnamese HIV positive outpatients: a cross-sectional study

Background

A high prevalence of symptoms of mental disorders (SOMD) has been found among people living with HIV/AIDS (PLHIV). Additionally, SOMD may impact on the prevalence of high-risk health behaviours (HRB). This study investigates the relationship between SOMD and HRB in a large sample of Vietnamese HIV positive outpatients.

Methods

A cross-sectional study was conducted with 400 outpatients at two HIV/AIDS clinics in Ho Chi Minh City, Vietnam, selected using a systematic sampling technique. Validated scales were used to measure SOMD, specifically symptoms of depression, anxiety, alcohol use disorder (AUD), substance use disorder (SUD) and HIV associated dementia (HAD). Participants completed a self-report questionnaire assessing HRB during the preceding 12 months including unsafe sexual practices and illicit drug use. Multivariable logistic regression models were used to evaluate associations between SOMD and HRB.

Results

The majority of participants (63.5%) were male and the median age was 34.0 years. Unsafe sexual practices and illicit drug use were reported by 13.8 and 5.5% of participants. The prevalences of HAD, depression, AUD, anxiety and SUD symptoms were 39.8, 36.5, 13.3 10.5, 3.3% respectively. There was no association between SOMD and HRB either with or without adjusting for correlates of HRB, except between symptoms of SUD and illicit drug use. PLHIV who had symptoms of SUD were more likely to use illicit drugs (adjusted Odds Ratio 81.14, 95% CI 12.55–524.47).

Conclusions

While the prevalence of SOMD among HIV positive outpatients was high, most SOMD were not associated with increased HRB. Only illicit drug use was predicted by symptoms of SUD. Screening PLHIV for symptoms of SUD may be useful for detecting people likely to be engaging in illicit drug use to reduce the risk of secondary disease transmission.

Preintervention Profiles of Information, Motivational, and Behavioral Self-Efficacy for Methamphetamine Use and HIV Medication Adherence Among Gay and Bisexual Men

Although rates of crystal methamphetamine use in the United States have fallen from their peak in the mid-2000s, use remains a major public health concern, which disproportionately affects gay and bisexual men (GBM). It poses a particular challenge for HIV-positive men, for whom it has been linked to medication adherence problems as well as compromised immune function. Although the information, motivation, and behavioral skills (IMB) model has been widely used to conceptualize health behavior, little is known about GBM's initial levels of information, motivation, and behavioral self-efficacy to improve HIV medication adherence and to reduce crystal methamphetamine use at the outset of treatment. The present study identified profiles of IMB factors related to HIV medication adherence and crystal methamphetamine use in a sample of 210 HIV-positive GBM who consented to participate in an intervention study. Results indicated three distinct patterns of IMB factors. The largest group was ready to change both adherence and methamphetamine use (n = 104). This group also had depression scores that were significantly lower than other groups. A second group appeared ready to change medication adherence, but was ambivalent about changing methamphetamine use (n = 60). This group reported significantly more symptoms of methamphetamine dependence than the other groups. A third group was characterized by global IMB barriers to change (n = 46). Results are discussed in the context of tailoring psychoeducation, motivational interviewing, and cognitive behavioral interventions to match these preintervention patterns of IMB factors.

Relationship-Based Predictors of Sexual Risk for HIV Among MSM Couples: A Systematic Review of the Literature

Behavioral and epidemiological studies report high risk for HIV among MSM couples. Over the last decade, studies have examined relationship dynamics associated with sexual risk for HIV. It is important to examine the impact this research has had on HIV prevention and what is still needed. We conducted a review of the literature focusing on relationship dynamics associated with sexual risk for HIV among MSM couples. Procedures used for this review were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses established to provide a framework for collecting, reviewing and reporting studies systematically (Mohler et al. in Ann Intern Med 151(4):264-269, 2009). We found that positive relationship dynamics are associated with less risk with partners outside the relationship, but were associated with greater odds of unprotected anal intercourse with primary partners. We also discuss other factors including sexual agreements about outside partners and make recommendations for next steps in HIV prevention research among MSM couples.

Methadone maintenance therapy and viral suppression among HIV-infected opioid users: The impacts of crack and injection cocaine use

BACKGROUND

Methadone maintenance therapy (MMT) is associated with improved HIV treatment outcomes among people who use drugs (PWUD). The extent to which these benefits are sustained in the context of ongoing cocaine use is unclear. We assessed differential impacts of MMT on HIV viral load (VL) suppression in relation to discrete patterns of cocaine use.

