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Thompson LJP, Genovese J, Hong Z, Singh MV, Singh VB. HIV-Associated Neurocognitive Disorder: A Look into Cellular and Molecular Pathology. Int J Mol Sci 2024; 25:4697. [PMID: 38731913 PMCID: PMC11083163 DOI: 10.3390/ijms25094697] [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: 03/25/2024] [Revised: 04/21/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Despite combined antiretroviral therapy (cART) limiting HIV replication to undetectable levels in the blood, people living with HIV continue to experience HIV-associated neurocognitive disorder (HAND). HAND is associated with neurocognitive impairment, including motor impairment, and memory loss. HIV has been detected in the brain within 8 days of estimated exposure and the mechanisms for this early entry are being actively studied. Once having entered into the central nervous system (CNS), HIV degrades the blood-brain barrier through the production of its gp120 and Tat proteins. These proteins are directly toxic to endothelial cells and neurons, and propagate inflammatory cytokines by the activation of immune cells and dysregulation of tight junction proteins. The BBB breakdown is associated with the progression of neurocognitive disease. One of the main hurdles for treatment for HAND is the latent pool of cells, which are insensitive to cART and prolong inflammation by harboring the provirus in long-lived cells that can reactivate, causing damage. Multiple strategies are being studied to combat the latent pool and HAND; however, clinically, these approaches have been insufficient and require further revisions. The goal of this paper is to aggregate the known mechanisms and challenges associated with HAND.
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Affiliation(s)
| | - Jessica Genovese
- Department of Life Sciences, Albany College of Pharmacy and Health Sciences, Albany, NY 12208, USA
| | - Zhenzi Hong
- Department of Life Sciences, Albany College of Pharmacy and Health Sciences, Albany, NY 12208, USA
| | - Meera Vir Singh
- Department of Neurology, University of Rochester, Rochester, NY 14642, USA
| | - Vir Bahadur Singh
- Department of Life Sciences, Albany College of Pharmacy and Health Sciences, Albany, NY 12208, USA
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2
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Thakarar K, Kohut M, Stoddard H, Burris D, Chessa F, Sikka MK, Solomon DA, Kershaw CM, Eaton E, Hutchinson R, Fairfield KM, Friedmann P, Stopka TJ. 'I feel like they're actually listening to me': a pilot study of a hospital discharge decision-making conversation guide for patients with injection drug use-associated infections. Ther Adv Infect Dis 2023; 10:20499361231165108. [PMID: 37034032 PMCID: PMC10074622 DOI: 10.1177/20499361231165108] [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] [Received: 12/09/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023] Open
Abstract
Background The prevalence of injection drug use (IDU)-associated infections and associated hospitalizations has been increasing for nearly two decades. Due to issues ranging from ongoing substance use to peripherally inserted central catheter safety, many clinicians find discharge decision-making challenging. Typically, clinicians advise patients to remain hospitalized for several weeks for intravenous antimicrobial treatment; however, some patients may desire other antimicrobial treatment options. A structured conversation guide, delivered by infectious disease physicians, intended to inform hospital discharge decisions has the potential to enhance patient participation in decisions. We developed a conversation guide in order to: (1) investigate its feasibility and acceptability and (2) examine experiences, outcomes, and lessons learned from use of the guide. Methods We interviewed physicians after they each piloted the conversation guide with two patients. We interviewed patients immediately after the conversation and again 4-6 weeks later. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data. Results Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N = 8) completed antimicrobial treatment. Nearly all participants believed the conversation guide was important for incorporating patient values and preferences. Patients reported an increased sense of autonomy, but felt post-discharge needs could be better addressed. Physician participants identified the guide's long length and inclusion of pain management as areas for improvement. Conclusions A novel conversation guide to inform hospital discharge decision-making for patients with IDU-associated infections was feasible, acceptable, and fostered the incorporation of patient preferences and values into decisions. While we identified areas for improvement, overall participants believed that this novel conversation guide helped to improve patient care and autonomy.
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Affiliation(s)
- Kinna Thakarar
- Department of Medicine, Tufts University School
of Medicine, Boston, MA 02111, USA
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
- Divisions of Infectious Disease and Addiction
Medicine, Department of Medicine, Maine Medical Center, 41 Donald B. Dean
Drive, Suite B, South Portland, ME 04106, USA
| | - Michael Kohut
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Henry Stoddard
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Deb Burris
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Frank Chessa
- Department of Medical Ethics, Tufts University
School of Medicine, Boston, MA, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Oregon Health
& Science University, Portland, OR, USA
| | - Daniel A. Solomon
- Division of Infectious Disease, Brigham and
Women’s Hospital, Boston, MA, USA
| | - Colleen M. Kershaw
- Section of Infectious Disease and
International Health, Dartmouth Hitchcock Medical Center, Lebanon, NH,
USA
- Department of Medicine, Geisel School of
Medicine, Dartmouth College, Hanover, NH, USA
| | - Ellen Eaton
- Division of Infectious Disease, School of
Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Hutchinson
- Division of Palliative Care, Maine Medical
Center, Portland, ME, USA
- Department of Medical Education, Tufts
University School of Medicine, Boston, MA, USA
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Kathleen M. Fairfield
- Department of Medicine, Maine Medical Center,
Portland, ME, USA
- Department of Medical Education, Tufts
University School of Medicine, Boston, MA, USA
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Peter Friedmann
- Office of Research, UMass Chan Medical School,
Worcester, MA, USA
| | - Thomas J. Stopka
- Department of Public Health and Community
Medicine, Tufts University School of Medicine, Boston, MA, USA
- Frank Chessa is also affiliated to Maine
Medical Center, Portland, ME, USA
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3
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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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Tsui JI, Akosile MA, Lapham GT, Boudreau DM, Johnson EA, Bobb JF, Binswanger IA, Yarborough BJH, Glass JE, Rossom RC, Murphy MT, Cunningham CO, Arnsten JH, Thakral M, Saxon AJ, Merrill JO, Samet JH, Bart GB, Campbell CI, Loree AM, Silva A, Stotts AL, Ahmedani B, Braciszewski JM, Hechter RC, Northrup TF, Horigian VE, Bradley KA. Prevalence and Medication Treatment of Opioid Use Disorder Among Primary Care Patients with Hepatitis C and HIV. J Gen Intern Med 2021; 36:930-937. [PMID: 33569735 PMCID: PMC8041979 DOI: 10.1007/s11606-020-06389-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/03/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. OBJECTIVE To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. DESIGN Retrospective observational cohort study using electronic health record and insurance data. PARTICIPANTS Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). MAIN MEASURES The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. KEY RESULTS The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). CONCLUSIONS Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.
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Affiliation(s)
- Judith I Tsui
- University of Washington/Harborview Medical Center, Seattle, USA
| | - Mary A Akosile
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Eric A Johnson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado, Colorado Permanente Medical Group, and the University of Colorado School of Medicine, Aurora, USA
| | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Rebecca C Rossom
- HealthPartners Institute, University of Minnesota, Bloomington, USA
| | - Mark T Murphy
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Seattle, USA
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, USA
| | - Julia H Arnsten
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, USA
| | - Manu Thakral
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, USA
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System/University of Washington School of Medicine, Seattle, USA
| | - Joseph O Merrill
- University of Washington/Harborview Medical Center, Seattle, USA
| | | | - Gavin B Bart
- Hennepin Healthcare, University of Minnesota, Minneapolis, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, USA
| | - Amy M Loree
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Angela Silva
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Seattle, USA
| | - Angela L Stotts
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, USA
| | - Brian Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
- Department of Psychiatry, Henry Ford Health System, Detroit, USA
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Oakland, USA
| | - Thomas F Northrup
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, USA
| | - Viviana E Horigian
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Florida, USA
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA.
