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Hui J, Reddon H, Fairbairn N, Choi J, Milloy MJ, Socias ME. Prevalence and Correlates of Heavy Alcohol use among People Living with HIV who use Unregulated Drugs in Vancouver, Canada. AIDS Behav 2024; 28:2427-2437. [PMID: 38662276 DOI: 10.1007/s10461-024-04341-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 04/26/2024]
Abstract
Among people living with HIV (PLWH), heavy alcohol use is associated with many negative health consequences. However, the impacts of heavy alcohol use are not well described for PLWH who use drugs. Thus, we investigated the prevalence and correlates of heavy alcohol use among a cohort of people who use drugs (PWUD) living with HIV in Vancouver, Canada. We accessed data from an ongoing community-recruited prospective cohort of PLWH who use drugs with linked comprehensive HIV clinical monitoring data. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods of heavy alcohol use between December 2005 and December 2019. Of the 896 participants included, 291 (32.5%) reported at least one period with heavy alcohol use. Periods of recent incarceration (Adjusted Odds Ratio [AOR] = 1.48, 95% Confidence Interval [CI]: 1.01-2.17), encounters with police (AOR = 1.87, 95% CI: 1.37-2.56), and older age (AOR = 1.05, 95% CI: 1.02-1.07) were positively associated with heavy alcohol use. Engagement in drug or alcohol treatment (AOR = 0.54, 95% CI: 0.42-0.70) and male gender (AOR = 0.46; 95% CI: 0.27-0.78) were negatively associated with heavy alcohol use. We observed that heavy alcohol use was clearly linked to involvement with the criminal justice system. These findings, together with the protective effects of substance use treatment, suggest the need to expand access for drug and alcohol treatment programs overall, and in particular through the criminal justice system to reduce alcohol-related harms among PLWH who use drugs.
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Affiliation(s)
- Jeremy Hui
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Hudson Reddon
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
| | - Nadia Fairbairn
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - JinCheol Choi
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - M-J Milloy
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Maria Eugenia Socias
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
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Nguyen CT, Nguyen HT, Vu TMT, Le Vu MN, Vu GT, Latkin CA, Ho CSH, Ho RCM. Mapping Studies of Alcohol Use Among People Living with HIV/AIDS During 1990-2019 (GAPRESEARCH). AIDS Behav 2023; 27:3981-3991. [PMID: 37338623 DOI: 10.1007/s10461-023-04112-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Abstract
Alcohol drinking has long been reported to be common in people living with HIV/AIDS, having biological and behavioral impacts on the transmission, progression, and prevention of HIV/AIDS. A total of 7059 eligible articles and reviews published in English from 1990 to 2019 were extracted from the WOS. Results show an increase in publication volume, while citations peak for papers published in 2006. Content analysis reveals a wide-ranging coverage of topics, with the most popular being effects of alcohol consumption on ART adherence and outcomes, alcohol-related sexual behaviors, TB co-infection, and psycho-socio-cultural considerations in examining and designing measures targeting alcohol use and interventions to reduce alcohol dependence in PLWHA. This calls for more active engagement of governments in research and in designing and implementing interventions, as well as collaborations and knowledge transfer from high-income countries to developing counterparts, to effectively address alcohol use-related issues in PLWHA, moving toward the HIV/AIDS eradication target.
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Affiliation(s)
- Cuong Tat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, 550000, Vietnam.
- Faculty of Medicine, Duy Tan University, Da Nang, 550000, Vietnam.
| | - Hien Thu Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, 550000, Vietnam
- Faculty of Medicine, Duy Tan University, Da Nang, 550000, Vietnam
| | - Thuc Minh Thi Vu
- Institute of Health Economics and Technology, Hanoi, 100000, Vietnam
| | - Minh Ngoc Le Vu
- Institute of Health Economics and Technology, Hanoi, 100000, Vietnam
| | - Giang Thu Vu
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 700000, Vietnam
| | - Carl A Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Cyrus S H Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore
| | - Roger C M Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, 119077, Singapore
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Muvvala SB, Gan G, Morford KL, Dziura J, Esserman D, Porter E, Chan PA, Cornman DH, Reynolds J, Yager JE, Fiellin DA, Edelman EJ. Facilitation and Preferred Models for Delivering Substance Use Disorder Treatment in HIV Clinics: Results From a Multisite Randomized Trial. J Addict Med 2023; 17:e388-e391. [PMID: 37934538 PMCID: PMC10726383 DOI: 10.1097/adm.0000000000001192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Integrated addiction treatment in HIV clinics is associated with improved outcomes, yet it is offered inconsistently and with variable models of care. We sought to evaluate the impact of Implementation Facilitation ("Facilitation") on clinician and staff preference for provision of addiction treatment in HIV clinics with on-site resources (all trained or designated on-site specialist) versus outside resources (outside specialist or refer out). METHODS From July 2017 to July 2020, surveys assessed clinician and staff preferences for addiction treatment models during control (ie, baseline), intervention, evaluation, and maintenance phases in 4 HIV clinics in the Northeast United States. RESULTS During the control phase, among 76 respondents (response rate, 58%), the proportions who preferred treatment with on-site resources for opioid use disorder (OUD), alcohol use disorder (AUD), and tobacco use disorder (TUD) were 63%, 55%, and 63%, respectively. Compared with control, there were no significant differences in preferred model during the intervention and evaluation phases except for AUD where there was an increased preference for treatment with on-site resources in the intervention versus control phase. Compared with control, during the maintenance phase, a higher proportion of clinicians and staff preferred providing addiction treatment with on-site resources versus outside resources: OUD, 75% (odds ratio [OR; 95% confidence interval {CI}], 1.79 [1.06-3.03]); AUD, 73% (OR [95% CI], 2.23 [1.36-3.65]), and TUD, 76% (OR [95% CI], 1.88 [1.11-3.18]). CONCLUSIONS The findings from this study lend support for "Facilitation" as a strategy to enhance clinician and staff preference for integrated addiction treatment in HIV clinics with on-site resources.
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Affiliation(s)
- Srinivas B Muvvala
- From the Program in Addiction Medicine, Yale School of Medicine, New Haven, CT (SBM, KLM, DAF, EJE); Department of Psychiatry, Yale School of Medicine, New Haven, CT (SBM); Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT (GG, JD, DE); Department of Internal Medicine, Yale School of Medicine, New Haven, CT (KLM, EP, DAF, EJE); Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT (DAF, EJE); Department of Emergency Medicine, Yale School of Medicine, New Haven, CT (JD, DAF); Department of Biostatistics, Yale School of Public Health, New Haven, CT (JD, DE, JR); Department of Medicine, Brown University, Providence, RI (PAC); Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT (DHC); Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY (JEY)
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Chichetto NE, Gebru NM, Plankey MW, Tindle HA, Koethe JR, Hanna DB, Shoptaw S, Jones DL, Lazar JM, Kizer JR, Cohen MH, Haberlen SA, Adimora AA, Lahiri CD, Wise JM, Freiberg MS. Syndemic trajectories of heavy drinking, smoking, and depressive symptoms are associated with mortality in women living with HIV in the United States from 1994 to 2017. Drug Alcohol Depend 2023; 249:110838. [PMID: 37352734 PMCID: PMC10726291 DOI: 10.1016/j.drugalcdep.2023.110838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/25/2023] [Accepted: 06/13/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Heavy drinking, smoking, and depression are common among people with HIV. Little is known about the co-occurring, synergistic effect of having two or more of these conditions long-term -a sustained syndemic - on mortality among women with HIV (WWH). METHODS Data from 3282 WWH of the Women's Interagency HIV Study from 1994 to 2017 were utilized. National Death Index review identified cause of death (n=616). Sustained syndemic phenotypes were based on membership in high-risk groups defined by group-based trajectory models of repeated self-reported alcohol use, smoking, and depressive symptoms and their co-occurrence. Cox proportional hazard models estimated associations of sustained syndemic phenotypes with all-cause, non-AIDS, and non-overdose mortality, adjusting for age, race/ethnicity, education, enrollment wave, illicit drug use, and time-varying HIV viral load and CD4+ T-cell count. RESULTS WWH were 58% Black and 26% Hispanic, with a mean baseline age of 36.7 years. Syndemic phenotypes included zero (45%, n=1463), heavy drinking only (1%, n=35), smoking only (28%, n=928), depressive symptoms only (9%, n=282), and 2+ trajectories (17%, n=574). Compared to zero trajectories, having 2+ trajectories was associated with 3.93 times greater all-cause mortality risk (95% CI 3.07, 5.04) after controlling for confounders and each high-risk trajectory alone. These findings persisted in sensitivity analyses, removing AIDS- and overdose-related mortalities. CONCLUSIONS Clustering of 2+ conditions of heavy drinking, smoking, and depression affected nearly one in five WWH and was associated with higher mortality than zero or one condition. Our findings underscore the need for coordinated screening and parsimonious treatment strategies for these co-occurring conditions.
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Affiliation(s)
| | | | | | - Hilary A Tindle
- Vanderbilt University Medical CenterNashville, TN37232, USA; Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare SystemNashville, TN37212USA
| | - John R Koethe
- Vanderbilt University Medical CenterNashville, TN37232, USA
| | - David B Hanna
- Albert Einstein College of MedicineBronx, NY10461, USA
| | - Steven Shoptaw
- David Geffen School of Medicine at UCLA, Los Angeles, CA90095USA
| | - Deborah L Jones
- University of Miami Miller School of MedicineMiami, FL33136, USA
| | | | - Jorge R Kizer
- San Francisco Veterans Affairs Health Care System, University of California, San Francisco, CA94121USA
| | - Mardge H Cohen
- Stroger Hospital/Cook County Health and Hospitals SystemChicago, IL60612, USA
| | - Sabina A Haberlen
- Johns Hopkins Bloomberg School of Public HealthBaltimore, MD21205, USA
| | | | - Cecile D Lahiri
- Department of Medicine, Division of Infectious Diseases, Emory UniversityAtlanta, GA30322, USA
| | - Jenni M Wise
- University of Alabama at BirminghamBirmingham, AL35294, USA
| | - Matthew S Freiberg
- Vanderbilt University Medical CenterNashville, TN37232, USA; Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare SystemNashville, TN37212USA
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Bernstein EY, Pfoh ER, Le P, Rothberg MB. Relationship Between Primary Care Providers' Perceptions of Alcohol Use Disorder And Pharmacotherapy Prescribing Rates. Alcohol Alcohol 2023; 58:54-59. [PMID: 36368012 DOI: 10.1093/alcalc/agac057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/07/2022] [Accepted: 10/07/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS Acamprosate, naltrexone and disulfiram are underprescribed for alcohol use disorder (AUD) with marked variability among primary care providers (PCPs). We aimed to identify differences between high and low prescribers of medications for AUD (MAUD) with regard to knowledge, experiences, prioritization and attitudes. METHODS We surveyed PCPs from a large healthcare system with at least 20 patients with AUD. Prescribing rates were obtained from the electronic health record (EHR). Survey responses were scored from strongly disagree (1) to strongly agree (5). Multiple imputation was used to generate attitude scores for 7 missing subjects. PCPs were divided into groups by the median prescribing rate and attitude. Comparisons were made using Wilcoxon rank-sum and regression. RESULTS Of the 182 eligible PCPs, 68 (37.4%) completed the survey. Most indicated willingness to attend an educational course (57.4%). Compared with low prescribers, high prescribers viewed the effectiveness of medications more favorably (short term 4.0 vs 3.7, P = 0.02; long term 3.5 vs 3.2, P = 0.04) and were more likely to view prescribing as part of their job (3.9 vs 3.4, P = 0.04). PCPs with positive attitudes (72.4%, CI 60.9-83.8%) had a prescribing rate of 5.0% (CI 3.5-6.5%) compared to 1.9% (CI 0.5-3.4%) among those with negative attitudes (P = 0.028). When stratified by attitude, belief in effectiveness was associated with higher prescribing among PCPs with positive attitudes but not those with negative attitudes. CONCLUSIONS PCPs indicated an interest in learning to prescribe MAUD. However, education alone may not be effective unless physicians have positive attitudes towards patients with AUD.
