Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs

Sleep disturbance, associated symptoms, and quality of life in adults living with HIV in Jakarta, Indonesia

Adverse symptom experiences, including sleep disturbances, are important negative predictors of quality of life (QoL), but few studies conducted in low-income countries have examined the impact of poor sleep and its associated symptoms on QoL among people living with HIV (PLWH). To this end, 200 PLWH who were receiving treatment with antiretroviral therapy (ART) were recruited through a community nongovernment organization in Jakarta, Indonesia. Validated instruments measured QoL, sleep disturbance, fatigue, pain, ART adherence, substance use, drug use severity, and methadone treatment. Descriptive statistics, bivariate correlations, and multivariate linear regression were conducted to identify independent correlates of QoL. Overall, participants perceived their QoL as being good to very good (mean = 105.70, standard deviation = 14.7) and higher among women than men (p < 0.05). After adjusting for sex, education, drug-use severity, and ART adherence, QoL was negatively associated with fatigue, insomnia, and pharmacological treatment with methadone. Along with other known symptoms of HIV, sleep problems and their complications are important to clinically address and research more fully to assure satisfying QoL among PLWH.

The impact of socioeconomic factors on the healthcare costs of people living with HIV in Turkey

Background

This study addresses an important field within HIV research, the impact of socioeconomic factors on the healthcare costs of people living with HIV/AIDS (PLHIV). We aimed to understand how different socioeconomic factors could create diverse healthcare costs for PLHIV in Turkey.

Methods

Data were collected between January 2017 and December 2017. HIV-positive people attending the clinic who had been referred to the national ART programme from January 1992 until December 2017 were surveyed. The questionnaire collected socioeconomic data. The cost data for the same patients was taken from the electronic database Probel Hospital Information Management System (PHIMS) for the same period. The PHIMS data include costs for medication (highly active antiretroviral therapy or HAART), laboratory, pathology, radiology, polyclinic, examination and consultation, hospitalisation, surgery and intervention, blood and blood products, supplies and other costs. Data were analysed using STATA 14.2 to estimate the generalised linear model (GLM).

Results

The findings of our GLM indicate that age, gender, marital and parental status, time since diagnosis, employment, wealth status, illicit drug use and CD4 cell count are the factors significantly related to the healthcare cost of patients. We found that compared with people who have AIDS (CD4 cells < 200 cells/mm³), people who have a normal range of CD4 cells (≥ 500 cells/mm³) have $1046 less in expenditures on average. Compared to younger people (19–39 years), older people (≥ 55) have $1934 higher expenditures on average. Costs are $644 higher on average for married people and $401 higher on average for people who have children. Healthcare costs are $518 and $651 higher on average for patients who are addicted to drugs and who use psychiatric drug(s), respectively. Compared to people who were recently diagnosed with HIV, people who were diagnosed ≥10 years ago have $743 lower expenditures on average.

Conclusion

Our results suggest that in addition to immunological status, socioeconomic factors play a substantial role in the healthcare costs of PLHIV. The key factors influencing the healthcare costs of PLHIV are also critical for public policy makers, healthcare workers, health ministries and employment community programs.

Synthetic Opioid Use and Common Injection-associated Viruses: Expanding the Translational Research Agenda

The US is in the midst of a major epidemic of opioid addiction and related comorbidities. People with opioid use disorder (OUD) are at significant risk for transmission of several blood-borne pathogens including the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Commonly abused opioids and their receptors promote viral replication and virus-mediated pathology. However, most studies demonstrating an adverse effect of drugs of abuse have been conducted in vitro, the specific effects of synthetic opioids on viral replication have been poorly characterized, and the evaluation of opioid-virus interactions in clinically relevant populations is rare. Rigorous characterization of the interactions among synthetic opioids, host cells, and common injection-associated viral infections will require an interdisciplinary research approach and translational studies conducted on humans. Such research promises to improve clinical management paradigms for difficult-to-treat populations, facilitate rational public health policies given severely strained resources, and reveal additional pathways for novel target-specific therapeutic interventions. This mini-review examines the published literature on the effects of opioids on HIV, HBV, and HCV pathogenesis and proposes a series of scientific questions and considerations to establish a translational research agenda focused on opioid-virus interactions.

HIV and drug related stigma and risk-taking behaviors among people who inject drugs: a systematic review and meta-analysis

The impact of HIV-related stigma on people living with HIV has been well documented, but there have been few studies examining how drug-related stigma impacts risk-taking in the lives of people who inject drugs (PWID). This meta-analysis aimed to determine HIV and drug-related stigma and the association it has with risk-taking behaviors among PWID. We searched PubMed, Science Direct, Web of Science, and Cochrane electronic databases independently in March 2019. After reviewing for any study duplicates the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR) and 95% confidence intervals. After a detailed assessment, a total of 14 studies containing 13,689 participants met the eligibility criteria. Among the potential risk factors: employment status, depression and sharing injecting paraphernalia had a significant relationship with HIV and drug stigma among PWIDs respectively (OR = 0.78, 95%CI = 0.62-0.98), (OR = 1.84, 95%CI = 1.45-2.33) and (OR = 2.20, 95%CI = 1.84-1.63). Illicit drug use related stigma was found to be associated with several concurrent effects. The impact of stigma should be considered in the development of drug use prevention strategies. Perceived stigma is correlated with numerous negative consequences in other populations including people living with HIV/AIDS. These data suggest this could also be generalized to people who inject drugs because it seems that individuals with internalized stigma experience drug dependence, reduced comfort in seeking help from services and higher rates of depression.

A community-based model of HIV care for men who have sex with men and transgender women in Chicago

Socioeconomically disadvantaged men who have sex with men (MSM) and transgender women (TGW) share a disproportionate burden of the HIV epidemic. Providing care in the community may help improve retention and treatment outcomes of these clients. Our objective was to compare HIV outcomes between a community-based model (CBM) and a hospital-based model (HBM) of HIV care. This was a retrospective cohort study of MSM and TGW with HIV treated at community clinics or at a hospital-based clinic. The primary outcome was the cumulative probability of virologic failure (HIV viral load ≥200 copies/ml). We conducted multivariable Cox proportional hazard regression to identify differences in outcome by care setting. Of 258 MSM and TGW, approximately half received care in the CBM. They were more likely to be African American (71% versus 59%), uninsured (48% versus 39%), and used illicit drugs (40% versus 25%). There was no difference in virologic failure by setting (58% CBM, 53% HBM; cumulative incidence of virologic failure: 35% CBM, 25% HBM; adjusted HR = 1.11; 95% CI: 0.88–1.39). Despite serving clients at greater risk for failure, virologic failure in our CBM was similar to a traditional HBM for MSM and TGW living with HIV.

Predictors of Medication Utilization for Opioid Use Disorder Among Medicaid-Insured HIV Patients in New York

BACKGROUND AND OBJECTIVES

This paper investigates the prevalence and predictors for opioid use disorder (OUD) pharmacotherapy utilization for Medicaid-insured patients with human immunodeficiency virus (HIV) in New York.

METHODS

We identified patients with HIV and OUD in 2014 in the New York State Medicaid claims data (n = 5621). The claims were used to identify individual client medication for addiction treatment (MAT) utilization, demographic information, and other medical and psychiatric health conditions. The logistic regression analyses were performed to explore the potential predictors of MAT service utilization among people with HIV and OUD.

RESULTS

Of 5621 identified patients with HIV and OUD, 3647 (65%) received some type of MAT. Eighty-seven percent of treated patients received methadone while 10% received buprenorphine and 3% utilized both the therapies.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

A substantial number of patients with HIV and OUD did not receive MAT. Findings suggest that there are opportunities to improve OUD care for patients with HIV and OUD, particularly among the younger generation, blacks, individuals living outside of New York City, and among those with serious psychiatric conditions. This initial study suggests that an additional research is needed to better understand how the gap in care affects this population. (Am J Addict 2020;29:151-154).