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Hoffman KA, Baker R, Kunkel LE, Waddell EN, Lum PJ, McCarty D, Korthuis PT. Barriers and facilitators to recruitment and enrollment of HIV-infected individuals with opioid use disorder in a clinical trial. BMC Health Serv Res 2019; 19:862. [PMID: 31752905 PMCID: PMC6868733 DOI: 10.1186/s12913-019-4721-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 11/07/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The CTN-0067 CHOICES trial tests implementation of extended-release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for opioid use disorders (OUD) in HIV clinics to improve HIV viral suppression. The study team investigated recruitment strategies to elucidate the barriers and facilitators to recruitment and enrollment in the study. MAIN TEXT Methods: Semi-structured, in-depth, digitally recorded interviews were completed with study recruitment-related staff and medical providers (n = 26) from six participating HIV clinics in the fall of 2018. Interviews probed 1) factors that might prevent prospective participants from engaging in study recruitment and enrollment procedures and 2) strategies used by study staff that encourage eligible patient participation. Interviews were transcribed and thematically analyzed using a content analysis approach. RESULTS All respondents reported that barriers to recruitment and enrollment included challenging patient social and structural factors (e.g., homelessness or living environments with high substance use, criminal justice involvement), difficulty locating patients with unsuppressed HIV viral load and OUD within the HIV clinic, time-consuming study enrollment processes, and stigma around HIV and OUD which inhibited treatment seeking. Some respondents observed that distrust of research and researchers impeded recruitment activities in the community. A specific medication-related barrier was patient fear of opioid abstinence required prior to XR-NTX induction. Facilitators of recruitment included use of trusted peer outreach/recruitment workers in the community, hospitalizations that offered windows of opportunities for screening and XR-NTX induction, providing participant transportation, and partnerships with harm reduction organizations for referrals. CONCLUSIONS Though study personnel encountered barriers to recruitment in the CHOICES study, persons with untreated HIV and OUD can be enrolled in multisite clinical trials by using enhanced recruitment strategies that extend outside of the HIV clinic. Employing peer outreach workers and collaborating with syringe service programs may be especially helpful in facilitating recruitment and merit inclusion in similar study protocols.
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Affiliation(s)
- Kim A. Hoffman
- Oregon Health and Science University- Portland State University, School of Public Health, 3181 SW Sam Jackson Park Rd., CB669, Portland, OR 97239-3088 USA
| | - Robin Baker
- Oregon Health and Science University- Portland State University, School of Public Health, 3181 SW Sam Jackson Park Rd., CB669, Portland, OR 97239-3088 USA
| | - Lynn E. Kunkel
- Oregon Health and Science University- Portland State University, School of Public Health, 3181 SW Sam Jackson Park Rd., CB669, Portland, OR 97239-3088 USA
| | - Elizabeth Needham Waddell
- Oregon Health and Science University- Portland State University, School of Public Health, 3181 SW Sam Jackson Park Rd., CB669, Portland, OR 97239-3088 USA
| | - Paula J. Lum
- Department of Medicine, University of California-San Francisco, San Francisco, CA USA
| | - Dennis McCarty
- Oregon Health and Science University- Portland State University, School of Public Health, 3181 SW Sam Jackson Park Rd., CB669, Portland, OR 97239-3088 USA
| | - P. Todd Korthuis
- Oregon Health and Science University- Portland State University, School of Public Health, 3181 SW Sam Jackson Park Rd., CB669, Portland, OR 97239-3088 USA
- Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR USA
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Satre DD, Anderson AN, Leibowitz AS, Levine-Hall T, Slome S, Flamm J, Hare CB, McNeely J, Weisner CM, Horberg MA, Volberding P, Silverberg MJ. Implementing electronic substance use disorder and depression and anxiety screening and behavioral interventions in primary care clinics serving people with HIV: Protocol for the Promoting Access to Care Engagement (PACE) trial. Contemp Clin Trials 2019; 84:105833. [PMID: 31446142 PMCID: PMC6760257 DOI: 10.1016/j.cct.2019.105833] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Substance use disorders (SUDs) and psychiatric disorders are common among people with HIV (PWH) and lead to poor outcomes. Yet these conditions often go unrecognized and untreated in primary care. METHODS The Promoting Access to Care Engagement (PACE) trial currently in process examines the impact of self-administered electronic screening for SUD risk, depression and anxiety in three large Kaiser Permanente Northern California primary care clinics serving over 5000 PWH. Screening uses validated measures (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]; and the Adult Outcomes Questionnaire [AOQ], which includes the Patient Health Questionnaire [PHQ-9] and Generalized Anxiety Disorder [GAD-2]) delivered via three modalities (secure messaging, tablets in waiting rooms, and desktop computers in exam rooms). Results are integrated automatically into the electronic health record. Based on screening results and physician referrals, behavioral health specialists embedded in primary care initiate motivational interviewing- and cognitive behavioral therapy-based brief treatment and link patients to addiction and psychiatry clinics as needed. Analyses examine implementation (screening and treatment rates) and effectiveness (SUD, depression and anxiety symptoms; HIV viral control) outcomes using a stepped-wedge design, with a 12-month intervention phase implemented sequentially in the clinics, and a 24-month usual care period prior to implementation in each clinic functioning as sequential observational phases for comparison. We also evaluate screening and treatment costs and implementation barriers and facilitators. DISCUSSION The study examines innovative, technology-facilitated strategies for improving assessment and treatment in primary care. Results may help to inform substance use, mental health, and HIV services. TRIAL REGISTRATION NCT03217058.
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Affiliation(s)
- Derek D Satre
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, Oakland, CA 94612, United States of America.
