Patterns of substance use among HIV-positive adults over 50: implications for treatment and medication adherence

Association of ART regimen and adherence to viral suppression: an observational study of a clinical population of people with HIV

Adherence to antiretroviral therapy (ART) is essential for the effective management of HIV, which includes keeping the HIV viral load undetectable. This study aimed to determine whether certain ART medications are more "forgiving" of poor adherence in achieving viral suppression. We identified subgroups of ART medication usage and determined the extent to which ART adherence is associated with viral suppression across those subgroups. Data came from claims and clinical records (2017-2019) of 3,552 HIV-positive adult members of a Medicaid managed care plan. Pharmacy fill data were examined to characterize ART medications using latent class analysis (LCA), which captures the complexity of real-world ART usage (i.e., multiple medications, ART switching). LCA yielded five ART medication patterns over three years, mostly characterized by recent medications and formulations of ART, though they varied in number of tablets and in medication class. Mixed effects logistic regression models were estimated to determine whether odds of viral suppression differed by ART adherence level. After adjusting for covariates, those with at least 90% adherence (i.e., 90 to < 95%) did not significantly differ from those with 95% adherence or greater in terms of viral suppression, which corroborates existing clinical recommendations. These findings can inform provider-patient communication for people with HIV, especially those who have difficulty maintaining adherence. This includes those experiencing unstable housing, mental health conditions, or substance use.

Pain, Substance Use Disorders, Mental Health, and Buprenorphine Treatment among Patients With and Without HIV

Treatment of opioid use disorder (OUD) with buprenorphine improves outcomes and mortality among people with HIV (PWH). However, engagement is low and is influenced by comorbidities. We examined the impact of patterns of co-occurring pain, substance use disorders (SUDs), and mental health diagnoses on buprenorphine initiation and retention in PWH. The Veterans Aging Cohort Study contained 7,875 patients (2,702 PWH and 5,173 without HIV) with new OUD clinical encounters (2008-2017). Buprenorphine initiation and retention were derived from prescription data. We identified patterns of co-occurring diagnoses (via ICD codes) and assessed the effects of class membership on both outcomes using latent class analysis and regression analyses. The mean age of patients was 55, 98% were male, 58% Black, 8% Hispanic, and only 8% initiated buprenorphine within 12 months of OUD diagnosis. Four classes of co-occurring diagnoses were identified: "Few Co-occurring Diagnoses" (42.3%); "Multiple Pain Conditions" (21.3%); "Pain + SUD" (18.4%) and "Pain + SUD + Mental Health" (18.0%). Patients in the "Pain + SUD" class and "Pain + SUD + Mental Health" class were significantly less likely to initiate buprenorphine and had 59% and 45% lower odds, respectively, of initiating buprenorphine compared with patients in the "Few Co-occurring Diagnoses" class; this effect did not vary by HIV status. Buprenorphine retention was not significantly associated with HIV status or class membership. However, Black Veterans were less likely to initiate or be retained in buprenorphine treatment. Higher comorbidity burden was negatively associated with buprenorphine initiation but not with retention. More research is warranted to determine other factors that may influence treatment retention.

Effectiveness of an intervention to improve ART adherence among men who have sex with men living with HIV: a randomized controlled trial in three public HIV clinics in Mexico

We conducted a parallel-group randomized controlled trial in three HIV clinics in Mexico to evaluate a user-centred habit-formation intervention to improve ART adherence among MSM living with HIV. We randomized 74 participants to the intervention group and 77 to the control group. We measured adherence at one, four, and ten months through medication possession ratio and self-reported adherence. Additionally, we measured viral load, CD4 cell count, major depression disorder symptoms, and alcohol and substance use disorder at baseline, fourth and tenth months. We found no statistically significant effect on adherence between groups. However, the intervention demonstrated positive results in major depression disorder symptoms (21% vs. 6%, p = 0.008) and substance use disorder (11% vs. 1%, p = 0.018) in the fourth month. The latter is relevant because, in addition to its direct benefit, it might also improve the chances of maintaining adequate adherence in the long term. This trial was retrospectively registered at ClinicalTrials.gov (trial number NCT03410680) on 8 January 2018.Trial registration: ClinicalTrials.gov identifier: NCT03410680.

Impaired extinction of cocaine seeking in HIV-infected mice is accompanied by peripheral and central immune dysregulation

Substance use disorders (SUDs) are highly comorbid with HIV infection, necessitating an understanding of the interactive effects of drug exposure and HIV. The relationship between HIV infection and cocaine use disorder is likely bidirectional, with cocaine use directly impacting immune function while HIV infection alters addiction-related behavior. To better characterize the neurobehavioral and immune consequences of HIV infection and cocaine exposure, this study utilizes a humanized mouse model to investigate the outcomes of HIV-1 infection on cocaine-related behaviors in a conditioned place preference (CPP) model, and the interactive effects of cocaine and HIV infection on peripheral and central nervous system inflammation. HIV infection selectively impairs cocaine CPP extinction without effecting reinstatement or cocaine seeking under conflict. Behavioral alterations are accompanied by immune changes in HIV infected mice, including increased prefrontal cortex astrocyte immunoreactivity and brain-region specific effects on microglia number and reactivity. Peripheral immune system changes are observed in human cytokines, including HIV-induced reductions in human TNFα, and cocaine and HIV interactions on GM-CSF levels. Together these data provide new insights into the unique neurobehavioral outcomes of HIV infection and cocaine exposure and how they interact to effect immune responses.

Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis

Women Living with HIV (WLHIV) who use substances face stigma related to HIV and substance use (SU). The relationship between the intersection of these stigmas and adherence to antiretroviral therapy (ART), as well as the underlying mechanisms, remains poorly understood. This study aimed to examine the association between intersectional HIV and SU stigma and ART adherence, while also exploring the potential role of depression and fear of negative evaluation (FNE) by other people in explaining this association. We analyzed data from 409 WLHIV collected between April 2016 and April 2017, Using Multidimensional Latent Class Item Response Theory analysis. We identified five subgroups (i.e., latent classes [C]) of WLHIV with different combinations of experienced SU and HIV stigma levels: (C1) low HIV and SU stigma; (C2) moderate SU stigma; (C3) higher HIV and lower SU stigma; (C4) moderate HIV and high SU stigma; and (C5) high HIV and moderate SU stigma. Medication adherence differed significantly among these classes. Women in the class with moderate HIV and high SU stigma had lower adherence than other classes. A serial mediation analysis suggested that FNE and depression symptoms are mechanisms that contribute to explaining the differences in ART adherence among WLHIV who experience different combinations of intersectional HIV and SU stigma. We suggest that FNE is a key intervention target to attenuate the effect of intersectional stigma on depression symptoms and ART adherence, and ultimately improve health outcomes among WLHIV.

Cocaine regulates antiretroviral therapy CNS access through pregnane-x receptor-mediated drug transporter and metabolizing enzyme modulation at the blood brain barrier

BACKGROUND

Appropriate interactions between antiretroviral therapies (ART) and drug transporters and metabolizing enzymes at the blood brain barrier (BBB) are critical to ensure adequate dosing of the brain to achieve HIV suppression. These proteins are modulated by demographic and lifestyle factors, including substance use. While understudied, illicit substances share drug transport and metabolism pathways with ART, increasing the potential for adverse drug:drug interactions. This is particularly important when considering the brain as it is relatively undertreated compared to peripheral organs and is vulnerable to substance use-mediated damage.

METHODS

We used an in vitro model of the human BBB to determine the extravasation of three first-line ART drugs, emtricitabine (FTC), tenofovir (TFV), and dolutegravir (DTG), in the presence and absence of cocaine, which served as our illicit substance model. The impact of cocaine on BBB integrity and permeability, drug transporters, metabolizing enzymes, and their master transcriptional regulators were evaluated to determine the mechanisms by which substance use impacted ART central nervous system (CNS) availability.

RESULTS

We determined that cocaine had a selective impact on ART extravasation, where it increased FTC's ability to cross the BBB while decreasing TFV. DTG concentrations that passed the BBB were below quantifiable limits. Interestingly, the potent neuroinflammatory modulator, lipopolysaccharide, had no effect on ART transport, suggesting a specificity for cocaine. Unexpectedly, cocaine did not breach the BBB, as permeability to albumin and 4 kDa FITC-dextran, as well as tight junction proteins and adhesion molecules remained unchanged. Rather, cocaine selectively decreased the pregnane-x receptor (PXR), but not constitutive androstane receptor (CAR). Consequently, drug transporter expression and activity decreased in endothelial cells of the BBB, including p-glycoprotein (P-gp), breast cancer resistance protein (BCRP), and multidrug resistance-associated protein 4 (MRP4). Further, cytochrome P450 3A4 (CYP3A4) enzymatic activity increased following cocaine treatment that coincided with decreased expression. Finally, cocaine modulated adenylate kinases that are required to facilitate biotransformation of ART prodrugs to their phosphorylated, pharmacologically active counterparts.

