Substance use and HIV disease progression in the HAART era: implications for the primary prevention of HIV

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

HIV-1 and opiates modulate miRNA profiles in extracellular vesicles

Opiate abuse increases the risk of HIV transmission and exacerbates HIV neuropathology by increasing inflammation and modulating immune cell function. Exosomal EVs(xEV) contain miRNAs that may be differentially expressed due to HIV infection or opiate abuse. Here we develop a preliminary exosomal-miRNA biomarker profile of HIV-infected PBMCs in the context of opiate use. PBMCs infected with HIV were treated with increasing dosages of morphine for 72 hours, the culture supernatants were collected, and the exosomes isolated using differential centrifugation. Exosomal miRNAs were extracted, expression levels determined via Nanostring multiplexed microRNA arrays, and analyzed with Webgestalt. The effect of the exosomes on neuronal function was determined by measuring calcium. Preliminary findings show that HIV-1 infection altered the miRNA profile of PBMC-derived EVs concurrently with opiate exposure. MicroRNA, hsa-miR-1246 was up-regulated 12-fold in the presence of morphine, relative to uninfected control. PBMCs infected with HIV-1 MN, an X4-tropic HIV-1 strain and exposed to morphine, displayed a trend which suggests potential synergistic effects between HIV-1 infection and morphine exposure promoting an increase in viral replication. Dose-dependent differences were observed in miRNA expression as a result of opiate exposure. The xEVs derived from PBMCs exposed to morphine or HIV modulated neuronal cell function. SH-SY5Y cells, treated with xEVs derived from ART-treated PBMCs, exhibited increased viability while for SH-SY5Ys exposed to xEVs derived from HIV-1 infected PBMCs viability was decreased compared to the untreated control. Exposing SH-SY5Y to xEVs derived from HIV-infected PBMCs resulted in significant decrease in calcium signaling, relative to treatment with xEVs derived from uninfected PBMCs. Overall, HIV-1 and morphine induced differential miRNA expression in PBMC-derived exosomes, potentially identifying mechanisms of action or novel therapeutic targets involved in opiate use disorder, HIV neuropathology, TNF signaling pathway, NF-κB signaling pathway, autophagy, and apoptosis in context of HIV infection.

Promoting HIV care continuum outcomes among people who use drugs and alcohol: a systematic review of randomized trials evaluating behavioral HIV care interventions published from 2011 to 2023

BACKGROUND

Substance use remains a robust predictor of HIV infection and a serious impediment to HIV care continuum progression for people living with HIV. The primary research question of this systematic review is focused on understanding the extent to which behavioral HIV care interventions have been efficacious in helping people who live with HIV and who use substances along the HIV care continuum.

METHODS

Using PubMed and ProQuest databases, we performed a systematic review of randomized trials of behavioral HIV care continuum interventions among people who use substances published from 2011 to August 2023, since the beginning of the treatment-as-prevention era.

RESULTS

We identified 11 studies (total participants: N = 5635), ten intentionally targeting substance-using populations. Four studies involved samples using ≥ 1 substance (e.g., alcohol, opioids, stimulants, marijuana); four involved injection drug use; one involved methamphetamine use; and one involved alcohol use. One study targeted a population with incidental substance use (i.e., alcohol, injection drug use, non-injection drug use reported in most participants). Each study defined one or more HIV care outcomes of interest. Viral suppression was an outcome targeted in 9/11 studies, followed by uptake of antiretroviral therapy (ART; 7/11), ART adherence (6/11), retention in care (5/11), and linkage to care (3/11). While most (nine) of the studies found significant effects on at least one HIV care outcome, findings were mostly mixed. Mediated (2/11) and moderated (2/11) effects were minimally examined.

CONCLUSIONS

The results from this systematic review demonstrate mixed findings concerning the efficacy of previous HIV care interventions to improve HIV care continuum outcomes among people who use substances. However, heterogeneity of study components (e.g., diversity of substances used/assessed, self-report vs. objective measures, attrition) prevent broad deductions or conclusions about the amenability of specific substance-using populations to HIV care intervention. More coordinated, comprehensive, and targeted efforts are needed to promote and disentangle intervention effects on HIV care continuum outcomes among substance-using populations.

Amphetamine use and its associations with antiretroviral adherence and viral load among sexual minority men and transgender women living with HIV

Substance use has complex associations to HIV disease progression. The current study tested the associations between several substances and HIV viral load while accounting for confounders relevant to HIV disease progression and substance use. Young sexual minority men and transgender women living with HIV (LWH) in Georgia (N = 385) completed measures and biological tests for HIV viral load and substance use. Multivariable regression models tested the role of specific drugs (i.e., alcohol, cannabis/THC, cocaine, and combined amphetamine and methamphetamine) directly on viral load and indirectly through antiretroviral (ART) adherence. ART adherence and HIV care self-efficacy were consistently associated with greater HIV suppression. Alcohol and cocaine were not associated with ART adherence or viral load. Cannabis was negatively associated with ART adherence (B = -.053, p = .037) but not viral load. Amphetamine/methamphetamine demonstrated significant direct effects on higher viral load (B = .708, p = .010) while indirectly influencing viral load through a negative association with ART adherence. Our findings support previous research demonstrating amphetamine/methamphetamine use impacts viral load both directly and indirectly through ART adherence. Interventions addressing amphetamine/methamphetamine use by young sexual minority men and transgender women LWH are urgently needed, and future research should focus on determining the mechanisms by which formulations of amphetamine impact HIV replication.Trial registration: ClinicalTrials.gov identifier: NCT03665532.

Nanosome-Mediated Delivery Of Hdac Inhibitors and Oxygen Molecules for the Transcriptional Reactivation of Latent Hiv-Infected Cd4+ T Cells

The treatment of human immunodeficiency virus (HIV) infection is notoriously difficult due to the ability of this virus to remain latent in the host's CD4+ T cells. Histone deacetylases (HDACs) interfere with DNA transcription in HIV-infected hosts, resulting in viral latency. Therefore, HDAC inhibitors can be used to activate viral transcription in latently infected cells, after which the virus can be eliminated through a shock-and-kill strategy. Here, a drug delivery system is developed to effectively deliver HDAC inhibitors to latent HIV-infected cells. Given that the efficacy of HDAC inhibitors is reduced under hypoxic conditions, oxygen-containing nanosomes are used as drug carriers. Oxygen-containing nanosomes can improve the efficiency of chemotherapy by delivering essential oxygen to cells. Additionally, their phospholipid bilayer structure makes them uniquely well-suited for drug delivery. In this study, a novel drug delivery system is developed by taking advantage of the oxygen carriers in these oxygen nanosomes, incorporating a multi-drug strategy consisting of HDAC inhibitors and PKA activators, and introducing CXCR4 binding peptides to specifically target CD4+ T cells. Oxygen nanosomes with enhanced targeting capability through the introduction of the CXCR4 binding peptide mitigate drug toxicity and slow down drug release. The observed changes in the expression of p24, a capsid protein of HIV, indirectly confirm that the proposed drug delivery system can effectively induce transcriptional reactivation of HIV in latent HIV-infected cells.

Astrocytes: Role in pathogenesis and effect of commonly misused drugs in the HIV infected brain

The roles of astrocytes as reservoirs and producers of a subset of viral proteins in the HIV infected brain have been studied extensively as a key to understanding HIV-associated neurocognitive disorders (HAND). However, their comprehensive role in the context of intersecting substance use and neurocircuitry of the reward pathway and HAND has yet to be fully explained. Use of methamphetamines, cocaine, or opioids in the context of HIV infection have been shown to lead to a faster progression of HAND. Glutamatergic, dopaminergic, and GABAergic systems are implicated in the development of HAND-induced cognitive impairments. A thorough review of scientific literature exploring the variety of mechanisms in which these drugs exert their effects on the HIV brain and astrocytes has revealed marked areas of convergence in overexcitation leading to increased drug-seeking behavior, inflammation, apoptosis, and irreversible neurotoxicity. The present review investigates astrocytes, the neural pathways, and mechanisms of drug disruption that ultimately play a larger holistic role in terms of HIV progression and drug use. There are opportunities for future research, therapeutic intervention, and preventive strategies to diminish HAND in the subset population of patients with HIV and substance use disorder.