Assessing mobile health feasibility and acceptability among HIV-infected cocaine users and their healthcare providers: guidance for implementing an intervention

BACKGROUND

Mobile health (mHealth) can provide innovative, cost-effective strategies to improve medication adherence and optimize HIV treatment outcomes. Very little, however, is known about the acceptability and feasibility of mHealth among people with HIV (PWH) who use drugs. Our study objective was to assess feasibility, acceptability, and barriers and facilitators of implementing an mHealth intervention among PWH who are cocaine users, a group for whom no pharmacological treatment to reduce cocaine use is available.

METHODS

Five focus groups (FGs) (N=20) were conducted with PWH who self-reported cocaine use in the past 30 days, with 3 groups (N=8) of healthcare providers. Topics included previous experience with smartphones; barriers and facilitators of mobile technology for health purposes; and attitudes toward receiving types of feedback about adherence.

RESULTS

Patients preferred text reminders over phone calls for reasons of privacy, accessibility and economizing phone minutes. Direct communication via text messages and phone calls was considered more appropriate for social workers and case managers, who have greater frequency of communication and deeper relationships with patients, and less so for doctors, who see patients less regularly than community health workers. Patients seem particular about who has what information, and overall, they seem to prefer that their medical information, especially HIV-related, stay within the confines of patient-provider relationships.

CONCLUSIONS

HIV still provokes stigma and makes health information particularly sensitive for both providers and patients. The rise of mobile technology and related applications such as mHealth, means that new norms have to be established for its use. Participants' suggestions and feedback informed the design of a subsequent mHealth pilot randomized control trial to improve medication adherence.

Online HIV information seeking and pre-exposure prophylaxis awareness among people who use drugs

People who use drugs (PWUD) remain at high risk for acquiring human immunodeficiency virus (HIV), both from injection and from sexual risk-taking. In 2016, 9% of 39,782 new HIV diagnoses occurred among people who inject drugs in the United States. Reaching PWUD with accurate information about and motivation for initiating pre-exposure prophylaxis (PrEP) remains challenging and remains the first crucial step in the knowledge-attitude-behavior change continuum. This study seeks to contribute to closing this information gap by examining the HIV information-seeking behaviors among PWUD who are not on PrEP, so as to identify potential strategies to increase adoption of HIV prevention such as PrEP as part of overall health and related to risk-taking behaviors. A cross-sectional survey was conducted in 2016 among HIV-negative PWUD (n = 400), 57.3% of whom reported injecting at least once in a week, chronically maintained on methadone treatment (MMT) at a large addiction treatment program. The study found that the number of hours spent online by people who use drugs was comparable to the general population. Awareness about PrEP and the seeking of HIV-related information was low in this population. Looking for sex partners online, perception of risk, having multiple partners were associated with seeking HIV information. Although using injection drugs was related to high perception of risk of acquiring HIV, it was not associated with seeking HIV information online. It is imperative to further understand the online HIV information seeking behavior of this population and provide targeted information in order to increase awareness and knowledge about HIV-related risk and methods of prevention, including information about PrEP.

Effect of expanding opioid agonist therapies on the HIV epidemic and mortality in Ukraine: a modelling study

BACKGROUND

As HIV incidence and mortality continue to increase in eastern Europe and central Asia, particularly among people who inject drugs (PWID), it is crucial to effectively scale-up opioid agonist therapy (OAT), such as methadone or buprenorphine maintenance therapy, to optimise HIV outcomes. With low OAT coverage among PWID, we did an optimisation assessment using current OAT procurement and allocation, then modelled the effect of increased OAT scale-up on HIV incidence and mortality for 23 administrative regions of Ukraine.

METHODS

We developed a linear optimisation model to estimate efficiency gains that could be achieved based on current procurement of OAT. We also developed a dynamic, compartmental population model of HIV transmission that included both injection and sexual risk to estimate the effect of OAT scale-up on HIV infections and mortality over a 10-year horizon. The compartmental population model was calibrated to HIV prevalence and incidence among PWID for 23 administrative regions of Ukraine. Sources for regional data included the SyrEx database, the Integrated Biological and Behavioral Survey, the Ukrainian Center for Socially Dangerous Disease Control of the Ministry of Health of Ukraine, the Public Health Center of the Ministry of Health of Ukraine, and the Ukrainian Census.

FINDINGS

Under a status-quo scenario (OAT coverage of 2·7% among PWID), the number of new HIV infections among PWID in Ukraine over the next 10 years was projected to increase to 58 820 (95% CI 47 968-65 535), with striking regional differences. With optimum allocation of OAT without additional increases in procurement, OAT coverage could increase from 2·7% to 3·3% by increasing OAT doses to ensure higher retention levels. OAT scale-up to 10% and 20% over 10 years would, respectively, prevent 4368 (95% CI 3134-5243) and 10 864 (7787-13 038) new HIV infections and reduce deaths by 7096 (95% CI 5078-9160) and 17 863 (12 828-23 062), relative to the status quo. OAT expansion to 20% in five regions of Ukraine with the highest HIV burden would account for 56% of new HIV infections and 49% of deaths prevented over 10 years.

INTERPRETATION

To optimise HIV prevention and treatment goals in Ukraine, OAT must be substantially scaled up in all regions. Increased medication procurement is needed, combined with optimisation of OAT dosing. Restricting OAT scale-up to some regions of Ukraine could benefit many PWID, but the regions most affected are not necessarily those with the highest HIV burden.

FUNDING

National Institute on Drug Abuse.

A client-centered relational framework on barriers to the integration of HIV and substance use services: a systematic review

Background

Given the close connection between human immunodeficiency virus (HIV) infection and substance use disorder (SUD), access to integrated HIV and SUD services is critical for individuals experiencing both challenges and their biopsychosocial conditions.

Method

Adopting an integrative method, this systematic review included 23 empirical studies published between 2000 and 2018. Articles investigated providers’ and clients’ perspectives on barriers to accessing integrated HIV and SUD services in various service settings (e.g., HIV primary care, SUD treatment, pharmacy).

Results

Using a client-centered relational framework, we identified barriers in three relational domains with “the client” as the focus of each: client-provider, client-organization, and client-system. The review shows that (1) barriers to HIV and SUD services do not exist in isolation, but in the dynamics within and across three relational domains; (2) service providers and clients often have different perceptions about what constitutes a barrier and the origin of such barriers; and (3) interprofessional and interorganizational collaborations are crucial for integrating HIV and SUD services.

Conclusion

This review points out the limitations of the conventional paradigm grouping barriers to service integration into isolated domains (client, provider, organization, or system). Reforms in service arrangements and provider training are recommended to address barriers to integrated services.

Patterns and Correlates of Prescription Opioid Receipt Among US Veterans: A National, 18-Year Observational Cohort Study

A better understanding of predisposition to transition to high-dose, long-term opioid therapy after initial opioid receipt could facilitate efforts to prevent opioid use disorder (OUD). We extracted data on 69,268 patients in the Veterans Aging Cohort Study who received any opioid prescription between 1998 and 2015. Using latent growth mixture modelling, we identified four distinguishable dose trajectories: low (53%), moderate (29%), escalating (13%), and rapidly escalating (5%). Compared to low dose trajectory, those in the rapidly escalating dose trajectory were proportionately more European-American (59% rapidly escalating vs. 38% low); had a higher prevalence of HIV (31% vs. 29%) and hepatitis C (18% vs. 12%); and during follow-up, had a higher incidence of OUD diagnoses (13% vs. 3%); were hospitalised more often [18.1/100 person-years (PYs) vs. 12.5/100 PY]; and had higher all-cause mortality (4.7/100 PY vs. 1.8/100 PY, all p < 0.0001). These measures can potentially be used in future prevention research, including genetic discovery.

A Longitudinal Analysis of Daily Pill Burden and Likelihood of Optimal Adherence to Antiretroviral Therapy Among People Living With HIV Who Use Drugs

OBJECTIVES

Among people living with HIV (PLWH), high levels of adherence to prescribed antiretroviral therapy (ART) is required to achieve optimal treatment outcomes. However, little is known about the effects of daily pill burden on adherence amongst PLWH who use drugs. We sought to investigate the association between daily pill burden and adherence to ART among members of this key population in Vancouver, Canada.