CONCLUSION

Our findings indicate that additional considerations are needed in CNS HIV treatment strategies for people who use cocaine, as it may limit ART efficacy through regulation of drug transport and metabolizing pathways at the BBB.

Racial, ethnic, and age disparities in the association of mental health symptoms and polysubstance use among persons in HIV care

We characterized polysubstance use burden and associations with mental health problems across demographic subgroups of PWH. In 2018-2020, as part of a primary care-based intervention study, PWH in care at three medical centers in Kaiser Permanente Northern California were screened for depression (PHQ-9≥10), anxiety (GAD-2≥3), and substance use (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]≥1 per substance). We used Poisson regression to estimate prevalence ratios (PRs) comparing polysubstance use prevalence (TAPS≥1 for ≥2 substances) between PWH with positive screens for depression or anxiety vs. neither, among all PWH, and stratified by race/ethnicity and age (restricted to men), adjusting for sociodemographics, CD4, and HIV load. Screened PWH (N = 2865) included 92% men, 56% White, 19% Black, and 15% Hispanic PWH, with a median age of 55 years. Overall, polysubstance use prevalence was 26.4% (95% CI 24.9%-28.1%). PWH with depression or anxiety (n = 515) had an adjusted polysubstance use PR of 1.26 (1.09-1.46) vs. PWH with neither (n = 2350). Adjusted PRs were 1.47 (1.11-1.96), 1.07 (0.74-1.54), and 1.10 (0.85-1.41) among Black, Hispanic, and White men, respectively. Adjusted PRs did not differ by age group. Interventions should consider jointly addressing mental health and substance use problems and potential drivers, e.g. stigma or socioeconomic factors.

Impaired extinction of cocaine seeking in HIV-infected mice is accompanied by peripheral and central immune dysregulation

Substance use disorders (SUDs) are highly comorbid with HIV infection, necessitating an understanding of the interactive effects of drug exposure and HIV. The relationship between HIV infection and cocaine use disorder is likely bidirectional, with cocaine use directly impacting immune function while HIV infection alters addiction-related behavior. To better characterize the neurobehavioral and immune consequences of HIV infection and cocaine exposure, this study utilized a humanized mouse model to investigate the outcomes of HIV-1 infection on cocaine-related behaviors in a conditioned place preference (CPP) model, and the interactive effects of cocaine and HIV infection on peripheral and central nervous system inflammation. HIV infection selectively impaired cocaine CPP extinction without effecting reinstatement or cocaine seeking under conflict were observed. Behavioral alterations were accompanied by immune changes in HIV infected mice, including increased prefrontal cortex astrocyte immunoreactivity and brain-region specific effects on microglia number and reactivity. Peripheral immune system changes were observed in both mouse and human cytokines, including HIV-induced reductions in mouse IL-1α and G-CSF and human TNFα, and cocaine induced alterations in mouse GM-CSF. Together these data provide new insights into the unique neurobehavioral outcomes of HIV infection and cocaine exposure and how they interact to effect immune responses.

How does the COVID-19 pandemic impact medication adherence of patients with chronic disease?: A systematic review

OBJECTIVE

To determine how the COVID-19 pandemic impacts patients with chronic disease medication adherence.

METHODS

Four electronic databases, PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text, were searched for literature between 2019 and 2021. Abstracts and later full texts were independently screened by the authors of this review using inclusion and exclusion criteria to determine relevance to our study. Joanna Briggs Institute (JBI) critical appraisal tools were used to assess the quality of included texts. Relevant information and data from the included texts were extracted into tables for data synthesis and analysis.

RESULTS

Ten studies met the study criteria, the most popular study design was cross-sectional design (n = 9, 90.0%), others were case series (n = 1, 10.0%). Barriers to medication adherence and facilitators of medication adherence were the major two themes that participants reported regarding the impact of COVID-19 on medication adherence. Moreover, these two main themes have been organized in sub-themes that are dealt with in-depth.

DISCUSSION

Our results could heighten healthcare providers, stakeholders, and policy leaders' awareness of providing appropriate support for chronic disease patients, especially regarding medication adherence. Future research incorporating programs that support patients' needs is recommended.

Impaired extinction of cocaine seeking in HIV-infected mice is accompanied by peripheral and central immune dysregulation

Substance use disorders (SUDs) are highly comorbid with HIV infection, necessitating an understanding of the interactive effects of drug exposure and HIV. The relationship between progressive HIV infection and cocaine use disorder is likely bidirectional, with cocaine use having direct effects on immune function while HIV infection can alter addiction-related behavior. To better characterized the neurobehavioral and immune consequences of HIV infection and cocaine exposure, this study utilized a humanized mouse model to investigate the outcomes of progressive HIV infection on cocaine-related behaviors in a cocaine conditioned place preference (CPP) model, and the interactive effects of cocaine and HIV infection on peripheral and central nervous system inflammation. HIV infection did not impact the formation of a cocaine CPP, but did result in resistance to extinction of the CPP. No effects of HIV on yohimbine-primed reinstatement or cocaine seeking under conflict were observed. These behavioral alterations were accompanied by immune changes in HIV infected mice, including increased prefrontal cortex astrocyte immunoreactivity and brain-region specific effects on microglia number and reactivity. Peripheral immune system changes were observed in both mouse and human markers. Among other targets, this included HIV-induced reductions in mouse IL-1α and G-CSF and human TNFα and cocaine-induced alterations in human TNFα and mouse GM-CSF such that cocaine exposure increases both cytokines only in the absence of HIV infection. Together these data provide new insights into the unique neurobehavioral processes underlying HIV infection and cocaine use disorders, and further how they interact to effect immune responses.

Cocaine Regulates Antiretroviral Therapy CNS Access Through Pregnane-X Receptor-Mediated Drug Transporter and Metabolizing Enzyme Modulation at the Blood Brain Barrier

Background

Appropriate interactions between antiretroviral therapies (ART) and drug transporters and metabolizing enzymes at the blood brain barrier (BBB) are critical to ensure adequate dosing of the brain to achieve HIV suppression. These proteins are modulated by demographic and lifestyle factors, including substance use. While understudied, illicit substances share drug transport and metabolism pathways with ART, increasing the potential for adverse drug:drug interactions. This is particularly important when considering the brain as it is relatively undertreated compared to peripheral organs and is vulnerable to substance use-mediated damage.

Methods

We used an in vitro model of the human BBB to determine the extravasation of three first-line ART drugs, emtricitabine (FTC), tenofovir (TFV), and dolutegravir (DTG), in the presence and absence of cocaine, which served as our illicit substance model. The impact of cocaine on BBB integrity and permeability, drug transporters, metabolizing enzymes, and their master transcriptional regulators were evaluated to determine the mechanisms by which substance use impacted ART central nervous system (CNS) availability.

Results

We determined that cocaine had a selective impact on ART extravasation, where it increased FTC's ability to cross the BBB while decreasing TFV. DTG concentrations that passed the BBB were below quantifiable limits. Interestingly, the potent neuroinflammatory modulator, lipopolysaccharide, had no effect on ART transport, suggesting a specificity for cocaine. Unexpectedly, cocaine did not breach the BBB, as permeability to albumin and tight junction proteins and adhesion molecules remained unchanged. Rather, cocaine selectively decreased the pregnane-x receptor (PXR), but not constitutive androstane receptor (CAR). Consequently, drug transporter expression and activity decreased in endothelial cells of the BBB, including p-glycoprotein (P-gp), breast cancer resistance protein (BCRP), and multidrug resistance-associated protein 4 (MRP4). Further, cytochrome P450 3A4 (CYP3A4) enzymatic activity increased following cocaine treatment that coincided with decreased expression. Finally, cocaine modulated adenylate kinases are required to facilitate biotransformation of ART prodrugs to their phosphorylated, pharmacologically active counterparts.

Conclusion

Our findings indicate that additional considerations are needed in CNS HIV treatment strategies for people who use cocaine, as it may limit ART efficacy through regulation of drug transport and metabolizing pathways at the BBB.

HIV viremia contributes to neurocognitive impairments in persons who use cocaine

Persons with HIV (PWH) who use illicit drugs are at elevated risk for neurocognitive impairment (NCI). This study investigated the effects of HIV disease and HIV viremia on NCI among adults who use cocaine. PWH who were not virologically suppressed showed greater global deficits compared to participants with HIV viral suppression and HIV-negative participants, but no differences emerged between the latter two groups. These findings highlight the adverse effects of poorly controlled HIV disease on NCI, beyond the independent effects of cocaine on cognition, and underscore the importance of strengthening the HIV care continuum for persons who use cocaine.