| | - Alexandra N Anderson
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, Oakland, CA 94612, United States of America
| | - Amy S Leibowitz
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, Oakland, CA 94612, United States of America
| | - Tory Levine-Hall
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, Oakland, CA 94612, United States of America
| | - Sally Slome
- Kasier Permanente Oakland Medical Center, 3801 Howe St, Oakland, CA 94611, United States of America
| | - Jason Flamm
- Kaiser Permanente Sacramento Medical Center, 2025 Morse Ave, Sacramento, CA 95825, United States of America
| | - C Bradley Hare
- Kaiser Permanente San Francisco Medical Center, 2238 Geary Blvd, San Francisco, CA 94115, United States of America
| | - Jennifer McNeely
- New York University School of Medicine, 550 1st Ave., New York, NY 10016, United States of America
| | - Constance M Weisner
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, United States of America; Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, Oakland, CA 94612, United States of America
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, 2101 East Jefferson, Rockville, MD 20852, United States of America
| | - Paul Volberding
- AIDS Research Institute, University of California San Francisco, San Francisco, CA, 94158, United States of America
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, Oakland, CA 94612, United States of America
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Shokoohi M, Bauer GR, Kaida A, Logie CH, Lacombe-Duncan A, Milloy MJ, Lloyd-Smith E, Carter A, Loutfy M. Patterns of social determinants of health associated with drug use among women living with HIV in Canada: a latent class analysis. Addiction 2019; 114:1214-1224. [PMID: 30698902 PMCID: PMC6992379 DOI: 10.1111/add.14566] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/13/2018] [Accepted: 01/21/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Identifying typologies of social determinants of health (SDoH) vulnerability influencing drug use practices among women living with HIV (WLWH) can help to address associated harms. This research aimed to explore the association of SDoH clusters with drug use among WLWH. DESIGN Latent class analysis (LCA) was used to identify the distinct clusters of SDoH. Inverse probability weighting (IPW) was employed to account for confounding and potential selection bias. Associations were analyzed using generalized linear model with log link and Poisson distribution, and then weighted risk ratio (RR) and 95% confidence intervals (CI) were reported. SETTING AND PARTICIPANTS Data from 1422 WLWH recruited at time-point 1 of the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS, 2013-15), with 1252 participants at 18 months follow-up (time-point 2). MEASUREMENTS Drug use was defined as use of illicit/non-prescribed opioids/stimulants in the past 6 months. SDoH indicators included: race discrimination, gender discrimination, HIV stigma, social support, access to care, food security, income level, employment status, education, housing status and histories of recent sex work and incarceration. FINDINGS LCA identified four SDoH classes: no/least SDoH adversities (6.6%), discrimination/stigma (17.7%), economic hardship (30.8%) and most SDoH adversities (45.0%). Drug use was reported by 17.5% and 17.2% at time-points 1 and 2, respectively. WLWH with no/least SDoH adversities were less likely to report drug use than those in economic hardship class (weighted RR = 0.13; 95% CIs = 0.03, 0.63), discrimination/stigma class (weighted RR = 0.15; 95% CIs = 0.03, 0.78), and most SDoH adversities class (weighted RR = 0.13; 95% CIs = 0.03, 0.58). CONCLUSIONS Social determinants of health vulnerabilities are associated with greater likelihood of drug use, underscoring the significance of addressing interlinked social determinants and drug use through the course of HIV care and treatment.
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Affiliation(s)
- Mostafa Shokoohi
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, ON, Canada
| | - Greta R. Bauer
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, ON, Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Carmen H. Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | | | - M-J Milloy
- British Columbia Centre on Substance Use, St. Paul’s Hospital, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Allison Carter
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Mona Loutfy
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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8
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Lesko CR, Keil AP, Moore RD, Chander G, Fojo AT, Lau B. Measurement of Current Substance Use in a Cohort of HIV-Infected Persons in Continuity HIV Care, 2007-2015. Am J Epidemiol 2018; 187:1970-1979. [PMID: 29701832 PMCID: PMC6118067 DOI: 10.1093/aje/kwy092] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 04/18/2018] [Accepted: 04/18/2018] [Indexed: 01/02/2023] Open
Abstract
Accurate, routine measurement of recent illicit substance use is challenging. The Johns Hopkins Human Immunodeficiency Virus Clinical Cohort (Baltimore, Maryland) collects 2 imperfect but routine measurements of recent substance use: medical record review and self-interview. We used Bayesian latent class modeling to estimate sensitivity and specificity of each measurement as well as prevalence of substance use among 2,064 patients engaged in care during 2007-2015. Sensitivity of medical record review was higher than sensitivity of self-interview for cocaine and heroin use; posterior estimates ranged from 44% to 76% for cocaine use and from 39% to 67% for heroin use, depending on model assumptions and priors. In contrast, sensitivity of self-interview was higher than sensitivity of medical record review for any alcohol use, hazardous alcohol use, and cigarette smoking. Posterior estimates of sensitivity of self-interview were generally above 80%, 85%, and 87% for each substance, respectively. Specificity was high for all measurements. From one model, we estimated prevalence of substance use in the cohort to be 12.5% for cocaine, 9.3% for heroin, 48.5% for alcohol, 21.4% for hazardous alcohol, and 55.4% for cigarettes. Prevalence estimates from other models were generally comparable. Measurement error of substance use is nontrivial and should be accounted for in subsequent analyses.
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Affiliation(s)
- Catherine R Lesko
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Alexander P Keil
- Department of Epidemiology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Richard D Moore
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Geetanjali Chander
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anthony T Fojo
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Bryan Lau
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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9
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A qualitative study examining the benefits and challenges of incorporating patient-reported outcome substance use and mental health questionnaires into clinical practice to improve outcomes on the HIV care continuum. BMC Health Serv Res 2018; 18:419. [PMID: 29879962 PMCID: PMC5992635 DOI: 10.1186/s12913-018-3203-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/14/2018] [Indexed: 11/24/2022] Open
Abstract
Background Inadequate identification and treatment of substance use (SU) and mental health (MH) disorders hinders retention in HIV care. The objective of this study was to elicit stakeholder input on integration of SU/MH screening using computer-assisted patient-reported outcomes (PROs) into clinical practice. Methods We conducted semi-structured interviews with HIV-positive patients who self-reported SU/MH symptoms on a computer-assisted PROs (n = 19) and HIV primary care providers (n = 11) recruited from an urban academic HIV clinic. Interviews were audio-recorded and transcribed. We iteratively developed codes and organized key themes using editing style analysis. Results Two themes emerged: (1) Honest Disclosure: Some providers felt PROs might improve SU/MH disclosure; more were concerned that patients would not respond honestly if their provider saw the results. Patients were also divided, stating PROs could help overcome stigma but that it could be harder to disclose SU/MH to a computer versus a live person. (2) Added Value in the Clinical Encounter: Most providers felt PROs would fill a practice gap. Patients had concerns regarding confidentiality but indicated PROs would help providers take better care of them. Conclusions Both patients and providers indicated that PROs are potentially useful clinical tools to improve detection of SU/MH. However, patients and providers expressed conflicting viewpoints about disclosure of SU/MH using computerized PROs. Future studies implementing PROs screening interventions must assess concerns over confidentiality and honest disclosure of SU/MH to understand the effectiveness of PROs as a clinical tool. More research is also needed on patient-centered integration of the results of PROs in HIV care. Electronic supplementary material The online version of this article (10.1186/s12913-018-3203-x) contains supplementary material, which is available to authorized users.