METHODS

Data was drawn from ACCESS, a prospective cohort of HIV-positive PWUD in Vancouver, Canada. Generalized linear mixed-effects were used to model the independent effect of MMT on VL suppression across strata of frequency of cocaine injection and crack smoking (≥daily versus <daily), after adjustment for confounders.

RESULTS

The analysis included 397 HIV-positive opioid users who completed ≥1 study interview between 2005 and 2014. At baseline, 304 (77%) reported participation in MMT, 37 (9%) ≥daily cocaine injection, and 158 (40%) ≥daily crack smoking. In adjusted analyses, MMT remained independently associated with increased odds of VL suppression in both strata of crack smokers (AOR=3.11, 95% CI: 1.86-5.21 and AOR=1.48, 95%CI: 1.04-2.09, for ≥daily and <daily smokers, respectively), and among <daily cocaine injectors (AOR=1.88, 95%CI 1.38-2.56), but not among ≥daily cocaine injectors (AOR=1.37, 95%CI 0.53-3.49). Longer retention on MMT was positively associated with VL suppression in all strata of cocaine injection and crack smoke.

CONCLUSIONS

Exposure to MMT was associated with increased odds of VL suppression among HIV- positive opioid users regardless of crack use. However, this beneficial effect of MMT was lost among frequent cocaine injectors with shorter retention on MMT.

A Multi-Group Latent Class Analysis of Chronic Medical Conditions Among Men Who Have Sex with Men

Until recently, research on the health of gay and other men who have sex with men (MSM) has focused on risk for and the health consequences of HIV and other sexually transmitted infections. A multigroup latent class analysis examined a range of lifetime chronic medical conditions (CMCs) among MSM. Covariates included sociodemographics, substance use, psychological distress, and HIV serostatus. A two-class model best fit the medical condition data: a low probabilities class for most CMCs and a moderate to high probabilities (MHP) class. HIV serostatus was associated with increased within-class probabilities for some CMCs, particularly gastrointestinal and skin disorders. Only increasing age and use of erectile dysfunction drugs were directly associated with increased odds of being in the MHP class whereas methamphetamine use, identifying as gay, and lower alcohol use were indirectly associated. Implications of the findings for future research and the health care needs of MSM are discussed.

A community-engaged randomized controlled trial of an integrative intervention with HIV-positive, methamphetamine-using men who have sex with men

Background

Contingency management (CM) is an evidence-based intervention providing tangible rewards as positive reinforcement for abstinence from stimulants such as methamphetamine. Integrative approaches targeting affect regulation could boost the effectiveness of CM in community-based settings and optimize HIV/AIDS prevention efforts.

Methods/Design

This randomized controlled trial with HIV-positive, methamphetamine-using men who have sex with men (MSM) is examining the efficacy of a 5-session, individually delivered positive affect regulation intervention – Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS). ARTEMIS is designed to sensitize individuals to non-drug-related sources of reward as well as assist with managing depression and other symptoms of stimulant withdrawal during CM. HIV-positive, methamphetamine-using MSM who are enrolled in a community-based, 12-week CM program are randomized to receive ARTEMIS or an attention-matched control condition. Follow-up assessments are conducted at 3, 6, 12, and 15 months after enrollment in CM. Four peripheral venous blood samples are collected over the 15-month follow-up with specimen banking for planned biomarker sub-studies. The primary outcome is mean HIV viral load. Secondary outcomes include: sustained HIV viral suppression, T-helper cell count, psychological adjustment, stimulant use, and potentially amplified transmission risk behavior.

Discussion

Implementation of this randomized controlled trial highlights the importance of delineating boundaries between research activities and community-based service provision. It also provides insights into best practices for integrating the distinct agendas of academic and community partners in clinical research. This trial is currently enrolling and data collection is anticipated to be completed in September of 2018.

Trial registration

This trial was registered on clinicaltrials.gov (NCT01926184) on August 16, 2013.

The effects of cocaine on HIV transcription

Illicit drug users are a high-risk population for infection with the human immunodeficiency virus (HIV). A strong correlation exists between prohibited drug use and an increased rate of HIV transmission. Cocaine stands out as one of the most frequently abused illicit drugs, and its use is correlated with HIV infection and disease progression. The central nervous system (CNS) is a common target for both drugs of abuse and HIV, and cocaine intake further accelerates neuronal injury in HIV patients. Although the high incidence of HIV infection in illicit drug abusers is primarily due to high-risk activities such as needle sharing and unprotected sex, several studies have demonstrated that cocaine enhances the rate of HIV gene expression and replication by activating various signal transduction pathways and downstream transcription factors. In order to generate mature HIV genomic transcript, HIV gene expression has to pass through both the initiation and elongation phases of transcription, which requires discrete transcription factors. In this review, we will provide a detailed analysis of the molecular mechanisms that regulate HIV transcription and discuss how cocaine modulates those mechanisms to upregulate HIV transcription and eventually HIV replication.