METHODS

We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services study, a long-running community-recruited cohort of PLWH who use illicit drugs linked to comprehensive HIV clinical records. The longitudinal relationship between daily pill burden and the odds of ≥95% adherence to ART among ART-exposed individuals was analyzed using multivariable generalized linear mixed-effects modeling, adjusting for sociodemographic, behavioural, and structural factors linked to adherence.

RESULTS

Between December 2005 and May 2014, the study enrolled 770 ART-exposed participants, including 257 (34%) women, with a median age of 43 years. At baseline, 437 (56.7%) participants achieved ≥95% adherence in the previous 180 days. Among all interview periods, the median adherence was 100% (interquartile range 71%-100%). In a multivariable model, a greater number of pills per day was negatively associated with ≥95% adherence (adjusted odds ratio [AOR] 0.87 per pill, 95% confidence interval [CI] 0.84-0.91). Further analysis showed that once-a-day ART regimens were positively associated with optimal adherence (AOR 1.39, 95% CI 1.07-1.80).

CONCLUSIONS

In conclusion, simpler dosing demands (ie, fewer pills and once-a-day single tablet regimens) promoted optimal adherence among PLWH who use drugs. Our findings highlight the need for simpler dosing to be encouraged explicitly for PWUD with multiple adherence barriers.

Global patterns of opioid use and dependence: harms to populations, interventions, and future action

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.

Perspectives on the HIV continuum of care among adult opioid users in New York City: a qualitative study

BACKGROUND

Engagement in the HIV care continuum combined with office-based opioid treatment remains a cornerstone in addressing the intertwined epidemics of opioid use disorder (OUD) and HIV/AIDS. Factors influencing patient engagement with OUD and HIV care are complex and require further study.

METHODS

In this qualitative study, in-depth interviews were conducted among 23 adult patients who use drugs (PWUD) in an inpatient detoxification program in New York City. The semi-structured interview guide elicited participant experiences with various phases of the HIV care continuum, including factors influencing access to HIV care, interactions with HIV and primary care providers, preferences around integrated care approaches for OUD and HIV, and barriers experienced beyond clinical settings which affected access to HIV care (e.g., insurance issues, transportation, cost, retrieving prescriptions from their pharmacy). Data collection and thematic analysis took place concurrently using an iterative process-based established qualitative research method.

RESULTS

Respondents elicited high acceptability for integrated or co-located care for HIV and OUD in primary care. Factors influencing engagement in HIV care included (1) access to rapid point-of-care HIV testing and counseling services, (2) insurance coverage and costs related to HIV testing and receipt of antiretroviral therapy (ART), (3) primary care providers offering HIV care and buprenorphine, (4) illicit ART sales to pharmacies, (5) disruption in supplies of ART following admissions to inpatient detoxification or residential treatment programs, (6) in-person and telephone contact with peer support networks and clinic staff, (7) stigma, and (8) access to administrative support in primary care to facilitate reengagement with care following relapse, behavioral health services, transportation vouchers, and relocation from subsidized housing exposing patients to actively using peers.

CONCLUSION

These findings suggest expanding clinical and administrative support in primary care for PWUDs with patient navigators, case managers, mobile health interventions, and peer support networks to promote linkage and retention in care.

Brief Report: Reduced Use of Illicit Substances, Even Without Abstinence, Is Associated With Improved Depressive Symptoms Among People Living With HIV

PURPOSE

Substance use is linked with poor outcomes among people living with HIV (PLWH) and is associated with mental health disorders. This analysis examines the impact of decreasing substance use, even without abstinence, on depressive symptoms among PLWH.

METHODS

Data are from PLWH enrolled in the Centers for AIDS Research Network of Integrated Clinical Sites cohort. Participants completed longitudinal assessments of substance use (modified ASSIST) and depressive symptoms (PHQ-9). Changes in substance use frequency were categorized as abstinence, reduced use, and nondecreasing use. Adjusted linear mixed models with time-updated change in substance use frequency and depressive symptom scores were used to examine associations between changes in the use of individual substances and depressive symptoms. Analyses were repeated using joint longitudinal survival models to examine associations with a high (PHQ-9 ≥10) score.

RESULTS

Among 9905 PLWH, 728 used cocaine/crack, 1016 used amphetamine-type substances (ATS), 290 used illicit opiates, and 3277 used marijuana at baseline. Changes in ATS use were associated with the greatest improvements in depressive symptoms: stopping ATS led to a mean decrease of PHQ-9 by 2.2 points (95% CI: 1.8 to 2.7) and a 61% lower odds of PHQ-9 score ≥10 (95% CI: 0.30 to 0.52), and decreasing ATS use led to a mean decrease of 1.7 points (95% CI: 1.2 to 2.3) and a 62% lower odds of PHQ-9 score ≥10 (95% CI: 0.25 to 0.56). Stopping and reducing marijuana and stopping cocaine/crack use were also associated with improvement in depressive symptoms.

CONCLUSIONS

We demonstrated that both substance use reduction and abstinence are associated with improvements in depressive symptoms over time.

Opioid Agonist Treatment and Improved Outcomes at Each Stage of the HIV Treatment Cascade in People Who Inject Drugs in Ukraine

BACKGROUND

The HIV treatment cascade is a crucial tool to guide HIV prevention and treatment strategies. The extent to which opioid agonist treatments (OATs) such as methadone and buprenorphine influence this cascade was examined in a nationwide study of people who inject drugs (PWID) in Ukraine.

SETTING

Cross-sectional stratified survey of PWID followed by HIV and hepatitis C virus testing in 5 Ukrainian cities.

METHODS

Opioid-dependent PWID (N = 1613) were sampled from January 2014 to March 2015. Analysis was confined to 520 participants with HIV, with 184 (35.4%) prescribed OAT. Weighted logistic regression models were used to assess independent factors associated with the 5 steps in the HIV treatment cascade.

RESULTS

Compared with PWID not on OAT (N = 336), participants who prescribed OAT (N = 184) were significantly more likely to be diagnosed (91% vs. 71%), linked (81% vs. 52%), and retained (69% vs. 35%) in HIV care, and prescribed (56% vs. 31%) and optimally (>95% of doses) adherent to antiretroviral therapy (41% vs. 22%). Receiving OAT contributed most as an independent factor with every step of the cascade. Other steps in the HIV treatment cascade were influenced by age, depression, and geographical variability.

CONCLUSIONS

OAT remains an essential and effective strategy to not only treat patients with opioid use disorder, but also a crucial strategy to engage PWID in care to meet UNAIDS 90-90-90 targets. Geographical differences suggest local structural impediments. With low OAT coverage prescribed for 2.9% of the estimated 347,000 PWID in Ukraine, OAT expansion requires strategic interventions that target the individual, clinical care settings, policies, and funding.

Physician Mistrust, Medical System Mistrust, and Perceived Discrimination: Associations with HIV Care Engagement and Viral Load

Medical mistrust is an important risk factor for many health outcomes. For individuals with HIV and substance use co-morbidities, mistrust may influence engagement with health care, and affect overall health and transmission risk. Medical mistrust can be measured by an individual's mistrust of his/her physician, or mistrust of the medical system. This study examined both types of mistrust among 801 substance-using individuals with uncontrolled HIV infection. The aims were to determine how physician mistrust, medical system mistrust, and discrimination experiences were associated with engagement in HIV primary care. Findings indicated higher levels of physician mistrust, but not medical system mistrust, were associated with a longer time since the last visit to an HIV provider. Longer time since seeing an HIV care provider was associated with higher viral load. This study refines our understanding of the relationship between mistrust and HIV care engagement for a large, diverse sample of substance-using individuals.