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Affiliation(s)
- Eden Y Bernstein
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, OH 44195, USA
| | | | - Phuc Le
- Center for Value-Based Care Research, Cleveland Clinic
| | - Michael B Rothberg
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, OH 44195, USA.,Center for Value-Based Care Research, Cleveland Clinic
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Edelman EJ, Gan G, Dziura J, Esserman D, Porter E, Becker WC, Chan PA, Cornman DH, Helfrich CD, Reynolds J, Yager JE, Morford KL, Muvvala SB, Fiellin DA. Effect of Implementation Facilitation to Promote Adoption of Medications for Addiction Treatment in US HIV Clinics: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2236904. [PMID: 36251291 PMCID: PMC9577676 DOI: 10.1001/jamanetworkopen.2022.36904] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Importance Medications for addiction treatment (MAT) are inconsistently offered in HIV clinics. Objective To evaluate the impact of implementation facilitation (hereafter referred to as "facilitation"), a multicomponent implementation strategy, on increasing provision of MAT for opioid use disorder (MOUD), alcohol use disorder (MAUD), and tobacco use disorder (MTUD). Design, Setting, and Participants Conducted from July 26, 2016, through July 25, 2020, the Working with HIV Clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study used an unblinded, stepped wedge design to sequentially assign each of 4 HIV clinics in the northeastern US to cross over from control (ie, baseline practices) to facilitation (ie, intervention) and then evaluation and maintenance periods every 6 months. Participants were adult patients with opioid, alcohol, or tobacco use disorder. Data analysis was performed from August 2020 to September 2022. Interventions Multicomponent facilitation. Main Outcomes and Measures Outcomes, assessed using electronic health record data, were provision of MAT among patients with opioid, alcohol, or tobacco use disorder during the evaluation (primary outcome) and maintenance periods compared with the control period. Results Among 3647 patients, the mean (SD) age was 49 (12) years, 1814 (50%) were Black, 781 (22%) were Hispanic, and 1407 (39%) were female; 121 (3%) had opioid use disorder, 126 (3%) had alcohol use disorder, and 420 (12%) had tobacco use disorder. Compared with the control period, there was no increase in provision of MOUD with facilitation during the evaluation period (243 patients [27%; 95% CI, 22%-32%] vs 135 patients [28%; 95% CI, 22%-35%]; P = .59) or maintenance period (198 patients [29%; 95% CI, 22%-36%]; P = .48). The change in provision of MAUD from the control period to the evaluation period was not statistically significant (251 patients [8%; 95% CI, 5%-12%] vs 112 patients [13%; 95% CI, 8%-21%]; P = .11); however, the difference increased and became significant during the maintenance period (180 patients [17%; 95% CI, 12%-24%]; P = .009). There were significant increases in provision of MTUD with facilitation during both the evaluation (810 patients [33%; 95% CI, 30%-36%] vs 471 patients [40%; 95% CI, 36%-45%]; P = .005) and maintenance (643 patients [38%; 95% CI, 34%-41%]; P = .047) periods. Conclusions and Relevance In this randomized clinical trial, facilitation led to increased provision of MTUD, delayed improvements in MAUD, and no improvements in MOUD in HIV clinics. Enhanced strategies, potentially including clinic and patient incentives, especially for MOUD, may be needed to further increase provision of MAT in HIV clinics. Trial Registration ClinicalTrials.gov Identifier: NCT02907944.
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Affiliation(s)
- E. Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Geliang Gan
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - William C. Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven
| | - Philip A. Chan
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Deborah H. Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs
| | | | - Jesse Reynolds
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | | | - Kenneth L. Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Srinivas B. Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - David A. Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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Morford KL, Muvvala SB, Chan PA, Cornman DH, Doernberg M, Porter E, Virata M, Yager JE, Fiellin DA, Edelman EJ. Patients' perspectives of medications for addiction treatment in HIV clinics: A qualitative study. J Subst Abuse Treat 2022; 139:108767. [PMID: 35341613 PMCID: PMC9187601 DOI: 10.1016/j.jsat.2022.108767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/22/2021] [Accepted: 03/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND While substance use disorders (SUD) disproportionately impact people with HIV (PWH), HIV clinics inconsistently provide evidence-based medications for addiction treatment (MAT). Patient receptivity to MAT is critical to enhance addiction treatment in these settings. However, we know little from patients about how to best integrate MAT into HIV clinics. METHODS This qualitative study used four focus groups informed by the Promoting Action on Research Implementation in Health Services framework to identify barriers and facilitators to receiving opioid, alcohol, and tobacco use disorder care in HIV clinics. The study population included 28 patients with HIV and SUD receiving care at one of four HIV clinics in the northeastern United States. Focus groups were recorded and transcribed for content analysis. The study also performed a brief survey assessing demographics and behaviors. RESULTS Focus groups revealed several major themes related to MAT in HIV clinics. Barriers included stigma around MAT, knowledge deficits about available MAT options and the impact of substance use on PWH, concerns about medication side effects, substance use screening without adequate clinician follow-up, and peers who discouraged MAT. Facilitators included recognition of substance use as a threat to overall health, integrated care from HIV clinicians, and support for addiction treatment from peers with lived experience. CONCLUSIONS Efforts to enhance MAT in HIV clinics should include patient education to help them recognize addiction as a chronic disease with available medication treatment options; clinician and staff training to promote integrated, multidisciplinary screening and treatment; and thoughtful inclusion of peers with lived experience.
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Affiliation(s)
- Kenneth L Morford
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States.
| | - Srinivas B Muvvala
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States
| | - Philip A Chan
- Department of Medicine, Brown University, 593 Eddy Street, Providence, RI 02903, United States
| | - Deborah H Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, 2006 Hillside Road, Unit 1248, Storrs, CT 06269-1248, United States
| | - Molly Doernberg
- Yale School of Public Health, 60 College Street, New Haven, CT 06510, United States
| | - Elizabeth Porter
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
| | - Michael Virata
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
| | - Jessica E Yager
- SUNY Downstate, 450 Clarkson Ave, Suite J, Brooklyn, NY 11203, United States
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT 06510, United States; Department of Emergency Medicine, Yale School of Medicine, 464 Congress Avenue #260, New Haven, CT 06519, United States
| | - E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT 06510, United States
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Lauckner C, Walthers J, Stuck J, Bryant K, Edelman EJ, Fiellin DA, Hansen NB, Kahler CW, Magill M, Mastroleo NR, Maisto SA. The Relationship Between Drinking Behavior and Conversational Processes During a Brief Alcohol Reduction Intervention for People with HIV. AIDS Behav 2022; 26:2067-2080. [PMID: 35001249 PMCID: PMC10461530 DOI: 10.1007/s10461-021-03553-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/26/2022]
Abstract
People with HIV (PWH) frequently engage in unhealthy alcohol use, which can adversely affect antiretroviral adherence and HIV disease progression. Brief interventions based on Motivational Interviewing (MI), including the Brief Negotiated Interview (BNI), can help to reduce drinking. This study examines MI processes observed during a single 15-20 min BNI session delivered by social workers to PWH with unhealthy alcohol use (N = 59) in the context of a stepped care intervention to reduce alcohol consumption. BNI sessions were coded for technical and relational processes encouraged in MI, such as autonomy support, instructive language, and self-exploration. Multiple regression analyses explored the relationship between: (1) Participants' pre-intervention drinking behaviors (weekly drinks and heavy drinking days) and these MI processes, and (2) MI processes and intervention outcomes. Results indicated that PWH who reported more weekly drinks at baseline engaged in less self-exploration, while social workers delivering the BNI used less instructive language for those who reported more heavy drinking days. PWH who engaged in more self-exploration and received more autonomy support had fewer heavy drinking days 6 months after the intervention. These findings suggest the value of providing more opportunities within BNIs to encourage self-exploration, as it may help to enhance intervention efficacy.
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Affiliation(s)
- Carolyn Lauckner
- Department of Behavioral Science, University of Kentucky College of Medicine, 464 Healthy Kentucky Research Bldg, 760 Press Ave, Lexington, KY, 40536, USA.
| | - Justin Walthers
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Jennifer Stuck
- Department of Behavioral Science, University of Kentucky College of Medicine, 464 Healthy Kentucky Research Bldg, 760 Press Ave, Lexington, KY, 40536, USA
| | - Kendall Bryant
- Division of HIV/AIDS Research, National Institute On Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - E Jennifer Edelman
- Program in Addiction Medicine and Center for Interdisciplinary Research on AIDS, Yale School of Medicine, Yale School of Public Health, New Haven, CT, USA
| | - David A Fiellin
- Program in Addiction Medicine and Center for Interdisciplinary Research on AIDS, Yale School of Medicine, Yale School of Public Health, New Haven, CT, USA
| | - Nathan B Hansen
- Department of Health Promotion and Behavior, University of Georgia College of Public Health, Athens, GA, USA
| | - Christopher W Kahler
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Molly Magill
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | | | - Stephen A Maisto
- Department of Psychology, Syracuse University College of Arts & Sciences, Syracuse, NY, USA
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Gordon KS, Becker WC, Bryant KJ, Crystal S, Maisto SA, Marshall BDL, McInnes DK, Satre DD, Williams EC, Edelman EJ, Justice AC. Patient-Reported Bothersome Symptoms Attributed to Alcohol Use Among People With and Without HIV. AIDS Behav 2022; 26:3589-3596. [PMID: 35553287 PMCID: PMC10084471 DOI: 10.1007/s10461-022-03628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 11/26/2022]
Abstract
Helping people with HIV (PWH) and without HIV (PWoH) understand the relationship between physical symptoms and alcohol use might help motivate them to decrease use. In surveys collected in the Veterans Aging Cohort Study from 2002 to 2018, PWH and PWoH were asked about 20 common symptoms and whether they thought any were caused by alcohol use. Analyses were restricted to current alcohol users (AUDIT-C > 0). We applied generalized estimating equations. The outcome was having any Symptoms Attributed to Alcohol use (SxAA). Primary independent variables were each of the 20 symptoms and HIV status. Compared to PWoH, PWH had increased odds of SxAA (OR 1.54; 95% CI 1.27, 1.88). Increased AUDIT-C score was also associated with SxAA (OR 1.32; 95% CI 1.28, 1.36), as were trouble remembering, anxiety, and weight loss/wasting. Evidence that specific symptoms are attributed to alcohol use may help motive people with and without HIV decrease their alcohol use.