Chronic pain and substance use disorders among older sexual minority men living with HIV: Implications for HIV disease management across the HIV care continuum

HIV continues to be a critical health issue for sexual minority men (SMM) in the USA. Chronic pain is common in individuals with HIV, including older SMM, and is associated with substance use behaviors. This cross-sectional study sought to address a gap in the literature by characterizing interrelationships among chronic pain, substance use disorders (SUDs), medication adherence, and engagement in HIV care among older (≥50) SMM living with HIV and chronic pain (N = 63). The unadjusted relationship between an opioid use disorder and pain indicated that participants with an opioid use disorder reported higher pain ratings than those without. Presence of alcohol use disorder was significantly associated with missed HIV-care appointments due to chronic pain or substance use, showing that individuals with an alcohol use disorder reported more missed appointments in the past year. Higher pain was significantly associated with the same missed appointments variable, such that those reporting higher pain ratings also reported more missed appointments in the past year. These findings provide preliminary evidence of the interrelationships among chronic pain, SUDs, and engagement in HIV care among older SMM living with HIV and suggest that pain management in this population might support fuller engagement in HIV care.

Factors associated with lack of care engagement among older, rural-dwelling adults living with HIV in the United States

PURPOSE

Most people living with HIV (PLH) in the United States are over age 50 and this sector of PLH continues to grow. Aging with HIV can be challenging due to comorbid medical conditions, mental health disorders, substance use, and lack of social and practical support. Additional challenges are faced by older PLH living in the rural United States, such as longer distances to health care, concerns over privacy and stigma, and social isolation. PLH in rural areas have higher mortality rates than urban PLH. We aimed to understand factors associated with HIV care engagement and quality of life in rural US adults over age 50.

METHODS

We conducted a cross-sectional study to evaluate the association between patient-level factors and a combined outcome variable encompassing multiple aspects of care engagement.

FINDINGS

Either online or on paper, 446 participants completed our survey. One-third of the participants (33%) were from the southern United States; one-third were women; one-third were non-White; and 24% completed the survey on paper. In multiple regression analysis, lower income, residing in the southern United States, lacking internet access at home, not having an HIV specialist provider, higher levels of stress, living alone, and longer distance to an HIV provider were all associated with lower engagement in HIV care.

CONCLUSIONS

Our findings demonstrated multiple potential options for interventions that could improve care engagement, such as providing and enhancing access to technology for health care engagement and remotely delivering social support and mental health services. Research on such potential interventions is needed for older, rural PLH.

Impacts of medical and non-medical cannabis on the health of older adults: Findings from a scoping review of the literature

BACKGROUND

Cannabis legalization has enabled increased consumption in older adults. Age-related mental, physical, and physiological changes may lead to differences in effects of cannabis in older adults compared to younger individuals.

OBJECTIVE

To perform a scoping review to map the evidence regarding the health effects of cannabis use for medical and non-medical purposes in older adults.

METHODS

Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched for systematic reviews (SRs), randomized controlled trials (RCTs) and non-randomized/observational studies (NRSs) assessing the health effects and associations of cannabis use (medical or non-medical) in adults ≥ 50 years of age. Included studies met age-related inclusion criteria or involved a priori identified health conditions common among older adults. Records were screened using a liberal accelerated approach and data charting was performed independently by two reviewers. Descriptive summaries, structured tables, effect direction plots and bubble plots were used to synthesize study findings.

FINDINGS

From 31,393 citations, 133 publications describing 134 unique studies (26 SRs, 36 RCTs, 72 NRSs) were included. Medical cannabis had inconsistent therapeutic effects in specific patient conditions (e.g., end-stage cancer, dementia), with a number of studies suggesting possible benefits while others found no benefit. For medical cannabis, harmful associations outnumbered beneficial, and RCTs reported more negative effects than NRSs. Cannabis use was associated with greater frequencies of depression, anxiety, cognitive impairment, substance use and problematic substance use, accidents/injuries, and acute healthcare use. Studies often were small, did not consistently assess harms, and did not adjust for confounding.

DISCUSSION

The effects of medical cannabis are inconsistent within specific patient conditions. For older adults, generally, the available evidence suggests cannabis use may be associated with greater frequencies of mental health issues, substance use, and acute healthcare use, and the benefit-to-risk ratio is unclear. Studies with a balanced assessment of benefits and harms may guide appropriate public health messaging to balance the marketing pressures of cannabis to older adults.

The relationship between substance use and physical activity among people living with HIV, chronic pain, and symptoms of depression: a cross-sectional analysis

ABSTRACTChronic pain, depression, and substance use are common among people living with HIV (PLWH). Physical activity can improve pain and mental health. Some substances such as cannabis may alleviate pain, which may allow PLWH to participate in more physical activity. However, risks of substance use include poorer mental health and HIV clinical outcomes. This cross-sectional analysis examined the relationships of self-reported substance use (alcohol, cannabis, and nicotine use), gender, and age with self-reports of walking, moderate physical activity, and vigorous physical activity, converted to Metabolic Equivalent of Task Units (METs), among 187 adults living with HIV, chronic pain, and depressive symptoms in the United States. Women reported less walking, vigorous activity, and total physical activity compared to men. Individuals who used cannabis reported more vigorous physical activity relative to those who did not use cannabis. These findings were partially accounted for by substance use*gender interactions: men using cannabis reported more vigorous activity than all other groups, and women with alcohol use reported less walking than men with and without alcohol use. Research is needed to increase physical activity among women who use substances and to evaluate reasons for the relationship between substance use and physical activity among men.

Polysubstance Use Patterns Associated With HIV Disease Severity Among Those With Substance Use Disorders: A Latent Class Analysis

OBJECTIVE

Polysubstance use is common among people with HIV infection (PWH) and with substance use disorder (SUD), but its effects are understudied. We aimed to identify polysubstance use patterns over time and assess their associations with HIV disease severity.

METHOD

In 233 PWH with current or past SUD, latent class analysis identified polysubstance use patterns based on the Alcohol Use Disorders Identification Test-Consumption and past-30-day use of cannabis, cocaine, opioids, and tranquilizers at baseline. We categorized changes in use patterns and tested associations between those changes and CD4 count and HIV viral suppression at 12 months in linear and logistic regressions.

RESULTS

Three patterns were identified at baseline: 18% did not use any substance (NONE--a priori defined); 63% used mostly cannabis and alcohol (CA); and 19% used opioids along with other drugs, including cocaine, tranquilizers, cannabis, and alcohol (MULTI). At 12 months, 40% moved from a high to a lower substance use class (MULTI to CA, either to NONE) or remained as NONE, 43% were in CA both times and 17% increased (NONE to CA, either to MULTI) or remained as MULTI. The adjusted mean CD4 count (for baseline covariates and baseline CD4 count) was significantly lower among participants increasing or remaining in MULTI (523, 95% CI [448, 598], cells/mm3) compared with those who decreased/abstained throughout (607, 95% CI [552, 663], p = .02). No significant difference was observed for HIV viral suppression.

CONCLUSIONS

We identified distinct polysubstance use patterns among PWH with SUD: cannabis/alcohol and opioids with alcohol and other drugs. Changes over time toward fewer substances/no use were associated with lower HIV disease severity based on CD4 count but not based on HIV viral suppression.

Cannabis Use Is Associated With Decreased Antiretroviral Therapy Adherence Among Older Adults With HIV

Background

Conflicting evidence exists on the impact of cannabis use on antiretroviral therapy (ART) adherence among people with human immunodeficiency virus (PWH). We leveraged data collected among older PWH to characterize longitudinal associations between cannabis use and ART adherence.

Methods

AIDS Clinical Trials Group (ACTG) A5322 study participants were categorized as <100% (≥1 missed dose in past 7 days) or 100% (no missed doses) ART adherent. Participants self-reported current (past month), intermittent (past year but not past month), and no cannabis (in past year) use at each study visit. Generalized linear models using generalized estimating equations were fit and inverse probability weighting was used to adjust for time-varying confounders and loss to follow-up.

Results

Among 1011 participants (median age, 51 years), 18% reported current, 6% intermittent, and 76% no cannabis use at baseline; 88% reported 100% ART adherence. Current cannabis users were more likely to be <100% adherent than nonusers (adjusted risk ratio [aRR], 1.53 [95% CI, 1.11-2.10]). There was no association between ART adherence and current versus intermittent (aRR, 1.39 [95% CI, .85-2.28]) or intermittent versus no cannabis use (aRR, 1.04 [95% CI, .62-1.73]).