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Rodriguez CV, Rubenstein KB, Linas B, Hu H, Horberg M. Increasing hepatitis C screening in a large integrated health system: science and policy in concert. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:e134-e140. [PMID: 29851444 PMCID: PMC6132051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To evaluate whether the updated 2013 US Preventive Services Task Force (USPSTF) hepatitis C virus (HCV) screening recommendations, related Affordable Care Act provisions, and the impending availability of efficacious therapies were associated with increased screening in an integrated health system. STUDY DESIGN We analyzed 665,339 records of adult patients visiting Kaiser Permanente Mid-Atlantic States clinics from 2003 to 2014. METHODS We used Cox proportional hazards to estimate time to HCV screening and confirmation after June 1, 2013, compared with prior. RESULTS HCV screening steadily increased over time, but it jumped 29% (P <.01) from 2013 to 2014 versus 4% (P <.01) from 2012 to 2013. The adjusted hazard ratio for HCV screening since June 2013 was 2.40 (95% CI, 2.34-2.47) times higher than it was pre-intervention among the birth cohort (those born 1945-1965) and 2.00 (95% CI, 1.96-2.04) times higher in those born in other years, representing a 1.20-fold (95% CI, 1.17-1.24) greater increase in the screening rate among the birth cohort. We also identified variability in those thought to be at higher risk of HCV infection. CONCLUSIONS HCV screening has been increasing in our healthcare system, more so since June 2013 and among the birth cohort. The availability of efficacious therapies and coverage policies coincident with the USPSTF recommendations may have facilitated access to screening and treatment in ways that were absent at the time of the 2012 CDC recommendations. Health systems must also be poised to make resources available to clinicians and patients in order to incentivize screening. Future research should inform a better understanding of incentives and barriers to screening and linkage to care from all stakeholder perspectives.
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Affiliation(s)
- Carla V Rodriguez
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, 2101 E Jefferson St, 3W, Rockville, MD 20852.
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O’Leary B, Strike C, Rohailla S, Barnes M, McDougall P, Baltzer Turje R, de Prinse K, Schaefer-McDaniel N, Chan Carusone S. Perspectives of healthcare workers about the delivery and evaluation of harm reduction services for people living with HIV who use substances. COGENT MEDICINE 2018. [DOI: 10.1080/2331205x.2018.1461005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Bill O’Leary
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street west, Toronto, Ontario, Canada M5S 1V4
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Canada
| | | | | | | | | | | | | | - Soo Chan Carusone
- Casey House, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Canada
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Abstract
Human immunodeficiency virus (HIV) enters the brain early after infecting humans and may remain in the central nervous system despite successful antiretroviral treatment. Many neuroimaging techniques were used to study HIV+ patients with or without opportunistic infections. These techniques assessed abnormalities in brain structures (using computed tomography, structural magnetic resonance imaging (MRI), diffusion MRI) and function (using functional MRI at rest or during a task, and perfusion MRI with or without a contrast agent). In addition, single-photon emission computed tomography with various tracers (e.g., thallium-201, Tc99-HMPAO) and positron emission tomography with various agents (e.g., [18F]-dexoyglucose, [11C]-PiB, and [11C]-TSPO tracers), were applied to study opportunistic infections or HIV-associated neurocognitive disorders. Neuroimaging provides diagnoses and biomarkers to quantitate the severity of brain injury or to monitor treatment effects, and may yield insights into the pathophysiology of HIV infection. As the majority of antiretroviral-stable HIV+ patients are living longer, age-related comorbid disorders (e.g., additional neuroinflammation, cerebrovascular disorders, or other dementias) will need to be considered. Other highly prevalent conditions, such as substance use disorders, psychiatric illnesses, and the long-term effects of combined antiretroviral therapy, all may lead to additional brain injury. Neuroimaging studies could provide knowledge regarding how these comorbid conditions impact the HIV-infected brain. Lastly, specific molecular imaging agents may be needed to assess the central nervous system viral reservoir.
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Affiliation(s)
- Linda Chang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States; Department of Medicine and Department of Neurology, John A. Burns School of Medicine, University of Hawaii, Manoa, United States.
| | - Dinesh K Shukla
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
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Amin P, Douaihy A. Substance Use Disorders in People Living with Human Immunodeficiency Virus/AIDS. Nurs Clin North Am 2017; 53:57-65. [PMID: 29362061 DOI: 10.1016/j.cnur.2017.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Persons living with human immunodeficiency virus (HIV)/AIDS have a substantial burden of co-occurring substance use disorders (SUDs); untreated alcohol and drug use disorders among people living with HIV/AIDS contribute to worse HIV care outcomes. SUDs are associated with key health behaviors and outcomes, including delays in seeking medical care, poor engagement in treatment, reduced adherence to medical treatment and antiretroviral therapy, immunosuppression, increased HIV transmission through risky sexual behaviors, and increased burdens on health care systems. HIV infection comorbid with SUD and a psychiatric disorder is a clinically challenging condition creating a complex set of medical and psychosocial challenges.
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Affiliation(s)
- Priyanka Amin
- Department of Psychiatry, Western Psychiatric Institute and Clinic of UPMC, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Antoine Douaihy
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA 15213, USA.
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Substance use among HIV-infected patients in Rio de Janeiro, Brazil: Agreement between medical records and the ASSIST questionnaire. Drug Alcohol Depend 2017. [PMID: 28646713 PMCID: PMC5712472 DOI: 10.1016/j.drugalcdep.2017.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Substance use assessment is a challenge in busy clinical settings that may adversely affect HIV-infected persons. This study aimed to evaluate agreement between the medical chart and a standardized substance use screening questionnaire. METHODS Of adults (n=1050) in HIV care in Rio de Janeiro who completed the World Health Organization's Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), we randomly selected 200 participants for medical chart review. Lifetime use of tobacco, alcohol, marijuana, and cocaine agreement between the medical record and ASSIST was evaluated using Kappa statistics. Sensitivity and specificity of chart information were also calculated. RESULTS The median age was 42.4 years, 60.3% were male and 49.5% were white. Prevalence of lifetime use reported in ASSIST was 55.3% (tobacco), 79.4% (alcohol), 23.1% (marijuana), and 20.7% (cocaine). Any information on lifetime use was found in the medical chart for tobacco (n=180, 90.5%), alcohol (n=183, 92.0%), marijuana (n=143, 71.8%), and cocaine (n=151, 75.9%). The Kappa statistic, sensitivity and specificity of the medical chart accurately identifying lifetime substance users per ASSIST were respectively 0.60, 0.71, and 0.91 for tobacco; 0.22, 0.75, and 0.51 for alcohol; 0.58, 0.51, and 0.98 for marijuana; and 0.73, 0.75, and 0.96 for cocaine. CONCLUSION Considering inaccuracies in the medical chart, the implementation of brief, standardized substance use screening is recommended in HIV care settings.
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Assessing Problematic Substance Use in HIV Care: Which Questions Elicit Accurate Patient Disclosures? J Gen Intern Med 2016; 31:1141-7. [PMID: 27197974 PMCID: PMC5023601 DOI: 10.1007/s11606-016-3733-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/08/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Substance use is associated with higher rates of antiretroviral non-adherence and poor HIV outcomes. This study examined how HIV care providers assess substance use, and which questions elicit accurate patient disclosures. METHODS We conducted a conversation analysis of audio-recorded encounters between 56 providers and 162 patients living with HIV (PLWH) reporting active substance use in post-encounter interviews (cocaine or heroin use in the past 30 days, > 4 days intoxicated in past 30 days, or AUDIT score ≥ 8). We assessed the frequency of substance use discussion, characterized the types of questions used by providers, and determined the frequency of accurate patient disclosure by question type. RESULTS In 55 reports of active substance use, providers already knew about the use (n = 16) or patients disclosed unpromptednn = 39). Among the remaining 155 instances of substance use in which providers had the opportunity to elicit disclosure, 78 reports (50 %) of substance use were not discussed. Of the remaining 77 reports in which the provider asked about substance use, 55 (71 %) patients disclosed and 22 (29 %) did not disclose. Questions were classified as: open-ended (n = 18, "How's the drinking going?"); normalizing (n = 14, "When was the last time you used?"); closed-ended (n = 36, "Have you used any cocaine?"); leading towards non-use (n = 9, "Have you been clean?"). Accurate disclosure followed 100 % of open-ended and normalizing questions, 58 % of closed-ended questions, and 22 % of leading questions. After adjusting for drug type, closed-ended questions were 41 % less likely (p < 0.001), and 'leading' questions 78 % less likely (p = 0.016) than broad and normalizing questions to elicit disclosures. CONCLUSION Providers in this sample missed almost half of the opportunities to identify and discuss substance use with PLWH. Providers can increase the probability of patient disclosure by using open-ended or normalizing questions that ask about the "last time" that the patient used drugs or alcohol.