Socio-ecological Barriers to Viral Suppression Among Transgender Women Living with HIV in San Francisco and Los Angeles, California

Troubling disparities in viral suppression persist among transgender (trans) women living with HIV in the US. We utilized baseline data from a randomized controlled trial of a behavioral intervention among trans women living with HIV in San Francisco and Los Angeles, to identify the socio-ecological correlates of biologically confirmed viral suppression (< 200 HIV-1 RNA copies/mL). Among 253 participants, the mean age was 43 (SD = 11), 46% identified as Black or African American and 35% were virally non-suppressed. In adjusted Poisson regression models, the following barriers to viral suppression were identified: injection drug use [adjusted risk ratio (aRR) 0.78, 95% CI 0.65-0.93, Z = - 2.64, p = 0.008], methamphetamine use (aRR 0.65, 95% CI 0.51-0.83, Z = - 3.45, p = 0.001), amphetamine use (aRR 0.62, 95% CI 0.44-0.87, Z = - 2.75, p = 0.006), homelessness (aRR 0.79, 95% CI 0.63-0.98, Z = - 2.06, p = 0.039), and sex work (aRR 0.60, 95% CI 0.41-0.86, Z = - 2.77, p = 0.009). These findings underscore the importance of interventions that address the socio-ecological barriers to viral suppression among trans women in urban settings.

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

Background

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

Methods

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

Results

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

Conclusion

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

Person-time spent with HIV viral load above 1500 copies/mL among Miami-Dade County Ryan White Program clients, 2017-2019: a retrospective analysis

HIV transmission risk significantly increases at HIV viral load (VL) >1500 copies/mL. We sought to determine the percentage of person-time spent with VL >1500 copies/mL (pPT >1500) and the associations of demographic, clinical, and psychosocial factors and this outcome among persons with HIV receiving care. A retrospective analysis of data from clients enrolled in the Ryan White Program from 2017 to 2019 was performed. We assessed pPT >1500 in HIV care by utilizing consecutive VL pairs and calculating the length of time between each pair and the corresponding time spent for the observation period. The association between pPT >1500 and selected client characteristics were analyzed using a random-effects zero-inflated negative binomial model. Among the 6390 clients, 42% were aged 50 or older, 52% MSM, and 59% Hispanic. Overall, 7.5% of clients spent, on average, 27.4 days per year at substantial risk of transmitting HIV. Younger age, AIDS diagnosis, and reported drug use in the preceding 12 months were associated with higher pPT >1500. Tailored interventions should be implemented to meet the unique HIV needs of groups with consistent viremia to significantly minimize transmission risk.

Mechanisms linking gender-based violence to worse HIV treatment and care outcomes among women in the United States

OBJECTIVE

To test whether substance use mediates the associations between gender-based violence (GBV) and suboptimal adherence to antiretroviral therapy (ART), and GBV and poor engagement in care, among women living with HIV (WLHIV) in the United States (US).

DESIGN

We analyzed longitudinal data collected among 1717 WLHIV in the Women's Interagency HIV Study (WIHS).

METHODS

From 2013 to 2017, WLHIV completed semi-annual assessments on GBV, substance use, and HIV treatment and care. Adjusted multilevel logistic regression models were built to estimate the impact of GBV on; suboptimal (<95%) adherence and at least one missed HIV care appointment without rescheduling in the past 6 months. Mediation analyses were performed to test whether heavy drinking and illicit drug use mediated the associations between GBV and the two HIV outcomes.

RESULTS

The mean age was 47 (standard deviation = 9), 5% reported experiencing GBV, 17% reported suboptimal adherence and 15% reported at least one missed appointment in the past 6 months. Women who experienced GBV had a significantly higher odds of suboptimal adherence [adjusted odds ratio (aOR) = 1.99; 95% confidence interval (CI) = 1.40-2.83] and missed appointments (aOR = 1.92, 95% CI = 1.32-2.33). Heavy drinking and illicit drug use mediated 36 and 73% of the association between GBV and suboptimal adherence and 29 and 65% of the association between GBV and missed appointments, respectively.

CONCLUSIONS

Substance use is an underlying mechanism through which GBV affects outcomes along the HIV care continuum among WLHIV in the US. To optimize HIV treatment and care among women, interventions should address the combined epidemics of substance use, violence, and HIV.

Through the Looking-Glass: Psychoneuroimmunology and the Microbiome-Gut-Brain Axis in the Modern Antiretroviral Therapy Era

OBJECTIVE

Depression, substance use disorders, and other neuropsychiatric comorbidities are common in people with HIV (PWH), but the underlying mechanisms are not sufficiently understood. HIV-induced damage to the gastrointestinal tract potentiates residual immune dysregulation in PWH receiving effective antiretroviral therapy. However, few studies among PWH have examined the relevance of microbiome-gut-brain axis: bidirectional crosstalk between the gastrointestinal tract, immune system, and central nervous system.

METHODS

A narrative review was conducted to integrate findings from 159 articles relevant to psychoneuroimmunology (PNI) and microbiome-gut-brain axis research in PWH.

RESULTS

Early PNI studies demonstrated that neuroendocrine signaling via the hypothalamic-pituitary-adrenal axis and autonomic nervous system could partially account for the associations of psychological factors with clinical HIV progression. This review highlights the need for PNI studies examining the mechanistic relevance of the gut microbiota for residual immune dysregulation, tryptophan catabolism, and oxytocin release as key biological determinants of neuropsychiatric comorbidities in PWH (i.e., body-to-mind pathways). It also underscores the continued relevance of neuroendocrine signaling via the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and oxytocin release in modifying microbiome-gut-brain axis functioning (i.e., mind-to-body pathways).

CONCLUSIONS

Advancing our understanding of PNI and microbiome-gut-brain axis pathways relevant to depression, substance use disorders, and other neuropsychiatric comorbidities in PWH can guide the development of novel biobehavioral interventions to optimize health outcomes. Recommendations are provided for biobehavioral and neurobehavioral research investigating bidirectional PNI and microbiome-gut-brain axis pathways among PWH in the modern antiretroviral therapy era.

The Interaction of HIV With Mental Health in the Modern Antiretroviral Therapy Era

ABSTRACT

People with HIV (PWH) receiving effective antiretroviral therapy (ART) continue to display residual immune dysregulation that amplifies the risk for neuropsychiatric comorbidities. At the same time, PWH commonly experience intersectional stigma and other psychosocial stressors that are linked to neuroendocrine stress responses, potentiate residual immune dysregulation, and alter other biobehavioral processes relevant to health outcomes. This special issue of Psychosomatic Medicine seeks to advance our understanding of the intersection of HIV with mental health in the modern ART era. Several articles cover topics related to the prevalence and treatment of psychiatric comorbidities among PWH such as depression, suicidality, and substance use disorders. Other articles delineate biobehavioral mechanisms relevant to mental health in PWH such as inflammation, immune activation, neuroendocrine signaling, cellular aging, the microbiome-gut-brain axis, and neurobehavioral processes. Collectively, the articles in this special issue highlight the continued importance of biobehavioral and neurobehavioral mental health research in the modern ART era.

Finding Sunshine on a Cloudy Day: A Positive Affect Intervention for Co-Occurring Methamphetamine Use and HIV

Among sexual minority men (i.e., gay, bisexual, and other men who have sex with men) living with HIV, those who use methamphetamine experience profound health disparities. Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS) is an evidence-based, 5-session, individually delivered positive affect intervention adapted for sexual minority men living with HIV who use methamphetamine. ARTEMIS was designed to amplify the benefits of evidence-based substance use interventions such as contingency management (CM) with this high-priority population. Delivering ARTEMIS during CM has been shown to assist participants in reducing stimulant use, increasing positive affect, and achieving durable reductions in HIV viral load. We describe the theoretical underpinnings of the ARTEMIS intervention, provide details of the training and session protocols with a case example, and discuss implications for future applications in research and clinical settings.

Characterization of basal ganglia volume changes in the context of HIV and polysubstance use

HIV and psychoactive substances can impact the integrity of the basal ganglia (BG), a neural substrate of cognition, motor control, and reward-seeking behaviors. This study assessed BG gray matter (GM) volume as a function of polysubstance (stimulant and opioid) use and HIV status. We hypothesized that comorbid polysubstance use and HIV seropositivity would alter BG GM volume differently than would polysubstance use or HIV status alone. We collected structural MRI scans, substance use history, and HIV diagnoses. Participants who had HIV (HIV +), a history of polysubstance dependence (POLY +), both, or neither completed assessments for cognition, motor function, and risk-taking behaviors (N = 93). All three clinical groups showed a left-lateralized pattern of GM reduction in the BG relative to controls. However, in the HIV + /POLY + group, stimulant use was associated with increased GM volume within the globus pallidus and putamen. This surpassed the effects from opioid use, as indicated by decreased GM volume throughout the BG in the HIV-/POLY + group. Motor learning was impaired in all three clinical groups, and in the HIV + /POLY + group, motor learning was associated with increased caudate and putamen GM volume. We also observed associations between BG GM volume and risk-taking behaviors in the HIV + /POLY- and HIV-/POLY + groups. The effects of substance use on the BG differed as a function of substance type used, HIV seropositivity, and BG subregion. Although BG volume decreased in association with HIV and opioid use, stimulants can, inversely, lead to BG volume increases within the context of HIV.

