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Soyer EM, McGinnis KA, Justice AC, Hsieh E, Rodriguez-Barradas MC, Williams EC, Park LS. COVID-19 Breakthrough Infection after Vaccination and Substance Use Disorders: A Longitudinal Cohort of People with and without HIV Receiving Care in the United States Veterans Health Administration. AIDS Behav 2024:10.1007/s10461-024-04449-1. [PMID: 39046612 DOI: 10.1007/s10461-024-04449-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2024] [Indexed: 07/25/2024]
Abstract
Research regarding HIV, substance use disorders (SUD), and SARS-CoV-2 infections after COVID-19 vaccination is limited. In the Veterans Aging Cohort Study (VACS)-HIV cohort, we followed vaccinated persons with HIV (PWH) and without HIV (PWoH) from 12/2020 to 3/2022 and linked SARS-CoV-2 test results for laboratory-confirmed breakthrough infection through 9/2022. We examined associations of substance use (alcohol use disorder [AUD], other SUD, smoking status) and HIV status and severity with breakthrough infections, using Cox proportional hazards regression hazard ratios (HR). To test for potential interactions between substance use and HIV, we fit survival models with a multiplicative interaction term. Among 24,253 PWH and 53,661 PWoH, 8.0% of PWH and 7.1% of PWoH experienced COVID-19 breakthrough. AUD (HR 1.42, 95% CI 1.32, 1.52) and other SUD (HR 1.49, 95% CI 1.39, 1.59) were associated with increased risk of breakthrough, and this was similar by HIV status (p-interaction > 0.09). Smoking was not associated with breakthrough. Compared to PWoH, PWH at all HIV severity levels had increased risk of breakthrough ranging from 9% for PWH with CD4 count ≥ 500 cells/µl (HR 1.09, 95% CI 1.02, 1.17) to 59% for PWH with CD4 count < 200 (HR 1.59, 95% CI 1.31, 1.92). Patients with AUD (HR 1.42, 95% CI 1.33, 1.52) and other SUD (HR 1.48, 95% CI 1.38, 1.59) had increased COVID-19 breakthrough risk, regardless of HIV status. HIV was associated with breakthrough; risk was greatest among PWH with lower CD4 count. In addition to inhibiting HIV treatment adherence and increasing HIV progression, AUD and other SUD may increase COVID-19 breakthrough risk.
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Affiliation(s)
- Elena M Soyer
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Washington State Health Care Authority, Olympia, WA, USA
| | | | - Amy C Justice
- Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Evelyn Hsieh
- Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Maria C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Lesley S Park
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
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Hoang THL, Nguyen VM, Adermark L, Alvarez GG, Shelley D, Ng N. Factors Influencing Tobacco Smoking and Cessation Among People Living with HIV: A Systematic Review and Meta-analysis. AIDS Behav 2024; 28:1858-1881. [PMID: 38478323 PMCID: PMC11161546 DOI: 10.1007/s10461-024-04279-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 06/10/2024]
Abstract
Tobacco smoking is highly prevalent among people living with HIV (PLWH), yet there is a lack of data on smoking behaviours and effective treatments in this population. Understanding factors influencing tobacco smoking and cessation is crucial to guide the design of effective interventions. This systematic review and meta-analysis of studies conducted in both high-income (HICs) and low- and middle-income countries (LMICs) synthesised existing evidence on associated factors of smoking and cessation behaviour among PLWH. Male gender, substance use, and loneliness were positively associated with current smoking and negatively associated with smoking abstinence. The association of depression with current smoking and lower abstinence rates were observed only in HICs. The review did not identify randomised controlled trials conducted in LMICs. Findings indicate the need to integrate smoking cessation interventions with mental health and substance use services, provide greater social support, and address other comorbid conditions as part of a comprehensive approach to treating tobacco use in this population. Consistent support from health providers trained to provide advice and treatment options is also an important component of treatment for PLWH engaged in care, especially in LMICs.