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Affiliation(s)
- Kirsha S Gordon
- VA Connecticut Healthcare System, 11ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - William C Becker
- VA Connecticut Healthcare System, 11ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Stephen Crystal
- Rutgers University School of Social Work, New Brunswick, NJ, USA
| | - Stephen A Maisto
- Syracuse University College of Arts and Sciences, Syracuse, NY, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - D Keith McInnes
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Derek D Satre
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Amy C Justice
- VA Connecticut Healthcare System, 11ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
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10
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Oldfield BJ, Li Y, Vickers-Smith R, Barry DT, Crystal S, Gordon KS, Kerns RD, Williams EC, Marshall BDL, Edelman EJ. Longitudinal analysis of the prevalence and correlates of heavy episodic drinking and self-reported opioid use among a national cohort of patients with HIV. Alcohol Clin Exp Res 2022; 46:600-613. [PMID: 35257397 PMCID: PMC9018502 DOI: 10.1111/acer.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 02/20/2022] [Accepted: 02/25/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Heavy episodic drinking (HED) is a risk factor for opioid-related overdose and negatively impacts HIV disease progression. Among a national cohort of patients with HIV (PWH), we examined sociodemographic and clinical correlates of concomitant HED and self-reported opioid use. METHODS We used data collected from 2002 through 2018 from the Veterans Aging Cohort Study, a prospective cohort including PWH in care at eight US Veterans Health Administration sites. HED was defined as consuming six or more drinks at least once in the year prior to survey collection. We examined the relationship between HED and self-reported opioid use and created a 4-level composite variable of HED and opioid use. We used multinomial logistic regression to estimate odds of reporting concomitant HED and self-reported opioid use. RESULTS Among 3702 PWH, 1458 (39.4%) reported HED during the study period and 350 (9.5%) reported opioid use. In the multinomial model, compared to reporting neither HED nor opioid use, lifetime housing instability (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.01 to 2.35), Veterans Aging Cohort Study Index 2.0 (a measure of disease severity; aOR 1.14, 95% CI 1.02 to 1.28), depressive symptoms (aOR 2.27, 95% CI 1.42 to 3.62), past-year cigarette smoking (aOR 3.06, 95% CI 1.53 to 6.14), cannabis use (aOR 1.69, 95% CI 1.09 to 2.62), and cocaine/stimulant use (aOR 11.54, 95% CI 7.40 to 17.99) were independently associated with greater odds of concomitant HED and self-reported opioid use. Compared to having attended no college, having some college or more (aOR 0.39, 95% CI 0.26 to 0.59) was associated with lower odds of concomitant HED and self-reported opioid use. CONCLUSIONS Among PWH, concomitant HED and self-reported opioid use are more common among individuals with depressive symptoms and substance use, structural vulnerabilities, and greater illness severity. Efforts to minimize opioid-related risk should address high-risk drinking as a modifiable risk factor for harm among these groups.
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Affiliation(s)
- Benjamin J Oldfield
- Fair Haven Community Health Care, New Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
| | - Yu Li
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Rachel Vickers-Smith
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, Kentucky, USA
| | | | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, Rutgers, New Jersey, USA
| | - Kirsha S Gordon
- Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Robert D Kerns
- Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA.,Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Health Services Research and Development, VA Puget Sound, Seattle, Washington, USA
| | | | - E Jennifer Edelman
- Yale School of Medicine, New Haven, Connecticut, USA.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut, USA
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11
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Lesko CR, Hutton HE, Edwards JK, McCaul ME, Fojo AT, Keruly JC, Moore RD, Chander G. Alcohol Use Disorder and Recent Alcohol Use and HIV Viral Non-Suppression Among People Engaged in HIV Care in an Urban Clinic, 2014-2018. AIDS Behav 2022; 26:1299-1307. [PMID: 34626264 PMCID: PMC8940688 DOI: 10.1007/s10461-021-03487-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 01/28/2023]
Abstract
We estimated joint associations between having history of alcohol use disorder (AUD) (based on prior ICD-9/ICD-10 codes) and recent self-reported alcohol use and viral non-suppression (≥ 1 viral load measurement > 20 copies/mL in the same calendar year as alcohol consumption was reported) among patients on ART enrolled in routine care, 2014-2018, in an urban specialty clinic. Among 1690 patients, 26% had an AUD, 21% reported high-risk alcohol use, and 39% had viral non-suppression. Relative to person-years in which people without AUD reported not drinking, prevalence of viral non-suppression was higher in person-years when people with AUD reported drinking at any level; prevalence of viral non-suppression was not significantly higher in person-years when people with AUD reported not drinking or person-years when people without AUD reported drinking at any level. No level of alcohol use may be "safe" for people with a prior AUD with regard to maintaining viral suppression.
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Affiliation(s)
- Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.
| | - Heidi E Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeanne C Keruly
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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12
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McCaul ME, Hutton HE, Cropsey KL, Crane HM, Lesko CR, Chander G, Mugavero MJ, Kitahata MM, Lau B, Saag MS. Decreased Alcohol Consumption in an Implementation Study of Computerized Brief Intervention among HIV Patients in Clinical Care. AIDS Behav 2021; 25:4074-4084. [PMID: 33993353 PMCID: PMC8594281 DOI: 10.1007/s10461-021-03295-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 12/28/2022]
Abstract
This prospective, nonrandomized implementation study evaluated a computerized brief intervention (CBI) for persons with HIV (PWH) and heavy/hazardous alcohol use. CBI was integrated into two HIV primary care clinics. Eligible patients were engaged in care, ≥ 18 years old, English speaking, endorsed heavy/hazardous alcohol use on the Alcohol Use Disorders Identification Test-C (AUDIT-C). Two 20-min computerized sessions using cognitive behavioral techniques were delivered by a 3-D avatar on touch screen tablets. Of 816 eligible AUDIT-C scores, 537 (66%) resulted in CBI invitation, 226 (42%) of invited patients enrolled, and 176 (78%) of enrolled patients watched at least one session. CBI enrollment was associated with a significant average reduction of 9.1 drinks/week (95% CI - 14.5, - 3.6) 4-12 months post-enrollment. Among those who participated in one or both sessions, average reduction in drinks/week was 11.7 drinks/week (95% CI - 18.8, - 4.6). There was corresponding improvement in AUDIT-C scores. Overall patients reported high levels of intervention satisfaction, particularly among older and Black patients. These promising results point to a practical intervention for alcohol reduction in this vulnerable patient population with elevated rates of heavy/hazardous drinking. Future research should examine strategies to increase initial engagement, strengthen intervention effects to increase the number of patients who achieve non-hazardous drinking, and examine the duration of therapeutic effects.
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Affiliation(s)
- Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 550 N Broadway, Suite 115, Baltimore, MD, 21205, USA.
| | - Heidi E Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 550 N Broadway, Suite 115, Baltimore, MD, 21205, USA
| | - Karen L Cropsey
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama At Birmingham, Birmingham, AL, USA
| | - Heidi M Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael S Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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13
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Jabour SM, Chander G, Riekert KA, Keruly JC, Herne K, Hutton H, Beach MC, Lau B, Moore RD, Monroe AK. The Patient Reported Outcomes as a Clinical Tool (PROACT) Pilot Study: What Can be Gained by Sharing Computerized Patient-Reported Mental Health and Substance Use Symptoms with Providers in HIV Care? AIDS Behav 2021; 25:2963-2972. [PMID: 33559775 DOI: 10.1007/s10461-021-03175-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Substance use and mental health (SU/MH) disorders are insufficiently recognized in HIV care. We examined whether conveying SU/MH screening results to patients and providers increased SU/MH discussions and action plans. Intervention participants completed a computerized patient-reported questionnaire before their HIV visit; screened positive on ≥ 1 measure: depression, anxiety, PTSD symptoms, at-risk alcohol use, or drug use; and reviewed screening results to decide which to prioritize with their provider. Screening results and clinical recommendations were conveyed to providers via medical record. A historic control included patients with positive screens but no conveyance to patient or provider. The patient-provider encounter was audio-recorded, transcribed, and coded. For the overall sample (n = 70; 38 control, 32 intervention), mean age (SD) was 51.8 (10.3), 61.4% were male, and 82.9% were Black. Overall, 93.8% raised SU/MH in the intervention compared to 50.0% in the control (p < 0.001). Action plans were made for 40.0% of intervention and 10.5% of control encounters (p = 0.049). Conveying screening results with clinical recommendations increased SU/MH action plans, warranting further research on this intervention to address SU/MH needs.
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14
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Chichetto NE, Kundu S, Freiberg MS, Koethe JR, Butt AA, Crystal S, So-Armah KA, Cook RL, Braithwaite RS, Justice AC, Fiellin DA, Khan M, Bryant KJ, Gaither JR, Barve SS, Crothers K, Bedimo RJ, Warner A, Tindle HA. Association of Syndemic Unhealthy Alcohol Use, Smoking, and Depressive Symptoms on Incident Cardiovascular Disease among Veterans With and Without HIV-Infection. AIDS Behav 2021; 25:2852-2862. [PMID: 34101074 PMCID: PMC8376776 DOI: 10.1007/s10461-021-03327-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
Unhealthy alcohol use, smoking, and depressive symptoms are risk factors for cardiovascular disease (CVD). Little is known about their co-occurrence - termed a syndemic, defined as the synergistic effect of two or more conditions-on CVD risk in people with HIV (PWH). We used data from 5621 CVD-free participants (51% PWH) in the Veteran's Aging Cohort Study-8, a prospective, observational study of veterans followed from 2002 to 2014 to assess the association between this syndemic and incident CVD by HIV status. Diagnostic codes identified cases of CVD (acute myocardial infarction, stroke, heart failure, peripheral artery disease, and coronary revascularization). Validated measures of alcohol use, smoking, and depressive symptoms were used. Baseline number of syndemic conditions was categorized (0, 1, ≥ 2 conditions). Multivariable Cox Proportional Hazards regressions estimated risk of the syndemic (≥ 2 conditions) on incident CVD by HIV-status. There were 1149 cases of incident CVD (52% PWH) during the follow-up (median 10.1 years). Of the total sample, 64% met our syndemic definition. The syndemic was associated with greater risk for incident CVD among PWH (Hazard Ratio [HR] 1.87 [1.47-2.38], p < 0.001) and HIV-negative veterans (HR 1.70 [1.35-2.13], p < 0.001), compared to HIV-negative with zero conditions. Among those with the syndemic, CVD risk was not statistically significantly higher among PWH vs. HIV-negative (HR 1.10 [0.89, 1.37], p = .38). Given the high prevalence of this syndemic combined with excess risk of CVD, these findings support linked-screening and treatment efforts.