The Effect of Buprenorphine on Human Immunodeficiency Virus Viral Suppression

BACKGROUND

Opioid use is prevalent among people living with human immunodeficiency virus (HIV; PLWH) and adversely affects HIV outcomes. We assessed the effect of buprenorphine (BUP) initiation on subsequent HIV viral loads.

METHODS

We identified PLWH from the Johns Hopkins HIV Clinical Cohort who initiated BUP between 2002 and 2017. Poisson regression with robust variance was used to estimate the prevalence of viral suppression (<200 copies/mL) before and after BUP initiation. We matched individuals who initiated BUP with controls based on viral load measurement dates and used prior event rate ratio (PERR) methods to estimate the effect of BUP initiation on viral suppression. PERR methods account for unmeasured confounders.

RESULTS

We identified 279 PLWH who initiated BUP. After BUP initiation, PLWH were more likely to be virally suppressed (prevalence ratio [PR], 1.19; 95% confidence interval [CI], 1.03-1.37). After matching PLWH who initiated BUP to controls and accounting for measured and unmeasured confounders, BUP initiation increased viral suppression for both those on antiretroviral therapy (ART) at baseline (PERR PR, 1.08; 95% CI, 1.00-1.18) and those not on ART at baseline (PR, 1.31; 95% CI, 1.10-1.61).

CONCLUSIONS

Our results indicate that the initiation of BUP results in an increase in the probability of being virally suppressed after accounting for both measured and unmeasured confounders. Persons with opioid use disorder should initiate BUP to not only treat substance use but also to increase viral suppression allowing for treatment as prevention.

Tina's ParTy line: Polysubstance use patterns in sexual minority men living with HIV who use methamphetamine

INTRODUCTION

This cross-sectional study examined the associations of demographic, structural and psychological factors with distinct typologies of polysubstance use in sexual minority men (SMM) living with HIV who use methamphetamine.

METHODS

In total, 161 SMM living with HIV who reported methamphetamine use in the past 3 months were recruited in San Francisco from 2013 to 2017 for a randomised controlled trial. A latent class analysis was conducted by leveraging baseline measures of self-reported use of 15 substances in the past 3 months as well as validated screening measures of hazardous alcohol and cannabis use. Correlates of latent class membership were examined using a three-step categorical latent variable logistic regression.

RESULTS

Four typologies of substance use were identified: (i) methamphetamine use only (43%); (ii) methamphetamine and crack-cocaine use (22%); (iii) party and play use-methamphetamine, gamma-hydroxybutyrate and amyl nitrites (i.e. poppers) with erectile dysfunction drugs (31%); and (iv) high polysubstance use (4%). SMM of colour and those with a history of incarceration were more commonly classified as engaging in methamphetamine and crack-cocaine use compared to party and play use. Men with higher sexual compulsivity scores were more commonly classified as engaging in party and play use and polysubstance use.

DISCUSSION AND CONCLUSIONS

There is substantial heterogeneity in polysubstance use patterns among SMM living with HIV who use methamphetamine. This will inform the development of tailored substance use interventions addressing the unique needs of SMM of colour and targeting sexual compulsivity as a prominent comorbidity for some men.

Pilot study of extended-release lorcaserin for cocaine use disorder among men who have sex with men: A double-blind, placebo-controlled randomized trial

Objective

To determine if men who have sex with men (MSM) with cocaine use disorder (CUD) and actively-using cocaine could be enrolled and retained in a pharmacologic intervention trial of lorcaserin—a novel 5-HT_2cR agonist—and determine the degree to which participants would adhere to study procedures.

Methods

This was a phase II randomized, double-blind, placebo-controlled pilot study with 2:1 random parallel group assignment to daily extended-release oral lorcaserin 20 mg versus placebo (clinicaltrials.gov identifier-NCT03192995). Twenty-two of a planned 45 cisgender MSM with CUD were enrolled and had weekly follow-up visits during a 12-week treatment period, with substance use counseling, urine specimen collection, and completion of audio-computer assisted self-interview (ACASI) behavioral risk assessments. Adherence was measured by medication event monitoring systems (MEMS) caps and self-report. This study was terminated early because of an FDA safety alert for lorcaserin’s long-term use.

Results

Eighty-six percent completed the trial, with 82% of weekly study follow-up visits completed. Adherence was 55.3% (lorcaserin 51.6% vs. placebo 66.2%) by MEMS cap and 56.9% (56.5% vs. placebo 57.9%) by self-report and did not differ significantly by treatment assignment. Intention-to-treat analyses (ITT) did not show differences in cocaine positivity by urine screen between the lorcaserin and placebo groups by 12 week follow-up (incidence risk ratio [IRR]: 0.96; 95%CI = 0.24–3.82, P = 0.95). However, self-reported cocaine use in timeline follow-back declined more significantly in the lorcaserin group compared to placebo (IRR: 0.66; 95%CI = 0.49–0.88; P = 0.004).

Conclusion

We found that it is feasible, acceptable, and tolerable to conduct a placebo-controlled pharmacologic trial for MSM with CUD who are actively using cocaine. Lorcaserin was not associated with significant reductions in cocaine use by urine testing, but was associated with significant reductions in self-reported cocaine use. Future research may be needed to continue to explore the potential utility of 5-HT_2cR agonists.

Dopamine Levels Induced by Substance Abuse Alter Efficacy of Maraviroc and Expression of CCR5 Conformations on Myeloid Cells: Implications for NeuroHIV

Despite widespread use of antiretroviral therapy (ART), HIV remains a major public health issue. Even with effective ART many infected individuals still suffer from the constellation of neurological symptoms now known as neuroHIV. These symptoms can be exacerbated by substance abuse, a common comorbidity among HIV-infected individuals. The mechanism(s) by which different types of drugs impact neuroHIV remains unclear, but all drugs of abuse increase central nervous system (CNS) dopamine and elevated dopamine increases HIV infection and inflammation in human myeloid cells including macrophages and microglia, the primary targets for HIV in the brain. Thus, drug-induced increases in CNS dopamine may be a common mechanism by which distinct addictive substances alter neuroHIV. Myeloid cells are generally infected by HIV strains that use the chemokine receptor CCR5 as a co-receptor, and our data indicate that in a subset of individuals, drug-induced levels of dopamine could interfere with the effectiveness of the CCR5 inhibitor Maraviroc. CCR5 can adopt distinct conformations that differentially regulate the efficiency of HIV entry and subsequent replication and using qPCR, flow cytometry, Western blotting and high content fluorescent imaging, we show that dopamine alters the expression of specific CCR5 conformations of CCR5 on the surface of human macrophages. These changes are not affected by association with lipid rafts, but do correlate with dopamine receptor gene expression levels, specifically higher levels of D1-like dopamine receptors. These data also demonstrate that dopamine increases HIV replication and alters CCR5 conformations in human microglia similarly to macrophages. These data support the importance of dopamine in the development of neuroHIV and indicate that dopamine signaling pathways should be examined as a target in antiretroviral therapies specifically tailored to HIV-infected drug abusers. Further, these studies show the potential immunomodulatory role of dopamine, suggesting changes in this neurotransmitter may also affect the progression of other diseases.

Trends in Methamphetamine Use Among Men Who Have Sex with Men in New York City, 2004-2017

Methamphetamine (meth) use among men who have sex with men (MSM) has been documented to be associated with HIV transmission among those who are HIV-negative and worsening HIV outcomes among those who are HIV-positive. Recent media reports have suggested recent increases in meth use in New York City (NYC), particularly among Hispanic/Latino and Black MSM. Using serial cross-sectional data from 2004 to 2017, we aim to describe trends in meth use and describe racial/ethnic patterns among MSM in NYC. Overall, we observed a decrease in meth use among MSM from 2004 to 2011 and an increase from 2011 to 2017. When stratified by race/ethnicity, use among White MSM decreased. Beginning in 2008, use among both Hispanic/Latino and Black MSM increased over time. These data provide more evidence that meth use may be increasing in Hispanic/Latino and Black MSM. Culturally-tailored and status-neutral interventions should be explored.