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Affiliation(s)
- Thanh H L Hoang
- School of Public Health and Community Medicine, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 18A, 41390, Gothenburg, Sweden.
| | - Van M Nguyen
- School of Public Health and Community Medicine, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Louise Adermark
- Department of Pharmacology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gloria G Alvarez
- School of Global Public Health, New York University, New York, USA
| | - Donna Shelley
- School of Global Public Health, New York University, New York, USA
| | - Nawi Ng
- School of Public Health and Community Medicine, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Lancaster KE, Stockton M, Remch M, Wester CW, Nash D, Brazier E, Adedimeji A, Finlayson R, Freeman A, Hogan B, Kasozi C, Kwobah EK, Kulzer JL, Merati T, Tine J, Poda A, Succi R, Twizere C, Tlali M, Groote PV, Edelman EJ, Parcesepe AM. Availability of substance use screening and treatment within HIV clinical sites across seven geographic regions within the IeDEA consortium. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 124:104309. [PMID: 38228025 PMCID: PMC10939808 DOI: 10.1016/j.drugpo.2023.104309] [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: 08/16/2023] [Revised: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Overwhelming evidence highlights the negative impact of substance use on HIV care and treatment outcomes. Yet, the extent to which alcohol use disorder (AUD) and other substance use disorders (SUD) services have been integrated within HIV clinical settings is limited. We describe AUD/SUD screening and treatment availability in HIV clinical sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. METHODS In 2020, 223 IeDEA HIV clinical sites from 41 countries across seven geographic regions completed a survey on capacity and practices related to management of AUD/ SUD. Sites provided information on AUD and other SUD screening and treatment practices. RESULTS Sites were from low-income countries (23%), lower-middle-income countries (38%), upper-middle income countries (17%) and high-income counties (23%). AUD and SUD screening using validated instruments were reported at 32% (n=71 located in 12 countries) and 12% (n=27 located in 6 countries) of the 223 sites from 41 countries, respectively. The North American region had the highest proportion of clinics that reported AUD screening (76%), followed by East Africa (46%); none of the sites in West or Central Africa reported AUD screening. 31% (n=69) reported both AUD screening and counseling, brief intervention, psychotherapy, or Screening, Brief Intervention, and Referral to Treatment; 8% (n=18) reported AUD screening and detox hospitalization; and 10% (n=24) reported both AUD screening and medication. While the proportion of clinics providing treatment for SUD was lower than those treating AUD, the prevalence estimates of treatment availability were similar. CONCLUSIONS Availability of screening and treatment for AUD/SUD in HIV care settings is limited, leaving a substantial gap for integration into ongoing HIV care. A critical understanding is needed of the multilevel implementation factors or feasible implementation strategies for integrating screening and treatment of AUD/SUD into HIV care settings, particularly for resource-constrained regions.
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Affiliation(s)
| | - Melissa Stockton
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Molly Remch
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Denis Nash
- City University of New York (CUNY), New York, NY, USA
| | - Ellen Brazier
- City University of New York (CUNY), New York, NY, USA
| | | | | | - Aimee Freeman
- Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Breanna Hogan
- Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | | | - Judiacel Tine
- Centre Hospitalier National Universitaire de Fann, Dakar, Senagal
| | - Armel Poda
- Université Polytechnique de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - Regina Succi
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Christelle Twizere
- Centre National de Référence en Matière de VIH/SIDA au Burundi, Bujumbura, Burundi
| | - Mpho Tlali
- University of Cape Town, Cape Town, South Africa
| | - Per von Groote
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
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Muvvala SB, Gan G, Morford KL, Dziura J, Esserman D, Porter E, Chan PA, Cornman DH, Reynolds J, Yager JE, Fiellin DA, Edelman EJ. Facilitation and Preferred Models for Delivering Substance Use Disorder Treatment in HIV Clinics: Results From a Multisite Randomized Trial. J Addict Med 2023; 17:e388-e391. [PMID: 37934538 PMCID: PMC10726383 DOI: 10.1097/adm.0000000000001192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Integrated addiction treatment in HIV clinics is associated with improved outcomes, yet it is offered inconsistently and with variable models of care. We sought to evaluate the impact of Implementation Facilitation ("Facilitation") on clinician and staff preference for provision of addiction treatment in HIV clinics with on-site resources (all trained or designated on-site specialist) versus outside resources (outside specialist or refer out). METHODS From July 2017 to July 2020, surveys assessed clinician and staff preferences for addiction treatment models during control (ie, baseline), intervention, evaluation, and maintenance phases in 4 HIV clinics in the Northeast United States. RESULTS During the control phase, among 76 respondents (response rate, 58%), the proportions who preferred treatment with on-site resources for opioid use disorder (OUD), alcohol use disorder (AUD), and tobacco use disorder (TUD) were 63%, 55%, and 63%, respectively. Compared with control, there were no significant differences in preferred model during the intervention and evaluation phases except for AUD where there was an increased preference for treatment with on-site resources in the intervention versus control phase. Compared with control, during the maintenance phase, a higher proportion of clinicians and staff preferred providing addiction treatment with on-site resources versus outside resources: OUD, 75% (odds ratio [OR; 95% confidence interval {CI}], 1.79 [1.06-3.03]); AUD, 73% (OR [95% CI], 2.23 [1.36-3.65]), and TUD, 76% (OR [95% CI], 1.88 [1.11-3.18]). CONCLUSIONS The findings from this study lend support for "Facilitation" as a strategy to enhance clinician and staff preference for integrated addiction treatment in HIV clinics with on-site resources.