Development of an evidence-based model of rapid testing, counseling and referral patients with HIV, HVC and other STDs in Mexican addiction treatment centers

Introduction. Efforts to identify new cases of HIV, HVC and other STIs, through the application of quick tests, focus on people who inject drugs, without taking into account the fact that the use of alcohol and other drugs of abuse inhibits decision making, increasing the transmission of STIs through risky sexual practices. Accordingly, it is necessary to have detection algorithms that consider people who use multiple drugs to improve the identification of new cases and their subsequent linkage with health services. Objective. This paper describes the development process of the OPB-APR model for the detection, counseling and referral of people with HIV and other STIs at addiction treatment centers. Method. The procedure is divided into three phases: 1. A literature review to identify the basic concepts of HIV and other STIs, substance use, risky sexual behaviors, quick tests, and specialized psychological counseling; 2. A feasibility study in which a health professional is trained to implement the OPB-APR model; 3. Drafting of the final version. Results. The final version of the OPB-APR model was obtained, which describes standardized procedures for detection, counseling and referral to health services. Discussion and conclusions. The OPB-APR model aims to strengthen the public health system by increasing the coverage of services for the detection of HIV, HCV and other STIs. The above through the implementation of standardized procedures among specialized and non-specialized health professionals of addiction care centers.

Criminal Justice System Involvement as a Risk Factor for Detectable Plasma HIV Viral Load in People Who Use Illicit Drugs: A Longitudinal Cohort Study

Among HIV-positive people who use illicit drugs (PWUD) in our setting, repeated periods of incarceration adversely affect ART adherence in a dose-dependent manner. However, the impact of non-custodial criminal justice involvement on HIV-related outcomes has not been previously investigated. Data were obtained from a longitudinal cohort of HIV-positive PWUD in a setting of universal no-cost ART and complete dispensation records. Multivariate generalized estimating equations were used to calculate the longitudinal odds of having a detectable HIV VL (VL) associated with custodial and non-custodial CJS exposure. Between 2005 and 2014, 716 HIV-positive ART-exposed PWUD were recruited. In multivariate analysis, both custodial [Adjusted odds ratio (AOR) 0.61, 95% CI 0.45-0.82] and noncustodial (AOR 0.78, 95% CI 0.62-0.99) involvement in the criminal justice system was associated with detectable HIV VL. Among HIV-positive PWUD, both custodial and non-custodial criminal justice involvement is associated with worse HIV treatment outcomes. Our findings highlight the need for increased ART adherence support across the full spectrum of the criminal justice system.

The Ryan White HIV/AIDS Program after the Patient Protection and Affordable Care Act full implementation: a critical review of predictions, evidence, and future directions

The Ryan White HIV/AIDS Program (RWHAP) has been effective in serving people living with HIV (PLWH). Our goal was to examine the impact of the implementation of the Affordable Care Act (ACA) on the program's role in HIV care and its clients. We utilized critical review to synthesize the literature on the anticipated effects of the ACA, and assess the evidence regarding the early effects of the ACA on the program and on PLWH who receive RWHAP services. To date, research on the impact of ACA on RWHAP has been fragmented. Despite the expected benefits of the ACA to PLWH, access and linkage to care, reducing inequity in HIV risk and access to care, and coping with comorbidities remain pressing challenges. There are additional gaps following ACA implementation related to immigrant care. RWHAP's proven success in addressing these challenges, and the political threats to ACA, highlight the need for maintaining the program to meet HIV care needs. More evidence on the role and impact of RWHAP in this new era is needed to guide policy and practice of care for PLWH. Additional research is needed to explore RWHAP care and its clients' health outcomes following ACA implementation, with a focus on at-risk groups such as immigrants, transgender women, homeless individuals, and PLWH struggling with mental health problems.

HIV and Substance Use Disorder: Role of the HIV Physician

The ongoing syndemic of substance use disorder and human immunodeficiency virus infection threatens progress made in preventing new infections and improving outcomes among those infected. To address this challenge effectively, human immunodeficiency virus physicians must take an increased role in the screening, diagnosis, and treatment of substance use disorders. Such treatment decreases human immunodeficiency virus risk behaviors and improves human immunodeficiency virus and substance use disorder-related outcomes. An effective response to this syndemic requires increased access to adjuvant interventions and a radical movement away from the current stigmatization and criminalization of those suffering from substance use disorders.

Prevalence and patterns of illicit drug use in people living with HIV in Spain: A cross-sectional study

This study assessed the prevalence and patterns of drug use among people living with HIV (PLHIV) in Spain. We conducted an observational cross-sectional study including 1401 PLHIV. Data were collected through 33 sites across Spain using an online computer-assisted self-administered interview. The survey measured use of illicit drugs and other substances, treatment adherence and health-related variables. To analyse patterns of drug use we performed cluster analysis in two stages. The most frequently consumed substances were: alcohol (86.7%), tobacco (55.0%), illicit drugs (49.5%), other substances (27.1%). The most prevalent illicit drugs used were cannabis (73.8%), cocaine powder (53.9%), and poppers (45.4%). Results found four clusters of PLHIV who used drugs. Two of them were composed mainly of heterosexuals (HTX): Cluster 1 (n = 172) presented the lowest polydrug use and they were mainly users of cannabis, and Cluster 2 (n = 84) grouped mostly men who used mainly heroin and cocaine; which had the highest percentage of people who inject drugs and presented the lowest level of treatment adherence (79.8±14.2; p < .0001). The other two clusters were composed mainly of men who have sex with men (MSM), who were mostly users of recreational drugs. Cluster 3 (n = 285) reported moderate consumption, both regarding frequency and diversity of drugs used, while Cluster 4 (n = 153) was characterized by the highest drug polyconsumption (7.4±2.2; p < .0001), and 4 grouped MSM who injected recreational drugs, and who reported the highest frequency of use of drugs in a sexual context (2.6±0.8; p < .0001) and rates of sexually transmitted infections (1.8±1.1; p < .01). This is the largest multi-centre cross-sectional study assessing the current prevalence and patterns of drug use among PLHIV in Spain. The highest prevalence of drug use was found among MSM, although HTX who used heroin and cocaine (Cluster 2) had the most problems with adherence to HIV treatment and the worst health status.

HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy

PURPOSE OF REVIEW

Scaling up evidence-based HIV prevention strategies like opioid agonist therapies (OAT), syringe services programs (SSPs), and antiretroviral therapy (ART) to mitigate the harms of drug injection is crucial within Eastern Europe and Central Asia (EECA), the only region globally where HIV incidence and mortality are increasing.

RECENT FINDINGS

Though the proportion of new HIV cases directly attributable to drug injection has recently declined, it remains a critical driver of HIV, especially to sexual partners. Concurrently, scale-up of OAT, SSPs, and ART has remained low, contributing to a volatile HIV epidemic among people who inject drugs (PWID). Despite evidence that drug injection contributes to an evolving HIV epidemic in EECA, coverage of evidence-based harm reduction programs remains substantially below needed targets. Due to a combination of punitive drug laws, ideological resistance to OAT among clinicians and policymakers, and inadequate domestic and international funding, limited progress has been observed in increasing the availability of these programs.

Syringe Decriminalization Advocacy in Red States: Lessons from the North Carolina Harm Reduction Coalition

PURPOSE OF REVIEW

Syringe access programs (SAPs) are cornerstone harm reduction interventions for combatting the national opioid epidemic. The goal of this paper is to describe effective advocacy strategies for enacting syringe decriminalization legislation to foster the expansion of SAPs in high-need areas amidst political opposition.

RECENT FINDINGS

Decades or research shows that SAPs prevent the transmission of HIV among people who inject drugs (PWID) and are a cost-effective tool for linking PWID to medical care, health education, and social services. In the USA, state laws criminalizing distribution and possession of syringes impede the expansion of SAPs into areas where they are sorely needed. In 2016, North Carolina became the first state to legalize SAPs with a Republican super majority. This paper distills strategies for community organizations seeking to advance syringe decriminalization legislation in politically conservative states with histories of prioritizing punitive sanctions over public health responses to drug use.

Integrated Models of Care for Individuals with Opioid Use Disorder: How Do We Prevent HIV and HCV?

Purpose of Review

To describe models of integrated and co-located care for opioid use disorder (OUD), hepatitis C (HCV), and HIV.

Recent Findings

The design and scale-up of multidisciplinary care models that engage, retain, and treat individuals with HIV, HCV, and OUD are critical to preventing continued spread of HIV and HCV. We identified 17 models within primary care (N = 3), HIV specialty care (N = 5), opioid treatment programs (N = 6), transitional clinics (N = 2), and community-based harm reduction programs (N = 1), as well as two emerging models.