Self-efficacy as a mediator of patient navigation interventions to engage persons living with HIV and substance use

BACKGROUND

People living with HIV who report substance use (PLWH-SU) face many barriers to care, resulting in an increased risk for poor health outcomes and the potential for ongoing disease transmission. This study evaluates the mechanisms by which Patient Navigation (PN) and Contingency Management (CM) interventions may work to address barriers to care and improve HIV outcomes in this population.

METHODS

Mediation analysis was conducted using data from a randomized, multi-site trial testing PN interventions to improve HIV care outcomes among 801 hospitalized PLHW-SU. Direct and indirect effects of PN and PN + CM were evaluated through five potential mediators-psychosocial conditions, healthcare avoidance, financial hardship, system barriers, and self-efficacy for HIV treatment adherence-on engagement in HIV care and viral suppression.

RESULTS

The PN + CM intervention had an indirect effect on improving engagement in HIV care at 6 months by increasing self-efficacy for HIV treatment adherence (β = 0.042, 95% CI = 0.008, 0.086). PN + CM also led to increases in viral suppression at 6 months (β = 0.090, 95% CI = 0.023, 0.168) and 12 months (β = 0.069, 95% CI = 0.009, 0.129) via increases in self-efficacy, although the direct effects were not significant. No mediating effects were observed for PN alone.

CONCLUSION

PN + CM interventions for PLWH-SU can increase an individual's self-efficacy for HIV treatment adherence, which in turn improves engagement in care at 6 months and may contribute to viral suppression over 12 months. Building self-efficacy may be a key factor in the success of such interventions and should be considered as a primary goal of PN + CM in practice.

Understanding disparities in viral suppression among Black MSM living with HIV in Atlanta Georgia

INTRODUCTION

Due to factors associated with structural racism, Black men who have sex with men (MSM) living with HIV are less likely to be virally suppressed compared to white MSM. Most of these data come from clinical cohorts and modifiable reasons for these racial disparities need to be defined in order to intervene on these inequities. Therefore, we examined factors associated with racial disparities in baseline viral suppression in a community-based cohort of Black and white MSM living with HIV in Atlanta, GA.

METHODS

We conducted an observational cohort of Black and white MSM living with HIV infection in Atlanta. Enrolment occurred from June 2016 to June 2017 and men were followed for 24 months; laboratory and behavioural survey data were collected at 12 and 24 months after enrolment. Explanatory factors for racial disparities in viral suppression included sociodemographics and psychosocial variables. Poisson regression models with robust error variance were used to estimate prevalence ratios (PR) for Black/white differences in viral suppression. Factors that diminished the PR for race by ≥5% were considered to meaningfully attenuate the racial disparity and were included in a multivariable model.

RESULTS

Overall, 26% (104/398) of participants were not virally suppressed at baseline. Lack of viral suppression was significantly more prevalent among Black MSM (33%; 69/206) than white MSM (19%; 36/192) (crude Prevalence Ratio (PR) = 1.6; 95% CI: 1.1 to 2.5). The age-adjusted Black/white PR was diminished by controlling for: ART coverage (12% decrease), housing stability (7%), higher income (6%) and marijuana use (6%). In a multivariable model, these factors cumulatively mitigated the PR for race by 21% (adjusted PR = 1.1 [95% CI: 0.8 to 1.6]).

CONCLUSIONS

Relative to white MSM, Black MSM living with HIV in Atlanta were less likely to be virally suppressed. This disparity was explained by several factors, many of which should be targeted for structural, policy and individual-level interventions to reduce racial disparities.

Blue Monday: Co-occurring Stimulant Use and HIV Persistence Predict Dysregulated Catecholamine Synthesis

BACKGROUND

This longitudinal study examined whether co-occurring stimulant use and HIV disease processes predicted greater risk for depression via dysregulated metabolism of amino acid precursors for neurotransmitters.

METHODS

In total, 110 sexual minority men (ie, gay, bisexual, and other men who have sex with men) living with HIV who had biologically confirmed recent methamphetamine use were enrolled in a randomized controlled trial. The kynurenine/tryptophan (K/T) and phenylalanine/tyrosine (P/T) ratios were measured over 15 months to index dysregulated metabolism of amino acid precursors for serotonin and catecholamines. Markers of gut-immune dysregulation such as lipopolysaccharide binding protein and soluble CD14 (sCD14), HIV persistence in immune cells (ie, proviral HIV DNA), and stimulant use were examined as predictors. These bio-behavioral measures, including the K/T and P/T ratios, were also examined as predictors of greater risk for depression over 15 months.

RESULTS

Higher time-varying sCD14 levels (β = 0.13; P = 0.04) and time-varying detectable viral loads (β = 0.71; P < 0.001) were independent predictors of a higher K/T ratio. Time-varying reactive urine toxicology results for stimulants (β = 0.53; P < 0.001) and greater proviral HIV DNA at baseline (β = 0.34; P < 0.001) independently predicted an increased P/T ratio. Greater time-varying, self-reported methamphetamine use uniquely predicted higher odds of screening positive for depression (Adjusted Odds Ratio = 1.08; 95% confidence interval: 1.01 to 1.17).

CONCLUSIONS

Ongoing stimulant use and HIV persistence independently predict dysregulated metabolism of amino acid precursors for catecholamines, but this did not explain amplified risk for depression.

Apathy is associated with poorer abstinence self-efficacy in individuals with methamphetamine dependence

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Used an apathy composite T-score approach validated in methamphetamine-dependence.

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Apathy, above other factors, associated with poorer drug abstinence self-efficacy.

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Methamphetamine use characteristics unrelated to drug abstinence self-efficacy.

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Social peer pressure was riskiest situation for potential methamphetamine relapse.

Background

Confidence in one’s ability to achieve and maintain drug abstinence (i.e., abstinence self-efficacy) is a strong predictor of substance use treatment outcomes. Neurobehavioral factors that may interfere with abstinence self-efficacy are less well established, particularly in methamphetamine (METH). This study investigated whether apathy, which is highly prevalent during active METH use and periods of abstinence, influences abstinence self-efficacy among METH dependent individuals.

Methods

Sixty-six participants with lifetime METH dependence and METH abuse/METH dependence diagnoses within the last 18 months (mean age [SD] = 39.5 years [10.7]), and no severe psychiatric or neurological diseases, completed the Methamphetamine Self-Efficacy Scale (MSES), alongside a comprehensive neurobehavioral evaluation. The MSES presents six situations that may lead to relapse and collects self-report ratings for two subscales: “Confidence” (i.e., confidence in one’s ability to abstain from using METH, or METH abstinence self-efficacy) and “Temptation” (i.e., how tempted one is to use METH) with regard to each situation. Apathy was measured using a composite T-score comprised of items and scales from three well-validated, self-report assessments.

Results

Multivariable linear regression found that higher Apathy T-scores were significantly associated with lower Confidence ratings (i.e., poorer METH abstinence self-efficacy; p < .05), independent of potentially relevant factors (e.g., Temptation to use METH, comorbid HIV disease, and neurocognitive impairment).

Conclusions

Elevated apathy may adversely impact one’s confidence to abstain from METH use. Findings highlight the importance of addressing apathy in order to improve METH abstinence self-efficacy, which may subsequently increase the likelihood of successful METH treatment outcomes.

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

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

HIV and opiates dysregulate K+- Cl- cotransporter 2 (KCC2) to cause GABAergic dysfunction in primary human neurons and Tat-transgenic mice

Approximately half of people infected with HIV (PWH) exhibit HIV-associated neuropathology (neuroHIV), even when receiving combined antiretroviral therapy. Opiate use is widespread in PWH and exacerbates neuroHIV. While neurons themselves are not infected, they incur sublethal damage and GABAergic disruption is selectively vulnerable to viral and inflammatory factors released by infected/affected glia. Here, we demonstrate diminished K+-Cl- cotransporter 2 (KCC2) levels in primary human neurons after exposure to HIV-1 or HIV-1 proteins ± morphine. Resulting disruption of GABAAR-mediated hyperpolarization/inhibition was shown using genetically-encoded voltage (Archon1) and calcium (GCaMP6f) indicators. The HIV proteins Tat (acting through NMDA receptors) and R5-gp120 (acting via CCR5) but not X4-tropic gp120 (acting via CXCR4), and morphine (acting through μ-opioid receptors) all induced KCC2 loss. We demonstrate that modifying KCC2 levels or function, or antagonizing NMDAR, CCR5 or MOR rescues KCC2 and GABAAR-mediated hyperpolarization/inhibition in HIV, Tat, or gp120 ± morphine-exposed neurons. Using an inducible, Tat-transgenic mouse neuroHIV model, we found that chronic exposure to Tat also reduces KCC2. Our results identify KCC2 as a novel therapeutic target for ameliorating the pathobiology of neuroHIV, including PWH exposed to opiates.