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Affiliation(s)
- Srinivas B Muvvala
- From the Program in Addiction Medicine, Yale School of Medicine, New Haven, CT (SBM, KLM, DAF, EJE); Department of Psychiatry, Yale School of Medicine, New Haven, CT (SBM); Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT (GG, JD, DE); Department of Internal Medicine, Yale School of Medicine, New Haven, CT (KLM, EP, DAF, EJE); Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT (DAF, EJE); Department of Emergency Medicine, Yale School of Medicine, New Haven, CT (JD, DAF); Department of Biostatistics, Yale School of Public Health, New Haven, CT (JD, DE, JR); Department of Medicine, Brown University, Providence, RI (PAC); Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT (DHC); Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY (JEY)
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Shahrir S, Crothers K, McGinnis KA, Chan KCG, Baeten JM, Wilson SM, Butt AA, Pisani MA, Baldassarri SR, Justice A, Williams EC. Receipt of Smoking Cessation Medications Among People With and Without Human Immunodeficiency Virus in the Veterans Aging Cohort Study (2003-2018). Open Forum Infect Dis 2023; 10:ofad089. [PMID: 36968969 PMCID: PMC10034589 DOI: 10.1093/ofid/ofad089] [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: 10/28/2022] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Background Nicotine replacement therapy, bupropion, and varenicline are smoking cessation medications (SCMs) shown to be similarly effective in people with and without human immunodeficiency virus (PWH and PWoH, respectively), although rates of receipt of these medications are unknown. Methods We identified patients in the Veterans Aging Cohort Study with electronic health record-documented current smoking using clinical reminder data for tobacco use (2003-2018). We measured receipt of SCMs using Veterans Affairs pharmacy data for outpatient prescriptions filled 0-365 days after current smoking documentation. We used log-linear, Poisson-modified regression models to evaluate the relative risk (RR) for receiving SCM by human immunodeficiency virus (HIV) status, the annual rate of receipt, and rate difference among PWH relative to PWoH. Results The sample included 92 632 patients (29 086 PWH), reflecting 381 637 documentations of current smoking. From 2003 to 2018, the proportion receiving SCMs increased from 15% to 34% for PWH and from 17% to 32% among PWoH. There was no statistical difference in likelihood of receiving SCM by HIV status (RR, 1.010; 95% confidence interval [CI], .994-1.026). Annual rates of receiving SCM increased for PWH by 4.3% per year (RR, 1.043; 95% CI, 1.040-1.047) and for PWoH by 3.7% per year (RR, 1.037; 95% CI, 1.036-1.038; rate difference +0.6% [RR, 1.006; 95% CI, 1.004-1.009]). Conclusions In a national sample of current smokers, receipt of SCM doubled over the 16-year period, and differences by HIV status were modest. However, fewer than 35% of current smokers receive SCM annually. Efforts to improve SCM receipt should continue for both groups given the known dangers of smoking.