Summary

Key components of such models are the provision of (1) medication-assisted treatment for OUD, (2) HIV and HCV treatment, (3) HIV pre-exposure prophylaxis, and (4) behavioral health services. Research is needed to understand differences in effectiveness between co-located and fully integrated care, combat the deleterious racial and ethnic legacies of the “War on Drugs,” and inform the delivery of psychiatric care. Increased access to harm reduction services is crucial.

Electronic supplementary material

The online version of this article (10.1007/s11904-018-0396-x) contains supplementary material, which is available to authorized users.

Prevalence and Correlates of Reporting Difficulty Taking Antiretroviral Treatment Among HIV-Positive Illicit Drug Users in Vancouver, Canada: A Longitudinal Analysis

People living with HIV who use illicit drugs continue to experience high rates of suboptimal treatment outcomes from antiretroviral therapy (ART). Although previous studies have identified important behavioural, social and structural barriers to ART adherence, the effects of patient-level factors have not been fully evaluated. Thus, we sought to investigate the prevalence and correlates of reporting ART was difficult to take among a cohort of illicit drug users in Vancouver, Canada. We accessed data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), an ongoing prospective cohort of HIV-positive illicit drug users linked to comprehensive HIV clinical monitoring records. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods in which individuals reported they found ART difficult to take. Between December 2005 and May 2014, 746 ART-exposed illicit drug users were recruited and contributed at least one study interview. Finding ART hard to take was reported by 209 (28.0%) participants at baseline, and 460 (61.7%) participants throughout the study period. Patients ingesting a greater daily pill count (adjusted odds ratio [AOR] = 1.12 per pill, 95% confidence interval [CI] 1.08-1.17) and experiencing barriers to healthcare (AOR = 1.64, 95% CI 1.34-2.01) were more likely to report difficulty taking ART. Patients less likely to report satisfaction with their HIV physician (AOR = 0.76, 95% CI 0.58-1.00) and achieve a non-detectable HIV viral load (AOR = 0.62, 95% CI 0.51-0.74) were more likely to report finding ART hard to take. In this community-recruited cohort of ART-exposed illicit drug users, a substantial proportion reported they found HIV treatment hard to take, which was clearly linked to higher dissatisfaction with healthcare experiences and, most importantly, a lower likelihood of experiencing optimal virologic outcomes. Our findings reveal a number of opportunities to improve HIV treatment experiences and outcomes for people who use illicit drugs, including the use of treatment regimens with lower pill burdens, as well as reducing barriers to healthcare access.

Factors Affecting HIV Testing among Youth in Kenya

With the high prevalence of HIV among youth in sub-Saharan Africa, it is vital to better understand factors affecting HIV testing among this population; this is the first step in the HIV treatment cascade. The purpose of this study was to examine factors related to behavioral intentions regarding HIV testing using existing pre-test data from the HIV SEERs (Stigma-reduction via Education, Empowerment, and Research) Project, a community-based participatory research program targeting 13-24-year-olds in Kenya. It was hypothesized that HIV knowledge, social support, subjective well-being, and mental health (depression, anxiety, and stress) would serve as facilitators to HIV testing while projected stigma and substance use would serve as barriers to HIV testing. In partial support of our hypotheses, findings from logistic regression analyses revealed that HIV knowledge, substance use, depression, and social support were significant predictors of HIV testing intentions. However, HIV knowledge and substance use served as facilitators while depression and social support served as barriers. While projected stigma was correlated with HIV testing intentions, it was not a significant predictor in the regression analysis. Subjective well-being, anxiety, and stress were not significant predictors in the regression analysis. These findings have important implications for HIV testing initiatives designed for youth in Kenya as well as future research on HIV testing with this population.

Integration of care for HIV and opioid use disorder

OBJECTIVE

We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings.

DESIGN

Systematic review.

METHODS

We searched Ovid MEDLINE, PubMed, Embase, PsycINFO and preidentified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country.

RESULTS

Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low-to-moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV-related and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits.

CONCLUSION

Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions.

REGISTRATION

A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).

Retention in care and mortality trends among patients receiving comprehensive care for HIV infection: a retrospective cohort study

BACKGROUND

Studies examining the relation between comprehensive care and health outcomes associated with comorbidities unrelated to HIV infection have focused mainly on the health outcomes of HIV-infected people and comorbid substance use disorders. We aimed to assess the impact of retention in comprehensive HIV infection care on overall, AIDS-related and non-AIDS-related mortality.

METHODS

Using a retrospective cohort design, we collected data for HIV-infected patients aged 19 years or more who first visited a comprehensive HIV infection clinic in Vancouver between Jan. 1, 2004, and Dec. 31, 2014. We defined retention in care as visit constancy (whether the patient attended the clinic at least once per given period) of 75% or greater. We used Poisson regression modelling to examine mortality trends. We performed Cox proportional hazards modelling to assess survival by retention during the first year of follow-up and identify factors associated with death.

RESULTS

A total of 2101 patients were included in the study. Of the 2101, 1340 (63.8%) were retained in the first year of care, and 271 (12.9%) died during the study period. Among the 264 cases in which the cause of death was known, although the primary underlying cause of death (74 [28.0%]) was AIDS-related, half of all AIDS-related deaths (37/74 [50%]) occurred early in the study (2004-2007). In later years, most deaths (147/184 [79.9%]) were non-AIDS-related. Overall mortality was significantly reduced among patients with higher retention in care during the first year of follow-up (per 20% increase in visit constancy; adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.79-0.96). Higher retention was also associated with reduced risk of AIDS-related death (adjusted HR 0.79, 95% CI 0.64-0.97).

INTERPRETATION

Although there was an overall trend toward decreased AIDS-related mortality over time, retention in care markedly decreased the likelihood of death. Maintaining patient engagement in comprehensive ancillary care is a patient-centred way of decreasing mortality rates among HIV-infected people.

Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study - a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV

Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, targeting effective analgesia in clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n = 41) were recruited from September 2015 to December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n = 187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: (1) a nurse care manager and electronic registry to assist with patient management; (2) opioid education and academic detailing; and (3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12 months. In parallel, PLWH receiving LTOT (n = 170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n = 117). Conclusions: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.

Ancillary service needs among persons new to HIV care and the relationship between needs and late presentation to care

Ancillary service needs likely influence time to diagnosis and presentation for HIV care. The effect of both met and unmet needs on late presentation to HIV care is not well understood. We used baseline data from 348 people with HIV (PWH) with no prior HIV care who enrolled in iENGAGE (a randomized controlled trial (RCT) of an intervention to support retention in care) at one of four HIV clinics in the US. A standardized baseline questionnaire collected information on ancillary service needs, and whether each need was presently unmet. We examined covariates known to be associated with disease stage at presentation to care and their association with needs. We subsequently assessed the relationship of needs with CD4 accounting for those other covariates by estimating prevalence ratios (PR) using inverse probability weights. Most patients enrolling in the RCT were male (79%) and the majority were Black (62%); median age was 34 years. Prevalence of any reported individual need was 69%. One-third of the sample had a baseline CD4 cell count <200, 42% between 200 and 499 and 27% ≥500. There was no statistically significant association between need or unmet need and baseline CD4. In general, psychiatric health and SU issues (depression, anxiety, and drug use) were consistently associated with higher prevalence of need (met and unmet). Additionally, the Black race was associated with higher basic resource needs (housing: PR 1.67, 95%CI 1.08-2.59; transportation: PR 1.65, 95% CI 1.12-2.45). Ancillary service needs (met and unmet) were common among patients new to HIV care and impacted vulnerable subgroups. However, we found no evidence that reporting a specific individual need, whether met or unmet, was associated with a timely presentation to HIV care. The impact of needs on subsequent steps of the HIV care continuum will be examined with longitudinal data.

"No more falling through the cracks": A qualitative study to inform measurement of integration of care of HIV and opioid use disorder

INTRODUCTION

Integration of HIV- and opioid use disorder (OUD)-related care is associated with improved patient outcomes. Our goal was to develop a novel instrument for measuring quality of integration of HIV and OUD-related care that would be applicable across diverse care settings.