Drug use and antiretroviral therapy (ART) interactions: a qualitative study to explore the knowledge, beliefs, adherence, and quality of life of people living with HIV taking ART and illicit drugs

Background

To explore the use of illicit drugs by people living with HIV (PLHIV) taking antiretroviral therapy (ART) and their relationship with variables relevant to the management of HIV infection, such as knowledge and beliefs about drug–drug interactions (DDIs), ART adherence, quality of life (QoL), and use of health-care resources.

Methods

21 PLHIV in Spain who concomitantly took illicit drugs and ART participated in this qualitative study. Eight experts collaborated in the design of the semi-structured interview guide which explored the following topics: illicit drug use, knowledge and beliefs about DDIs and their impact on ART adherence, the effects of using illicit drugs on health, QoL, and use of health-care resources. Four of those experts, who were PLHIV and members of the executive boards of non-government organizations (NGOs) from four Spanish regions, recruited the participants through their NGOs and carried out the face-to-face interviews. Content analysis of the qualitative data was conducted with the support of the MAXQDA 12 program.

Results

Participants were mainly men (85.7%) and only 14.3% of them were heterosexual. Content analysis showed that the most frequently consumed illicit drugs were poppers, cocaine, and cannabis. Participants were polydrug users and this was, in many cases, prior to HIV diagnosis. Most participants presented theoretical potential moderate DDIs that would require monitoring. More than three quarters of them were not aware of these DDIs. Participants reported interactive toxicity beliefs that lead to intentional nonadherence behaviors. In most cases (n = 17), the participant’s doctor knew about their drug use, however only six of them had had an open dialogue with their physician about it. Illicit drug use led to some health-related problems, mainly sexually transmitted infections. A positive QoL’s self-perception was found among several participants that used recreational illicit drugs.

Conclusions

Adequate information about DDIs and clues about how to manage ART when PLHIV are using illicit drugs could reduce the negative effects of such interactions and improve ART adherence and QoL.

Brief Report: Hazardous Cannabis Use and Monocyte Activation Among Methamphetamine Users With Treated HIV Infection

BACKGROUND

The use of stimulants, such as methamphetamine, has been associated with greater immune activation in treated HIV infection. However, relatively little is known about whether concomitant cannabis use is associated with lower immune activation among HIV-positive stimulant users.

SETTING

HIV-positive, sexual minority men with biologically confirmed, recent methamphetamine use were enrolled in San Francisco, CA.

METHODS

In total, 78 methamphetamine-using sexual minority men with an undetectable HIV viral load (<40 copies/mL) completed self-report measures of cannabis use and substance use disorder severity. Plasma biomarkers of monocyte activation (ie, sCD14 and sCD163) and intestinal barrier integrity (iFABP) were measured. The associations of hazardous cannabis use with these measurements were examined after adjusting for substance use disorder severity, age, antiretroviral therapy regimen, CD4 T-cell count, and interleukin-6.

RESULTS

Hazardous cannabis users had the highest mean sCD14 levels (2181 ng/mL) compared with nonhazardous users (1991 ng/mL) and nonusers (1859 ng/mL; P = 0.05). In adjusted analyses, greater cannabis use severity was associated with higher sCD14 compared with nonusers (unstandardized beta = 133.6 ng/mL, P = 0.03). Cannabis use severity was not significantly associated with sCD163 or iFABP.

CONCLUSIONS

Hazardous cannabis use is independently associated with elevations in a clinically relevant marker of immune activation in methamphetamine users with treated HIV.

Ethnicity as predictor of immune reconstitution among Malaysian HIV-positive patients treated with highly active antiretroviral therapy

The impact of sociodemographic and clinical factors on immune recovery and viral load suppression among HIV-1 positive patients treated with HAART particularly in Malaysia is largely unknown. This cross-sectional study enrolled 170 HIV-1-infected individuals of three major ethnicities who attended three HIV outpatient clinics in Malaysia. Questionnaire was used to obtain sociodemographic data while CD4 count and viral load data were gathered from hospital's record. Multiple factors were assessed for their predictive effects on CD4 count recovery (≥500 cells/mm³ ) and viral load suppression (≤50 copies/mL) using binary logistic regression. Most of the subjects were male (149/87.6%), in the age group 30 to 39 years old (78/45.9%) and got infected via homosexual contact (82/48.2%). Indians were associated with 11 times higher chance for CD4 recovery as compared to Malays at 8 to 12 months of HAART (adjusted OR: 10.948, 95% CI: 1.873, 64.001, P = .008). Viral load suppression was positively influenced by intravenous drug use (IVDU) status (adjusted OR: 35.224, 95% CI: 1.234, 1000.489, P = .037) at 4 to 6 months of HAART. Higher pretreatment CD4 count was a positive predictor for both initial immunological and virological responses while higher pretreatment viral load was a negative predictor for virological suppression only. In conclusion, ethnicity plays a significant role in determining early immune reconstitution in Malaysia, besides pretreatment CD4 count. Further studies are needed to identify possible biological factors underlying this association.

Defining Sexual Risk in the Era of Biomedical HIV Prevention: Implications for HIV Research and Practice

Advancing HIV behavioral science and its integration with recent biomedical prevention strategies-treatment as prevention and pre-exposure prophylaxis (PrEP)-is complicated because traditional definitions of sexual risk (condomless anal sex [CAS] or CAS with a serodiscordant partner) may not suffice given the success of biomedical prevention in the absence of condoms. To better understand how to define and understand risk in the era of biomedical HIV prevention, we assessed correlates of four different definitions of high-risk sexual behavior among a sample of 401 adult HIV-positive MSM (57% African American) residing in the New York City area: (1) a traditional model of risk defined as CAS with an HIV-negative or unknown serostatus partner; (2) a definition that considered participant viral load (VL); (3) a definition that considered partner PrEP use; and (4) a definition that considered participant HIV VL and partner PrEP use. Among participants reporting anal sex (n = 281) with a man in the past 3 months, 42% were considered high risk under Definition 1, 6% under Definition 2, 25% under Definition 3, and 2% under Definition 4. Correlates of risk varied across definitions. For example, while education was the strongest predictor of high-risk sexual behavior in Definitions 1 and 2, alcohol use and enacted stigma were the strongest predictors in the model that only accounted for partner PrEP use (Definition 3). These findings have implications for whom to reach for intervention efforts, the difficulty in meeting recruitment goals, and the types of interventions that should be used.

Crystal Methamphetamine Use and Initiation among Gay, Bisexual, and Other Men Who Have Sex with Men Living with HIV in a Treatment as Prevention Environment

Risk compensation in an HIV Treatment as Prevention (TasP) environment may increase high-risk sexual and substance use behaviors among people living with HIV. Objective: To examine recent crystal methamphetamine (CM) use/initiation in a longitudinal cohort of gay, bisexual, and other men who have sex with men (GBMSM) living with HIV in Metro Vancouver, Canada. Methods: Eligible participants were GBMSM aged >15 years who reported sex with another man in the past six months. Participants were recruited using respondent-driven sampling and self-completed a computer questionnaire every six months. We used multi-level generalized mixed-effect models to evaluate trends in recent CM use (past six months), multivariable logistic regression to identify covariates of recent CM use, and multivariable survival analysis to identify predictors of CM initiation. Results: Of 207 GBMSM living with HIV at enrollment, 44.3% reported recent CM use; there was a statistically non-significant decrease over the study period (41% in first period to 25% in final period, p = 0.087). HIV treatment optimism was not associated with CM use/initiation. CM use was positively associated with depressive symptomology, sexual escape motivation, transactional sex, number of anal sex partners, condomless anal sex with seroconcordant partners, STIs, and other substance use. Recent CM use was negatively associated with viral load sorting. CM initiation was predicted by escape motivation, transactional sex, and group sex participation. Conclusion: Results suggest that CM use among GBMSM living with HIV is prevalent and increased CM use/initiation is not a consequence of TasP public policy.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Post-traumatic Stress Disorder, Cocaine Use, and HIV Persistence

BACKGROUND

Post-traumatic stress disorder (PTSD) and stimulant use disorders are highly prevalent, commonly co-occur, and predict faster clinical HIV progression. However, scant research has examined if PTSD and cocaine use are associated with the HIV reservoir that persists in immune cells, lymphoid tissue, and organs of people living with HIV that are receiving effective treatment.