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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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17
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Nguyen Bich D, Korthuis PT, Nguyen Thu T, Van Dinh H, Le Minh G. HIV Patients' Preference for Integrated Models of Addiction and HIV Treatment in Vietnam. J Subst Abuse Treat 2016; 69:57-63. [PMID: 27568511 DOI: 10.1016/j.jsat.2016.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/29/2016] [Accepted: 07/13/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Integrated care models for HIV and substance use disorder (SUD) care are proposed as a strategy for closing gaps in the HIV care continuum and decreasing HIV transmission. We examined attitudes regarding integration of HIV and SUD treatment among HIV-infected patients with illicit drug and unhealthy alcohol use. METHOD We conducted a cross-sectional survey of HIV-infected patients receiving care at 5 HIV clinics in Hanoi, Vietnam, regarding substance use and attitudes toward HIV and SUD treatment integration. We used multivariate logistic regression to identify correlates of integrated care preference. RESULT Among 312 participants with current or past illicit drug use or unhealthy alcohol use, 81.4% preferred integrated treatment for HIV and SUD. In multivariate analysis, completing a college education (aOR 0.22, 95% CI 0.08, 0.65), risk of depression (aOR 3.51, 95% CI 1.57, 7.87), ever having received medication-assisted treatment for opioid use disorder (aOR 4.20, 95% CI 1.65, 10.69), being comfortable discussing substance use with counselors/nurses (aOR 3.86, 95% CI 1.38, 10.81) and having discussed alcohol use with their health providers (aOR 2.34, 95% CI 1.09, 4.99) were associated with patients' preference for integrated care, after adjusting for age and gender. CONCLUSION Most, but not all, HIV-infected patients with substance use preferred integrated HIV and SUD treatment. Our findings suggest that policies to expand integration of HIV and SUD treatment will be well received by most patients, and that stand-alone treatment options should be preserved for a significant minority.
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Abstract
BACKGROUND Alcohol brief intervention (BI) in primary care (PC) is effective, but remains underutilized despite multiple efforts to increase provider-initiated BI. An alternative approach to promote BI is to prompt patients to initiate alcohol-related discussions. Little is known about the role of patients in BI delivery. OBJECTIVES To determine the characteristics of PC patients who reported initiating BI with their providers, and to evaluate the association between the initiator (patient vs provider) and drinking after a BI. METHODS In the context of clinical trial, patients (n = 267) who received BI during a PC visit reported on the manner in which the BI was initiated, readiness to change, demographics, and recent history of alcohol consumption. Drinking was assessed again at 6-months after the BI. RESULTS Fifty percent of patients receiving a BI reported initiating the discussion of drinking themselves. Compared with those who reported a provider-initiated discussion, self-initiators were significantly younger (43.7 years vs 47.1 years; P = 0.03), more likely to meet Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for current major depression (24% vs 14%; P = 0.04), and more likely to report a history of alcohol withdrawal symptoms (68% vs 52%; P < 0.01). Baseline readiness to change, baseline consumption rates, and current DSM-IV alcohol dependence were not different between groups. In the 2 to 3 weeks after BI, self-initiators reported greater decreases in drinks per week (5.7 vs 2.4; P = 0.02), and drinking days per week (1.0 vs 0.3; P = 0.002). At 6-month follow-up, self-initiators showed significantly greater reductions in weekly drinking compared to those whose provider initiated the BI (P = 0.002). CONCLUSIONS Patient- and provider-initiated BI occurred with equal frequency, and patient-initiated BIs were associated with greater reductions in alcohol use. Future efforts to increase the BI rate in PC should include a focus on prompting patients to initiate alcohol-related discussions.
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Edelman EJ, Hansen NB, Cutter CJ, Danton C, Fiellin LE, O'Connor PG, Williams EC, Maisto SA, Bryant KJ, Fiellin DA. Implementation of integrated stepped care for unhealthy alcohol use in HIV clinics. Addict Sci Clin Pract 2016; 11:1. [PMID: 26763048 PMCID: PMC4711105 DOI: 10.1186/s13722-015-0048-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 12/23/2015] [Indexed: 11/19/2022] Open
Abstract
Background
Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists. Methods We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes. Results From the providers’ perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention. Conclusions Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).
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Affiliation(s)
- E Jennifer Edelman
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
| | - Nathan B Hansen
- Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA. .,College of Public Health, University of Georgia, 131 Wright Hall, Health Sciences Campus, Athens, GA, 30602, USA.
| | - Christopher J Cutter
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Cheryl Danton
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Lynn E Fiellin
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
| | - Patrick G O'Connor
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Emily C Williams
- VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value-Driven Care, 1100 Olive Way, Suite 1400, Seattle, WA, 98101, USA. .,Department of Health Services, University of Washington, 1959 NE Pacific Street, Magnuson Health Sciences Center, Room H-664, Seattle, WA, 98195, USA.
| | - Stephen A Maisto
- Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244, USA.
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, 5635 Fishers Lane, Bethesda, MD, 20892-7003, USA.
| | - David A Fiellin
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
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Satre DD, Leibowitz AS, Mertens JR, Weisner C. Advising depression patients to reduce alcohol and drug use: factors associated with provider intervention in outpatient psychiatry. Am J Addict 2014; 23:570-5. [PMID: 25164533 DOI: 10.1111/j.1521-0391.2014.12140.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 03/07/2014] [Accepted: 04/12/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Mental health clinicians have an important opportunity to help depression patients reduce co-occurring alcohol and drug use. This study examined demographic and clinical patient characteristics and service factors associated with receiving a recommendation to reduce alcohol and drug use from providers in a university-based outpatient psychiatry clinic. METHODS The sample consisted of 97 participants ages 18 and older who reported hazardous drinking (≥3 drinks/occasion), illegal drug use (primarily cannabis) or misuse of prescription drugs, and who scored ≥15 on the Beck Depression Inventory-II (BDI-II). Participants were interviewed at intake and 6 months. RESULTS At 6-month telephone interview, 30% of participants reported that a clinic provider had recommended that they reduce alcohol or drug use. In logistic regression, factors associated with receiving advice to reduce use included greater number of drinks consumed in the 30 days prior to intake (p = .035); and greater depression severity on the BDI-II (p = .096) and hazardous drinking at 6 months (p = .05). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE While participants with greater alcohol intake and depression symptom severity were more likely to receive advice to reduce use, the low overall rate of recommendation to reduce use highlights the need to improve alcohol and drug use intervention among depression patients, and potentially to address alcohol and drug training and treatment implementation issues among mental health providers.