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Affiliation(s)
- Natalie E Chichetto
- Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Office 315, Nashville, TN, 37203, USA.
| | - Suman Kundu
- Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Office 315, Nashville, TN, 37203, USA
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Office 315, Nashville, TN, 37203, USA
- Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - John R Koethe
- Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Office 315, Nashville, TN, 37203, USA
| | - Adeel A Butt
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, Weill-Cornell Medical College, Doha, USA
- Hamad Medical Corporation, Doha, Qatar
| | - Stephen Crystal
- Health Care Policy, and Aging Research and School of Social Work, Institute for Health, Rutgers University, New Brunswick, NJ, USA
| | - Kaku A So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Robert L Cook
- Department of Epidemiology, Colleges of Public Health and Health Professions and Medicine, University of Florida, Gainesville, FL, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Amy C Justice
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, New Haven, CT, USA
| | - David A Fiellin
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Maria Khan
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Kendall J Bryant
- National Institute On Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Julie R Gaither
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Shirish S Barve
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Roger J Bedimo
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alberta Warner
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CT, USA
| | - Hilary A Tindle
- Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Office 315, Nashville, TN, 37203, USA
- Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
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15
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Edelman EJ, Gan G, Dziura J, Esserman D, Morford KL, Porter E, Chan PA, Cornman DH, Oldfield BJ, Yager J, Muvvala SB, Fiellin DA. Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation. J Acquir Immune Defic Syndr 2021; 87:959-970. [PMID: 33675619 PMCID: PMC8192340 DOI: 10.1097/qai.0000000000002666] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/16/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics. SETTING Four HIV clinics in the northeastern United States. METHODS Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups. RESULTS Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork. CONCLUSIONS Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.
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Affiliation(s)
- E. Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Geliang Gan
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Kenneth L. Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Philip A. Chan
- Department of Medicine, Brown University, Providence, RI
| | - Deborah H. Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT
| | | | | | - Srinivas B. Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - David A. Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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16
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Dinani A, Khan A, Dieterich D. Emerging prevalence of fatty liver disease in HIV. Future Virol 2021. [DOI: 10.2217/fvl-2020-0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Fatty liver disease is a growing concern in people living with HIV, the main drivers are alcoholic liver disease and nonalcoholic fatty liver disease. It has shown to negatively impact HIV care continuum and result in notable non-HIV related morbidity and mortality. With the advancement in antiretroviral therapy and effective direct acting antivirals, fatty liver disease is surfacing as the next big challenge in this population like that observed in the general population. This review article summarizes the gravity of these two common diseases in HIV-infected people and aims to sheds light on an unmet need to develop effective methods to identify, screen and manage fatty liver disease in this unique population.
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Affiliation(s)
- Amreen Dinani
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ali Khan
- Department of Internal Medicine, Icahn School of Medicine, Mount Sinai West, New York, NY 10019, USA
| | - Douglas Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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17
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Edelman EJ, Dziura J, Esserman D, Porter E, Becker WC, Chan PA, Cornman DH, Rebick G, Yager J, Morford K, Muvvala SB, Fiellin DA. Working with HIV clinics to adopt addiction treatment using implementation facilitation (WHAT-IF?): Rationale and design for a hybrid type 3 effectiveness-implementation study. Contemp Clin Trials 2020; 98:106156. [PMID: 32976995 PMCID: PMC7511156 DOI: 10.1016/j.cct.2020.106156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tobacco, alcohol and opioid misuse are associated with substantial morbidity and mortality among people with HIV (PWH). Despite existence of evidence-based counseling and medications for addiction, these treatments are infrequently offered in HIV clinics. The Working with HIV clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study was conducted to address this implementation challenge. The study's goals were to conduct a formative evaluation of barriers to and facilitators of implementing addiction treatment for PWH followed by an evaluation of the impact of Implementation Facilitation (IF) on promoting adoption of addiction treatments and clinical outcomes. METHODS The study was conducted at four HIV clinics in the northeast United States, using a hybrid type 3 effectiveness-implementation stepped wedge design and guided by the Promoting Action on Research Implementation in Health Services Research (PARiHS) framework. A mixed-methods approach was used to identify evidence, context, and facilitation-related barriers to and facilitators of integration of addiction treatments into HIV clinics and to help tailor IF for each clinic. An evaluation was then conducted of the impact of IF on implementation outcomes, including provision of addiction treatment (primary outcome), organizational and clinician and staff readiness to adopt addiction treatment, and changes in organizational models of care used to deliver addiction treatment. The evaluation also included IF's impact on effectiveness outcomes, specifically HIV-related outcomes among patients eligible for addiction treatment. CONCLUSIONS Results will generate important information regarding the impact of IF as a reproducible strategy to promote addiction treatment in HIV clinics.
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Affiliation(s)
- E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America.
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America; Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States of America
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - William C Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Philip A Chan
- Department of Medicine, Brown University, Providence, RI, United States of America
| | - Deborah H Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT, United States of America
| | - Gabriel Rebick
- New York University, New York, NY, United States of America
| | - Jessica Yager
- SUNY Downstate, Brooklyn, NY, United States of America
| | - Kenneth Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Srinivas B Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
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Go VF, Hutton HE, Ha TV, Chander G, Latkin CA, Mai NVT, Quynh BX, Nguyen V, Sripaipan T, Lancaster KE, Blackburn N, Hershow RB, Dowdy DW, Frangakis C. Effect of 2 Integrated Interventions on Alcohol Abstinence and Viral Suppression Among Vietnamese Adults With Hazardous Alcohol Use and HIV: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2017115. [PMID: 32945875 PMCID: PMC7501538 DOI: 10.1001/jamanetworkopen.2020.17115] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Hazardous and heavy alcohol use is common among people living with HIV and may decrease antiretroviral therapy (ART) adherence, but limited data exist from randomized clinical trials about the effects of interventions on viral load. OBJECTIVE To compare the efficacy of 2 scalable ART clinic-based interventions on alcohol use and viral suppression. DESIGN, SETTING, AND PARTICIPANTS This 3-group randomized clinical trial was conducted among 440 adults with HIV who were being treated at 7 ART clinics in Thai Nguyen, Vietnam. Adults receiving ART with hazardous alcohol use (Alcohol Use Disorders Identification Test-Consumption score ≥4 for men or ≥3 for women) and no plans to leave Thai Nguyen were included. Data were collected from March 2016 to May 2018 and analyzed from June 2018 to February 2020. INTERVENTIONS Participants were randomly assigned (1:1:1) to standard of care (SOC), a combined intervention of motivational enhancement therapy and cognitive behavioral therapy (6 in-person sessions of 1 hour each and 3 optional group sessions), or a brief intervention with similar components as the combined intervention but consisting of 2 shorter in-person sessions and 2 telephone sessions. MAIN OUTCOMES AND MEASURES The primary study outcomes were percentage of days abstinent from alcohol, confirmed using the alcohol biomarker phosphatidylethanol, and viral suppression at 12 months after enrollment. RESULTS A total of 440 eligible individuals (mean [SD] age, 40.2 [5.8] years; 426 [96.8%] men) were enrolled; 147 (33.4%) were assigned to the combined intervention, 147 (33.4%) to the brief intervention, and 146 (33.2%) to SOC. In the combined intervention group, 112 participants (76.2%) attended all 6 sessions, and in the brief intervention group, 124 (84.4%) attended all 4 sessions; in the whole sample, 390 (88.6%) completed 12 months of follow-up. At 12 months, the mean (SE) percentage of days abstinent was 65% (3.1%) among those in the combined intervention group, 65% (3.2%) among those in the brief intervention group, and 50% (3.4%) among those in the in the SOC group (Cohen d for combined intervention vs SOC and brief intervention vs SOC: 39%; 95% CI, 15% to 64%). Viral suppression (ie, <20 copies of HIV-1 RNA per milliliter) at 12 months was higher after the brief intervention than SOC (difference, 11%; 95% CI, 2% to 20%), but the difference between the combined intervention and SOC was not significantly different (difference, 5%; 95%, CI, -5% to 15%). CONCLUSIONS AND RELEVANCE In this study, the brief intervention resulted in a significant increase in percentage of days abstinent from alcohol and a significant increase in viral suppression after 12 months. Future implementation science studies evaluating scale-up of the brief intervention are needed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02720237.
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Affiliation(s)
- Vivian F. Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Heidi E. Hutton
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tran V. Ha
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- University of North Carolina Vietnam, Hanoi, Vietnam
| | - Geetanjali Chander
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Carl A. Latkin
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Bui X. Quynh
- University of North Carolina Vietnam, Hanoi, Vietnam
| | - Vu Nguyen
- University of North Carolina Vietnam, Hanoi, Vietnam
| | - Teerada Sripaipan
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Kathryn E. Lancaster
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Natalie Blackburn
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Rebecca B. Hershow
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - David W. Dowdy
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Infectious Diseases, Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Division of Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Constantine Frangakis
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Parcesepe AM, Lancaster K, Edelman EJ, DeBoni R, Ross J, Atwoli L, Tlali M, Althoff K, Tine J, Duda SN, Wester CW, Nash D. Substance use service availability in HIV treatment programs: Data from the global IeDEA consortium, 2014-2015 and 2017. PLoS One 2020; 15:e0237772. [PMID: 32853246 PMCID: PMC7451518 DOI: 10.1371/journal.pone.0237772] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/02/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Substance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes. METHODS We report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014-2015 survey and 237 sites in 44 countries participated in the 2017 survey. We compared changes over time for 147 sites that participated in both surveys. RESULTS In 2014-2015, most sites (75%) reported providing substance use-related education on-site (i.e., at the HIV clinic or the same health facility). Approximately half reported on-site screening for substance use (52%) or referrals for substance use treatment (51%). In 2017, the proportion of sites providing on-site substance use-related education, screening, or referrals increased by 9%, 16%, and 8%, respectively. In 2017, on-site substance use screening and referral were most commonly reported at sites serving only adults (compared to only children/adolescents or adults and children/adolescents; screening: 86%, 37%, and 59%, respectively; referral: 76%, 47%, and 46%, respectively) and at sites in high-income countries (compared to upper middle income, lower middle income or low-income countries; screening: 89%, 76%, 68%, and 45%, respectively; referral: 82%, 71%, 57%, and 34%, respectively). CONCLUSION Although there have been increases in the proportion of sites reporting substance use education, screening, and referral services across IeDEA sites, gaps persist in the integration of substance use services into HIV care, particularly in relation to screening and referral practices, with reduced availability for children/adolescents and those receiving care within resource-constrained settings.
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Affiliation(s)
- Angela M Parcesepe
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Kathryn Lancaster
- Department of Epidemiology, The Ohio State University, Columbus, Ohio, United States of America
| | - E Jennifer Edelman
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Raquel DeBoni
- National Institute of Infectology, Evandro Chagas, Fiocruz, Brazil
| | - Jeremy Ross
- TREAT Asia/amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Lukoye Atwoli
- Department of Mental Health, Moi University School of Medicine, Eldoret, Kenya
| | - Mpho Tlali
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Keri Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Judicaël Tine
- Maladies Infectieuses du Centre Hospitalier, National Universitaire de FANN, Dakar, Senegal
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - C William Wester
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee, United States of America
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Department of Epidemiology and Biostatistics, City University of New York, New York, New York, United States of America
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20
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Edelman EJ, Maisto SA, Hansen NB, Cutter CJ, Dziura J, Deng Y, Fiellin LE, O'Connor PG, Bedimo R, Gibert CL, Marconi VC, Rimland D, Rodriguez-Barradas MC, Simberkoff MS, Tate JP, Justice AC, Bryant KJ, Fiellin DA. Integrated stepped alcohol treatment for patients with HIV and at-risk alcohol use: a randomized trial. Addict Sci Clin Pract 2020; 15:28. [PMID: 32727618 PMCID: PMC7388231 DOI: 10.1186/s13722-020-00200-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 07/09/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND At-risk levels of alcohol use threaten the health of patients with HIV (PWH), yet evidence-based strategies to decrease alcohol use and improve HIV-related outcomes in this population are lacking. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among PWH and at-risk alcohol use. METHODS In this multi-site, randomized trial conducted between January 28, 2013 through July 14, 2017, we enrolled PWH and at-risk alcohol use [defined as alcohol consumption of ≥ 14 drinks per week or ≥ 4 drinks per occasion in men ≤ 65 years old or ≥ 7 drinks per week or ≥ 3 drinks per occasion in women or men > 65 years old]. ISAT (n = 46) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 47) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat principles. RESULTS Despite a multi-pronged approach, we only recruited 37% of the target population (n = 93/254). Among ISAT participants, 50% advanced to Step 2, among whom 57% advanced to Step 3. Participants randomized to ISAT and TAU had no observed difference in drinks per week over the past 30 days at week 24 (primary outcome) [least square means (Ls mean) (95% CI) = 8.8 vs. 10.6; adjusted mean difference (AMD) (95% CI) = - 0.4 (- 3.9, 3.0)]. CONCLUSION An insufficient number of patients were interested in participating in the trial. Efforts to enhance motivation of PWH with at-risk alcohol use to engage in alcohol-related research and build upon ISAT are needed. Trial registration Clinicaltrials.gov: NCT01410123, First posted August 4, 2011.