Conclusions

Among a cohort of older PWH, current cannabis users had a higher risk of <100% ART adherence compared to nonusers. These findings have important clinical implications as suboptimal ART adherence is associated with ART drug resistance, virologic failure, and elevated risk for mortality. Further research is needed to elucidate the mechanisms by which cannabis use decreases ART adherence in older PWH and to advance the development of more efficacious methods to mitigate nonadherence in this vulnerable population.

Substance Use and Adherence to Antiretroviral Therapy among People Living with HIV in the United States

People with HIV (PWH) report substance use at higher rates than HIV-uninfected individuals. The potential negative impact of single and polysubstance use on HIV treatment among diverse samples of PWH is underexplored. PWH were recruited from the Center for Positive Living at the Montefiore Medical Center (Bronx, NY, USA) from May 2017-April 2018 and completed a cross-sectional survey with measures of substance use, antiretroviral therapy (ART) use, and ART adherence. The overall sample included 237 PWH (54.1% Black, 42.2% female, median age 53 years). Approximately half of the sample reported any current substance use with 23.1% reporting single substance use and 21.4% reporting polysubstance use. Polysubstance use was more prevalent among those with current cigarette smoking relative to those with no current smoking and among females relative to males. Alcohol and cannabis were the most commonly reported polysubstance combination; however, a sizeable proportion of PWH reported other two, three, and four-substance groupings. Single and polysubstance use were associated with lower ART adherence. A thorough understanding of substance use patterns and related adherence challenges may aid with targeted public health interventions to improve HIV care cascade goals, including the integration of substance use prevention into HIV treatment and care settings.

The impact of social capital and mental health on medication adherence among older people living with HIV (PLWH)

Background

The number of older people living with HIV (PLWH) is increasing. Although there are many studies affecting medication adherence, research on the impact of social capital and mental health on medication adherence in this particular population is limited.

Method

Data were collected from an ongoing observational prospective cohort study, starting from November 2018, among older PLWH in Sichuan province, China. Five hundred twenty-one participants were interviewed. Social capital consists of the individual and family (IF) scale, and the community and society (CS) scale. The presence of probable depression and probable anxiety were assessed using the CES-D-10 and GAD-7 scales. Adherence was defined as taking ≥80% of prescribed HIV medication in 4 days prior to the interview. Two sets of Firth’ penalized regression analyses were used to estimate the association between social capital, mental health, and medication adherence.

Results

The prevalence of non-adherence was 18.2% (95/521) among older PLWH in this study. After adjusting for significant factors, the CS social capital (OR: 0.92, 95%CI:0.85–0.99, p < 0.05) and probable anxiety (OR:1.73, 95%CI:1.07–2.80, p < 0.05) were associated with non-adherence.

Conclusion

This study highlighted that the effects of social capital and mental health on older PLWH’s adherence, which implied that the need to develop interventions to concern for mental health and enhance CS social capital to help the older PLWH better manage HIV medication adherence.

Treatment for alcohol use disorder among persons with and without HIV in a clinical care setting in the United States

BACKGROUND

Alcohol use disorders (AUD) can lead to poor health outcomes. Little is known about AUD treatment among persons with HIV (PWH). In an integrated health system in Northern California, 2014-2017, we compared AUD treatment rates between PWH with AUD and persons without HIV (PWoH) with AUD.

METHODS

Using Poisson regression with GEE, we estimated prevalence ratios (PRs) comparing the annual probability of receiving AUD treatment (behavioral intervention or dispensed medication), adjusted for sociodemographics, psychiatric comorbidities, insurance type, and calendar year. Among PWH, we examined independent AUD treatment predictors using PRs adjusted for calendar year only.

RESULTS

PWH with AUD (N = 633; 93% men, median age 49) were likelier than PWoH with AUD (N = 7006; 95% men, median age 52) to have depression (38% vs. 21%) and a non-alcohol substance use disorder (SUD, 48% vs. 25%) (both P < 0.01). Annual probabilities of receiving AUD treatment were 45.4% for PWH and 34.4% for PWoH. After adjusting, there was no difference by HIV status (PR 1.02 [95% CI 0.94-1.11]; P = 0.61). Of treated PWH, 59% received only a behavioral intervention, 5% only a medication, and 36% both, vs. 67%, 4%, 30% for treated PWoH, respectively. Irrespective of HIV status, the most common medication was gabapentin. Among PWH, receiving AUD treatment was associated with having depression (PR 1.78 [1.51-2.10]; P < 0.01) and another SUD (PR 2.68 [2.20-3.27]; P < 0.01).

CONCLUSIONS

PWH with AUD had higher AUD treatment rates than PWoH with AUD in unadjusted but not adjusted analyses, which may be explained by higher psychiatric comorbidity burden among PWH.

Characterizing substance use typologies and their association with HIV viral load outcomes: A latent class analysis among sexual minority men living with HIV

BACKGROUND

Racially diverse sexual minority men (SMM) are disproportionately impacted by the U.S. HIV epidemic. Substance use, particularly stimulant use, may impact viral suppression for SMM living with HIV. The current study sought to characterize patterns of substance use via latent class analysis (LCA) and test associations between those patterns and future viral load outcomes, among SMM living with HIV.

METHODS

Data were drawn from Thrive With Me (TWM), an RCT of an mHealth intervention targeting ART adherence among SMM living with HIV. LCA was performed with six dichotomous indicators of substance use, derived from validated measures and urinalysis results, to determine substance use classes at baseline. Bivariate and multivariable logistic regression models tested associations between baseline substance use classes and HIV viral load 5-months post-baseline.

RESULTS

Among 383 SMM living with HIV, we identified a three-class model of substance use fit best: low probability substance use (81.3 %), high probability hazardous alcohol, marijuana, and cocaine use (7.5 %), and high probability methamphetamine and amphetamine use (11.2 %). Additionally, the high probability amphetamine use class was less likely to be virally suppressed at 5-month follow-up compared to the low probability substance use class [Adjusted Odds Ratio = 3.34, 95 % Confidence Interval = 1.39-7.99, p = .0069].

CONCLUSION

We identified that some patterns of substance use (i.e., methamphetamine and amphetamine use), but possibly not others (e.g., alcohol, marijuana, and cocaine use), are potentially important intervention targets for improving HIV-related outcomes among racially diverse SMM living with HIV.

Conduct Problems and Adherence to COVID-19 Guidelines: A Developmental Psychopathology-Informed Approach

COVID-19 underscores the importance of understanding variation in adherence to rules concerning health behaviors. Children with conduct problems have difficulty with rule adherence, and linking early conduct problems with later adherence to COVID-19 guidelines can provide new insight into public health. The current study employed a sample (N = 744) designed to examine the longitudinal consequences of childhood conduct problems (Mean age at study entry = 8.39). The first objective was to link early conduct problems with later adherence to both general and specific COVID-19 guidelines during emerging adulthood (M age = 19.07). The second objective was to prospectively examine how interactional (i.e., callous unemotional traits, impulsivity) and cumulative (i.e., educational attainment, work status, substance use) continuity factors mediated this association. The third objective was to examine differences in sex assigned at birth in these models. Direct associations were observed between childhood conduct problems and lower general, but not specific COVID-19 guideline adherence. Conduct problems were indirectly associated with both general and specific adherence via higher levels of callous unemotional traits, and with specific adherence via higher problematic substance use. No differences in the models were observed across sex assigned at birth. Findings provide insight into both how developmental psychopathology constructs are useful for understanding COVID-19 guideline adherence, and the ways in which conduct problems may shape health outcomes.

African American/Black and Latino Adults with Detectable HIV Viral Load Evidence Substantial Risk for Polysubstance Substance Use and Co-occurring Problems: A Latent Class Analysis

Substance use problems are highly prevalent among persons living with (PLWH) in the United States and serve as serious barriers to engagement in HIV care. Yet, in contrast to studies of single substances, little is known about patterns of polysubstance use in this population. Moreover, other risk factors (e.g., financial hardship, incarceration, homelessness, and mental health distress) are also prevalent and complicate HIV management. The present study drew on a cross-sectional survey with African American/Black and Latino (AABL) adult PLWH from low socioeconomic status backgrounds in New York City who were insufficiently engaged in HIV care and evidenced detectable HIV viral load (N = 512). We used latent class analysis (LCA) to explore patterns of polysubstance use and their relationships to financial hardship, incarceration, homelessness, and mental health. LCA yielded three substance use classes: Class 1, a high polysubstance use/high-risk substance use class (9%); Class 2, a polysubstance use/moderate substance use risk class (18%); and Class 3, a moderate polysubstance use/moderate-to-low-risk substance use class (74%). Mental health symptoms were prevalent in all classes, but Class 1 had greater mental health distress than the other two classes. Current homelessness was more prevalent in Classes 1 and 2. We cannot end the HIV epidemic without engaging and treating AABL PLWH who have serious barriers to engagement along the HIV care continuum, and who evidence polysubstance use along with co-occurring risk factors. Clinical settings can develop outreach and engagement approaches to bring this subpopulation of PLWH into care settings, and further, specialized services are needed to successfully screen, treat, and retain them.