Controlling HIV among people who inject drugs in Eastern Europe and Central Asia: insights from modeling

BACKGROUND

Although there is evidence of the effectiveness of needle and syringe programme (NSP), opioid substitution therapy (OST) and antiretroviral therapy (ART) in reducing HIV prevalence, most Central and Eastern European sub-regions still have low or no coverage of most or all of these interventions.

METHODS

We conducted a modelling analysis to consider the potential impact on HIV incidence and prevalence of OST, NSP and ART in three illustrative epidemic scenarios: Russia (St. Petersburg); Estonia (Tallinn) and Tajikistan (Dushanbe). For each intervention, we consider the coverage needed of each intervention separately or in combination to: (1) achieve a 30% or 50% relative reduction in HIV incidence or prevalence over 10 years; and (2) reduce HIV incidence to below 1% or HIV prevalence below 10% after 20 years. A sensitivity analysis for St. Petersburg considered the implications of greater on no risk heterogeneity, none or more sexual HIV transmission, like-with-like mixing, different injecting cessation rates and assuming a lower HIV acute phase cofactor.

RESULTS

For St. Petersburg, when OST, NSP and ART are combined, only 14% coverage of each intervention is required to achieve a 30% reduction in HIV incidence over 10 years. Similar findings are obtained for Tallinn and Dushanbe. In order to achieve the same reductions in HIV prevalence over 10 years, over double the coverage level is required relative to what was needed to achieve the same reduction in HIV incidence in that setting. To either reduce HIV incidence to less than 1% or HIV prevalence to less than 10% over 20 years, with all interventions combined, projections suggest that very high coverage levels of 74–85% are generally required for the higher prevalence settings of Tallinn and St. Petersburg, whereas lower coverage levels (23–34%) are needed in Dushanbe. Coverage requirements are robust to increased sexual HIV transmission, risk heterogeneity and like-with-like mixing, as well as to assuming a lower HIV acute phase cofactor or different injecting cessation rate.

CONCLUSION

The projections suggest that high but achievable coverage levels of NSP can result in large decreases (30%) in HIV incidence in settings with high HIV prevalence among PWID. Required coverage levels are much lower when interventions are combined or in lower prevalence settings. However, even when all three interventions are combined, the targets of reducing HIV incidence to less than 1% or prevalence to less than 10% in 20 years may be hard to achieve except in lower prevalence settings.

Methamphetamine Exposure Combined with HIV-1 Disease or gp120 Expression: Comparison of Learning and Executive Functions in Humans and Mice

Methamphetamine dependence is a common comorbid condition among people living with HIV, and may exacerbate HIV-associated neurocognitive disorders. Animal models of neuroAIDS suggest that the gp120 protein may also cause cognitive impairment. The present work evaluated the separate and combined effects of HIV/gp120 and methamphetamine on learning and executive functions in both humans and transgenic mice. Human participants were grouped by HIV serostatus (HIV+ or HIV-) and lifetime methamphetamine dependence (METH+ or METH-). A neurocognitive test battery included domain-specific assessments of learning and executive functions. Mice (gp120+ and gp120-) were exposed to either a methamphetamine binge (METH+) or saline (METH-), then tested in the attentional-set-shifting task to assess learning and executive functions. In humans, HIV status was associated with significant impairments in learning, but less so for executive functions. The frequency of learning impairments varied between groups, with the greatest impairment observed in the HIV+/METH+ group. In mice, gp120 expression was associated with impairments in learning but not reversal learning (executive component). The greatest proportion of mice that failed to complete the task was observed in the gp120+/METH+ group, suggesting greater learning impairments. Our cross-species study demonstrated that HIV in humans and gp120 in mice impaired learning, and that a history of methamphetamine exposure increased the susceptibility to HIV-associated neurocognitive deficits in both species. Finally, the similar pattern of results in both species suggest that the gp120 protein may contribute to HIV-associated learning deficits in humans.

Cocaine-mediated impact on HIV infection in humanized BLT mice

Cocaine abuse has been shown to have broad-ranging effects on human immunity. With regards to HIV infection, in vitro studies have shown that cocaine enhances infection of stimulated lymphocytes. Moreover, cohort studies in the pre- and post-HAART era have linked stimulant abuse with increased HIV pathogenesis. The latter data, however, have been undermined by a series of confounding factors underscoring the importance of controlled in vivo models to fully assess the impact of cocaine use and abuse on HIV infection and pathogenesis. Here, we have infected humanized mice with HIV-1 following acute cocaine exposure to assess the impact on infection. Stimulant exposure resulted in increased inflammatory cytokine expression, accelerated HIV infection, while blunting effector function of cytotoxic T lymphocytes. These data demonstrate cocaine’s multifactorial impact on HIV infection that extends beyond high-risk behavior.