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Affiliation(s)
- Derek D Satre
- Department of Psychiatry, University of California at San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California Region, Oakland, California
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Schneider M, Chersich M, Temmerman M, Degomme O, Parry CD. The impact of alcohol on HIV prevention and treatment for South Africans in primary healthcare. Curationis 2014; 37:1137. [PMID: 25686283 DOI: 10.4102/curationis.v37i1.1137] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 02/17/2014] [Accepted: 02/21/2014] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Antiretroviral treatment (ART) has substantially reduced morbidity and mortality for HIV patients. In South Africa, with the largest ART programme globally, attention is needed not only on the further expansion of ART coverage, but also on factors which undermine its effectiveness, such as alcohol use. OBJECTIVE Given the decentralised approach of nurse-initiated and -sustained ART in the South African primary health sector, it is important to document key aspects of alcohol use to be conveyed to HIV-positive individuals and those at risk for HIV. METHOD This study comprised a narrative review of relevant literature. RESULTS Alcohol acts through both behavioural and physiological pathways to impact on the acquisition, further transmission and then progression of HIV disease. Besides links to risky sex, alcohol undermines the immune system, raising susceptibility to contracting and then countering HIV and other infections. There are important drug interactions between alcohol and ART, or therapies for opportunistic infections and other co-morbidities. Moreover, alcohol undermines adherence to the medication which is essential for effective ART. CONCLUSION Primary healthcare clinic attendees need evidence-based information on the detrimental effects of alcohol consumption on HIV infection, which ensue throughout the clinical course of HIV. This spans the role of alcohol consumption as a risk factor for HIV infection, HIV replication in infected individuals, a person's response to HIV infection and HIV treatment. Primary healthcare workers, especially nurses and HIV counsellors, require training in order to screen for and provide appropriate interventions for HIV-positive patients, those on treatment and treatment-naïve patients, who will benefit from reduced alcohol consumption or the cessation thereof.
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Affiliation(s)
- Michelle Schneider
- Alcohol, Tobacco and other Drug Research Unit Research Unit, Medical Research Council.
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22
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Living with addiction: the perspectives of drug using and non-using individuals about sharing space in a hospital setting. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2014; 25:640-9. [PMID: 24679487 DOI: 10.1016/j.drugpo.2014.02.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 02/13/2014] [Accepted: 02/18/2014] [Indexed: 11/24/2022]
Abstract
Hospitals seem to be places where harm reduction approaches could have great benefit but few have responded to the needs of people who use drugs. Drawing on recent theoretical contributions to harm reduction from health geography, we examine how the implementation of harm reduction is shaped by space and contested understandings of place and health. We examine how drug use and harm reduction approaches pose challenges and offer opportunities in hospital-based care using interview data from people living with HIV and who were or had recently been admitted to a hospital with an innovative harm reduction policy. Our data reveal the contested spatial arrangements (and the related practices and corporeal relations) that occur due to the discordance between harm reduction and hospital regulatory policy. Rather than de-stigmatising drug use at Casey House Hospital, the adoption of the harm reduction policy sparked inter-client conflict, reproduced dominant discourses about health and drug users, and highlights the challenges of sharing space when drug use is involved. The hospital setting produces particular ways of being for people who use and those who do not use drugs and the demarcation of space in a drug using context. Moving forward, harm reduction practice and research needs to consider more than just interactions between drug users and healthcare providers, or the role of administrative policies; it needs to position ethics at the forefront of understanding the collisions between people, drug use, place, and space. We raise questions about the relationship between subjectivity and spatial arrangements in mediating the success of harm reduction.
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Abstract
Clinical management of HIV must account for the "triple diagnosis" of HIV, psychiatric diagnosis, and substance use disorders and requires integrated treatment services that focus beyond just mitigation of substance use and psychiatric and medical symptoms but also address other health behaviors. Because clinical management of HIV/AIDS has shifted significantly with the advent of highly active antiretroviral therapies (HAART) in the mid 1990s, a literature review focusing on literature published since 2000, and using relevant key words was conducted using a wide range of literature search databases. This literature review was complemented by studies to expand on specific treatment modalities for which there was a dearth of literature addressing HIV infected cohorts and to provide discussion of issues around substance abuse treatment as an HIV prevention tool. Existing models of substance abuse treatment including cognitive behavioral therapy and motivational interviewing have proven to be useful for enhancing adherence and reducing substance use in outpatient populations, while methadone maintenance and directly observed treatment have been useful with specific subgroups of users. Contextualization of services heightens the likelihood of successful outcomes and relapse prevention.
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Bankoff SM, McCullough MB, Pantalone DW. Patient-provider relationship predicts mental and physical health indicators for HIV-positive men who have sex with men. J Health Psychol 2013; 18:762-72. [PMID: 23449678 DOI: 10.1177/1359105313475896] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We used secondary data analysis to examine associations among aspects of patient-provider relationships and mental and physical health indicators. Positive patient perceptions of patient-provider relationships were associated with fewer mental health symptoms in this outpatient sample of HIV-positive men who have sex with men (N = 171). Regression analyses revealed the role of anxiety and depression in explaining associations between two aspects of patient-provider relationships (i.e. quality of information offered and provider interactional style) and health-related quality of life. The findings demonstrated the importance of patient-provider relationships to improving physical health and functioning and maintaining engagement in care, among HIV-positive men who have sex with men.
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Affiliation(s)
- Sarah M Bankoff
- Department of Psychology, Suffolk University, 41 Temple Street, Boston, MA 02114, USA.
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Ray MK, Beach MC, Nicolaidis C, Choi D, Saha S, Korthuis PT. Patient and provider comfort discussing substance use. Fam Med 2013; 45:109-117. [PMID: 23378078 PMCID: PMC3608897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Substance use is a prevalent issue in primary care with wide-reaching implications, particularly for the care of HIV-infected patients. This analysis identified patient and provider characteristics associated with high comfort discussing substance use in HIV primary care clinics using multivariable logistic regression. METHODS A total of 413 patients and 44 providers completed surveys on their comfort discussing substance use. Additional independent variables from surveys included demographics, drug and alcohol use, self-efficacy, and activation for patients. Provider-level data included demographics, training, practice descriptors, and stress levels. RESULTS The majority of patients (76%) and providers (73%) reported high comfort. In multivariable analysis, patients with current problematic alcohol use or current drug use were half as likely to report high comfort compared to their non-substance-using peers. Higher patient self-efficacy and high levels of patient activation were independently associated with increased odds of high patient comfort. While provider-level characteristics were not associated with provider comfort, the types of patients a provider saw were. Namely, the proportion of patients on antiretroviral therapy was inversely associated with the odds of high provider comfort, whereas the proportion of patients with high patient activation was positively associated. CONCLUSIONS Patients likely to benefit from a discussion of substance use, those with current use, are the least likely to report comfort discussing that use. Interventions that increase patient activation or self-efficacy may also increase their comfort. This research guides future interventions to increase the prevalence of discussions on substance use.
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Affiliation(s)
- Moira K Ray
- Department of Family Medicine, and Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR 97239, USA.