METHODS

Grounded in community-based participatory research principles, we conducted a qualitative study from August through November 2017 to inform modification of the Behavioral Health Integration in Medical Care (BHIMC) instrument, a validated measure of quality of integration of behavioral health in primary care. We conducted semi-structured interviews of patients (n = 22), focus groups with clinical staff (n = 24), and semi-structured interviews of clinic leadership (n = 5) in two urban centers in Connecticut.

RESULTS

We identified three themes that characterize optimal integration of HIV- and OUD-related care: (1) importance of mitigating mismatches in resources and knowledge, particularly resources to address social risks and knowledge gaps about evidence-based treatments for OUD; (2) need for patient-centered policies and inter-organization communication, and (3) importance of meeting people where they are, geographically and at their stage of change. These themes highlighted aspects of integrated care for HIV and OUD not captured in the original BHIMC.

CONCLUSIONS

Patients, clinical staff, and organization leadership perceive that addressing social risks, communication across agencies, and meeting patients in their psychosocial and structural context are important for optimizing integration of HIV and OUD-related care. Our proposed, novel instrument is a step towards measuring and improving service delivery locally and nationally for this vulnerable population.

Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions

BACKGROUND

People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). However, PrEP has been underutilized in this population, and PrEP adherence intervention needs are understudied.

METHODS

To inform PrEP intervention development, we reviewed evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID. Guided by a behavioral model of healthcare utilization and using the PICOS framework, we conducted a systematic review in four electronic databases to identify original research studies of ART adherence in HIV-infected PWID in the United States and Canada between Jan 1, 2006-Dec 31, 2016. We synthesized and interpreted findings related to developing recommendations for PrEP adherence interventions for PWID.

RESULTS

After excluding 618 duplicates and screening 1049 unique records, we retained 20 studies of PWID (mean n = 465) with adherence-related outcomes (via pharmacy records: n = 9; self-report: n = 8; biological markers: n = 5; electronic monitoring: n = 2). Predisposing factors (patient-level barriers to adherence) included younger age, female sex, and structural vulnerability (e.g., incarceration, homelessness). Enabling resources (i.e., facilitators) that could be leveraged or promoted by interventions included self-efficacy, substance use treatment, and high-quality patient-provider relationships. Competing needs that require specific intervention strategies or adaptations included markers of poor physical health, mental health comorbidities (e.g., depression), and engagement in transactional sex.

CONCLUSIONS

HIV treatment adherence research carries important lessons for efforts to optimize PrEP adherence among PWID. Despite limitations, this systematic review suggests that strategies are needed to engage highly vulnerable and marginalized sub-groups of this underserved population (e.g., younger PWID, women who inject drugs) in PrEP adherence-related research and programming.

Contextual compatibility of three empirically supported behavior therapies for cART adherence among patients with substance use disorders

Though substance use disorders complicate adherence to combination antiretroviral therapy (cART), cognitive-behavioral therapy (CBT), contingency management (CM), and motivational interviewing (MI) each demonstrate efficacy to improve cART adherence among substance-using patients. To inform dissemination of these therapies, this mixed-method study was undertaken involving a full-day site visit to each of four HIV care settings. At each setting, an initial administrator interview elicited setting data. Paired focus groups with setting staff and patients then served as forums for open discussion and live polling of the therapies' respective contextual compatibility. Focus group recordings were subjected to a phenomenological narrative analysis by multidisciplinary investigators, and staff/patient compatibility ratings were analyzed via generalized linear models. Findings include: (1) emergent themes among staff of adaptability, patient-centeredness, and mission-congruence as desired therapy attributes, (2) emergent themes among patients of intrinsic motivation, respect for patient autonomy in illness management, and fairness among service recipients as desired therapy attributes; and (3) comparatively stronger staff perception of compatibility for MI than CBT or CM, and a similar albeit less robust or reliable pattern among patients. Collective findings support MI as a behavior therapy of choice for broad dissemination to HIV care settings to improve cART adherence of patients with substance use disorders.

Research priorities to inform "Treat All" policy implementation for people living with HIV in sub-Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA)

INTRODUCTION

"Treat All" - the treatment of all people with HIV, irrespective of disease stage or CD4 cell count - represents a paradigm shift in HIV care that has the potential to end AIDS as a public health threat. With accelerating implementation of Treat All in sub-Saharan Africa (SSA), there is a need for a focused agenda and research to identify and inform strategies for promoting timely uptake of HIV treatment, retention in care, and sustained viral suppression and addressing bottlenecks impeding implementation.

METHODS

The Delphi approach was used to develop consensus around research priorities for Treat All implementation in SSA. Through an iterative process (June 2017 to March 2018), a set of research priorities was collectively formulated and refined by a technical working group and shared for review, deliberation and prioritization by more than 200 researchers, implementation experts, policy/decision-makers, and HIV community representatives in East, Central, Southern and West Africa.

RESULTS AND DISCUSSION

The process resulted in a list of nine research priorities for generating evidence to guide Treat All policies, implementation strategies and monitoring efforts. These priorities highlight the need for increased focus on adolescents, men, and those with mental health and substance use disorders - groups that remain underserved in SSA and for whom more effective testing, linkage and care strategies need to be identified. The priorities also reflect consensus on the need to: (1) generate accurate national and sub-national estimates of the size of key populations and describe those who remain underserved along the HIV-care continuum; (2) characterize the timeliness of HIV care and short- and long-term HIV care continuum outcomes, as well as factors influencing timely achievement of these outcomes; (3) estimate the incidence and prevalence of HIV-drug resistance and regimen switching; and (4) identify cost-effective and affordable service delivery models and strategies to optimize uptake and minimize gaps, disparities, and losses along the HIV-care continuum, particularly among underserved populations.

CONCLUSIONS

Reflecting consensus among a broad group of experts, researchers, policy- and decision-makers, PLWH, and other stakeholders, the resulting research priorities highlight important evidence gaps that are relevant for ministries of health, funders, normative bodies and research networks.

Potential drivers of HIV acquisition in African-American women related to mass incarceration: an agent-based modelling study

Background

The United States has the highest incarceration rate in the world. Incarceration can increase HIV risk behaviors for individuals involved with the criminal justice system and may be a driver of HIV acquisition within the community.

Methods

We used an agent-based model to simulate HIV transmission in a sexual-contact network representing heterosexual African American men and women in Philadelphia to identify factors influencing the impact of male mass incarceration on HIV acquisition in women. The model was calibrated using surveillance data and assumed incarceration increased the number of sexual contacts and decreased HIV care engagement for men post-release. Incarceration of a partner increased the number of sexual contacts for women. We compared a counterfactual scenario with no incarceration to scenarios varying key parameters to determine what factors drove HIV acquisition in women.

Results

Setting the duration of male high-risk sexual behavior to two years post-release increased the number of HIV transmissions to women by more than 20%. Decreasing post-release HIV care engagement and increasing HIV acquisition risk attributable to sexually transmitted infections (STIs) also increased the number of HIV transmissions to women. Changing the duration of risk behavior for women, the proportion of women engaging in higher risk behavior, and the relative risk of incarceration for HIV-infected men had minimal impact.

Conclusion

The mass incarceration of African American men can increase HIV acquisition in African American women on a population-level through factors including post-release high-risk behaviors, disruption of HIV care engagement among formerly incarcerated men, and increased STI prevalence. These findings suggest that the most influential points of intervention may be programs seeking to reduce male risk behaviors and promote HIV care engagement post-release, as well as STI testing and treatment programs for recently incarcerated men, as well as women with incarcerated partners.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6304-x) contains supplementary material, which is available to authorized users.