HIV, aging, and adherence: an update and future directions

PURPOSE OF REVIEW

To highlight recent data on antiretroviral adherence in older people living with HIV (PLWH), describe the most relevant pharmacokinetic antiretroviral studies, and identify critical research gaps in this population.

RECENT FINDINGS

Overall, studies have found that older PLWH are more likely to be adherent to antiretroviral therapy (ART). Although multiple methods to measure adherence are available (self-report, pharmacy refills, electronic device monitors, drug concentrations), there is currently no 'gold standard' adherence measure or sufficient evidence to suggest a preferred method in older patients. Recently, studies evaluating antiretroviral concentrations in hair and dried blood spots in older patients identified no major differences when compared with younger individuals. Similarly, although pharmacokinetic studies in older PLWH are scarce, most data reveal no significant pharmacokinetic differences in the aging population. Furthermore, no specific guidelines or treatment recommendations regarding ART dose modification or long-term toxicity in aging PLWH are available, mostly because of the exclusion of this population in clinical trials.

SUMMARY

How aging influences adherence and pharmacokinetics remains poorly understood. As the population of older PLWH increases, research focusing on adherence, toxicity, drug--drug interactions, and the influence of comorbidities is needed.

Perspectives on Pain, Engagement in HIV Care, and Behavioral Interventions for Chronic Pain Among Older Sexual Minority Men Living with HIV and Chronic Pain: A Qualitative Analysis

OBJECTIVE AND METHODS

The transition of HIV from an acute, fatal illness to a chronic health condition has shifted the treatment needs of people living with HIV (PLWH). PLWH, including sexual minority men (SMM), are living longer and are subject to health concerns often associated with aging. A major health concern of older SMM living with HIV who report problematic substance use is chronic pain. This qualitative analysis of 15 one-on-one interviews with older SMM living with HIV and chronic pain aimed to characterize this population's experiences with pain, engagement in HIV care, and problematic substance use. This study was conducted in a community health center in Boston, MA. We also solicited suggestions for preferred intervention strategies.

RESULTS

Three main themes emerged from the interview transcripts: 1) the impact of chronic pain and pain treatment on engagement in HIV clinical care; 2) the impact of substance use on chronic pain; and 3) response to interventions to address chronic pain and substance use.

CONCLUSIONS

These findings underscore the need for interventions that address the structural, physical, and psychological barriers to engagement in medical and self-care that affect older SMM living with HIV and chronic pain.

Polysubstance use and adherence to antiretroviral treatment in the Miami Adult Studies on HIV (MASH) cohort

Evidence for a relationship between polysubstance use, depression, and adherence to antiretroviral therapy (ART) is limited. The objectives of this study were to examine the associations of depression, illicit drug, and alcohol use with adherence to ART. People living with HIV (PLHIV) from the Miami Adult Studies on HIV cohort were asked about the number of doses of their ART medication missed to assess ART adherence. Harmful alcohol drinking was evaluated using the Alcohol Use Disorders Identification Test and illicit substance use assessed with self-report and urine screen. The Center for Epidemiologic Studies Depression Scale was used to assess depression symptoms. Of 391 PLHIV, 16.6% missed at least one dose (range:1-4) in the past four days. Cocaine/crack, opiate use, and depression were significantly independently associated with a greater mean number of doses missed. The mean number of doses missed was significantly greater among participants who used alcohol in combination with cocaine/crack, marijuana, and tobacco compared to non-users. In conclusion, polysubstance use increased the risk for poor ART adherence among PLHIV. The use of cocaine/crack or opiates individually and depressive symptoms also promote poor ART adherence. An integrated approach targeting substance disorders and depression may help achieve better ART adherence.

Demand curve analysis of marijuana use among persons living with HIV

BACKGROUND

Despite medicalization and legalization of marijuana use, factors influencing demand for marijuana among persons living with HIV (PLWH) are incompletely understood. This knowledge gap undermines effective clinical management and policies. This study used demand curve simulation methods to address these issues.

METHODS

Marijuana-using PLWH (N = 119) completed experimental tasks to simulate amount of marijuana purchasing/use across different costs (money or time), and likelihood of reselling marijuana or marijuana therapeutic-use registration card in relation to profits. Additional simulations assessed purchasing of marijuana relative to other drug and non-drug goods.

RESULTS

Simulated marijuana use decreased as money and time costs increased. Consumption was greater for participants with more severe Cannabis Use Disorder (CUD) and anxiety, intermediate pain levels, and past 90-day opioid use. Whereas few participants chose to sell their registration card, marijuana resale (diversion) steeply increased with profit. Likelihood of seeking marijuana therapeutic-use certification decreased in relation to registration card money cost, having to visit more physicians to get a signature, and delay to receiving the card, and increased with duration of certification. Participants who reported recent opioid use were more likely to seek certification. Consumption of several commodities assessed was independent of marijuana.

CONCLUSIONS

Simulated marijuana use was related to participants' clinical profile (CUD, anxiety and pain symptoms, recent opioid use), and unrelated to purchasing other goods. Likelihood of seeking marijuana therapeutic-use registration was affected by several types of costs and recent opioid use. Participants were unlikely to divert registration cards. We discuss clinical and policy implications of these findings.

Psychopathology and HIV diagnosis among older adults in the United States: disparities by age, sex, and race/ethnicity

In 2016, 17% of new HIV infections in the US were among adults aged 50 and older. Differences by age, sex, and race/ethnicity exist among older people living with HIV. Co-morbid mental health and substance use disorders (SUD) are also major challenges for this population. This study examined the association between generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), SUD, depression, and HIV diagnosis among adults aged 50 and older, and the disparities by age, sex, and race/ethnicity. Data were obtained from Cerner Corporation's Health Facts® database. Multivariable logistic regression models were used to determine the associations between GAD, PTSD, SUD, and depression, and HIV diagnosis. Results were also stratified by age group, sex, and race/ethnicity. Overall, there were positive associations between SUD, depression, GAD, PTSD and HIV; and differences by age, sex and race/ethnicity existed in these associations. For example, after adjusting for age, race/ethnicity and marital status, men who were diagnosed with GAD were 10 times more likely (adjusted OR: 10.3; 95% CI: 8.75 - 12.1) to have an HIV diagnosis compared to men who were not diagnosed with GAD. Women who were diagnosed with GAD were five times more likely (adjusted OR: 5.01; 95% CI: 3.81 - 6.58) to have an HIV diagnosis compared to women who were not diagnosed with GAD. HIV prevention and intervention programs for older adults should address GAD, PTSD, SUD and depression and consider the age, sex and racial/ethnic disparities in the association between psychopathology and HIV.

Drug Use Among Adolescents and Young Adults with Unsuppressed HIV Who Use Alcohol: Identifying Patterns of Comorbid Drug Use and Associations with Mental Health

Youth living with HIV (YLWH; aged 16-24) are at elevated risk of alcohol and drug use. Studies in older populations have identified patterns or profiles of multiple substance use differentially associated with mental health and anti-retroviral therapy (ART) adherence. No studies of YLWH have yet examined such patterns. A sample of 179 YLWH, reporting ART non-adherence and alcohol use, were recruited at five Adolescent Trials Network clinics in urban areas of the US between November 2014 and August 2017. Participants completed the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) to assess substance use involvement scores, and the Brief Symptom Inventory. Latent Profile Analysis identified three substance use patterns: minimal illicit drug use (15.1%), cannabis only (56.4%), and global polysubstance use (28.5%). Global polysubstance users experienced more mental health problems compared to the minimal illicit drug use group. The co-occurrence of drug use with alcohol was common among these YLWH-all of whom reported ART adherence problems-indicating the importance of interventions capable of addressing multiple substance use rather than alcohol alone.

A tai chi/qigong intervention for older adults living with HIV: a study protocol of an exploratory clinical trial

Background

Almost half of people living with HIV (PLWH) in the USA are over 50 years of age; this is expected to increase to 70% by 2020. Yet, few interventions exist for older PLWH that address psychological and physical symptoms combined, both prevalent in this population. There is a need to find innovative and accessible interventions that can help older PLWH to manage their symptoms. Mind-body interventions, like tai chi/qigong (TCQ), improve both physical and psychological health. TCQ is a series of slow, low-impact meditative movements that integrates breathwork, meditation, and stances.