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Unhealthy alcohol and illicit drug use are associated with decreased quality of HIV care. J Acquir Immune Defic Syndr 2012; 61:171-8. [PMID: 22820808 DOI: 10.1097/qai.0b013e31826741aa] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND HIV-infected patients with substance use experience suboptimal health outcomes, possibly because of variations in care. OBJECTIVES To assess the association between substance use and the quality of HIV care (QOC) received. RESEARCH DESIGN Retrospective cohort study. SUBJECTS HIV-infected patients enrolled in the Veterans Aging Cohort Study. MEASURES We collected self-report substance use data and abstracted 9 HIV quality indicators (QIs) from medical records. Independent variables were unhealthy alcohol use (AUDIT-C score ≥4) and illicit drug use (self-report of stimulants, opioids, or injection drug use in past year). Main outcome was the percentage of QIs received, if eligible. We estimated associations between substance use and QOC using multivariable linear regression. RESULTS The majority of the 3410 patients were male (97.4%) and black (67.0%) with a mean age of 49.1 years (SD = 8.8). Overall, 25.8% reported unhealthy alcohol use, 22% illicit drug use, and participants received 81.5% (SD = 18.9) of QIs. The mean percentage of QIs received was lower for those with unhealthy alcohol use versus not (59.3% vs. 70.0%, P < 0.001) and those using illicit drugs vs. not (57.8% vs. 70.7%, P < 0.001). In multivariable models, unhealthy alcohol use (adjusted β -2.74; 95% confidence interval: -4.23 to -1.25) and illicit drug use (adjusted β -3.51; 95% CI: -4.99 to -2.02) remained inversely associated with the percentage of QIs received. CONCLUSIONS Although the overall QOC for these HIV-infected Veteran patients was high, gaps persist for those with unhealthy alcohol and illicit drug use. Interventions that address substance use in HIV-infected patients may improve the QOC received.
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Abstract
The objective of this study was to estimate the influence of substance use on the quality of patient-provider communication during HIV clinic encounters. Patients were surveyed about unhealthy alcohol and illicit drug use and rated provider communication quality. Audio-recorded encounters were coded for specific communication behaviors. Patients with vs. without unhealthy alcohol use rated the quality of their provider's communication lower; illicit drug user ratings were comparable to non-users. Visit length was shorter, with fewer activating/engaging and psychosocial counseling statements for those with vs. without unhealthy alcohol use. Providers and patients exhibited favorable communication behaviors in encounters with illicit drug users vs. non-users, demonstrating greater evidence of patient-provider engagement. The quality of patient-provider communication was worse for HIV-infected patients with unhealthy alcohol use but similar or better for illicit drug users compared with non-users. Interventions should be developed that encourage providers to actively engage patients with unhealthy alcohol use.
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Improving adherence to HIV quality of care indicators in persons with opioid dependence: the role of buprenorphine. J Acquir Immune Defic Syndr 2011; 56 Suppl 1:S83-90. [PMID: 21317600 DOI: 10.1097/qai.0b013e31820bc9a5] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients. METHODS We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible × 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants. RESULTS One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (β 8.55; 95% confidence interval, 2.06-15.0). CONCLUSIONS In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes.
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Korthuis PT, Tozzi MJ, Nandi V, Fiellin DA, Weiss L, Egan JE, Botsko M, Acosta A, Gourevitch MN, Hersh D, Hsu J, Boverman J, Altice FL. Improved quality of life for opioid-dependent patients receiving buprenorphine treatment in HIV clinics. J Acquir Immune Defic Syndr 2011; 56 Suppl 1:S39-45. [PMID: 21317593 PMCID: PMC3073082 DOI: 10.1097/qai.0b013e318209754c] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioid dependence and HIV infection are associated with poor health-related quality of life (HRQOL). Buprenorphine/naloxone (bup/nx) provided in HIV care settings may improve HRQOL. METHODS We surveyed 289 HIV-infected opioid-dependent persons treated with clinic-based bup/nx about HRQOL using the Short Form Health Survey (SF-12) administered at baseline, 3, 6, 9, and 12 months. We used normalized SF-12 scores, which correspond to a mean HRQOL of 50 for the general US population (SD 10, possible range 0-100). We compared mean normalized mental and physical composite and component scores in quarters 1, 2, 3, and 4 with baseline scores using generalized estimating equation models. We assessed the effect of clinic-based bup/nx prescription on HRQOL composite scores using mixed effects regression with site as random effect and time as repeated effect. RESULTS Baseline normalized SF-12 scores were lower than the general US population for all HRQOL domains. Average composite mental HRQOL improved from 38.3 (SE 12.5) to 43.4 (SE 13.2) [β 1.13 (95% CI: 0.72 to 1.54)] and composite physical HRQOL remained unchanged [β 0.21 (95% CI: -0.16 to 0.57)] over 12 months follow-up. Continued bup/nx treatment across all 4 quarters was associated with improvements in both physical [β 2.38 (95% CI: 0.63 to 4.12)] and mental [β 2.51 (95% CI: 0.42 to 4.60)] HRQOL after adjusting for other contributors to HRQOL. CONCLUSIONS Clinic-based bup/nx maintenance therapy is potentially effective in ameliorating some of the adverse effects of opioid dependence on HRQOL for HIV-infected populations.
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Affiliation(s)
- P Todd Korthuis
- Department of Medicine, Oregon Health and Science University, Portland, OR 97239-3098, USA.
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Proeschold-Bell RJ, Heine A, Pence BW, McAdam K, Quinlivan EB. A cross-site, comparative effectiveness study of an integrated HIV and substance use treatment program. AIDS Patient Care STDS 2010; 24:651-8. [PMID: 20846009 DOI: 10.1089/apc.2010.0073] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Co-occurrence of HIV and substance abuse is associated with poor outcomes for HIV-related health and substance use. Integration of substance use and medical care holds promise for HIV patients, yet few integrated treatment models have been reported. Most of the reported models lack data on treatment outcomes in diverse settings. This study examined the substance use outcomes of an integrated treatment model for patients with both HIV and substance use at three different clinics. Sites differed by type and degree of integration, with one integrated academic medical center, one co-located academic medical center, and one co-located community health center. Participants (n=286) received integrated substance use and HIV treatment for 12 months and were interviewed at 6-month intervals. We used linear generalized estimating equation regression analysis to examine changes in Addiction Severity Index (ASI) alcohol and drug severity scores. To test whether our treatment was differentially effective across sites, we compared a full model including site by time point interaction terms to a reduced model including only site fixed effects. Alcohol severity scores decreased significantly at 6 and 12 months. Drug severity scores decreased significantly at 12 months. Once baseline severity variation was incorporated into the model, there was no evidence of variation in alcohol or drug score changes by site. Substance use outcomes did not differ by age, gender, income, or race. This integrated treatment model offers an option for treating diverse patients with HIV and substance use in a variety of clinic settings. Studies with control groups are needed to confirm these findings.