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Affiliation(s)
- Shahida Shahrir
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
| | - Kristina Crothers
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | | | - Kwun C G Chan
- Departments of Biostatistics and Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
| | - Jared M Baeten
- Departments of Global Health, Medicine and Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Sarah M Wilson
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham Veterans Affairs Healthcare System, Durham, North Carolina, USA
| | - Adeel A Butt
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Departments of Medicine and Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
- Corporate Quality and Patient Safety Department, Hamad Medical Corporation Doha Qatar, Doha, Qatar
| | - Margaret A Pisani
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Stephen R Baldassarri
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Amy Justice
- Veterans Affairs CT Healthcare System, West Haven, Connecticut, USA
- Departments of Internal Medicine and Health Policy and Management, Yale University Schools of Medicine and Public Health, New Haven, Connecticut, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Services Research & Development, Seattle, Washington, USA
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Edelman EJ, Gan G, Dziura J, Esserman D, Porter E, Becker WC, Chan PA, Cornman DH, Helfrich CD, Reynolds J, Yager JE, Morford KL, Muvvala SB, Fiellin DA. Effect of Implementation Facilitation to Promote Adoption of Medications for Addiction Treatment in US HIV Clinics: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2236904. [PMID: 36251291 PMCID: PMC9577676 DOI: 10.1001/jamanetworkopen.2022.36904] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Importance Medications for addiction treatment (MAT) are inconsistently offered in HIV clinics. Objective To evaluate the impact of implementation facilitation (hereafter referred to as "facilitation"), a multicomponent implementation strategy, on increasing provision of MAT for opioid use disorder (MOUD), alcohol use disorder (MAUD), and tobacco use disorder (MTUD). Design, Setting, and Participants Conducted from July 26, 2016, through July 25, 2020, the Working with HIV Clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study used an unblinded, stepped wedge design to sequentially assign each of 4 HIV clinics in the northeastern US to cross over from control (ie, baseline practices) to facilitation (ie, intervention) and then evaluation and maintenance periods every 6 months. Participants were adult patients with opioid, alcohol, or tobacco use disorder. Data analysis was performed from August 2020 to September 2022. Interventions Multicomponent facilitation. Main Outcomes and Measures Outcomes, assessed using electronic health record data, were provision of MAT among patients with opioid, alcohol, or tobacco use disorder during the evaluation (primary outcome) and maintenance periods compared with the control period. Results Among 3647 patients, the mean (SD) age was 49 (12) years, 1814 (50%) were Black, 781 (22%) were Hispanic, and 1407 (39%) were female; 121 (3%) had opioid use disorder, 126 (3%) had alcohol use disorder, and 420 (12%) had tobacco use disorder. Compared with the control period, there was no increase in provision of MOUD with facilitation during the evaluation period (243 patients [27%; 95% CI, 22%-32%] vs 135 patients [28%; 95% CI, 22%-35%]; P = .59) or maintenance period (198 patients [29%; 95% CI, 22%-36%]; P = .48). The change in provision of MAUD from the control period to the evaluation period was not statistically significant (251 patients [8%; 95% CI, 5%-12%] vs 112 patients [13%; 95% CI, 8%-21%]; P = .11); however, the difference increased and became significant during the maintenance period (180 patients [17%; 95% CI, 12%-24%]; P = .009). There were significant increases in provision of MTUD with facilitation during both the evaluation (810 patients [33%; 95% CI, 30%-36%] vs 471 patients [40%; 95% CI, 36%-45%]; P = .005) and maintenance (643 patients [38%; 95% CI, 34%-41%]; P = .047) periods. Conclusions and Relevance In this randomized clinical trial, facilitation led to increased provision of MTUD, delayed improvements in MAUD, and no improvements in MOUD in HIV clinics. Enhanced strategies, potentially including clinic and patient incentives, especially for MOUD, may be needed to further increase provision of MAT in HIV clinics. Trial Registration ClinicalTrials.gov Identifier: NCT02907944.
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Affiliation(s)
- E. Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Geliang Gan
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - William C. Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven
| | - Philip A. Chan
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Deborah H. Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs
| | | | - Jesse Reynolds
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | | | - Kenneth L. Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Srinivas B. Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - David A. Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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Morford KL, Muvvala SB, Chan PA, Cornman DH, Doernberg M, Porter E, Virata M, Yager JE, Fiellin DA, Edelman EJ. Patients' perspectives of medications for addiction treatment in HIV clinics: A qualitative study. J Subst Abuse Treat 2022; 139:108767. [PMID: 35341613 PMCID: PMC9187601 DOI: 10.1016/j.jsat.2022.108767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/22/2021] [Accepted: 03/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND While substance use disorders (SUD) disproportionately impact people with HIV (PWH), HIV clinics inconsistently provide evidence-based medications for addiction treatment (MAT). Patient receptivity to MAT is critical to enhance addiction treatment in these settings. However, we know little from patients about how to best integrate MAT into HIV clinics. METHODS This qualitative study used four focus groups informed by the Promoting Action on Research Implementation in Health Services framework to identify barriers and facilitators to receiving opioid, alcohol, and tobacco use disorder care in HIV clinics. The study population included 28 patients with HIV and SUD receiving care at one of four HIV clinics in the northeastern United States. Focus groups were recorded and transcribed for content analysis. The study also performed a brief survey assessing demographics and behaviors. RESULTS Focus groups revealed several major themes related to MAT in HIV clinics. Barriers included stigma around MAT, knowledge deficits about available MAT options and the impact of substance use on PWH, concerns about medication side effects, substance use screening without adequate clinician follow-up, and peers who discouraged MAT. Facilitators included recognition of substance use as a threat to overall health, integrated care from HIV clinicians, and support for addiction treatment from peers with lived experience. CONCLUSIONS Efforts to enhance MAT in HIV clinics should include patient education to help them recognize addiction as a chronic disease with available medication treatment options; clinician and staff training to promote integrated, multidisciplinary screening and treatment; and thoughtful inclusion of peers with lived experience.