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Affiliation(s)
- E Jennifer Edelman
- Yale School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06510, USA.
| | | | - Nathan B Hansen
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06510, USA.,College of Public Health, University of Georgia, Athens, GA, 30602, USA
| | | | - James Dziura
- Yale Center for Analytic Sciences, Yale University School of Public Health, New Haven, CT, 06511, USA
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale University School of Public Health, New Haven, CT, 06511, USA
| | - Lynn E Fiellin
- Yale School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Patrick G O'Connor
- Yale School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA
| | - Roger Bedimo
- Veterans Affairs North Texas Health Care System and UT Southwestern, Dallas, TX, 75216, USA
| | - Cynthia L Gibert
- D.C. VAMC and George, Washington University School of Medicine and Health Sciences, Washington, D.C, 20422, USA
| | - Vincent C Marconi
- Atlanta VAMC and Emory University School of Medicine, Atlanta, GA, 30033, USA
| | - David Rimland
- Atlanta VAMC and Emory University School of Medicine, Atlanta, GA, 30033, USA
| | | | - Michael S Simberkoff
- VA NY Harbor Healthcare System and New York University School of Medicine, New York, NY, 10010, USA
| | - Janet P Tate
- Yale School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.,VA Connecticut Healthcare System, Veterans Aging Cohort Study, West Haven, CT, 06516, USA
| | - Amy C Justice
- Yale School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.,VA Connecticut Healthcare System, Veterans Aging Cohort Study, West Haven, CT, 06516, USA
| | - Kendall J Bryant
- National Institute On Alcohol Abuse and Alcoholism HIV/AIDS Program, Bethesda, MD, 20892-7003, USA
| | - David A Fiellin
- Yale School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06510, USA
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21
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Khan MR, Young KE, Caniglia EC, Fiellin DA, Maisto SA, Marshall BDL, Edelman EJ, Gaither JR, Chichetto NE, Tate J, Bryant KJ, Severe M, Stevens ER, Justice A, Braithwaite SR. Association of Alcohol Screening Scores With Adverse Mental Health Conditions and Substance Use Among US Adults. JAMA Netw Open 2020; 3:e200895. [PMID: 32163167 PMCID: PMC7068229 DOI: 10.1001/jamanetworkopen.2020.0895] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Alcohol screening may be associated with health outcomes that cluster with alcohol use (ie, alcohol-clustering conditions), including depression, anxiety, and use of tobacco, marijuana, and illicit drugs. OBJECTIVE To quantify the extent to which alcohol screening provides additional information regarding alcohol-clustering conditions and to compare 2 alcohol use screening tools commonly used for this purpose. DESIGN, SETTING, AND PARTICIPANTS This longitudinal cohort study used data from the Veterans Aging Cohort Study. Data were collected at 8 Veterans Health Administration facilities from 2003 through 2012. A total of 7510 participants were enrolled, completed a baseline survey, and were followed up. Veterans with HIV were matched with controls without HIV by age, race, sex, and site of care. Data were analyzed from January 2019 to December 2019. EXPOSURES The Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) were used to assess alcohol use, with 4 risk groups delineated for each test: score 0 to 7 (reference), score 8 to 15, score 16 to 19, and score 20 to 40 (maximum score) for the full AUDIT and score 0 to 3 (reference), score 4 to 5, score 6 to 7, and score 8 to 12 (maximum score) for the AUDIT-C. MAIN OUTCOMES AND MEASURES Alcohol-clustering conditions, including self-reported symptoms of depression and anxiety and use of tobacco, marijuana, cocaine, other stimulants, opioids, and injection drugs. RESULTS A total of 6431 US patients (6104 [95%] men; median age during survey years 2003-2004, 50 years [range, 28-86 years; interquartile range, 44-55 years]) receiving care in the Veterans Health Administration completed 1 or more follow-up surveys when the AUDIT was administered and were included in the present analyses. Of the male participants, 4271 (66%) were African American, 1498 (24%) were white, and 590 (9%) were Hispanic. The AUDIT and AUDIT-C scores were associated with each alcohol-clustering condition. In particular, an AUDIT score of 20 or higher (vs <8, the reference) was associated with symptoms of depression (odds ratio [OR], 8.37; 95% CI, 6.20-11.29) and anxiety (OR, 8.98; 95% CI, 6.39-12.60) and with self-reported use of tobacco (OR, 14.64; 95% CI, 8.94-23.98), marijuana (OR, 12.41; 95% CI, 8.61-17.90), crack or cocaine (OR, 39.47; 95% CI, 27.38-56.90), other stimulants (OR, 21.31; 95% CI, 12.73-35.67), and injection drugs (OR, 8.67; 95% CI, 5.32-14.13). An AUDIT score of 20 or higher yielded likelihood ratio (sensitivity / 1 - specificity) values greater than 3.5 for depression, anxiety, crack or cocaine use, and other stimulant use. Associations between AUDIT-C scores and alcohol-clustering conditions were more modest. CONCLUSIONS AND RELEVANCE Alcohol screening can inform decisions about further screening and diagnostic assessment for alcohol-clustering conditions, particularly for depression, anxiety, crack or cocaine use, and other stimulant use. Future studies using clinical diagnoses rather than screening tools to assess alcohol-clustering conditions may be warranted.
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Affiliation(s)
- Maria R. Khan
- Department of Population Health, New York University School of Medicine, New York
| | - Kailyn E. Young
- Department of Population Health, New York University School of Medicine, New York
| | - Ellen C. Caniglia
- Department of Population Health, New York University School of Medicine, New York
| | - David A. Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | | | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Julie R. Gaither
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Natalie E. Chichetto
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Janet Tate
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - MacRegga Severe
- Department of Population Health, New York University School of Medicine, New York
| | - Elizabeth R. Stevens
- Department of Population Health, New York University School of Medicine, New York
| | - Amy Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Scott R. Braithwaite
- Department of Population Health, New York University School of Medicine, New York
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Oldfield BJ, McGinnis KA, Edelman EJ, Williams EC, Gordon AJ, Akgün K, Crystal S, Fiellin LE, Gaither JR, Goulet JL, Korthuis PT, Marshall BDL, Justice AC, Bryant K, Fiellin DA, Kraemer KL. Predictors of initiation of and retention on medications for alcohol use disorder among people living with and without HIV. J Subst Abuse Treat 2019; 109:14-22. [PMID: 31856946 DOI: 10.1016/j.jsat.2019.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Infrequent use of and poor retention on evidence-based medications for alcohol use disorder (MAUD) represent a treatment gap, particularly among people living with HIV (PLWH). We examined predictors of MAUD initiation and retention across HIV status. METHODS From Veterans Aging Cohort Study (VACS) data, we identified new alcohol use disorder (AUD) diagnoses from 1998 to 2015 among 163,339 individuals (50,826 PLWH and 112,573 uninfected, matched by age, sex, and facility). MAUD initiation was defined as a prescription fill for naltrexone, acamprosate or disulfiram within 30 days of a new diagnosis. Among those who initiated, retention was defined as filling medication for ≥80% of days over the following six months. We used multivariable logistic regression to assess patient- and facility-level predictors of AUD medication initiation across HIV status. RESULTS Among 10,603 PLWH and 24,424 uninfected individuals with at least one AUD episode, 359 (1.0%) initiated MAUD and 49 (0.14%) were retained. The prevalence of initiation was lower among PLWH than those without HIV (adjusted odds ratio [AOR] 0.66, 95% confidence interval [CI] 0.51-0.85). Older age (for PLWH: AOR 0.78, 95% CI 0.61-0.99; for uninfected: AOR 0.70, 95% CI 0.61-0.80) and black race (for PLWH: AOR 0.63, 95% CI 0.0.49-0.1.00; for uninfected: AOR 0.63, 95% CI 0.48-0.83), were associated with decreased odds of initiation for both groups. The low frequency of retention precluded multivariable analyses for retention. CONCLUSIONS For PLWH and uninfected individuals, targeted implementation strategies to expand MAUD are needed, particularly for specific subpopulations (e.g. black PLWH).
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Affiliation(s)
- Benjamin J Oldfield
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America.
| | - Kathleen A McGinnis
- Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - E Jennifer Edelman
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Emily C Williams
- School of Public Health, University of Washington, Seattle, WA, United States of America; Health Services Research and Development, VA Puget Sound Healthcare Services, Seattle, WA, United States of America
| | - Adam J Gordon
- Department of Medicine, University of Utah, Salt Lake City, UT, United States of America; Department of Medicine, Salt Lake City VA Health Care System, Salt Lake City, UT, United States of America
| | - Kathleen Akgün
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Stephen Crystal
- School of Social Work, Rutgers University, New Brunswick, NJ, United States of America
| | - Lynn E Fiellin
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Julie R Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America
| | - Joseph L Goulet
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - P Todd Korthuis
- Department of Medicine, Oregon Health Sciences University, Portland, OR, United States of America
| | - Brandon D L Marshall
- School of Public Health, Brown University, Providence, RI, United States of America
| | - Amy C Justice
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States of America
| | - David A Fiellin
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Kevin L Kraemer
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
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Sherman KE, Peters MG, Thomas DL. HIV and the liver. TOPICS IN ANTIVIRAL MEDICINE 2019; 27:101-110. [PMID: 31634861 PMCID: PMC6892621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/05/2019] [Indexed: 06/10/2023]
Abstract
Among individuals with HIV infection, liver disease remains an important cause of morbidity and mortality, even with the availability of agents that cure hepatitis C infection and suppress hepatitis B replication. The causes of liver disease are multifaceted and continue to evolve as the population ages and new etiologies arise. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis and hepatitis viruses such as A, D, and E have emerged even as hepatitis C has receded. Newer antiretroviral agents may increase risk of weight gain and subsequent fatty infiltration, and prior use of nucleotide-based therapies may continue to impact liver health. Several barriers including economics, social stigma, and psychiatric disease impact identification of liver disease, as well as management and treatment interventions. Hepatocellular carcinoma is emerging as a more common and late-diagnosed complication in those with HIV infection and liver disease.