METHOD

This cross-sectional study enrolled 48 HIV-positive persons with sustained undetectable viral load (< 20 copies/mL) in the past year to examine the associations of PTSD and recent cocaine use with two measures of HIV persistence in immune cells: (1) proviral HIV DNA and (2) cell-associated (CA)-HIV RNA.

RESULTS

Greater PTSD symptoms were significantly associated with lower proviral HIV DNA (r = - 0.30, p = 0.041) but not with CA-HIV RNA. Greater severity of PTSD symptom clusters for intrusions (Standardized Beta = - 0.30, p = 0.038) and hyperarousal (Standardized Beta = - 0.30, p = 0.047) were independently associated with lower proviral HIV DNA. Although participants with recent cocaine use had a significantly shorter duration of sustained undetectable HIV viral load (19.9 versus 26.9 months; p = 0.047), cocaine use was not significantly associated with proviral HIV DNA or CA-HIV RNA.

CONCLUSION

Further research is needed to examine the potentially bi-directional pathways linking PTSD symptom severity and HIV persistence.

Randomized controlled trial of a positive affect intervention to reduce HIV viral load among sexual minority men who use methamphetamine

INTRODUCTION

In the era of HIV treatment as prevention (TasP), evidence-based interventions that optimize viral suppression among people who use stimulants such as methamphetamine are needed to improve health outcomes and reduce onward transmission risk. We tested the efficacy of positive affect intervention delivered during community-based contingency management (CM) for reducing viral load in sexual minority men living with HIV who use methamphetamine.

METHODS

Conducted in San Francisco, this Phase II randomized controlled trial tested the efficacy of a positive affect intervention for boosting and extending the effectiveness of community-based CM for stimulant abstinence to achieve more durable reductions in HIV viral load. From 2013 to 2017, 110 sexual minority men living with HIV who had biologically confirmed, recent methamphetamine use were randomized to receive a positive affect intervention (n = 55) or attention-control condition (n = 55). All individual positive affect intervention and attention-control sessions were delivered during three months of community-based CM where participants received financial incentives for stimulant abstinence. The 5-session positive affect intervention was designed to provide skills for managing stimulant withdrawal symptoms as well as sensitize individuals to natural sources of reward. The attention-control condition consisted of neutral writing exercises and self-report measures.

RESULTS

Men randomized to the positive affect intervention displayed significantly lower log10 HIV viral load at six, twelve and fifteen months compared to those in the attention-control condition. Men in the positive affect intervention also had significantly lower risk of at least one unsuppressed HIV RNA (≥200 copies/mL) over the 15-month follow-up. There were concurrent, statistically significant intervention-related increases in positive affect as well as decreases in the self-reported frequency of stimulant use at six and twelve months.

CONCLUSIONS

Delivering a positive affect intervention during community-based CM with sexual minority men who use methamphetamine achieved durable and clinically meaningful reductions in HIV viral load that were paralleled by increases in positive affect and decreases in stimulant use. Further clinical research is needed to determine the effectiveness of integrative, behavioural interventions for optimizing the clinical and public health benefits of TasP in sexual minority men who use stimulants such as methamphetamine.

High Levels of Syndemics and Their Association with Adherence, Viral Non-suppression, and Biobehavioral Transmission Risk in Miami, a U.S. City with an HIV/AIDS Epidemic

Miami is a Southeastern United States (U.S.) city with high health, mental health, and economic disparities, high ethnic/racial diversity, low resources, and the highest HIV incidence and prevalence in the country. Syndemic theory proposes that multiple, psychosocial comorbidities synergistically fuel the HIV/AIDS epidemic. People living with HIV/AIDS in Miami may be particularly affected by this due to the unique socioeconomic context. From April 2017 to October 2018, 800 persons living with HIV/AIDS in a public HIV clinic in Miami completed an interviewer-administered behavioral and chart-review cross-sectional assessment to examine the prevalence and association of number of syndemics (unstable housing, low education, depression, anxiety, binge drinking, drug use, violence, HIV-related stigma) with poor ART adherence, unsuppressed HIV viral load (≥ 200 copies/mL), and biobehavioral transmission risk (condomless sex in the context of unsuppressed viral load). Overall, the sample had high prevalence of syndemics (M = 3.8), with almost everyone (99%) endorsing at least one. Each syndemic endorsed was associated with greater odds of: less than 80% ART adherence (aOR 1.64, 95% CI 1.38, 1.98); having unsuppressed viral load (aOR 1.16, 95% CI 1.01, 1.33); and engaging in condomless sex in the context of unsuppressed viral load (1.78, 95% CI 1.30, 2.46). The complex syndemic of HIV threatens to undermine the benefits of HIV care and are important to consider in comprehensive efforts to address the disproportionate burden of HIV/AIDS in the Southern U.S. Achieving the 90-90-90 UNAIDS and the recent U.S. "ending the epidemic" targets will require efforts addressing the structural, social, and other syndemic determinants of HIV treatment and prevention.

A Pilot Study of a Mobile App to Support HIV Antiretroviral Therapy Adherence Among Men Who Have Sex with Men Who Use Stimulants

APP+ is a theoretically-grounded mobile app intervention to improve antiretroviral (ART) adherence among men who have sex with men (MSM) who use stimulants. We assessed the feasibility and acceptability of APP+ in a six-month randomized controlled trial among a national sample of 90 MSM recruited online; secondarily, we examined changes in self-reported ART adherence by study arm. Retention at the final assessment was 82%, and acceptability ratings were comparable to other technology-based interventions. MSM in the APP+ group reported higher self-reported percentage ART adherence in the past 30 days at the four-month timepoint compared to a no-treatment control group (89.0% vs. 77.2%). However, once access to the app was removed after month four, group differences in ART adherence diminished by month six. APP+ may be a potentially promising intervention approach for MSM living with HIV who use stimulants but would require enhancements to optimize acceptability and demonstrate more sustained effects.

A systematic review of substance use and substance use disorders in patients with cancer

OBJECTIVE

Few studies examined substance use in cancer patients. The aims of this systematic review were to summarize this evidence, identify methodological limitations, and provide future research directions.

METHOD

Articles on substance use in cancer (focused on illicit substance, opioid, and alcohol use) were searched in Medline, PsycINFO, and PsycARTICLES.

RESULTS

On the basis of inclusion criteria, 28 studies were reviewed. Twenty-one contained empiric data from 500,123 participants; seven were review or conceptual papers. All studies were published between 1995 and 2018. Quality assessment revealed relatively low risk of bias and high methodological quality. Five studies examined substance use or substance use disorder (SUD) broadly. Mean ages ranged from 17.6 to 74.7 years. Substance use rates ranged from 2% to 35%, with a median opioid rate of 18% and 25.5% for alcohol. Nine of the studies had samples comprised either mostly or exclusively of advanced cancer patients. Disease groups included breast, head & neck, and gastric cancer. None of the studies used a theoretical framework or model.

CONCLUSIONS

Given the prevalence of substance use in cancer patients, interventions are needed. Further theory-grounded studies are warranted to foster the translation of research into clinical practice and elucidate substance use management recommendations.

Pathways to Health: an Examination of HIV-Related Stigma, Life Stressors, Depression, and Substance Use

BACKGROUND

Despite antiretroviral treatment (ART) being an efficacious treatment for HIV, essentially making it a chronic non-terminal illness, two related and frequent concerns for many people living with HIV/AIDS (PLWHA) continue to be HIV-related stigma and life stress. These two variables are frequently associated with depression, substance use, and poorer functional health. Studies to date have not fully examined the degree to which these constructs may be associated within one model, which could reveal a more nuanced understanding of how HIV-related stigma and life stress affect functional health in PLWHA.

METHODS

The current study employed hybrid structural equation modeling to examine the interconnectedness and potential indirect relationships of HIV-related stigma and life stress to worse health through substance use and depression, controlling for ART adherence and age. Participants were 240 HIV-infected individuals who completed a biopsychosocial assessment battery upon screening for an RCT on treating depression in those infected with HIV.