Integrated Care on Leaving Hospital Against Medical Advice Among HIV-Infected People with Substance Use Disorders

HIV-infected people with substance use disorders (HIV-SUDs) are at increased risk of leaving hospital against medical advice (LHAMA). The aim of this study was to evaluate the incidence of LHAMA in HIV-SUDs admitted to a patient-centered hospital where they receive integrated care, including healthcare, substance use treatment, and social support. Observational study was conducted at an urban acute-care university teaching hospital. Integrated care included a specialist in addiction medicine and a social worker incorporated into the medical staff. LHAMA was defined as participants leaving the hospital without the physician's permission and not returning within 6 h. Two hundred and ninety-nine HIV-SUDs were hospitalized, and 79 (26.4%) patients were readmitted, generating a total of 517 admissions during 2010-2016. Over the study period, 45 LHAMA were registered, yielding an incidence of 8.7%. On multiple logistic regression analysis, admission for malignancies (OR:4.2; p .02), retention in substance use treatment (OR:0.3; p .01), intravenous substance use (OR:3.1; 0.05), and marginally being foreign (OR:2.1; p .06) were independent factors associated with LHAMA. Despite the patient-centered hospital care, including integrated care, patients with lack of SUD treatment or with intravenous substance use are at increased risk of LHAMA. So, additional measures are necessary to reduce the risk of LHAMA among HIV-SUD.

Cognitive-affective depressive symptoms and substance use among Latino and non-Latino White patients in HIV care: an analysis of the CFAR network of integrated clinical systems cohort

The disparity in viral suppression rates between Latino and non-Latino White patients in HIV care appears to be narrowing, but it is unclear if depression and substance use perpetuate this disparity. We analyzed electronic medical records from the CFAR network of integrated clinical systems cohort. First observations/enrollment data collected between 2007 and 2013 were analyzed, which included survey (race/ethnicity, depression, substance use, adherence) and clinical data (viral suppression). We estimated indirect effects with a regression-based bootstrapping method. In 3129 observations, Latinos and non-Latino Whites did not differ in depression or alcohol use (ORs 1.11, 0.99, ns), but did in drug use (OR 1.13, p < .001). For all patients, depression and substance use were indirectly associated with small increases (ORs 1.02-1.66) in the odds for a detectable viral load, via worse adherence. We conclude that variables not captured in EMR systems (e.g., health literacy, structural factors) may better explain viral suppression disparities that persist.

Harmful alcohol drinking among HIV-positive people in Nepal: an overlooked threat to anti-retroviral therapy adherence and health-related quality of life

Background: People living with Human Immunodeficiency Virus (HIV) often suffer from alcohol-use disorders resulting in their poor health and treatment outcomes. Little is known about the association of harmful alcohol drinking with their adherence to anti-retroviral therapy (ART) and health-related quality of life (QOL) in low-resource settings.

Objective: This study aimed to investigate associations between harmful alcohol drinking, adherence to ART and health-related QOL in HIV-positive people, stratified by gender, in Nepal.

Methods: We conducted a cross-sectional study of 682 HIV-positive people on ART to measure their self-reported harmful alcohol drinking and non-adherence to ART in the previous month of data collection. We also measured health-related QOL using a WHOQOL-HIV BREF scale. The association between harmful alcohol drinking and non-adherence to ART was examined using multiple logistic regressions. Additionally, multiple linear regressions examined association between harmful alcohol drinking and QOL.

Results: Harmful alcohol drinking was associated with non-adherence to ART among men (AOR: 2.48, 95% CI: 1.50, 4.11, p < 0.001) and women (AOR: 2.52, 95% CI: 1.32, 4.80, p = 0.005). Men were more likely to have lower score for the psychological (β = −0.55, p = 0.021) and level of independence (β = −0.68, p = 0.018) domains when they had harmful alcohol drinking. Moreover, women were more likely to have lower scores for the physical (β = −1.01, p = 0.015), social relations (β = −0.82, p = 0.033), environmental (β = −0.88, p = 0.011), and spiritual (β = −1.30, p = 0.005) domains of QOL when they had harmful alcohol drinking.

Conclusions: Harmful alcohol drinking had a negative association with ART adherence and QOL in both HIV-positive men and women in Nepal. Screening for alcohol-use disorders and community-based counseling services should be provided while delivering ART services to improve treatment adherence and QOL.

Psychiatric Comorbidities among People Who Inject Drugs in Hai Phong, Vietnam: The Need for Screening and Innovative Interventions

The objective of this study is to describe psychiatric comorbidities, associated factors, and access to psychiatric assessment and care in a cohort of people who inject drugs (PWID) in Hai Phong, Vietnam. Mental health was assessed after 12 months' follow-up using the Mini International Neuropsychiatric Interview questionnaire (MINI 5.0.0). PWID medical history, drug use, and sociodemographic and clinical characteristics were also collected. Among 188 PWID who participated in the assessment, 48 (25.5%) had at least one psychiatric disorder and 19 (10.1%) had 2 or more psychiatric disorders. The most common current psychiatric disorders were major depressive episode (12.2%) and psychotic disorder (4.8%), reaching 10.1% for the latter when lifetime prevalence was considered. Females were more likely than males to have at least one psychiatric disorder, a major depressive disorder, or an anxiety disorder. Methamphetamine use was associated with an increased risk of presenting a lifetime psychotic syndrome. Problematic alcohol consumption was associated with an increased risk of having at least one psychiatric disorder. Psychiatric comorbidities are frequent among PWID in Vietnam. These results highlight the need for routine assessment and innovative interventions to address mental health needs among PWID. Community-based interventions targeting mental health prevention and care should be strongly supported.

Prevalence, Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV

We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.

Retention in HIV care during the 3 years following release from incarceration: A cohort study

BACKGROUND

Sustained retention in HIV care (RIC) and viral suppression (VS) are central to US national HIV prevention strategies, but have not been comprehensively assessed in criminal justice (CJ) populations with known health disparities. The purpose of this study is to identify predictors of RIC and VS following release from prison or jail.

METHODS AND FINDINGS

This is a retrospective cohort study of all adult people living with HIV (PLWH) incarcerated in Connecticut, US, during the period January 1, 2007, to December 31, 2011, and observed through December 31, 2014 (n = 1,094). Most cohort participants were unmarried (83.7%) men (77.0%) who were black or Hispanic (78.1%) and acquired HIV from injection drug use (72.6%). Prison-based pharmacy and custody databases were linked with community HIV surveillance monitoring and case management databases. Post-release RIC declined steadily over 3 years of follow-up (67.2% retained for year 1, 51.3% retained for years 1-2, and 42.5% retained for years 1-3). Compared with individuals who were not re-incarcerated, individuals who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p < 0.001) but less likely to have VS (72% versus 81%; p = 0.048). Using multivariable logistic regression models (individual-level analysis for 1,001 individuals after excluding 93 deaths), both sustained RIC and VS at 3 years post-release were independently associated with older age (RIC: adjusted odds ratio [AOR] = 1.61, 95% CI = 1.22-2.12; VS: AOR = 1.37, 95% CI = 1.06-1.78), having health insurance (RIC: AOR = 2.15, 95% CI = 1.60-2.89; VS: AOR = 2.01, 95% CI = 1.53-2.64), and receiving an increased number of transitional case management visits. The same factors were significant when we assessed RIC and VS outcomes in each 6-month period using generalized estimating equations (for 1,094 individuals contributing 6,227 6-month periods prior to death or censoring). Additionally, receipt of antiretroviral therapy during incarceration (RIC: AOR = 1.33, 95% CI 1.07-1.65; VS: AOR = 1.91, 95% CI = 1.56-2.34), early linkage to care post-release (RIC: AOR = 2.64, 95% CI = 2.03-3.43; VS: AOR = 1.79; 95% CI = 1.45-2.21), and absolute time and proportion of follow-up time spent re-incarcerated were highly correlated with better treatment outcomes. Limited data were available on changes over time in injection drug use or other substance use disorders, psychiatric disorders, or housing status.

CONCLUSIONS

In a large cohort of CJ-involved PLWH with a 3-year post-release evaluation, RIC diminished significantly over time, but was associated with HIV care during incarceration, health insurance, case management services, and early linkage to care post-release. While re-incarceration and conditional release provide opportunities to engage in care, reducing recidivism and supporting community-based RIC efforts are key to improving longitudinal treatment outcomes among CJ-involved PLWH.