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Affiliation(s)
- Kenneth E. Sherman
- Send correspondence to Kenneth E. Sherman, MD, PhD, University of Cincinnati College of Medicine, Division of Digestive Diseases, 231 Albert Sabin Way, Cincinnati, OH 45267-0595, or to
| | - Marion G. Peters
- Professor of Medicine at University of California San Francisco in San Francisco, California
| | - David L. Thomas
- Professor of Medicine at Johns Hopkins University in Baltimore, Maryland
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24
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Edelman EJ, Maisto SA, Hansen NB, Cutter CJ, Dziura J, Deng Y, Fiellin LE, O'Connor PG, Bedimo R, Gibert CL, Marconi VC, Rimland D, Rodriguez-Barradas MC, Simberkoff MS, Tate JP, Justice AC, Bryant KJ, Fiellin DA. Integrated stepped alcohol treatment for patients with HIV and liver disease: A randomized trial. J Subst Abuse Treat 2019; 106:97-106. [PMID: 31540617 DOI: 10.1016/j.jsat.2019.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/07/2019] [Accepted: 08/08/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND There is no known safe level of alcohol use among patients with HIV and liver disease. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use, HIV, and liver outcomes among patients with HIV and liver disease. METHODS In this multi-site, randomized trial conducted between January 28, 2013 through July 15, 2016, we enrolled 95 patients with HIV and liver disease [defined as having active hepatitis C infection or FIB-4 score > 1.45]. ISAT (n = 49) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 46) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat. RESULTS Among ISAT participants, 55% advanced to Step 2, among whom 70% advanced to Step 3. Participants randomized to ISAT and TAU increased abstinence (primary outcome) over time. Abstinence rates were non-significantly higher by self-report (38% vs. 23%, adjusted odds ratio [AOR] [95% CI] = 2.6 [0.8, 9.0]) and phosphatidylethanol (43% vs. 32%, AOR [95% CI] = 1.8 [0.5, 6.3] among those randomized to ISAT vs. TAU at week 24. VACS Index scores (AMD [95% CI] = 1.1 [-3.2, 5.5]) and the proportion with an undetectable HIV viral load (AOR [95% CI] = 0.3 [0.1, 1.3]) did not differ by group at week 24 (p values >0.05). ISAT had non-significantly lower FIB-4 scores (adjusted mean difference [AMD] [95% CI] = -0.2 [-0.9, 0.5]), ALT (AMD [95% CI] = -7 [-20, 7]) and AST (AMD [95% CI] = -4 [-15, 7]) at week 24 compared to TAU. CONCLUSION ISAT is feasible and potentially effective at enhancing delivery of evidence-based alcohol treatment to promote alcohol abstinence and improve liver biomarkers among patients with HIV and liver disease.
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Affiliation(s)
- E Jennifer Edelman
- Yale School of Medicine, New Haven, CT 06510, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT 06510, United States of America.
| | - Stephen A Maisto
- Syracuse University, Syracuse, NY 13244, United States of America
| | - Nathan B Hansen
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT 06510, United States of America; College of Public Health, University of Georgia, Athens, GA 30602, United States of America
| | | | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT 06511, United States of America
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT 06511, United States of America
| | - Lynn E Fiellin
- Yale School of Medicine, New Haven, CT 06510, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT 06510, United States of America
| | | | - Roger Bedimo
- Veterans Affairs North Texas Health Care System, UT Southwestern, Dallas, TX 75216, United States of America
| | - Cynthia L Gibert
- D.C. VAMC, George Washington University School of Medicine and Health Sciences, Washington, DC 20422, United States of America
| | - Vincent C Marconi
- Atlanta VAMC, Emory University School of Medicine, Atlanta, GA 30033, United States of America
| | - David Rimland
- Atlanta VAMC, Emory University School of Medicine, Atlanta, GA 30033, United States of America
| | | | - Michael S Simberkoff
- VA NY Harbor Healthcare System, New York University School of Medicine, New York, NY 10010, United States of America
| | - Janet P Tate
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Amy C Justice
- Yale School of Medicine, New Haven, CT 06510, United States of America; VA Connecticut Healthcare System, Veterans Aging Cohort Study, West Haven, CT 06516, United States of America
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, Bethesda, MD 20892-7003, United States of America
| | - David A Fiellin
- Yale School of Medicine, New Haven, CT 06510, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT 06510, United States of America
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Cook RL, Zhou Z, Miguez MJ, Quiros C, Espinoza L, Lewis JE, Brumback B, Bryant K. Reduction in Drinking was Associated With Improved Clinical Outcomes in Women With HIV Infection and Unhealthy Alcohol Use: Results From a Randomized Clinical Trial of Oral Naltrexone Versus Placebo. Alcohol Clin Exp Res 2019; 43:1790-1800. [PMID: 31373701 PMCID: PMC6684328 DOI: 10.1111/acer.14130] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Alcohol consumption is associated with poor health outcomes in women living with HIV (WLWH), but whether medication can help to reduce drinking in non-treatment-seeking women or whether reduction in drinking improves HIV outcomes is unclear. We conducted a randomized clinical trial (RCT) of daily oral naltrexone (50 mg) versus placebo in WLWH who met criteria for current unhealthy alcohol use. METHODS WLWH with current unhealthy alcohol use (>7 drinks/wk or >3 drinks/occasion) were randomly assigned to daily oral naltrexone 50 mg (n = 96) or placebo (n = 98) for 4 months. Drinking outcomes, including the proportion of women who reduced ( RESULTS The participants' mean age was 48 years, 86% were African American, and 94% were receiving HIV antiretroviral therapy. Among all participants, 89% and 85% completed the 4-month and 7-month follow-ups, respectively. Participants in both groups substantially reduced drinking over time. At 1 and 3 months, naltrexone was associated with a greater reduction in drinking (p < 0.05), but the proportion who reduced/quit drinking at 4 months (52% vs. 45%, p = 0.36) or 7 months (64% in both groups) was not different. HIV viral suppression at follow-up was significantly better in participants who reduced/quit drinking versus those continuing unhealthy alcohol use at 4 months (72% vs. 53%, p = 0.02) and 7 months (74% vs. 54%, p = 0.02). CONCLUSIONS Participating in an RCT to reduce drinking was associated with significant drinking reduction regardless of medication assignment, suggesting that nonmedication aspects of research study participation (e.g., repeated assessments and support from research staff) could be important interventions to help reduce drinking outside of research studies. Drinking reduction was associated with improved HIV viral suppression, providing evidence to support recommendations to avoid unhealthy alcohol use among WLWH.
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Affiliation(s)
- Robert L. Cook
- Department of Epidemiology, (RLC, ZZ), University of Florida, Gainesville
| | - Zhi Zhou
- Department of Epidemiology, (RLC, ZZ), University of Florida, Gainesville
| | - Maria Jose Miguez
- Florida, School of Integrated Science and Humanity, (MJM, CQ), Florida International University, Miami, Florida
| | - Clery Quiros
- Florida, School of Integrated Science and Humanity, (MJM, CQ), Florida International University, Miami, Florida
| | - Luis Espinoza
- Public Health & Medical Affairs, (LE), Gilead Sciences Inc., Miami, Florida
| | - John E. Lewis
- Psychiatry & Behavioral Sciences, (JEL), University of Miami School of Medicine, Miami, Florida
| | - Babette Brumback
- Biostatistics, (BB), University of Florida, Gainesville, Florida
| | - Kendall Bryant
- Alcohol and HIV/AIDS Research, (KB), National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
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Addressing unhealthy alcohol use among people living with HIV: recent advances and research directions. Curr Opin Infect Dis 2019; 31:1-7. [PMID: 29176446 DOI: 10.1097/qco.0000000000000422] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Unhealthy alcohol use is prevalent among people living with HIV (PLWH). We sought to identify the most current literature examining the impact of unhealthy alcohol on health outcomes and latest developments on how to best intervene. RECENT FINDINGS New research shows that PLWH have heightened morbidity and mortality at lower levels of alcohol consumption compared with HIV-uninfected persons. Studies published since 2016 have further elucidated the effects of persistent unhealthy alcohol use on HIV treatment outcomes over time. Screening and brief interventions, as well as pharmacologic treatment, can reduce unhealthy alcohol use among PLWH. SUMMARY Unhealthy alcohol use is an important and modifiable risk factor for poor health and HIV treatment outcomes among PLWH. More research is needed to encourage and maintain engagement in alcohol-related interventions and improve implementation.
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Chichetto NE, Mannes ZL, Allen MK, Cook RL, Ennis N. HIV care provider perceptions and approaches to managing unhealthy alcohol use in primary HIV care settings: a qualitative study. Addict Sci Clin Pract 2019; 14:21. [PMID: 31174601 PMCID: PMC6555986 DOI: 10.1186/s13722-019-0150-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 05/11/2019] [Indexed: 01/02/2023] Open
Abstract
Background HIV care providers often serve as the specialist and the primary care point-of-contact for persons living with HIV (PLWH) and unhealthy alcohol use. The purpose of the present qualitative study was to understand HIV care provider perceptions and approaches to managing unhealthy alcohol use in HIV primary care settings. Methods Using a semi-structured interview guide, in-depth interviews were conducted among 14 HIV care providers (5 medical doctors, 5 nurse practitioners/physician assistants, 2 medical assistants, 2 clinical administrative staff) in private and public HIV clinics, across urban and rural areas of Florida. Interviews were coded using a grounded theory approach with inter-rater consensus. Results Six themes were identified. In summary, providers reported (1) inconsistent assessment of alcohol consumption, as well as (2) varying levels of confidence in self-report of alcohol use which may be affected by patient provider rapport and trust. While providers (3) acknowledge potential negative impacts of alcohol use on health outcomes and HIV treatment, providers reported (4) inconsistent recommendations regarding alcohol use among their patients. Lastly, providers reported (5) limited resources for patients with unhealthy alcohol use and (6) low confidence in their ability to help patients reduce use. Conclusions Results from our study suggest salient differences in provider approaches to the assessment and management of unhealthy alcohol use in HIV primary care settings. Implementation of care for unhealthy alcohol use in these settings may be facilitated through use of clinically useful, validated alcohol use assessments and use of evidence-based recommendations of alcohol use/non-use among PLWH. Training in brief intervention techniques for alcohol reduction may increase provider confidence and support in the management of unhealthy alcohol use among PLWH.