RESULTS

Both HIV-related stigma and stressful life events were directly related to depression, and depression was directly related to health. There were significant indirect effects from stigma and stress to health via depression. There were no significant effects involving substance use.

CONCLUSION

It is important to continue to develop ways to address stigma, stressful life events, and their effects on distress in those living with HIV. Expanding our knowledge of disease progression risk factors beyond ART adherence is important to be able to design adjuvant interventions, particularly because treatment means that people living with HIV have markedly improved life expectancy and that successful treatment means that HIV is not transmittable to others.

Age matters: differences in correlates of self-reported HIV antiretroviral treatment adherence between older and younger Black men who have sex with men living with HIV

Black men who have sex with men (BMSM) show lower levels of adherence to antiretroviral therapy (ART) for HIV medications than other racial/ethnic groups in the U.S. Yet, little is known about age differences in factors that predict ART adherence among BMSM. We combined data from two surveys of HIV-positive BMSM, resulting in 209 participants (130 aged 18-50 years; 79 aged 50 years or older). Multivariate linear regressions examined associations between baseline characteristics and adherence to HIV medications as well as interactions of baseline characteristics with age. The associations between trust in healthcare and doctor satisfaction ratings with higher adherence were stronger for older vs younger men (p < .05); the association between problem drinking and lower adherence was stronger among younger men (p < .05). Future research should examine how interventions may address these age-specific factors to improve ART adherence among BMSM living with HIV.

Associations between drug use patterns and viral load suppression among HIV-positive individuals who use support services in New York City

BACKGROUND

Drug use (DU) represents a significant barrier to maintaining physical health among people living with HIV (PLWH). Few studies, however, have examined the relationship between DU over time and HIV treatment outcomes. Such studies are needed because an individual's risk of poor health outcomes may vary with their DU behaviors. We examined associations between DU patterns over time and unsuppressed viral load (VL).

METHODS

The sample included 7896 PLWH in New York City who completed ≥3 substance use assessments over a 24-month period. DU was defined as crystal methamphetamine, crack/cocaine, heroin, and/or recreational prescription medication use in the last three months. Four behavior patterns were constructed: (1) persistent use (DU reported on each assessment); (2) intermittent use-active (DU reported on the third, but not all previous assessments); (3) intermittent use-inactive (DU reported previously with no DU reported on the third assessment); (4) persistent non-use (no DU reported on any assessment). Unsuppressed VL (>200 copies/mL) was assessed based on the last VL value in the New York City HIV Surveillance Registry in the 12 months following an individual's third DU assessment.

RESULTS

Compared with persistent non-users, individuals with intermittent use-inactive (aOR = 1.24, 95% CI = 1.03-1.49), intermittent use-active (aOR = 1.68, 95% CI = 1.36-2.06), and persistent use (aOR = 2.21, 95% CI = 1.69-2.89) were significantly more likely to have unsuppressed VL.

CONCLUSIONS

While providers may be more likely to intervene with persistent or active drug users, our findings suggest the importance of addressing the risk of poor HIV treatment outcomes among those with any DU behavior.

Mental health disorders and substance use among people living with HIV in Nepal: their influence on non-adherence to anti-retroviral therapy

People living with HIV often experience mental health disorders and engage in substance use. Evidence, however, is limited about the influence of mental health disorders and substance use on non-adherence to ART. We conducted a cross-sectional study among 682 HIV-positive people on ART in Nepal. We measured their depressive symptoms, anxiety, stress levels, substance use, and non-adherence to ART. We developed logistic regression models to examine the association of mental health disorders and substance use with non-adherence to ART. Experiencing depressive symptoms was positively associated with ART non-adherence among HIV-positive people (men: AOR = 2.77, p = .001; women: AOR = 3.69, p = .001). Additionally, both men and women were more likely to have non-adherence to ART when they had anxiety (men: AOR = 2.19, p = .022; women AOR = 2.83, p = .001) and higher stress scores (men: AOR = 1.11, p = .001; women: AOR = 1.08, p = .001). While substance use was associated with non-adherence only in HIV-positive men (AOR = 3.12, p < .001). Depressive symptoms, anxiety, and high level of stress had negative roles on adherence in HIV-positive men and women. While substance use had a negative role on ART adherence among men only. Results highlight that the HIV-positive people should be screened and provided treatment and psychosocial support while providing ART services to improve their medication adherence.

The Longitudinal Effects of Non-injection Substance Use on Sustained HIV Viral Load Undetectability Among MSM and Heterosexual Men in Brazil and Thailand: The Role of ART Adherence and Depressive Symptoms (HPTN 063)

The effect of non-injection substance use on HIV viral load (VL) is understudied in international settings. Data are from HPTN063, a longitudinal observational study of HIV-infected individuals in Brazil, Thailand, and Zambia, with focus on men with VL data (Brazil = 146; Thailand = 159). Generalized linear mixed models (GLMM) assessed whether non-injection substance use (stimulants, cannabis, alcohol, polysubstance) was associated with VL undetectability. ART adherence and depressive symptoms were examined as mediators of the association. In Thailand, substance use was not significantly associated with VL undetectability or ART adherence, but alcohol misuse among MSM was associated with increased odds of depression (AOR = 2.75; 95% CI 1.20, 6.32, p = 0.02). In Brazil, alcohol misuse by MSM was associated with decreased odds of undetectable VL (AOR = 0.34; 95% CI 0.13, 0.92, p = 0.03). Polysubstance use by heterosexual men in Brazil was associated with decreased odds of ART adherence (AOR = 0.25; 95% CI 0.08, 0.78, p = 0.02). VL suppression appears attainable among non-injection substance users. Substance use interventions among HIV-positive men should address depression, adherence, and VL undetectability.

Over the influence: The HIV care continuum among methamphetamine-using men who have sex with men

BACKGROUND

HIV-positive persons who use stimulants such as methamphetamine experience greater difficulties in navigating the HIV care continuum. In the era of HIV treatment as prevention (TasP), little is known about the prevalence and correlates of success along the HIV care continuum among people who use stimulants.

SETTING

San Francisco, California USA METHODS: Cross-sectional study that enrolled 129 HIV-positive men who have sex with men (MSM) from 2013 through 2017 who had biologically confirmed, recent methamphetamine use. Multivariable logistic regressions were built to identify correlates of success across the HIV care continuum.

RESULTS

Although two-thirds (87/129) of participants had undetectable HIV viral load (<40 copies/mL), only one-in-four (32/129) reported taking at least 90% of their antiretroviral therapy (ART). Those who were homeless in the past year (adjusted odds ratio [aOR] = 0.20; 95% CI = 0.06-0.65) had 80% lower odds of being undetectable and adherent to ART. Substance use disorder treatment was associated with 77% lower odds of being engaged in HIV care (aOR = 0.23; 95% CI = 0.06-0.84) but also close to 3-fold greater odds of being adherent to ART (aOR = 2.91; 95% CI = 1.12-7.60).

CONCLUSION

Despite the fact that many HIV-positive, methamphetamine-using MSM are able to achieve undetectable viral load in this sample, difficulties with ART adherence threaten to undermine the clinical and public health benefits of TasP. Expanded efforts to boost the effectiveness of TasP in this population should focus on meeting the unique needs of homeless individuals, optimizing ART adherence, and facilitating the integration of HIV care with substance use disorder treatment.

Avoidant Coping Mediates the Relationship Between Self-Efficacy for HIV Disclosure and Depression Symptoms Among Men Who Have Sex with Men Newly Diagnosed with HIV

HIV diagnosis presents a critical opportunity to reduce secondary transmission, improve engagement in care, and enhance overall well-being. To develop relevant interventions, research is needed on the psychosocial experiences of newly diagnosed individuals. This study examined avoidant coping, self-efficacy for HIV disclosure decisions, and depression among 92 newly diagnosed men who have sex with men who reported recent sexual risk behavior. It was hypothesized that avoidant coping would mediate the relationship between self-efficacy and depression. Cross-sectional surveys were collected from participants 3 months after HIV diagnosis. To test for mediation, multiple linear regressions were conducted while controlling for HIV disclosure to sexual partners. Self-efficacy for HIV disclosure decisions showed a negative linear relationship to depression symptoms, and 99% of this relationship was mediated by avoidant coping. The index of mediation of self-efficacy on depression indicated a small-to-medium effect. Higher self-efficacy was related to less avoidant coping, and less avoidant coping was related to decreased depression symptoms, all else held constant. These findings highlight the role of avoidant coping in explaining the relationship between self-efficacy for HIV disclosure decisions and depression.