Methods

The present study is an exploratory clinical trial that will evaluate the acceptability and feasibility of a 12-week, small group TCQ intervention (n = 24), a sham qigong control condition (n = 24), and a standard of care control condition (n = 24) for older people living with HIV/AIDS. It will also explore any preliminary associations between the TCQ intervention and symptom alleviation. Participants will be recruited from community-based health and social services organizations in Miami, FL, and randomized to one of the 3 conditions.

Discussion

We will assess feasibility and acceptability through questionnaires and adherence to TCQ. We will assess preliminary associations with symptoms such as depression, anxiety, social support, chronic HIV-related fatigue, and clinical outcomes. These will be described through proportions, means, and changes over time through graphing techniques. Outcomes will be assessed at baseline, at post-intervention, and at 3 months follow-up. These preliminary analyses also will provide information necessary to estimate effect size and power needed for a larger clinical trial.

Trial registration

ClinicalTrials.gov NCT03840525. Registered on 16 July 2018.

A descriptive analysis of concurrent alcohol and substance use among patients living with HIV/HCV co-infection

The objectives of this study were to estimate the prevalence of concurrent alcohol and substance use among patients living with HIV/HCV co-infection and to compare demographic and clinical characteristics of those with concurrent alcohol and substance to those with alcohol or substance use, and to those who were abstinent. We conducted an analysis of patient reported outcomes data of patients living with HIV/HCV co-infection (n = 327) who transitioned from primary care to sub-specialty care for evaluation of candidacy for HCV treatment at a university-affiliated HIV Clinic. The prevalence of self-reported concurrent alcohol and substance use was 33%. A higher proportion of those with concurrent alcohol and substance use were currently smoking tobacco, and those who were abstinent had higher ratings of health-related quality of life compared to those with alcohol or substance use. To reduce patients' risk for progression to advanced stages of HIV, HCV, and liver-related disease due to continued alcohol and substance and tobacco use, social workers and other health care professionals are encouraged to develop and implement intervention strategies to assist patients living with HIV/HCV co-infection in efforts to achieve behavioral change.

Polysubstance Use Patterns among Justice-Involved Individuals Who Use Opioids

AIM

The current study explores pre-incarceration polysubstance use patterns among a justice-involved population who use opioids. Design: Setting: Data from prison and jail substance use programing in the state of Kentucky from 2015-2017 was examined. Participants: A cohort of 6,569 individuals who reported both pre-incarceration use of opioids and reported the use of more than one substance per day. Measurements: To determine the different typologies of polysubstance use involving opioids, latent profile analysis of the pre-incarceration thirty-day drug use of eight substances was conducted. Multinomial logistic regression predicted latent profile membership. Findings: Six unique profiles of polysubstance use involving opioids and other substances were found; Primarily Alcohol (9.4%), Primarily Heroin (19.0%), Less Polysubstance Use (34.3%), Tranquilizer Polysubstance Use (16.3%), Primarily Buprenorphine (7.8%), and Stimulant-Opioid (13.2%). Profiles differed by rural/urban geography, injection drug use, physical, and mental health symptoms. Conclusion: Findings indicate the heterogeneity of opioid use among a justice-involved population. More diverse polysubstance patterns may serve as a proxy to identifying individuals with competing physical and mental health needs. Future interventions could be tailored to polysubstance patterns during the period of justice-involvement.

Psychosocial Well-Being and HIV-Related Immune Health Outcomes among HIV-Positive Older Adults: Support for a Biopsychosocial Model of HIV Stigma and Health

Evidence suggests that psychosocial stress negatively impacts immunological health in HIV-positive individuals. However, few studies have explored this association in substance-using older adults living with HIV (OALWH). We evaluated the effect of depression, loneliness, substance use problems, and HIV stigma on primary markers of immune function in a sample of 120 OALWH with substance-related issues. HIV stigma correlated with the greatest number of factors, including depression, loneliness, and substance use problems. Older age and antiretroviral adherence were associated with viral suppression, which was in turn associated with higher percentage of CD4 count. Multivariate path analyses demonstrated that lower HIV stigma and viral suppression were the only factors independently associated with higher percentage of CD4 count, with a significant indirect effect of adherence on CD4 through viral suppression. HIV stigma emerged as the most salient factor associated with both psychosocial well-being and immune health in the current study, suggesting that it is a critical factor to consider in future interventions for the rapidly growing population of OALWH.

A Modified Alcohol SBI for Use among Older Adults Living with HIV

Older adults living with HIV may have health conditions that amplify the potentially negative health effects of alcohol use. We adapted the Comorbidity Alcohol Risk Evaluation Tool (CARET) screening tool for at-risk drinking to reflect HIV/AIDS and related conditions, medications, and behaviors. The adapted CARET-HIV along with a brief intervention was administered to 27 older men living with HIV. The CARET-HIV identified the same number of at-risk drinkers as the original CARET (n = 24) but identified more risk domains. Most participants welcomed receiving information about risks associated with their drinking, but some felt "embarrassed" or "guilty" discussing their drinking. This is particularly salient within the context of HIV discourse, which has historically assigned blame of HIV infection on personal choices. The SBI was generally acceptable to participants. The modified CARET can help providers integrate discussion of alcohol use into the context of HIV care for personalized feedback.

Alcohol Use and Ethnicity Independently Predict Antiretroviral Therapy Nonadherence Among Patients Living with HIV/HCV Coinfection

BACKGROUND

Adherence to antiretroviral therapy (ART) is important to counter synergistic effects of HIV and hepatitis C (HCV) in patients living with coinfection. Predictors of ART nonadherence among patients living with HIV/HCV coinfection are not well established. This knowledge would be advantageous for clinicians and behavioral health specialists who provide care to patients living with HIV/HCV coinfection.

OBJECTIVES

The purpose of this study was to assess prevalence and predictors of ART nonadherence in a sample of patients living with HIV/HCV coinfection who were actively in HIV clinical care.

METHOD

A sample of patients living with HIV/HCV coinfection who received care at a university-affiliated HIV clinic (n = 137) between January 2013 and July 2017 were included in the study. Computerized patient-reported data or outcomes (PROs) and electronic medical record data of these respective patients were collected and analyzed. Binomial logistic regression was used to examine predictors of ART nonadherence.

RESULTS

The prevalence of ART nonadherence was 31%. In multivariate analysis, African American ethnicity (OR = 3.28, CI 1.241-8.653, p = 0.017) and a higher number of alcoholic drinks per drinking day (OR = 1.31, CI 1.054-1.639, p = 0.015) were positively associated with ART nonadherence.

CONCLUSIONS

Behavioral health providers are encouraged to incorporate alcohol use reduce interventions in HIV clinical settings to reduce ART nonadherence among patients living with HIV/HCV coinfection. Additionally, public health professionals and researchers, and clinicians are encouraged to use inductive methods to discover why ART nonadherence disproportionately impacts African American patients living with HIV/HCV coinfection and to develop approaches that are sensitive to those respective barriers.

The Association Between Marijuana Use and HIV Continuum of Care Outcomes: a Systematic Review

PURPOSE OF REVIEW

Approximately 77% of HIV-infected adults report lifetime marijuana use. Given the high rates and social acceptability of marijuana use among HIV-infected individuals, it is important to gain a stronger understanding of if, and how, marijuana impacts HIV care cascade outcomes. The purpose of this study is to systematically review recent articles that assess the relationship between marijuana use and HIV continuum of care outcomes.

RECENT FINDINGS

One hundred and ninety articles from PubMed were considered for inclusion, and 15 were included in the review. The studies focus on marijuana use among HIV-infected individuals aware of their serostatus (k = 4), individuals engaged in treatment (k = 1), marijuana use in association with adherence to antiretroviral medications (k = 6), and marijuana use in relation to multiple stages of the HIV care cascade (k = 4). Preliminary findings from the small number of studies revealed an association between marijuana use, especially current heavy use, and HIV seropositivity. However, results from studies assessing marijuana use and treatment engagement and adherence to antiretroviral medications were inconsistent and inconclusive. Additional research is needed to assess the nuanced relationship between marijuana use and HIV continuum of care outcomes, especially among subgroups of HIV-infected individuals, such as men who have sex with men and young adults.

Substance Use Screening in HIV Care Settings: a Review and Critique of the Literature

PURPOSE OF REVIEW

People living with human immunodeficiency virus/AIDS (PLWHA) experience high prevalence of substance use disorders (SUD). HIV care settings represent a unique opportunity to identify possible SUD, to provide SUD interventions, and to improve linkage to SUD treatment. The aims of this paper are to (a) review and critique the extant literature examining substance use screening approaches among PLWHA in HIV care settings and (b) provide recommendations for future clinical practice.