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Affiliation(s)
- Natalie E Chichetto
- Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, Nashville, TN, 37203, USA.
| | - Zachary L Mannes
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
| | - Megan K Allen
- Department of Epidemiology, Colleges of Public Health and Health Professions and Medicine, University of Florida, Gainesville, FL, USA
| | - Robert L Cook
- Department of Epidemiology, Colleges of Public Health and Health Professions and Medicine, University of Florida, Gainesville, FL, USA
| | - Nicole Ennis
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Center for Translational Behavioral Science, Tallahassee, FL, USA
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Bensley KM, Fortney J, Chan G, Dombrowski JC, Ornelas I, Rubinsky AD, Lapham GT, Glass JE, Williams EC. Differences in Receipt of Alcohol-Related Care Across Rurality Among VA Patients Living With HIV With Unhealthy Alcohol Use. J Rural Health 2019; 35:341-353. [PMID: 30703856 PMCID: PMC6639081 DOI: 10.1111/jrh.12345] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE It is unknown whether receipt of evidence-based alcohol-related care varies by rurality among people living with HIV (PLWH) with unhealthy alcohol use-a population for whom such care is particularly important. METHODS All positive screens for unhealthy alcohol use (AUDIT-C ≥ 5) among PLWH were identified using Veterans Health Administration electronic health record data (10/1/09-5/30/13). Three domains of alcohol-related care were assessed: brief intervention (BI) within 14 days, and specialty addictions treatment or alcohol use disorder (AUD) medications (filled prescription for naltrexone, disulfiram, acamprosate, or topiramate) within 1 year of positive screen. Adjusted Poisson models and recycled predictions were used to estimate predicted prevalence of outcomes across rurality (urban, large rural, small rural), clustered on facility. Secondary analyses assessed outcomes in the subsample with documented AUD. FINDINGS 4,581 positive screens representing 3,458 PLWH (3,112 urban, 130 large rural, and 216 small rural) were included; 49.1% had diagnosed AUD. PLWH in large rural areas had highest receipt of BI (urban 56.6%, 95% CI: 55.0-58.2; large rural 66.0%, CI: 58.6-73.5; small rural 60.7%, CI: 54.6-67.0). PLWH in urban areas had highest receipt of specialty addictions treatment (urban 28.2%, CI: 26.7-29.8; large rural 19.7%, CI: 13.1-26.2; small rural 19.6%, CI: 14.1-25.0). There was no difference in receipt of AUD medications, although overall receipt was low (3%-4%). Results were similar in the subsample with AUD. CONCLUSION Among PLWH with unhealthy alcohol use, those in rural areas may be vulnerable to under-receipt of specialty addictions treatment. Targeted interventions may help ensure PLWH receive recommended care regardless of rurality.
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Affiliation(s)
- Kara M Bensley
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Alcohol Research Group, Public Health Institute, Emeryville, California
| | - John Fortney
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
| | - Gary Chan
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Julia C Dombrowski
- Department of Medicine and Allergy & Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - India Ornelas
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Anna D Rubinsky
- Kidney Health Research Collaborative, University of California San Francisco, and VA San Francisco Healthcare System, San Francisco, California
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Emily C Williams
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
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Agabio R, Leggio L. HIV and alcohol use disorder: we cannot ignore the elephant in the room. Lancet HIV 2019; 6:e485-e486. [PMID: 31109914 DOI: 10.1016/s2352-3018(19)30074-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Roberta Agabio
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Monserrato, Italy.
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Basic Research and National Institute on Drug Abuse Intramural Research Program, National Institutes of Health, Bethesda, MD, USA; Medication Development Program, National Institute on Drug Abuse Intramural Research Program, National Institutes of Health, Baltimore, MD, USA; Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
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Edelman EJ, Maisto SA, Hansen NB, Cutter CJ, Dziura J, Deng Y, Fiellin LE, O'Connor PG, Bedimo R, Gibert CL, Marconi VC, Rimland D, Rodriguez-Barradas MC, Simberkoff MS, Tate JP, Justice AC, Bryant KJ, Fiellin DA. Integrated stepped alcohol treatment for patients with HIV and alcohol use disorder: a randomised controlled trial. Lancet HIV 2019; 6:e509-e517. [PMID: 31109915 DOI: 10.1016/s2352-3018(19)30076-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/21/2019] [Accepted: 03/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among patients living with HIV and alcohol use disorder. METHODS In this multisite, randomised controlled trial, conducted in five Veterans Affairs-based HIV clinics in the USA (Atlanta, GA; Brooklyn-Manhattan, NY; Dallas and Houston, TX; and Washington, DC), we recruited people living with HIV and an alcohol use disorder who were not otherwise receiving formal alcohol treatment. Patients were eligible if they were aged 18 years or older, HIV positive, English speaking, and met criteria for alcohol use disorder by the Diagnostic and Statistical Manual for Mental Disorders-IV criteria for alcohol abuse or dependence. Key exclusion criteria included if the patient was acutely suicidal or had a psychiatric condition that affected their ability to participate in counselling interventions, or if they had any medical conditions that would preclude completing the study or cause harm during the course of the study. Using a web-based clinical trial management system, we randomly assigned participants (1:1) to receive ISAT or treatment as usual; patients, investigators, and clinicians were unmasked to allocation. ISAT involved three steps: step 1, addiction physician management, comprising eight sessions; step 2, addiction physician management plus motivational enhancement therapy, comprising four sessions; and step 3, specialty referral. Participants were stepped up at weeks 4 and 12 if they exceeded a priori drinking criteria. Treatment as usual involved referral to substance use treatment services. The primary outcome was number of drinks per week over the past 30 days at week 24 by use of the timeline followback method, assessed in the intention-to-treat population. Adverse events were tracked throughout the study period in all randomly assigned participants. This trial is registered at ClinicalTrials.gov, number NCT01410123. FINDINGS Between Jan 28, 2013, and July 14, 2017, 128 of 351 patients assessed for eligibility were eligible and randomly assigned to receive ISAT (n=63) or treatment as usual (n=65). Mean age was 54 years (range 23-70), 125 (98%) of 128 participants were men, and 101 (79%) were black. 25 (20%) were lost to follow-up. In the ISAT group, of 57 participants who did not die or withdraw, 30 (52%) advanced to step 2, and 17 (57%) of 30 advanced to step 3. 32 (51%) of 63 participants assigned to ISAT versus 17 (26%) of 65 assigned to treatment as usual received at least one alcohol treatment medication (p=0·004). Participants in both groups decreased their alcohol consumption, but at week 24 we did not detect a difference in number of drinks per week between the groups (least squares mean 10·4 drinks per week [SD 16·5] in the ISAT group vs 15·6 drinks per week [SD 17·6] in the treatment as usual group; adjusted mean difference -4·2, 95% CI -9·4 to 0·9; p=0·11). One adverse event occurred that was possibly related to treatment occurred in the ISAT group (headache). INTERPRETATION ISAT increases the receipt of alcohol treatment medications and counselling without changes in drinking at week 24. Strategies to implement and enhance ISAT are needed. Future efforts should focus on promoting ISAT with attention to enhancing patient engagement and retention in alcohol-related care. FUNDING US National Institute on Alcohol Abuse and Alcoholism.
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Affiliation(s)
- E Jennifer Edelman
- Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA.
| | | | - Nathan B Hansen
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA; College of Public Health, University of Georgia, Athens, GA, USA
| | | | - James Dziura
- Yale School of Medicine, New Haven, CT, USA; Yale Center for Analytic Sciences, Yale University School of Public Health, New Haven, CT, USA
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale University School of Public Health, New Haven, CT, USA
| | - Lynn E Fiellin
- Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | | | - Roger Bedimo
- Veterans Affairs North Texas Health Care System and UT Southwestern, Dallas, TX, USA
| | - Cynthia L Gibert
- Washington DC Veterans Affairs Medical Center and George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Vincent C Marconi
- Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Atlanta, GA, USA
| | - David Rimland
- Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Atlanta, GA, USA
| | | | - Michael S Simberkoff
- Veterans Affairs NY Harbor Healthcare System and New York University School of Medicine, New York, NY, USA
| | - Janet P Tate
- Yale School of Medicine, New Haven, CT, USA; Veterans Affairs Connecticut Healthcare System, Veterans Aging Cohort Study, West Haven, CT, USA
| | - Amy C Justice
- Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA; Veterans Affairs Connecticut Healthcare System, Veterans Aging Cohort Study, West Haven, CT, USA
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, Bethesda, MD, USA
| | - David A Fiellin
- Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
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Oldfield BJ, Muñoz N, Boshnack N, Leavitt R, McGovern MP, Villanueva M, Tetrault JM, Edelman EJ. "No more falling through the cracks": A qualitative study to inform measurement of integration of care of HIV and opioid use disorder. J Subst Abuse Treat 2019; 97:28-40. [PMID: 30577897 DOI: 10.1016/j.jsat.2018.11.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/06/2018] [Accepted: 11/19/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Benjamin J Oldfield
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America.
| | - Nicolas Muñoz
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | | | - Robert Leavitt
- AIDS Project New Haven, New Haven, CT, United States of America
| | - Mark P McGovern
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Merceditas Villanueva
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America
| | - Jeanette M Tetrault
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - E Jennifer Edelman
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America
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Edelman EJ, Moore BA, Holt SR, Hansen N, Kyriakides TC, Virata M, Brown ST, Justice AC, Bryant KJ, Fiellin DA, Fiellin LE. Efficacy of Extended-Release Naltrexone on HIV-Related and Drinking Outcomes Among HIV-Positive Patients: A Randomized-Controlled Trial. AIDS Behav 2019; 23:211-221. [PMID: 30073637 DOI: 10.1007/s10461-018-2241-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
We sought to test the efficacy of extended-release naltrexone (XR-NTX) on HIV-related and drinking outcomes. From April 2011-February 2015, we conducted a 4-site randomized double-blind placebo controlled clinical trial involving 51 HIV-positive patients with heavy drinking and < 95% antiretroviral (ART) adherence. All participants received counseling. The primary outcome was proportion with ≥ 95% ART adherence. Secondary outcomes included HIV biomarkers, VACS Index score, and past 30-day heavy drinking days. Based on receipt of ≥ 5 injections, 23 participants were retained at 24 weeks. We did not detect an effect of XR-NTX on ART adherence (p = 0.38); undetectable HIV viral load (p = 0.26); CD4 cell count (p = 0.75) or VACS Index score (p = 0.70). XR-NTX was associated with fewer heavy drinking days (p = 0.03). While XR-NTX decreases heavy drinking days, we did not detect improvements in ART adherence or HIV outcomes. Strategies to improve retention in alcohol treatment and HIV-related outcomes among heavy drinking HIV-positive patients are needed.
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Knox J, Wall M, Witkiewitz K, Kranzler HR, Falk D, Litten R, Mann K, O'Malley SS, Scodes J, Anton R, Hasin DS. Reduction in Nonabstinent WHO Drinking Risk Levels and Change in Risk for Liver Disease and Positive AUDIT-C Scores: Prospective 3-Year Follow-Up Results in the U.S. General Population. Alcohol Clin Exp Res 2018; 42:2256-2265. [PMID: 30204248 PMCID: PMC6263142 DOI: 10.1111/acer.13884] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 09/04/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Abstinence is often the treatment aim for alcohol use disorders (AUD), but this may deter individuals who prefer drinking reduction goals from entering treatment, and be an overly restrictive end point in alcohol clinical trials. Nonabstinent drinking reductions that predict improvement in how individuals feel or function may be useful clinical trial outcomes, for example, reductions in the 4-category World Health Organization (WHO) drinking risk levels. To investigate the clinical relevance of these reductions, we examined their relationship with 2 outcomes of interest to medical providers: liver disease, and positive scores on an alcohol screening measure. METHODS Current drinkers in a U.S. national survey (n = 21,925) were interviewed in 2001 to 2002 (Wave 1) and re-interviewed 3 years later (Wave 2). WHO drinking risk levels, liver disease, and the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) were assessed at both waves. Adjusted odds ratios (aORs) were used to indicate the association of change in WHO drinking risk levels with Wave 2 liver disease and AUDIT-C scores. RESULTS Wave 1 very-high-risk drinkers who reduced 1, 2, or 3 WHO drinking risk levels had significantly lower odds of Wave 2 liver disease (aORs = 0.34, 0.23, 0.17) and positive AUDIT-C scores (aORs = 0.27, 0.09, 0.03). Wave 1 high-risk drinkers who reduced 1 or 2 WHO risk levels had significantly lower odds of positive AUDIT-C scores (aORs = 0.61, 0.25). Adjusting for alcohol dependence or AUDIT-C scoring variations did not affect results. CONCLUSIONS In the highest-risk drinkers, reductions in WHO drinking risk levels predicted lower likelihood of liver disease and positive AUDIT-C scores. Results add to findings that reductions in the 4-category WHO drinking risk levels are a meaningful indicator of how individuals feel and function, and could serve as nonabstinent end points in clinical trials. Results also connect the WHO risk drinking levels to commonly used alcohol screening questions, which may be more familiar to healthcare providers.