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Affiliation(s)
- Kenneth L Morford
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States.
| | - Srinivas B Muvvala
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States
| | - Philip A Chan
- Department of Medicine, Brown University, 593 Eddy Street, Providence, RI 02903, United States
| | - Deborah H Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, 2006 Hillside Road, Unit 1248, Storrs, CT 06269-1248, United States
| | - Molly Doernberg
- Yale School of Public Health, 60 College Street, New Haven, CT 06510, United States
| | - Elizabeth Porter
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
| | - Michael Virata
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
| | - Jessica E Yager
- SUNY Downstate, 450 Clarkson Ave, Suite J, Brooklyn, NY 11203, United States
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT 06510, United States; Department of Emergency Medicine, Yale School of Medicine, 464 Congress Avenue #260, New Haven, CT 06519, United States
| | - E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT 06510, United States
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Bold KW, Deng Y, Dziura J, Porter E, Sigel KM, Yager JE, Ledgerwood DM, Bernstein SL, Edelman EJ. Practices, attitudes, and confidence related to tobacco treatment interventions in HIV clinics: a multisite cross-sectional survey. Transl Behav Med 2022; 12:726-733. [PMID: 35608982 PMCID: PMC9260059 DOI: 10.1093/tbm/ibac022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Tobacco use disorder (TUD) is a major threat to health among people with HIV (PWH), but it is often untreated. Among HIV clinicians and staff, we sought to characterize practices, attitudes, and confidence addressing TUD among PWH to identify potential opportunities to enhance provision of care. Cross-sectional deidentified, web-based surveys were administered from November 4, 2020 through December 15, 2020 in HIV clinics in three health systems in the United States Northeast. Surveys assessed provider characteristics and experience, reported practices addressing tobacco use, and knowledge and attitudes regarding medications for TUD. Chi-square tests or Fisher's exact tests were used to examine differences in responses between clinicians and staff who were prescribers versus nonprescribers and to examine factors associated with frequency of prescribing TUD medications. Among 118 survey respondents (56% prescribers), only 50% reported receiving prior training on brief smoking cessation interventions. Examining reported practices identified gaps in the delivery of TUD care, including counseling patients on the impact of smoking on HIV, knowledge of clinical practice guidelines, and implementation of assessment and brief interventions for smoking. Among prescribers, first-line medications for TUD were infrequently prescribed and concerns about medication side effects and interaction with antiretroviral treatments were associated with low frequency of prescribing. HIV clinicians and staff reported addressable gaps in their knowledge, understanding, and practices related to tobacco treatment. Additional work is needed to identify ways to ensure adequate training for providers to enhance the delivery of TUD treatment in HIV clinic settings.
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Affiliation(s)
- Krysten W Bold
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, USA
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Keith M Sigel
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jessica E Yager
- State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - David M Ledgerwood
- Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
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9
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Chalouni M, Pol S, Sogni P, Fontaine H, Lacombe K, Lacombe JM, Esterle L, Dorival C, Bourlière M, Bani-Sadr F, de Ledinghen V, Zucman D, Larrey D, Salmon D, Carrat F, Wittkop L, Martinez V. Direct, indirect and total effect of HIV coinfection on the risk of non-liver-related cancer in hepatitis C virus-infected patients treated by direct-acting antivirals: a mediation analysis. HIV Med 2021; 22:924-935. [PMID: 34402547 DOI: 10.1111/hiv.13153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/19/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES HIV-coinfected patients experience higher incidences of non-liver-related cancers than HCV-monoinfected patients. Chronic inflammation, immunosuppression, but also higher tobacco or alcohol consumption and metabolic dysregulation could explain this higher risk. We aimed to estimate the direct, indirect and total effects of HIV coinfection on the risk of non-liver-related cancers in HCV participants treated with direct-acting antivirals (DAAs). METHODS Up to four HCV-monoinfected participants from the ANRS CO22 HEPATHER cohort were matched by age and sex to HIV/HCV-coinfected participants from the ANRS CO13 HEPAVIH cohort. Participants were followed from DAA initiation until the occurrence of a non-liver-related cancer. Counterfactual mediation analysis was carried out to estimate the direct (chronic inflammation and immunosuppression), indirect (tobacco and alcohol consumption and metabolic syndrome) and total effect of HIV coinfection on the risk of non-liver-related cancers. RESULTS 548 HIV/HCV-coinfected and 2016 monoinfected participants were included. Overall, HIV coinfection was associated with a 3.7-fold [95% confidence interval (CI): 1.7-7.0] higher risk of non-liver-related cancers in HCV participants. This increased risk was explained by significant direct effect [hazard ratio (HR) = 3.4, 95% CI: 1.7-6.6] but not indirect effect (HR = 1.1, 95% CI: 0.8-1.5) of HIV coinfection. CONCLUSIONS In HCV participants treated with DAAs, the direct effect of HIV coinfection, reflecting chronic inflammation and immunosuppression, was associated with a 3.7-fold higher risk of non-liver-related cancer. By contrast, the indirect effect of HIV coinfection, reflecting higher tobacco and alcohol consumption and metabolic dysregulation, was not significantly associated with the risk of non-liver-related cancers.