RECENT FINDINGS

Twenty-one peer-reviewed articles that examined substance screening approaches employed in HIV and other primary care settings were included in the review. There was limited literature reporting on the implementation and evaluation of substance use screening practices within HIV care settings, and methodological rigor varied across studies. Further, the use of validated substance use screening measures or incorporation of other substance use screening approaches (e.g., use of urine drug testing) within routine HIV care practice is limited. Strategies to implement routine substance use screening within HIV care and incorporate additional substance use assessment, brief interventions, and referral to specialty substance use treatment are discussed. Use of self-report substance use screening measures using web- or computer-delivered approaches that can be integrated within electronic health record systems is particularly promising. HIV care practices should consider potential models to optimally screen and treat SUD. Co-location of HIV and SUD treatment services may be optimal; when co-located services are not possible, strategies to consistently provide brief intervention approaches and referrals to specialty SUD treatment are needed.

The prevalence of alcohol use disorders among people living with HIV/AIDS: a systematic review and meta-analysis

BACKGROUND

Alcohol use disorder (AUD) is common among people living with HIV/AIDS (PLWHA) and associated with a greater risk of poor medication adherence, unsafe sexual behaviors as well as poor quality of life. To our knowledge, there is no previous systematic review and meta-analysis that reported the pooled prevalence estimate of AUD among PLWHA. Therefore, this review aimed to systematically review the available studies on the prevalence of AUD among PLWHA and forward possible recommendations for future clinical practice and research.

METHODS

PubMed, EMBASE, Psych INFO and SCOPUS databases were searched to identify the relevant studies. We have also scanned the reference lists of the eligible studies to supplement our electronic search. We used the Comprehensive Meta-Analysis software versions 3.0 to conduct a meta-analysis. Subgroup and sensitivity analysis were performed and Cochran's Q- and the I²- test were employed to see the heterogeneity. The presence of publication bias was explored by utilizing Egger's test and visual inspection of the symmetry in funnel plots.

RESULTS

A total of 25 studies with 25,154 participants across developed and developing countries were included in the final analysis. Our meta-analysis revealed that the pooled prevalence estimate of AUD among PLWHA was found to be 29.80% (95% CI; 24.10-35.76). The prevalence of AUD was higher in males (26.90%) than female (13.37%) HIV patients. In this study, the pooled prevalence of AUD was considerably higher (31.52%) when measured by Alcohol Use Disorders Identification Test (AUDIT) as compared to Composite International Diagnostic Interview (CIDI) (13.51%). In addition, the pooled prevalence of AUD was higher in the developed countries (42.09%) while lower for developing countries (24.52%).

CONCLUSION

In the current study, the pooled prevalence estimates of AUD among PLWHA was considerably high (29.80%). Screening and appropriate management of AUD among PLWHA are recommended.

HIV Care Trajectories as a Novel Longitudinal Assessment of Retention in Care

Consistent engagement in care is associated with positive health outcomes among people living with HIV (PLWH). However, traditional retention measures ignore the evolving dynamics of engagement in care. To understand the longitudinal patterns of HIV care, we analyzed medical records from 2008 to 2015 of PLWH ≥ 18 years-old receiving care at a public, hospital-based HIV clinic (N = 2110). Using latent class analysis, we identified five distinct care trajectory classes: (1) consistent care (N = 1281); (2) less frequent care (N = 270); (3) return to care after initial attrition (N = 192); (4) moderate attrition (N = 163); and (5) rapid attrition (N = 204). The majority of PLWH in Class 1 (73.9%) had achieved sustained viral suppression (viral load ≤ 200 copies/mL at last test and > 12 months prior) by study end. Among the other care classes, there was substantial variation in sustained viral suppression (61.1% in Class 2 to 3.4% in Class 5). Care trajectories could be used to prioritize re-engagement efforts.

Daily factors driving daily substance use and chronic pain among older adults with HIV: An exploratory study using ecological momentary assessment

BACKGROUND

Adults 50 and older make up approximately 50% of persons living with HIV. Multiple co-morbidities are common among this group, including chronic pain and substance abuse, yet little is known about the daily factors that either enhance or inhibit these experiences or behaviors. This study explored daily drivers of substance use, pain, and relief from pain among older adults living with HIV utilizing ecological momentary assessment (EMA).

METHOD

Participants (N = 55), ages 49-71, completed seven consecutive days of daily EMA online surveys prior to treatment initiation within a randomized controlled trial. Multilevel modeling tested predictors of pain, substance use, and relief from pain by examining within- and between-person relationships.

RESULTS

Results revealed an associational, reciprocal relationship between daily worst pain and daily drinking, where greater worst pain ratings predicted heavier drinking and heavier drinking predicted greater daily and overall pain. Greater happiness and poorer quality of sleep predicted greater daily worst pain. Exercising and overall confidence to cope with pain without medication were associated with lower levels of daily worst pain. Finally, spending less time with a loved one over time and reporting any coping behavior were associated with relief from pain.

CONCLUSION

Investigation of daily factors that drive pain and substance use behaviors among this unique population help inform which daily factors are most risky to their health and well-being. Alcohol use emerged as the only substance associated with both driving pain and responding to pain. Findings suggest key points for prevention and intervention.

Alcohol use disorder and associated factors among individuals living with HIV in Hawassa City, Ethiopia: a facility based cross- sectional study

Background

Individuals living with HIV/AIDS with co-occurring harmful alcohol use may require specialized intervention or even multi-disciplinary team follow-up and management. This study was aimed to assess alcohol use disorder and associated factors among people living with HIV/AIDS in Hawassa city, Ethiopia, 2019.

Methods

A facility based cross-sectional study was conducted among 195 people living with HIV/AIDS who had follow-up visit at Hawassa University Comprehensive Specialized hospital. A systematic sampling technique was used to recruit the study participants. Alcohol used disorders identification test (AUDIT) was used to measure alcohol consumption, drinking behaviors, and alcohol-related problems. The binary logistic regression model was used to see the association between alcohol use disorder (AUD) and the independent variables. The strength of association was measured by odds ratios with 95% confidence intervals. Statistical significance declared at P < 0.05.

Results

The mean age of the study participants was 29.88 (±SD = 10.89) years. The magnitude of alcohol use disorder among people living with HIV/AIDS was 31.8%. Being male [AOR = 2.43, (95% CI: 1.76, 5.76)], having poor social support [AOR = 1.34, (95% CI: 1.12, 6.73)], being medication non-adherent [AOR = 1.78, (95% CI: 1.33, 6.79)], current khat chewing [AOR = 1.67, (95% CI: 1.16, 5.45)] and current cigarette smoking [AOR = 3.76, (95% CI: 2.16, 7.54)] had statistically significant association with alcohol use disorder.

Conclusion

In the current study, magnitude of alcohol use disorder among people living with HIV was high and, calls for integrating services provided to HIV patients in HIV care and treatment clinic which enhances timely detection and management of AUD cases. This also alerts the stakeholders in HIV prevention and control programs to invest a greater efforts to retain patients in addiction treatment and rehabilitation centers. Lastly, appropriate screening and health education on consequences of alcohol use disorder is warranted.

Determining the Roles that Club Drugs, Marijuana, and Heavy Drinking Play in PrEP Medication Adherence Among Gay and Bisexual Men: Implications for Treatment and Research

Researchers have established that substance use interferes with anti-retroviral medication adherence among gay and bisexual men (GBM) living with HIV. There is limited parallel examination of pre-exposure prophylaxis (PrEP) adherence among HIV-negative GBM. We conducted retrospective 30-day timeline follow-back interviews and prospective semi-weekly diary data for 10 weeks with 104 PrEP-using GBM, half of whom engaged in club drug use (ketamine, ecstasy, GHB, cocaine, or methamphetamine)-generating 9532 days of data. Participants reported their day-by-day PrEP, club drug, marijuana, and heavy alcohol use (5 + drinks in one sitting). On average, club drug users were no more likely to miss a dose of PrEP than non-club drug users (M = 1.6 doses, SD = 3.0, past 30 days). However, we found that club drug use (at the event level) increased the odds of missing a dose on the same day by 55% and the next day (e.g., a "carryover effect") by 60%. Further, missing a dose on one day increased the odds of missing a dose the following day by eightfold. We did not identify an event-level effect of marijuana use or heavy drinking on PrEP adherence. Our data suggest club drug users could have greater protective effects from daily oral or long-acting injectable PrEP compared to a time-driven PrEP regimen because of the concurrence of club drug use and PrEP non-adherence.