Substance use and its impact on care outcomes among HIV-infected individuals in Manitoba

The high prevalence of substance use among HIV-infected individuals creates numerous challenges to patient care. This study was undertaken in order to understand the impact of substance use on care outcomes for HIV-infected individuals in Manitoba. Clinical records of 564 HIV-infected individuals in care at Health Sciences Centre in Winnipeg, Manitoba were reviewed. Clinical data were extracted from patient charts for substance users (illicit substance users, alcohol abusers and chronic users of opioids or benzodiazepines) and non-users. Substance users and non-users were analysed using chi-square analysis and logistic regression models to compare basic socio-demographic and clinic variables. Chi-square and analysis of variance were used to compare a subset of substance users based on similar socio-demographic and clinical characteristics. Among HIV-infected individuals in Manitoba, 38% were substance users with over-representation by Aboriginals, females, young adults and residents of Winnipeg's core areas. Opioids and benzodiazepines were the most commonly used substances with the majority of substance users having used multiple classes of substances in their lifetime. Substance users were more likely than non-users to have missed clinic appointments. Among substance users, missed appointments were more common among those who self-identified as Aboriginal, female, young adults, residents of Winnipeg's core areas, heterosexuals and those who had abused alcohol or cocaine/crack. Aboriginal substance users were also less likely to achieve viral load suppression compared to non-Aboriginal substance users. With the high prevalence of substance use among HIV-infected individuals in Manitoba, it is important to identify at-risk individuals in order to implement appropriate care strategies and improve treatment adherence and health outcomes.

Chronic inflammation and the role for cofactors (hepatitis C, drug abuse, antiretroviral drug toxicity, aging) in HAND persistence

HIV-associated neurocognitive disorders (HAND) is a group of syndromes of varying degrees of cognitive impairment affecting up to 50 % of HIV-infected individuals. The neuropathogenesis of HAND is thought to be driven by HIV invasion and productive replication within brain perivascular macrophages and endogenous microglia, and to some degree by restricted infection of astrocytes. The persistence of HAND in individuals experiencing suppression of systemic HIV viral load with antiretroviral therapy (ART) is incompletely explained, and suggested factors include chronic inflammation, persistent HIV replication in brain macrophages, effects of aging on brain vulnerability, and co-morbid conditions including hepatitis C (HCV) co-infection, substance abuse, and CNS toxicity of ART, among other factors. This review discusses several of these conditions: chronic inflammation, co-infection with HCV, drugs of abuse, aging, and antiretroviral drug effects. Effectively managing these co-morbid conditions in individuals with and without HAND is critical for improving neurocognitive outcomes and decreasing HIV-associated morbidity.

Crystal methamphetamine use and HIV medical outcomes among HIV-infected men who have sex with men accessing support services in New York

BACKGROUND

Drug use poses multiple challenges to maintaining physical health among HIV-infected individuals, particularly with regard to disease progression. Few studies, however, have examined the association between the use of crystal methamphetamine ("crystal meth") and HIV disease progression specifically among HIV-infected men who have sex with men (MSM). Understanding this relationship among HIV-infected MSM is particularly critical because of the high rates of crystal meth use reported in the population.

METHODS

Associations between recent crystal meth use and poor HIV medical outcomes (viral load>200 copies/mL, CD4 count <350 cells/mm(3)) were analyzed for 2896 HIV-infected MSM enrolled in Ryan White Part A programs in the greater New York metropolitan area between November 2010 and June 2012.

RESULTS

Crystal meth use (reported by 4%) was independently associated with unsuppressed viral load (AOR=1.8, CI=1.1-2.9) in multivariate analyses controlling for sociodemographic characteristics. There was no significant relationship between crystal meth use and low CD4 counts.

CONCLUSIONS

To date, little research has examined how crystal meth use influences HIV medical outcomes among HIV-infected MSM. This analysis showed a significant independent association between crystal meth use and unsuppressed viral load among MSM in an HIV service population. Future studies should examine biological and psychosocial mediators, moderators and confounders of this relationship to inform intervention development for MSM crystal meth users in HIV care settings.