Adherence to antiretroviral therapy and correlation with adverse effects and coinfections in people living with HIV/AIDS in the municipality of Goiás State

INTRODUCTION

Acquired immunodeficiency syndrome is an advanced stage of a human immunodeficiency virus infection. The antiretroviral therapy aims to improve the life quality of HIV patients and a good adherence is essential for a better prognosis. This study aimed to evaluate the adherence of human immunodeficiency virus/acquired immunodeficiency syndrome patients to antiretroviral therapy recommended by the Brazilian health system in Anápolis/Goiás, and correlate the level of adherence with sociodemographic data and clinical-laboratory variables.

METHODS

Adherence to antiretroviral therapy was assessed using the Questionnaire for Evaluation of Adherence to Antiretroviral Therapy. The sociodemographic data were collected using a standardized questionnaire and the clinical-laboratory records were reviewed.

RESULTS

Among 220 patients included, 59% (129/220) were men and the average age was 41 years. Infection was acquired primarily through sexual contact (92%, 202/220), and 69% (152/220) of the patients were heterosexual. Approximately 86% (188/220) of the patients had good or strict adherence to antiretroviral therapy. In our study, the use of illicit drugs was associated with low adherence to antiretroviral therapy (p=0.0004), and no significant association was observed between adherence levels and other sociodemographic data (p>0.05). The logistic regression indicated that adverse effects (p=0.0018) and sexual orientation (p=0.0152) were associated with the level of adherence to antiretroviral therapy. Patients with good or strict adherence had higher CD4+T lymphocyte count (p<0.0001) and undetectable viral load (p<0.0001). Patients with low adherence (14%, 32/220) had higher frequency of adverse events (p=0.0009). The frequency of coinfections was 25% (55/220), with syphilis and tuberculosis being the most common coinfections.

CONCLUSIONS

Adherence was related to use of illicit drugs, adverse effects, and sexual orientation.

HIV treatment outcomes among formerly incarcerated transitions clinic patients in a high prevalence setting

BACKGROUND

Incarceration disproportionately affects people living with HIV/AIDS. When people are released from jail or prison, they face multiple barriers to HIV care, and those who do engage in care may have suboptimal HIV treatment outcomes. A limited number of studies have investigated HIV treatment outcomes among people who have been released from incarceration.

METHODS

We conducted a retrospective cohort study comparing HIV viral load (VL) suppression and retention in care 12 months after entry into care among patients of a post-incarceration Transitions Clinic (TC) and a comparison group who received HIV care in the same community. Of 138 participants, 38 TC patients were matched to 100 non-TC controls based on age, race/ethnicity, gender, and date of HIV care entry.

RESULTS

There was no significant difference in clinical study outcomes between TC and non-TC patients: 63% vs. 67% (p = 0.67) were retained in care and 54% vs. 63% (p = 0.33) had suppressed VL at 12 months. After adjusting for substance use disorder and viral load suppression at the start of treatment, the odds ratio of TC patients' 12-month retention was 0.60 (95% CI 0.25-1.49) and VL suppression was 0.44 (95% CI 0.16-1.23) compared with non-TC patients.

CONCLUSIONS

Our findings show HIV care outcomes for patients at a post-incarceration Transitions Clinic that are similar to those of community-based comparison patients. The transitions clinic model, which provides medical, behavioral health, and supportive services to formerly incarcerated people, may be an effective model of care for this population; however, more scholarship is needed to quantify the components most effective in supporting retention in care and viral load suppression.

Assessment of barrier severity and willingness to enter opioid agonist treatment among people who inject drugs in Ukraine

BACKGROUND

Opioid agonist therapies (OAT) in Ukraine were first introduced in 2004 not as addiction treatment, but for HIV prevention. Numerous obstacles have thwarted OAT scale-up, including individual constraints and structural barriers.

METHODS

A cross-sectional survey of 1613 opioid dependent people who inject drugs (PWID) were recruited in 2014-2015 using stratified sampling in Kyiv, Odesa, Mykolayiv, Dnipro and Lviv. Analysis was restricted to a subset of 811 PWID who never received OAT. Barriers to OAT were assessed based on reasons why study participants were reluctant to enroll into OAT. A Rasch model from the Item Response Theory was applied to 24 potential barriers, used to score their severity and estimate a latent composite measure for each person's willingness and ability to participate in OAT.

RESULTS

The Rasch model confirmed the cumulative nature of barriers with concerns over treatment efficacy, safety and tolerability being more prevalent than barriers related to logistical constraints, opportunity costs and social stigma. If barriers related to treatment perception and logistics were eliminated, the average barrier number would decrease from 10 to 2.2. Participants were more likely to have a higher resistance to OAT entry if they experienced fewer overdoses, did not attain higher education, were not previously incarcerated and if their peers did not have a higher level of resistance to OAT.

CONCLUSIONS

Understanding the interdependence of various barriers and attitudes toward OAT can improve the rate of OAT expansion and ameliorate entry into substance abuse treatment programs in Ukraine.

Effect of Rational Emotive Health Therapy on Alcohol Use Among Community-dwelling, HIV-positive Patients

BACKGROUND

Patients who have tested positive for the human immunodeficiency virus (HIV) and who also experience alcohol use disorder (AUD) symptoms have worse clinical outcomes when compared with those who do not have AUD symptoms. The objective of the present study was to determine the effect of rational emotive health therapy (REHT) on AUD among community-dwelling, HIV-positive patients in the Southeastern region of Nigeria.

METHODS

The research design included a pretest/post-test control group with a total of 124 community-dwelling, HIV-positive patients with AUD symptoms participating in the study. The measures employed for data collection included Alcohol-related Irrational Beliefs Scale (AIBS) and Alcohol Use Disorder Scale (AUDS). Repeated measures analysis of variance was used for statistical analysis.

RESULTS

The result obtained at the initial assessment indicated that AUD was severe. Furthermore, REHT intervention led to a significant reduction in AUD symptoms, as shown by a reduction in AUDS and AIBS scores with time in the treatment group compared to those in the waitlist control group after the intervention. Also, the effect of REHT was positively maintained in the treatment group participants at follow-up assessment.

CONCLUSION

The presence of HIV symptoms alone does not cause HIV-positive patients to be dependent on alcohol; rather, irrational beliefs about the infection may contribute to unhealthy feelings and abuse of alcohol. Rational emotive health therapy is an effective approach that can be employed by therapists and health counselors in helping HIV-positive patients to think rationally about themselves and work to be able to overcome HIV-related, as well as alcohol-related, irrational beliefs.

Prevalence, Diagnosis, and Treatment Rates of Mood Disorders among Opioid Users under Criminal Justice Supervision

BACKGROUND

Individuals involved in the criminal justice system have disproportionately high rates of psychiatric disorders when compared to the general U.S.

POPULATION

If left untreated, the likelihood of subsequent arrest increases and risk for adverse health consequences is great, particularly among opioid users.

OBJECTIVES

To explore the prevalence, characteristics, and treatment of mood disorders among justice involved opioid-dependent populations.

METHODS

The current study enrolled 258 treatment-seeking opioid-dependent individuals under community-based criminal justice supervision (e.g., probation, parole) screened from the larger parent study, Project STRIDE, a seek/test/treat randomized control trial (RCT) examining HIV and opioid use treatment. During baseline, individuals were screened for depression using the Patient Health Questionnaire-9 (PHQ-9) and screened for bipolar disorder using the Mood Disorder Questionnaire (MDQ) tool.

RESULTS

Overall, 78 (30%) participants screened positive for moderate to severe depression and 54 (21%) screened positive for bipolar disorder. Participants self-reported mood disorders at higher rates than they screened positive for these conditions. Participants screening positive for these conditions experienced significantly greater family, legal, and medical problems on the Addiction Severity Index-Lite (ASI-Lite) than those who did not screen positive. Incidence of a lifetime suicide attempt was found to be associated with a positive screen for both mood disorders. Prescribed psychotropic treatment utilization was similar among those who screened positive for depression or bipolar disorder with approximately 38% reporting taking medication.

IMPORTANCE

Findings suggest universal mood disorder screening to improve comprehensive psychiatric care and treatment of opioid-dependent justice-involved individuals.