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Bazazi AR, Wickersham JA, Wegman MP, Culbert GJ, Pillai V, Shrestha R, Al-Darraji H, Copenhaver MM, Kamarulzaman A, Altice FL. Design and implementation of a factorial randomized controlled trial of methadone maintenance therapy and an evidence-based behavioral intervention for incarcerated people living with HIV and opioid dependence in Malaysia. Contemp Clin Trials 2017; 59:1-12. [PMID: 28479216 DOI: 10.1016/j.cct.2017.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 04/13/2017] [Accepted: 05/03/2017] [Indexed: 12/13/2022]
Abstract
Incarcerated people living with HIV and opioid dependence face enormous challenges to accessing evidence-based treatment during incarceration and after release into the community, placing them at risk of poor HIV treatment outcomes, relapse to opioid use and accompanying HIV transmission risk behaviors. Here we describe in detail the design and implementation of Project Harapan, a prospective clinical trial conducted among people living with HIV and opioid dependence who transitioned from prison to the community in Malaysia from 2010 to 2014. This trial involved 2 interventions: within-prison initiation of methadone maintenance therapy and an evidence-based behavioral intervention adapted to the Malaysian context (the Holistic Health Recovery Program for Malaysia, HHRP-M). Individuals were recruited and received the interventions while incarcerated and were followed for 12months after release to assess post-release HIV transmission risk behaviors and a range of other health-related outcomes. Project Harapan was designed as a fully randomized 2×2 factorial trial where individuals would be allocated in equal proportions to methadone maintenance therapy and HHRP-M, methadone maintenance therapy alone, HHRP-M alone, or control. Partway through study implementation, allocation to methadone maintenance therapy was changed from randomization to participant choice; randomization to HHRP-M continued throughout. We describe the justification for this study; the development and implementation of these interventions; changes to the protocol; and screening, enrollment, treatment receipt, and retention of study participants. Logistical, ethical, and analytic issues associated with the implementation of this study are discussed.
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Affiliation(s)
- Alexander R Bazazi
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, CT, USA; Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA.
| | - Jeffrey A Wickersham
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; University Malaya, Centre of Excellence for Research in AIDS (CERiA), Kuala Lumpur, Malaysia
| | - Martin P Wegman
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; University of Florida College of Medicine, Department of Health Outcomes and Policy, Gainesville, FL, USA
| | - Gabriel J Culbert
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; University of Illinois at Chicago College of Nursing, Department of Health Systems Science, Chicago, IL, USA
| | - Veena Pillai
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; University Malaya, Centre of Excellence for Research in AIDS (CERiA), Kuala Lumpur, Malaysia
| | - Roman Shrestha
- University of Connecticut Health Center, Department of Community Medicine & Health Care, Farmington, CT, USA; University of Connecticut, Department of Allied Health Sciences, Storrs, CT, USA
| | - Haider Al-Darraji
- University Malaya, Centre of Excellence for Research in AIDS (CERiA), Kuala Lumpur, Malaysia; Centre for International Health, Department of Preventive and Social Medicine, University of Otago, Dunedin 9016, New Zealand
| | - Michael M Copenhaver
- University of Illinois at Chicago College of Nursing, Department of Health Systems Science, Chicago, IL, USA
| | - Adeeba Kamarulzaman
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; University Malaya, Centre of Excellence for Research in AIDS (CERiA), Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, CT, USA; Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; University Malaya, Centre of Excellence for Research in AIDS (CERiA), Kuala Lumpur, Malaysia
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The Influence of Neurocognitive Impairment, Depression, and Alcohol Use Disorders on Health-Related Quality of Life among Incarcerated, HIV-Infected, Opioid Dependent Malaysian Men: A Moderated Mediation Analysis. AIDS Behav 2017; 21:1070-1081. [PMID: 27544515 DOI: 10.1007/s10461-016-1526-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Prior research has widely recognized neurocognitive impairment (NCI), depression, and alcohol use disorders (AUDs) as important negative predictors of health-related quality of life (HRQoL) among people living with HIV (PLWH). No studies to date, however, have explored how these neuropsychological factors operate together and affect HRQoL. Incarcerated male PLWH (N = 301) meeting criteria for opioid dependence were recruited from Malaysia's largest prison. Standardized scales for NCI, depression, alcohol use disorders (AUDs) and HRQoL were used to conduct a moderated mediation model to explore the extent to which depression mediated the relationship between NCI, HRQoL, and AUDs using an ordinary least squares regression-based path analytic framework. Results showed that increasing levels of NCI (B = -0.1773, p < 0.001) and depression (B = -0.6147, p < 0.001) were negatively associated with HRQoL. The effect of NCI on HRQoL was significantly (Sobel z = -3.5600, p < 0.001) mediated via depression (B = -0.1230, p < 0.001). Furthermore, the conditional indirect effect of NCI on HRQoL via depression for individuals with AUDs was significant (B = -0.9099, p = 0.0087), suggesting a moderated mediation effect. The findings disentangle the complex relationship using a moderated mediation model, demonstrating that increasing levels of NCI, which can be reduced with HIV treatment, negatively influenced HRQoL via depression for individuals with AUDs. This highlights the need for future interventions to target these complex interplay between neuropsychological factors in order to improve HRQoL among PLWH, particularly incarcerated PLWH with AUDs.
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