Stimulant use and progression to AIDS or mortality after the initiation of highly active antiretroviral therapy

BACKGROUND

HIV-positive persons who use stimulants (eg, methamphetamine) experience profound health disparities, but it remains unclear whether these persist after highly active antiretroviral therapy (HAART) initiation. Conducted within the Multicenter AIDS Cohort Study, this investigation examined whether stimulant use is associated with progression to AIDS or all-cause mortality after the initiation of HAART.

METHODS

Using marginal structural modeling, the cumulative proportion of visits where any stimulant use was reported (ie, 0%, 1%-49%, 50%-99%, and 100%) was examined as a time-varying predictor of (1) all-cause mortality and (2) AIDS or all-cause mortality.

RESULTS

Among the 1313 men who have sex with men (MSM) who initiated HAART, findings showed no significant association of any level of stimulant use with all-cause mortality. A competing risk analysis indicated that no level of stimulant use was associated with increased AIDS-related or non-AIDS mortality separately. Among the 648 participants without AIDS at HAART initiation, a secondary analysis indicated that stimulant use at 50% or more of study visits was associated with a 1.5-fold increase in the odds of progression to AIDS or all-cause mortality (adjusted odds ratio = 1.54; 95% confidence interval: 1.02 to 2.33; P < 0.05).

CONCLUSIONS

HIV-positive stimulant-using MSM receiving HAART seem to face no greater overall risks for all-cause, AIDS-related, or non-AIDS mortality compared with nonusers. However, men without AIDS at HAART initiation who more frequently reported stimulant use demonstrated modestly increased odds of progression to AIDS or all-cause mortality. Comprehensive approaches are needed to optimize the effectiveness of HAART with stimulant-using MSM.

Expression of HIV gp120 protein increases sensitivity to the rewarding properties of methamphetamine in mice

Methamphetamine abuse and human immunodeficiency virus (HIV) infection induce neuropathological changes in corticolimbic brain areas involved in reward and cognitive function. Little is known about the combined effects of methamphetamine and HIV infection on cognitive and reward processes. The HIV/gp120 protein induces neurodegeneration in mice, similar to HIV-induced pathology in humans. We investigated the effects of gp120 expression on associative learning, preference for methamphetamine and non-drug reinforcers, and sensitivity to the conditioned rewarding properties of methamphetamine in transgenic (tg) mice expressing HIV/gp120 protein (gp120-tg). gp120-tg mice learned the operant response for food at the same rate as non-tg mice. In the two-bottle choice procedure with restricted access to drugs, gp120-tg mice exhibited greater preference for methamphetamine and saccharin than non-tg mice, whereas preference for quinine was similar between genotypes. Under conditions of unrestricted access to methamphetamine, the mice exhibited a decreased preference for increasing methamphetamine concentrations. However, male gp120-tg mice showed a decreased preference for methamphetamine at lower concentrations than non-tg male mice. gp120-tg mice developed methamphetamine-induced conditioned place preference at lower methamphetamine doses compared with non-tg mice. No differences in methamphetamine pharmacokinetics were found between genotypes. These results indicate that gp120-tg mice exhibit no deficits in associative learning or reward/motivational function for a natural reinforcer. Interestingly, gp120 expression resulted in increased preference for methamphetamine and a highly palatable non-drug reinforcer (saccharin) and increased sensitivity to methamphetamine-induced conditioned reward. These data suggest that HIV-positive individuals may have increased sensitivity to methamphetamine, leading to high methamphetamine abuse potential in this population.

Stimulant use and HIV disease management among men in same-sex relationships

BACKGROUND

Research conducted to date has focused primarily on identifying individual-level, psychological determinants of stimulant use and HIV disease management. The present cross-sectional study examined relationship factors as correlates of stimulant use and HIV disease management among men who have sex with men (MSM).

METHODS

In total, 266 male couples completed a baseline assessment for a cohort study examining the role of relationship factors in HIV treatment. A computer-based assessment of relationship factors, self-reported alcohol and substance use, and self-reported anti-retroviral therapy (ART) adherence was administered. All HIV-positive participants also provided a blood sample to measure viral load.

RESULTS

After controlling for demographic characteristics and relationship factors, men in a primary relationship with a stimulant-using partner had more than six-fold greater odds of reporting any stimulant use in the past three months. Among HIV-positive participants on ART (n=371), having a stimulant-using partner was independently associated with 67% lower odds of reporting perfect 30-day ART adherence and more than two-fold greater odds of displaying a detectable HIV viral load. In contrast, more partner-level alcohol use was independently associated with greater odds of reporting perfect 3-day ART adherence and lower odds of displaying a detectable HIV viral load.