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Affiliation(s)
- Justin Knox
- Department of Epidemiology, Columbia University Medical Center, New York, New York
- New York State Psychiatric Institute, New York, New York
| | - Melanie Wall
- Department of Epidemiology, Columbia University Medical Center, New York, New York
- New York State Psychiatric Institute, New York, New York
- Department of Biostatistics, Columbia University Medical Center, New York, New York
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Henry R Kranzler
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Daniel Falk
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Raye Litten
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Karl Mann
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | | | - Raymond Anton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Deborah S Hasin
- Department of Epidemiology, Columbia University Medical Center, New York, New York
- New York State Psychiatric Institute, New York, New York
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Edelman EJ, Oldfield BJ, Tetrault JM. Office-Based Addiction Treatment in Primary Care: Approaches That Work. Med Clin North Am 2018; 102:635-652. [PMID: 29933820 DOI: 10.1016/j.mcna.2018.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Primary care is an important setting for delivering evidence-based treatment to address substance use disorders. To date, effective approaches to treat, care largely incorporate pharmacotherapy with counseling-based interventions and rely on multidisciplinary teams. There is strong support for primary care-based approaches to address alcohol and opioid use disorder with growing data focused on people living with human immunodeficiency virus and those experiencing incarceration. Future work should focus on the implementation of these effective approaches to decrease health disparities among people with substance use and to identify optimal approaches to address substance use in primary care and specialty settings.
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Affiliation(s)
- E Jennifer Edelman
- Department of Medicine, Yale University School of Medicine and Public Health, 367 Cedar Street, E.S. Harkness Memorial Hall, Building A, Suite 401, New Haven, CT 06510, USA.
| | - Benjamin J Oldfield
- National Clinician Scholars Program, Yale University School of Medicine, PO Box 208088, New Haven, CT 06520, USA
| | - Jeanette M Tetrault
- Department of Internal Medicine, Yale University School of Medicine, 367 Cedar Street, Suite 305, New Haven, CT 06510, USA
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Williams EC, Achtmeyer CE, Young JP, Berger D, Curran G, Bradley KA, Richards J, Siegel MB, Ludman EJ, Lapham GT, Forehand M, Harris AHS. Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics. J Gen Intern Med 2018; 33:258-267. [PMID: 29086341 PMCID: PMC5834954 DOI: 10.1007/s11606-017-4202-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/30/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely. OBJECTIVE This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including "segmenting the market," to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications. DESIGN Qualitative, interview-based study. PARTICIPANTS Twenty-four providers from five VA PC clinics. APPROACH Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review. KEY RESULTS Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective "tool" or "foot in the door" for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have. CONCLUSIONS We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.
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Affiliation(s)
- Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA. .,Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Carol E Achtmeyer
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA
| | - Jessica P Young
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
| | - Douglas Berger
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Geoffrey Curran
- Central Arkansas Veterans Health Care System, Little Rock, AR, USA
| | - Katharine A Bradley
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Julie Richards
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Michael B Siegel
- Department of Community Health Sciences, Boston University School of Public Heath, Boston, MA, USA
| | - Evette J Ludman
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Gwen T Lapham
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.,Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA
| | - Mark Forehand
- Foster School of Business, University of Washington, Seattle, WA, USA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Sherman KE, Peters MG, Thomas D. Human immunodeficiency virus and liver disease: A comprehensive update. Hepatol Commun 2017; 1:987-1001. [PMID: 30838978 PMCID: PMC5721407 DOI: 10.1002/hep4.1112] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/29/2017] [Accepted: 09/19/2017] [Indexed: 12/16/2022] Open
Abstract
Among persons living with human immunodeficiency virus (HIV) infection, liver disease remains a major cause of morbidity and mortality. While the etiologies are varied and often overlapping in the individual patient, the underlying mechanisms, including oxidative stress, direct activation of stellate cells, HIV interaction with hepatocytes, and bacterial translocation with systemic immune activation, seem to be unifying characteristics. Early and fully suppressive HIV antiretroviral therapy is a mainstay of management either before or concurrent with treatment of etiologic cofactors, including hepatitis C virus, hepatitis B virus, and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis. Significant barriers to care that still exist include liver disease recognition, appropriate linkage to care, ongoing substance abuse, and psychiatric comorbidities in the HIV-infected population. Emerging issues in these patients include acute and chronic hepatitis E, underreported hepatitis D, and a rising incidence of hepatocellular carcinoma. (Hepatology Communications 2017;1:987-1001).
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Chokron Garneau H, Venegas A, Rawson R, Ray LA, Glasner S. Barriers to initiation of extended release naltrexone among HIV-infected adults with alcohol use disorders. J Subst Abuse Treat 2017; 85:34-37. [PMID: 28527854 DOI: 10.1016/j.jsat.2017.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 04/28/2017] [Accepted: 05/08/2017] [Indexed: 11/24/2022]
Abstract
Alcohol consumption is a major risk factor for the acquisition of HIV/AIDS and is associated with greater disease burden and mortality among those who become HIV-infected. Of the extant pharmacological treatments for alcohol use disorders, naltrexone is recognized as one of the most efficacious, producing robust reductions in alcohol craving and use. Given that treatment with oral naltrexone has been limited by problems with adherence, which are particularly prevalent among individuals with multiple chronic, co-occurring conditions, long-acting formulations may be a promising approach for HIV-infected substance users. However, little is known about the barriers to initiation of extended-release naltrexone (XR-NTX) treatment among alcohol users living with HIV. In this report we present and discuss the content analysis of open-ended survey questions, as well as lessons learned, with regards to barriers to initiation and maintenance of XR-NTX treatment collected as part of an RCT evaluating a cognitive behavioral text messaging intervention for HIV-infected adults with alcohol use disorders. Barriers to initiation and maintenance of XR-NTX pharmacotherapy among HIV+ individuals with alcohol use disorders seem to fall in one of two categories: [1] barriers that are amenable to change, which include distance and transportation issues, fear of injections, and belief that alcohol use does not warrant pharmacotherapy, and [2] barriers that are not amenable to change, such as the potential interaction of XR-NTX with another medication regimen.
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Affiliation(s)
- Hélène Chokron Garneau
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States.
| | - Alexandra Venegas
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States
| | - Richard Rawson
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States
| | - Lara A Ray
- University of California Los Angeles, Department of Psychology, Los Angeles, CA, United States
| | - Suzette Glasner
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States
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Among patients with unhealthy alcohol use, those with HIV are less likely than those without to receive evidence-based alcohol-related care: A national VA study. Drug Alcohol Depend 2017; 174:113-120. [PMID: 28324813 PMCID: PMC5444382 DOI: 10.1016/j.drugalcdep.2017.01.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Alcohol use has important adverse effects on people living with HIV (PLWH). This study of patients with recognized unhealthy alcohol use estimated and compared rates of alcohol-related care received by PLWH and HIV- patients. METHODS Outpatients from the Veterans Health Administration who had one or more positive screen(s) for unhealthy alcohol use (AUDIT-C≥5) documented in their medical records 10/2009-5/2013 were eligible. Primary and secondary outcomes were brief intervention documented ≤14days after a positive alcohol screen, and a composite measure of any alcohol-related care (brief intervention, specialty addictions treatment or pharmacotherapy documented ≤365 days), respectively. Unadjusted and adjusted regression analyses compared alcohol-related care outcomes in PLWH and HIV- patients. RESULTS The sample included 830,825 outpatients (3,514 PLWH), reflecting 1,172,606 positive screens (1-5 per patient). For PLWH, 57.0% (95% confidence interval 55.4-58.5%) of positive screens were followed by brief intervention, compared to 73.8% (73.7-73.9%) for HIV- patients [relative rate: 0.77 (0.75-0.79), p<0.001]. After adjustment, comparable proportions were 61.0% (59.3-62.6%) for PLWH and 73.7% (73.6-73.8%) for HIV- patients [adjusted RR=0.83 (0.80-0.85); p<0.001]. Secondary outcome results were similar: for PLWH and HIV- patients, 67.1% (65.7-68.6%) and 77.7% (95% CI 77.7-77.8%) of positive screens, respectively, were followed by any alcohol-related care after adjustment [adjusted RR=0.86 (0.85-0.88), p<0.001]. CONCLUSIONS In this large national sample of VA outpatients with unhealthy alcohol use, PLWH were less likely to receive alcohol-related care than HIV- patients. Special efforts may be needed to ensure alcohol-related care reaches PLWH.
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Fuster D, Sanvisens A, Bolao F, Rivas I, Tor J, Muga R. Alcohol use disorder and its impact on chronic hepatitis C virus and human immunodeficiency virus infections. World J Hepatol 2016; 8:1295-1308. [PMID: 27872681 PMCID: PMC5099582 DOI: 10.4254/wjh.v8.i31.1295] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/04/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
Alcohol use disorder (AUD) and hepatitis C virus (HCV) infection frequently co-occur. AUD is associated with greater exposure to HCV infection, increased HCV infection persistence, and more extensive liver damage due to interactions between AUD and HCV on immune responses, cytotoxicity, and oxidative stress. Although AUD and HCV infection are associated with increased morbidity and mortality, HCV antiviral therapy is less commonly prescribed in individuals with both conditions. AUD is also common in human immunodeficiency virus (HIV) infection, which negatively impacts proper HIV care and adherence to antiretroviral therapy, and liver disease. In addition, AUD and HCV infection are also frequent within a proportion of patients with HIV infection, which negatively impacts liver disease. This review summarizes the current knowledge regarding pathological interactions of AUD with hepatitis C infection, HIV infection, and HCV/HIV co-infection, as well as relating to AUD treatment interventions in these individuals.
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Williams EC, Hahn JA, Saitz R, Bryant K, Lira MC, Samet JH. Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions. Alcohol Clin Exp Res 2016; 40:2056-2072. [PMID: 27696523 PMCID: PMC5119641 DOI: 10.1111/acer.13204] [Citation(s) in RCA: 202] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/28/2016] [Indexed: 12/20/2022]
Abstract
Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.
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Affiliation(s)
- Emily C Williams
- Veterans Health Administration (VA) Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Judith A Hahn
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Richard Saitz
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.,Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kendall Bryant
- Consortiums for HIV/AIDS and Alcohol Research Translation (CHAART) National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Jeffrey H Samet
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts. .,Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
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