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Affiliation(s)
| | - Amy Heine
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Brian Wells Pence
- Department of Community and Family Medicine, Global Health Institute, Duke University, Durham, North Carolina
| | - Keith McAdam
- Department of Psychiatry, Duke University, Durham, North Carolina
| | - Evelyn Byrd Quinlivan
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Bell C, Metsch LR, Vogenthaler N, Cardenas G, Rodriguez A, Locascio V, Kuper T, Scharf E, Marquez A, Yohannan M, del Rio C. Never in care: characteristics of HIV-infected crack cocaine users in 2 US cities who have never been to outpatient HIV care. J Acquir Immune Defic Syndr 2010; 54:376-80. [PMID: 20173648 PMCID: PMC2888612 DOI: 10.1097/qai.0b013e3181d01d31] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are very limited data available of the correlates of HIV-infected crack users who have never been to HIV care. METHODS Interviews were conducted at bedside with HIV-infected crack cocaine users who were recruited from the inpatient wards at Jackson Memorial Hospital in Miami, FL, and Grady Memorial Hospital in Atlanta, GA, between August 2006 and July 2009. Participants were asked about their sociodemographic characteristics, drug use, drug/alcohol treatment history, use of HIV care, perceived social support, and mental health status. Multiple logistic regression was performed to identify factors associated with never having been to HIV care. RESULTS Among 355 study participants, 21% reported never having been to a doctor or clinic for HIV care. Higher adjusted odds of never having been in care were associated with an annual income of less than $5000 [adjusted odds ratio (AOR) = 8.17, 95% confidence interval (CI) = 3.35 to 19.94], residence in Atlanta compared with Miami (AOR = 2.57, 95% CI = 1.36 to 4.83), no history of drug treatment (AOR = 4.13, 95% CI = 2.24 to 7.62), and not being helped into care at the time of HIV diagnosis (AOR = 2.83, 95% CI = 1.56 to 5.15). CONCLUSIONS Our data show that a significant proportion of HIV-infected crack cocaine users in 2 city hospitals have never been to HIV care. Interventions at the time of HIV diagnosis and drug treatment participation may facilitate linkage to care.
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Affiliation(s)
- Christine Bell
- Department of Global Health, Rollins School of Public Health, and Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Lisa R Metsch
- Department of Epidemiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Nicholas Vogenthaler
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Gabriel Cardenas
- Department of Epidemiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Allan Rodriguez
- Department of Epidemiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Virginia Locascio
- Department of Epidemiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Tamy Kuper
- Department of Epidemiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Elizabeth Scharf
- Department of Global Health, Rollins School of Public Health, and Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Alexandra Marquez
- Department of Global Health, Rollins School of Public Health, and Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Mary Yohannan
- Department of Global Health, Rollins School of Public Health, and Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Carlos del Rio
- Department of Global Health, Rollins School of Public Health, and Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
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Knowlton AR, Arnsten JH, Eldred LJ, Wilkinson JD, Shade SB, Bohnert AS, Yang C, Wissow LS, Purcell DW. Antiretroviral use among active injection-drug users: the role of patient-provider engagement and structural factors. AIDS Patient Care STDS 2010; 24:421-8. [PMID: 20578910 DOI: 10.1089/apc.2009.0240] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
HIV-seropositive, active injection-drug users (IDUs), compared with other HIV populations, continue to have low rates of highly active antiretroviral therapy (HAART) use, contributing to disparities in their HIV health outcomes. We sought to identify individual-level, interpersonal, and structural factors associated with HAART use among active IDUs to inform comprehensive, contextually tailored intervention to improve the HAART use of IDUs. Prospective data from three semiannual assessments were combined, and logistic general estimating equations were used to identify variables associated with taking HAART 6 months later. Participants were a community sample of HIV-seropositive, active IDUs enrolled in the INSPIRE study, a U.S. multisite (Baltimore, Miami, New York, San Francisco) prevention intervention. The analytic sample included 1,225 observations, and comprised 62% males, 75% active drug users, 75% non-Hispanic blacks, and 55% with a CD4 count <350; 48% reported HAART use. Adjusted analyses indicated that the later HAART use of IDUs was independently predicted by patient-provider engagement, stable housing, medical coverage, and more HIV primary care visits. Significant individual factors included not currently using drugs and a positive attitude about HAART benefits even if using illicit drugs. Those who reported patient-centered interactions with their HIV primary care provider had a 45% greater odds of later HAART use, and those with stable housing had twofold greater odds. These findings suggest that interventions to improve the HIV treatment of IDUs and to reduce their HIV health disparities should be comprehensive, promoting better patient-provider engagement, stable housing, HAART education with regard to illicit drug use, and integration of drug-abuse treatment with HIV primary care.
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Affiliation(s)
- Amy R. Knowlton
- Department of Health, Behavior and Society; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Julia H. Arnsten
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Lois J. Eldred
- At the time of the study, was at the Special Projects of National Significance, HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland. Now at the Johns Hopkins School of Medicine, Baltimore, Maryland
| | - James D. Wilkinson
- Departments of Pediatrics and Epidemiology and Public Health, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Starley B. Shade
- AIDS Research Institute, University of California, San Francisco, California
| | - Amy S. Bohnert
- At the time of the study was at the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. Now at Veterans Affairs, National Serious Mental Illness Treatment Research Evaluation Center, Ann Arbor, Michigan
| | - Cui Yang
- Department of Health, Behavior and Society; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lawrence S. Wissow
- Department of Health, Behavior and Society; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W. Purcell
- Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Meade CS, Hansen NB, Kochman A, Sikkema KJ. Utilization of medical treatments and adherence to antiretroviral therapy among HIV-positive adults with histories of childhood sexual abuse. AIDS Patient Care STDS 2009; 23:259-66. [PMID: 19260772 PMCID: PMC2856435 DOI: 10.1089/apc.2008.0210] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
HIV is a chronic, life-threatening illness that necessitates regular and consistent medical care. Childhood sexual abuse (CSA) is a common experience among HIV-positive adults and may interfere with treatment utilization. This study examined rates and correlates of treatment utilization among HIV-positive adults with CSA enrolled in a coping intervention trial in New York City. The baseline assessment included measures of treatment utilization, mental health, substance abuse, and other psychosocial factors. In 2002-2004, participants (50% female, 69% African-American, M = 42.3 +/- 6.8 years old) were recruited. Nearly all (99%) received HIV medical care. However, 20% had no outpatient visits and 24% sought emergency services in the past 4 months. Among 184 participants receiving antiretroviral therapy (ART), 22% were less than 90% adherent in the past week. In a multivariable logistic regression model, no outpatient treatment was associated with African American race (AOR = 3.46 [1.42-8.40]), poor social support (AOR = 1.59 [1.03-2.45]), and abstinence from illicit drug use (AOR = 0.37 [0.16-0.85]). Emergency service utilization was associated with HIV symptoms (AOR = 2.30 [1.22-4.35]), binge drinking (AOR=2.92 (1.18-7.24)), and illicit drug use (AOR = 1.98 [1.02-3.85]). Poor medication adherence was associated with trauma symptoms (AOR = 2.64 [1.07-6.75]) and poor social support (AOR = 1.82 [1.09-2.97]). In sum, while participants had access to HIV medical care, a sizable minority did not adhere to recommended guidelines and thus may not be benefiting optimally from treatment. Interventions targeting HIV-positive adults with CSA histories may need to address trauma symptoms, substance abuse, and poor social support that interfere with medical treatment utilization and adherence.
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Affiliation(s)
- Christina S Meade
- McLean Hospital/Harvard Medical School, Belmont, Massachusetts, USA.
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