CONCLUSIONS

Partner-level stimulant use is an important risk factor for individual-level stimulant use and difficulties with HIV disease management among MSM. To optimize the effectiveness of HIV treatment as prevention, clinical research is needed to develop couples-based interventions targeting stimulant use as a potential driver of detectable HIV viral load.

Community-based harm reduction substance abuse treatment with methamphetamine-using men who have sex with men

Harm reduction approaches endeavor to assist individuals with avoiding the most detrimental consequences of risk taking behaviors, but limited research has documented the outcomes of harm reduction substance abuse treatment. In total, 211 methamphetamine-using men who have sex with men (MSM) enrolled in two outcome studies of substance abuse treatment programs that were implementing an evidence-based, cognitive-behavioral intervention (i.e., the Matrix Model) from a harm reduction perspective. Study 1 (N = 123) examined changes in self-reported substance use, Addiction Severity Index (ASI) composite scores, and HIV care indicators over a 12-month follow-up. Study 2 (N = 88) assessed changes in substance use, sexual risk taking, and HIV care indicators over a 6-month follow-up. Participants in study 1 reported reductions in cocaine/crack use as well as decreases in the ASI drug and employment composite scores. Among HIV-positive participants in study 1 (n = 75), 47 % initiated or consistently utilized anti-retroviral therapy and this was paralleled by significant increases in self-reported undetectable HIV viral load. Study 2 participants reported reductions in methamphetamine use, erectile dysfunction medication use in combination with other substances, and sexual risk-taking behavior while using methamphetamine. Participants in both studies reported concurrent increases in marijuana use. Taken together, these studies are among the first to observe that clients may reduce stimulant use and concomitant sexual risk-taking behavior during harm reduction substance abuse treatment. Randomized controlled trials are needed to examine the differential effectiveness of harm reduction and abstinence-based approaches to substance abuse treatment.

Detrimental impact of remote methamphetamine dependence on neurocognitive and everyday functioning in older but not younger HIV+ adults: evidence for a legacy effect?

Prior studies examining the combined adverse effects of HIV and methamphetamine (MA) on the central nervous system (CNS) have focused on younger to middle-aged adults with recent MA use diagnoses. Aging, HIV, and MA all converge on prefrontal and temporolimbic neural systems and confer independent risk for neurocognitive and functional decline. Thus, this study sought to determine the residual impact of a remote history of MA dependence on neurocognitive and real-world outcomes in older people living with HIV (PLWH). Participants included 116 older (≥50 years) and 94 younger (<40 years) adults classified into one of six study groups based on HIV serostatus (HIV+/HIV-) and lifetime histories of MA dependence (MA+/MA-): older HIV-MA- (n = 36), older HIV+MA- (n = 49), older HIV+MA+ (n = 31), younger HIV-MA- (n = 27), younger HIV+MA- (n = 33), and younger HIV+MA+ (n = 34). No participant-met criteria for current MA use disorders and histories of MA dependence were remote in both the older (average of nearly 9 years prior to evaluation) and younger (average of over 2 years prior to evaluation) HIV+MA+ groups. Findings revealed that a remote history of MA dependence exerts a significant detrimental impact on specific aspects of neurocognitive performance (e.g., memory) and a broad range of real-world functioning outcomes (e.g., employment) among older, but not younger PLWH. These results suggest that MA-associated neurotoxicity may have significant "legacy" effects on both neurocognitive and functional outcomes to which older PLWH are particularly vulnerable.

Engagement in HIV Medical Care and Technology Use among Stimulant-Using and Nonstimulant-Using Men who have Sex with Men

Aims of this study were to assess the associations between stimulant use and attitudes toward and engagement in HIV medical care and to examine technology use among stimulant-using and nonstimulant-using men who have sex with men (MSM). HIV-positive MSM (n = 276; mean age = 42 years; 71% white, non-Hispanic; 43% with college degree) completed an online survey in 2009. Most men (69%) had not missed any scheduled HIV medical appointments in the past year, while 23% had missed at least one, and 9% had not attended any appointments. Stimulant use was significantly associated with not attending any HIV medical appointments in the unadjusted model (relative risk ratio (RRR) = 2.84, 95% CI [1.07, 7.58]), as well as in models adjusted for demographic (RRR = 3.16, 95% CI [1.13, 8.84]) and psychosocial (RRR = 3.44, 95% CI [1.17, 10.15]) factors (Ps < 0.05). Fewer stimulant-using than non-stimulant-using men rated HIV medical care a high priority (57% versus 85%; P < 0.01). Few significant differences were found in online social networking or mobile phone use between stimulant-using and non-stimulant-using MSM, even when stratified by engagement in HIV care. Findings indicate that stimulant use is uniquely associated with nonengagement in HIV medical care in this sample, and that it may be possible to reach stimulant-using MSM using online social networking and mobile technologies.