Substance Use Among Older People Living With HIV: Challenges for Health Care Providers

Older people living with HIV (OPLWH) have higher rates of substance use (tobacco, alcohol, and other drugs) than their HIV-negative peers. Addressing health care needs of OPLWH who use substances is more challenging than for those who do not: they are highly impacted by comorbid conditions, substance use can interact with other medications (including antiretroviral therapy-ART) and reduce their effectiveness, and substance use has been associated with reduced adherence to ART and increased risky behaviors (including sexual risks). People who use substances also suffer disparities along the HIV continuum of care, resulting in lower viral suppression rates and poorer health outcomes. They are especially impacted by stigma and stress, which have implications for HIV treatment and care. Recommendations for health care providers working with OPLWH who use substances include: (1) the need to screen and refer for multiple associated conditions, and (2) training/continuing education to enhance care management and maximize health outcomes.

Establishing the feasibility, acceptability and preliminary efficacy of a multi-component behavioral intervention to reduce pain and substance use and improve physical performance in older persons living with HIV

Older persons living with HIV (PLWH), often defined as age 50 years and older, are a rapidly growing population, with high rates of chronic pain, substance use, and decreased physical functioning. No interventions currently exist that address all three of these health outcomes simultaneously. An 8-week behavioral intervention combining cognitive-behavioral therapy and tai chi reinforced with text messaging (CBT/TC/TXT) was developed and pilot tested in a community-based AIDS service organization with substance using PLWH aged 50 years and older who experienced chronic pain. Fifty-five participants were enrolled in a three arm randomized controlled trial that compared the CBT/TC/TXT intervention (N = 18) to routine Support Group (SG) (N = 19) and Assessment Only (AO) (N = 18) to assess the intervention's feasibility, acceptability and preliminary efficacy to reduce pain and substance use and improve physical performance. Participants were assessed at baseline, treatment-end (week 8) and week 12. Feasibility and acceptability indicators showed moderate levels of participant enrollment (62% of those eligible), excellent 12-week assessment completion (84%) and high attendance at CBT and tai chi sessions (>60% attended at least 6 of 8 sessions). Efficacy indicators showed within-group improvements from baseline to week 12 in the CBT/TC/TXT group, including all four substance use outcomes, percent pain relief in the past 24 h, and in two physical performance measures. Observed between-group changes included greater reductions in days of heavy drinking in the past 30 days for both CBT/TC/TXT (19%) and SG (13%) compared to the AO group. Percent pain relief in the past 24 h improved in the CBT/TC/TXT group relative to SG, and the CBT/TC/TXT's physical performance score improved relative to both the SG and AO groups. Findings demonstrate that the CBT/TC/TXT intervention is feasible to implement, acceptable and has preliminary efficacy for reducing substance use and pain and improving physical performance among a vulnerable population of older PLWH.

Revisiting Successful Aging With HIV Through a Revised Biopsychosocial Model: An Update of the Literature

The concept of successful aging was recognized only recently by HIV researchers because people living with HIV (PLWH) in the early epidemic were not expected to survive. With the introduction of antiretrovirals that block viral replication, PLWH are now aging with HIV. Given the complex nature of HIV within the social, economic, and political climates in which it occurs, a holistic model of successful aging is needed to guide researchers and clinicians. Several overarching models exist, but must be updated for rapidly advancing HIV and aging research agendas. We provide an updated, adapted, and integrated biopsychosocial model of successful aging with HIV based on the principles of Baltes and Baltes (1998) on 8 essential components of successful aging: (a) length of life, (b) biological health, (c) mental health, (d) cognitive efficiency, (e) social competence, (f) productivity, (g) personal control, and (h) life satisfaction. Clinical practice and research implications are highlighted.

High-risk behaviours, and their associations with mental health, adherence to antiretroviral therapy and HIV parameters, in HIV-positive men who have sex with men

Objectives

To investigate the patterns and frequency of multiple risk behaviours (alcohol, drugs, smoking, higher risk sexual activity) among men who have sex with men (MSM) living with HIV.

Methods

Cross sectional study.

Results

147 out of 819 HIV‐positive MSM exhibited a high‐risk phenotype (defined as >3 of smoking, excess alcohol, sexually transmitted infection and recent recreational drug use). This phenotype was associated with younger age, depressive symptoms and <90% adherence in multivariable logistic regression.

Conclusion

In a cohort of MSM, a small, but significant proportion exhibited multiple concurrent risk behaviours.

Differentially classified methamphetamine-using men who have sex with men: A latent class analysis

CONTEXT

Substance use interventions for methamphetamine-using men who have sex with men (MSM) are limited by the assumption that they are a uniform group. We hypothesized that an LCA would identify distinct patterns of substance use and demographic and psychosocial variables associated with different substance-using groups would aid in understanding distinctions. Using cross-sectional data from 343 methamphetamine-using MSM, we conducted an LCA to model the patterns of polysubstance use then examined how the classes varied on psychosocial variables defined by the Information-Motivation-Behavioral Skills (IMB) model.

FINDINGS

Because we were interested in identifying patterns of polysubstance use (PSU) among our sample, we identified four classes: minimal PSU, marijuana PSU, cocaine/hallucinogens PSU, and designer drugs/heroin PSU. Men in the marijuana PSU class were less likely to have positive attitudes towards methamphetamine than participants in the other three classes. Men in the Cocaine and Hallucinogens PSU class were more likely to have higher PANAS scores (OR = 13.00 [3.25, 52.07]) compared to the other classes, and they were more likely to have higher self-efficacy to enact safer substance use strategies (OR = 10.72 [3.23, 35.47]). MSM in the Designer Drug and Heroin PSU class were more likely to have a diagnosis of Hepatitis B (OR = 4.07 [0.86, 19.36] despite having higher knowledge of sexual health practices (OR = 0.55 [0.36, 0.84].

CONCLUSIONS

Differential classification for methamphetamine-using MSM suggests an opportunity for tailored interventions and secondary prevention programs. By understanding how men vary on illicit substance use, interventionists can routinely screen and link men before they potentially progress to another classification.

Smartphone-based ecological momentary assessment (EMA) of alcohol and cannabis use in older adults with and without HIV infection

INTRODUCTION

Ecological momentary assessment (EMA) has been used to characterize substance use among adult populations; however, little is known about the validity of EMA and the patterns and predictors of substance use among older adults with and without HIV infection.

METHODS

Thirty-five (22 HIV-positive, 13 HIV-negative) older adults aged 50-74 were assessed for 14days and completed up to four smartphone-based surveys per day.

RESULTS

Participants completed an average of 89.5% of possible EMA surveys. EMA self-reported alcohol and cannabis use were significantly positively correlated with laboratory-assessed, self-reported days of alcohol (r=0.52, p=0.002) and cannabis (r=0.61, p<0.001) used and quantity of alcohol (r=0.42, p=0.013) and cannabis (r=0.41, p=0.016) used in the 30days prior to baseline assessment. In a subset of 15 alcohol or cannabis users, preliminary analyses of the effects of mood and pain on alcohol or cannabis use showed: 1) greater anxious mood predicted substance use at the next EMA survey (OR=1.737, p=0.023), 2) greater happiness predicted substance use later in the day (OR=1.383, p<0.001), and 3) higher pain level predicted substance use earlier in the day (OR=0.901, p=0.005).

CONCLUSIONS

Findings demonstrate that EMA-measured alcohol and cannabis use has convergent validity among older adults with and without HIV infection. Preliminary results showing predictors of substance use highlight the importance of gathering EMA data to examine daily variability and time-dependent antecedents of substance use among this population.

A Cross-Sectional Study of Depressive Symptoms and Risky Alcohol Use Behaviors Among HIV Primary Care Patients in New York City

An association between problem drinking and depression among HIV-infected individuals has been previously demonstrated; however, which specific risky drinking behaviors are associated with higher levels of depression has not yet been investigated. Using an adult sample of HIV-infected primary care patients (78% male, 94% Black or Hispanic), we investigated whether depressive symptoms are associated with various risky drinking behaviors. Participants were administered the Beck Depression Inventory-II to assess depressive symptoms, and the Alcohol Use Disorders and Associated Disabilities Interview Schedule-IV to evaluate alcohol involvement. Participants with depressive symptoms (26%) were at higher risk for alcohol dependence [adjusted odds ratio (AOR) 3.8; 95% CI 2.0-7.2], regular binge drinking (AOR 2.0; 95% CI 1.1-3.8), and regular daytime drinking (AOR 2.1; 95% CI 1.2-3.8), in comparison with their non-depressed counterparts. Because both depression and unhealthy drinking negatively affect medication adherence and clinical outcomes, a better understanding of the association between depression and certain risky drinking behaviors among HIV-infected individuals is vital to improving their care and prognoses.