Applying behavioral activation to sustain and enhance the effects of contingency management for reducing stimulant use among individuals with HIV infection

There is a high prevalence of stimulant use among HIV-infected individuals, which is associated with suboptimal antiretroviral therapy (ART) adherence, HIV treatment interruptions, detectable HIV viral load, and transmission of HIV via increased sexual risk behavior. Contingency management (CM) is an initially effective treatment for stimulant use. However, the effects of CM are not sustained after the active intervention has ended. One potential contributor to the intractability of existing treatments may be a lack of attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. As a potential approach to address the CM rebound effect - informed by our formative qualitative research with the participant population - we conducted an open pilot trial of an intervention combining CM-BA for HIV-infected individuals with stimulant use disorder. Participants completed weekly BA therapy sessions (10-16 sessions) and thrice-weekly toxicology screenings (12 weeks); contingencies were rewarded for negative toxicology tests to support reengagement into positive life activities. Major assessments were conducted at baseline, 3-, and 6-months. Toxicology screening was repeated prior to the 6-month assessment. Eleven participants with stimulant use disorder enrolled; 7 initiated treatment and completed the full intervention. The mean age was 46 (SD = 5.03) and 14% identified as a racial/ethnic minority. Of the completers, the mean change score in self-reported stimulant use within the past 30 days (within-person change; reduction in self-reported stimulant use) was 4.14 days at 3 months and 5.0 days at 6 months [Cohen's d = 0.89]. The mean change score in weekly toxicology screens (reduction in positive toxicology screens) was .71 at 3 months and 1 at 6 months [Cohen's d = 1.05]. Exit interviews indicated that the integrated intervention was well received and acceptable. This study provides preliminary evidence that a combined CM-BA intervention for this population was feasible (100% retention at 6-months), acceptable (100% of intervention sessions attended; participants rated the intervention 'acceptable' or 'very acceptable'), and may be an option to augment the potency and sustained impact of CM for this population. Future pilot testing using a randomized controlled design is warranted.

Testing the Efficacy of Combined Motivational Interviewing and Cognitive Behavioral Skills Training to Reduce Methamphetamine Use and Improve HIV Medication Adherence Among HIV-Positive Gay and Bisexual Men

Prior research has identified subgroups of HIV-positive gay and bisexual men (GBM) based upon information, motivation, and behavioral skills (IMB) profiles related to HIV medication adherence and methamphetamine use. We conducted a randomized controlled trial of a combined motivational interview (MI) and cognitive behavioral therapy (CBT) intervention tailored specifically to the unique context of HIV-positive GBM, and tested whether IMB profiles moderated treatment effects. HIV-positive GBM (N = 210) were randomized to MI + CBT or an attention-matched education control. Both conditions resulted in reduced methamphetamine use, improved medication adherence (and higher CD4 and lower viral loads), and fewer acts of condomless anal sex at 3, 6, 9 and 12 months post-intervention. Furthermore, the MI + CBT condition achieved greater improvements in medication adherence for men who had greater barriers to change compared to similarly-classified men in the control condition, suggesting the importance of pre-intervention profiles for tailoring future interventions.

Psychosocial Correlates of Monocyte Activation and HIV Persistence in Methamphetamine Users

This cross-sectional study investigated the associations of psychosocial factors relevant to recovery from substance use disorders with monocyte activation and HIV persistence in a sample of 84 HIV-positive, methamphetamine-using sexual minority men with undetectable HIV viral load (<40 copies/mL). We examined if psychosocial factors were associated with decreased soluble CD14 (sCD14) and lower proviral HIV DNA. Multiple linear regression models adjusted for age, anti-retroviral therapy regimen, and CD4+ T-cell count. Time on ART was also included in models examining proviral HIV DNA. Greater self-efficacy for managing methamphetamine triggers and higher social support for abstinence were independently associated with lower sCD14. Greater social support for abstinence was also independently associated with lower proviral HIV DNA. Psychosocial factors relevant to recovery from substance use disorders are associated with lower monocyte activation and decreased proviral HIV DNA. Findings underscore the need for longitudinal research to identify plausible mechanisms linking psychosocial factors and substance use with biological processes relevant to HIV pathogenesis.

Recent stimulant use and leukocyte gene expression in methamphetamine users with treated HIV infection

Stimulant use may accelerate HIV disease progression through biological and behavioral pathways. However, scant research with treated HIV-positive persons has examined stimulant-associated alterations in pathophysiologic processes relevant to HIV pathogenesis. In a sample of 55 HIV-positive, methamphetamine-using sexual minority men with a viral load less than 200 copies/mL, we conducted RNA sequencing to examine patterns of leukocyte gene expression in participants who had a urine sample that was reactive for stimulants (n = 27) as compared to those who tested non-reactive (n = 28). Results indicated differential expression of 32 genes and perturbation of 168 pathways in recent stimulant users. We observed statistically significant differential expression of single genes previously associated with HIV latency, cell cycle regulation, and immune activation in recent stimulant users (false discovery rate p < 0.10). Pathway analyses indicated enrichment for genes associated with inflammation, innate immune activation, neuroendocrine hormone regulation, and neurotransmitter synthesis. Recent stimulant users displayed concurrent elevations in plasma levels of tumor necrosis factor - alpha (TNF-α) but not interleukin 6 (IL-6). Further research is needed to examine the bio-behavioral mechanisms whereby stimulant use may contribute to HIV persistence and disease progression.

Methamphetamine-associated dysregulation of the hypothalamic-pituitary-thyroid axis

Methamphetamine and HIV impair thyroid function, but few studies have investigated their combined effects on thyroid dysregulation. This study examined the associations of methamphetamine use alone and in combination with HIV on thyroid function among men in South Florida. Measures of thyroid function in methamphetamine-using, HIV-infected (METH+HIV+; n = 127) and HIV-negative (METH+HIV-; n = 46) men who have sex with men (MSM) were compared to non-methamphetamine-using, HIV-negative men (METH-HIV-; n = 136). Thyroid function was dysregulated in methamphetamine-using MSM, irrespective of HIV status. Both meth-using groups had greater odds of abnormal thyroid stimulating hormone levels and significantly higher mean free triiodothyronine (T3) levels. Elevated free T3 was associated with greater depressive symptoms. Overall, outcomes have important implications for assessment of thyroid function in methamphetamine users, particularly among those presenting with depression.

Intervention to Increase HIV Testing Among Substance-Using Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Young men who have sex with men (YMSM) and transgender people in the Detroit Metro Area are the only risk group for whom the incidence of HIV and sexually transmitted infections (STI) has increased since 2000, with HIV incidence nearly doubling among youth. Substance use (including alcohol), which is relatively frequent among YMSM and transgender people, creates barriers to the optimal delivery of HIV prevention and care services. Standard HIV counseling, testing, and referral (CTR) is limited in providing strategies to identify and address substance use. Hence, in its current form, CTR may not be serving the prevention needs of substance-using YMSM and transgender people. Brief counseling interventions, grounded in principles of motivational interviewing, may offer a mechanism to meet the HIV prevention and care needs of substance-using YMSM and transgender people.

OBJECTIVE

This prospective, 4-arm, factorial randomized controlled trial aims to examine the efficacy of an motivational interviewing-based substance use brief intervention (SUBI) on participants' substance use and engagement in HIV prevention.

METHODS

The research implements a prospective randomized controlled trial (Project Swerve) of 600 YMSM and transgender people recruited both online and in person. Eligibility criteria include participants who (1) are between the ages of 15 to 29 years, (2) live in the Detroit Metro Area, (3) self-identify as a man or transgender man or woman, (4) have had sexual contact with a man in the 6 months before enrollment, (5) self-report binge drinking or any substance use in the 3 months before enrollment, and (6) self-report an unknown or negative HIV status upon enrollment. Participants are randomized to receive, 3-months apart starting at baseline, 2 individual sessions. Sessions are CTR-only, SUBI-only, CTR followed by SUBI, or SUBI followed by CTR.

RESULTS

Project Swerve was launched in April 2017 and enrollment is ongoing.

CONCLUSIONS

Incorporating a SUBI that utilizes the principles of motivational interviewing into HIV CTR provides an opportunity to tailor counseling services for YMSM and transgender people to address additional client barriers to HIV and STI testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02945436; http://clinicaltrials.gov/ct2/show/NCT02945436 (Archived by WebCite at http://www.webcitation.org/6yFyOK57w).