Clinical uncertainties, health service challenges, and ethical complexities of HIV "test-and-treat": a systematic review

Despite the HIV "test-and-treat" strategy's promise, questions about its clinical rationale, operational feasibility, and ethical appropriateness have led to vigorous debate in the global HIV community. We performed a systematic review of the literature published between January 2009 and May 2012 using PubMed, SCOPUS, Global Health, Web of Science, BIOSIS, Cochrane CENTRAL, EBSCO Africa-Wide Information, and EBSCO CINAHL Plus databases to summarize clinical uncertainties, health service challenges, and ethical complexities that may affect the test-and-treat strategy's success. A thoughtful approach to research and implementation to address clinical and health service questions and meaningful community engagement regarding ethical complexities may bring us closer to safe, feasible, and effective test-and-treat implementation.

Concurrent classification accuracy of the HIV dementia scale for HIV-associated neurocognitive disorders in the CHARTER Cohort

BACKGROUND

The HIV Dementia Scale (HDS) was developed to screen for HIV-associated neurocognitive disorders (HAND), but concerns have persisted regarding its substandard sensitivity. This study aimed to examine the classification accuracy of the HDS using raw and norm-based cut points and to evaluate the contribution of the HDS subtests to predicting HAND.

METHODS

A total of 1580 HIV-infected participants from 6 US sites completed the HDS, and a gold standard neuropsychological battery, on which 51% of participants were impaired.

RESULTS

Sensitivity and specificity to HAND using the standard raw HDS cut point were 24% and 92%, respectively. The raw HDS subtests of attention, recall, and psychomotor speed significantly contributed to classification of HAND, whereas visuomotor construction contributed the least. A modified raw cut point of 14 yielded sensitivity of 66% and specificity of 61%, with cross-validation. Using norms also significantly improved sensitivity to 69% with a concomitant reduction of specificity to 56%, whereas the positive predictive value declined from 75% to 62% and negative predictive value improved from 54% to 64%. The HDS showed similarly modest rates of sensitivity and specificity among subpopulations of individuals with minimal comorbidity and successful viral suppression.

CONCLUSIONS

Findings indicate that while the HDS is a statistically significant predictor of HAND, particularly when adjusted for demographic factors, its relatively low diagnostic classification accuracy continues to hinder its clinical utility. A raw cut point of 14 greatly improved the sensitivity of the previously established raw cut score, but may be subject to ceiling effects, particularly on repeat assessments.

Substance use disorders and HIV/AIDS prevention and treatment intervention: research and practice considerations

Social workers are often on the front lines of the HIV/AIDS epidemic delivering prevention education and interventions, offering or linking individuals to HIV testing, and working to improve treatment access, retention, and adherence, especially among vulnerable populations. Individuals with substance use disorders face additional challenges to reducing sexual and drug risk behaviors, as well as barriers to testing, treatment, and antiretroviral therapy adherence. This article presents current data on HIV transmission and research evidence on prevention and intervention with substance abusers and highlights how individual social workers can take advantage of this knowledge in practice and through adoption and implementation within organizations.

Psychological processes and stimulant use among men who have sex with men

BACKGROUND

Prior research established that psychological factors are associated with the frequency of stimulant (i.e., cocaine, crack, and methamphetamine) use among substance-using men who have sex with men (MSM). The present investigation examined whether and how psychological factors are associated with engagement in any stimulant use in the broader population of MSM.

METHODS

A probability sample of 879 MSM residing in San Francisco was obtained using random digit dialing from May of 2002 through January of 2003. Of these, 711 participants (81%) completed a mail-in questionnaire that assessed psychological factors and substance use. After accounting for demographic factors, a multiple logistic regression analysis examined correlates of any self-reported stimulant use during the past 6 months. Path analyses examined if the use of alcohol or other substances to avoid negative mood states (i.e., substance use coping) mediated the associations of sexual compulsivity and depressed mood with stimulant use.

RESULTS

Younger age (adjusted OR [AOR]=0.58; 95% CI=0.47-0.70), HIV-positive serostatus (AOR=2.55; 95% CI=1.61-4.04), greater depressed mood (AOR=1.26; 95% CI=1.05-1.52) and higher sexual compulsivity (AOR=1.46; 95% CI=1.18-1.80) were independently associated with increased odds of stimulant use. Substance use coping partially mediated the associations of sexual compulsivity (β(indirect)=0.11, p<.001) and depressed mood (β(indirect)=0.13, p<.001) with stimulant use.

CONCLUSIONS

Clinical research is needed to examine if interventions targeting sexual compulsivity and emotion regulation reduce stimulant use among MSM.

Methamphetamine use and neuropsychiatric factors are associated with antiretroviral non-adherence

The present study assesses the impact of methamphetamine (METH) on antiretroviral therapy (ART) adherence among HIV+ persons, as well as examines the contribution of neurocognitive impairment and other neuropsychiatric factors [i.e., major depressive disorder (MDD), antisocial personality disorder (ASPD), and attention deficit disorder (ADHD)] for ART non-adherence. We examined HIV+ persons with DSM-IV-diagnosed lifetime history of METH abuse/dependence (HIV+ /METH+ ; n=67) as compared to HIV+ participants with no history of METH abuse/dependence (HIV+ /METH - ; n=50). Ancillary analyses compared these groups with a small group of HIV+ /METH+ persons with current METH abuse/dependence (HIV+ /CU METH+ ; n=8). Non-adherence was defined as self-report of any skipped ART dose in the last four days. Neurocognitive functioning was assessed with a comprehensive battery, covering seven neuropsychological domains. Lifetime METH diagnosis was associated with higher rates of detectable levels of plasma and CSF HIV RNA. When combing groups (i.e., METH+ and METH- participants), univariate analyses indicated co-occurring ADHD, ASPD, and MDD predicted ART non-adherence (p's < 0.10; not lifetime METH status or neurocognitive impairment). A significant multivariable model including these variables indicated that only MDD uniquely predicted ART non-adherence after controlling for the other variables (p<0.05). Ancillary analyses indicated that current METH users (use within 30 days) were significantly less adherent (50% prevalence of non-adherence) than lifetime METH+ users and HIV+ /METH- participants and that neurocognitive impairment was associated with non-adherence (p's < 0.05). METH use disorders are associated with worse HIV disease outcomes and ART medication non-adherence. Interventions often target substance use behaviors alone to enhance antiretroviral treatment outcomes; however, in addition to targeting substance use behaviors, interventions to improve ART adherence may also need to address coexisting neuropsychiatric factors and cognitive impairment to improve ART medication taking.

Psychiatric correlates of HAART utilization and viral load among HIV-positive impoverished persons

OBJECTIVE

Research on the role psychiatric factors in HIV disease management has yielded discrepant findings, possibly because prior studies did not include comprehensive psychiatric screeners. This study administered a validated screener to examine psychiatric correlates of highly active antiretroviral therapy (HAART) utilization and viral load.

DESIGN

Community-recruited, HIV-positive impoverished persons provided sociodemographic information, completed a Diagnostic Interview Schedule that screened for psychiatric disorders, and provided a blood sample to measure HIV disease markers.

METHODS

In this cross-sectional investigation with 227 participants, a multiple logistic regression model examined correlates of HAART utilization compared to a reference group that was eligible for (i.e. CD4(+) cell count <350 cells/μl) but not taking HAART. A multiple linear regression model examined correlates of HIV viral load among 147 participants on HAART.

RESULTS

Sleeping on the street [adjusted OR (AOR) = 0.06; 95% confidence interval (CI) = 0.01–0.26] and screening positive for a stimulant use disorder (AOR = 0.29; 95% CI = 0.13–0.65) were independently associated with lower odds of HAART utilization. Conversely, enrollment in the AIDS Drug Assistance Program (AOR = 3.94; 95% CI = 1.45–10.73) and receipt of mental health treatment (AOR = 4.78; 95% CI = 1.77–12.87) were independently associated with increased odds of HAART utilization. Among those on HAART, screening positive for a severe mental illness was independently associated with a six-fold higher viral load.

CONCLUSION

Providing psychiatric treatment could optimize health outcomes among HIV-positive impoverished persons and boost the effectiveness of 'test and treat' approaches to HIV prevention.

Psychiatric risk factors for HIV disease progression: the role of inconsistent patterns of antiretroviral therapy utilization

BACKGROUND

In the era of antiretroviral therapy (ART), depression and substance use predict hastened HIV disease progression, but the underlying biological or behavioral mechanisms that explain these effects are not fully understood.

METHODS

Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up.

RESULTS

Elevated affective symptoms of depression independently predicted ART discontinuation [adjusted odds ratio = 1.39, 95% confidence interval (CI) = 1.08 to 1.78], and use of stimulants at least weekly independently predicted intermittent ART utilization (adjusted odds ratio = 2.62, 95% CI = 1.45 to 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became nonsignificant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation.

CONCLUSIONS

Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.