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Affiliation(s)
- Mathieu Chalouni
- Univ. Bordeaux, ISPED, Inserm, Bordeaux Population Health Research Center, team MORPH3EUS, UMR 1219, CIC-EC 1401, F-33000 Bordeaux, France
| | - Stanislas Pol
- Université de Paris, Assistance Publique - Hôpitaux de Paris Centre, Hôpital Cochin, Département d'Hépatologie, INSERM U-1223, Institut Pasteur, Paris, France.,Université de Paris, Paris, France
| | - Philippe Sogni
- Université de Paris, Assistance Publique - Hôpitaux de Paris Centre, Hôpital Cochin, Département d'Hépatologie, INSERM U-1223, Institut Pasteur, Paris, France.,Université de Paris, Paris, France
| | - Helene Fontaine
- Université de Paris, Assistance Publique - Hôpitaux de Paris Centre, Hôpital Cochin, Département d'Hépatologie, INSERM U-1223, Institut Pasteur, Paris, France
| | - Karine Lacombe
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F75012, Paris, France.,APHP. Est, Hôpital Saint-Antoine, Service de Maladies Infectieuses et Tropicales, Paris, F75012, France
| | | | - Laure Esterle
- Univ. Bordeaux, ISPED, Inserm, Bordeaux Population Health Research Center, team MORPH3EUS, UMR 1219, CIC-EC 1401, F-33000 Bordeaux, France
| | - Céline Dorival
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F75012, Paris, France
| | - Marc Bourlière
- Department of Hepatology and Gastroenterology, Hôpital Saint Joseph, Marseille, France
| | - Firouzé Bani-Sadr
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims, France
| | - Victor de Ledinghen
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Haut-Lévêque, Service d'Hépatologie, Bordeaux, France.,INSERM U1053, Université de Bordeaux, Bordeaux, France
| | - David Zucman
- Hôpital Foch, service de médecine interne, Suresnes, France
| | - Dominique Larrey
- Service des maladies de l'appareil digestif, Hôpital Saint Eloi, IBR- Inserm, Montpellier, France
| | - Dominique Salmon
- Université de Paris, Paris, France.,Service Maladies infectieuses et tropicales, AP-HP. Centre, Hôpital Cochin Hôtel Dieu, Paris, France
| | - Fabrice Carrat
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F75012, Paris, France.,AP-HP. Est, Hôpital Saint-Antoine, Unité de Santé Publique, Paris, France
| | - Linda Wittkop
- Univ. Bordeaux, ISPED, Inserm, Bordeaux Population Health Research Center, team MORPH3EUS, UMR 1219, CIC-EC 1401, F-33000 Bordeaux, France.,CHU de Bordeaux, Pôle de santé publique, F-33000 Bordeaux, France
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10
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Kaufman A, Ciccolo JT, Berzon RA, Edelman EJ. Preface to special collection of articles on interventions for promoting smoking cessation among individuals with HIV. Contemp Clin Trials 2021; 110:106518. [PMID: 34400363 DOI: 10.1016/j.cct.2021.106518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Annette Kaufman
- Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, 9609 Medical Center Dr, Rockville, MD 20850, United States of America.
| | - Joseph T Ciccolo
- Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, 9609 Medical Center Dr, Rockville, MD 20850, United States of America.
| | - Rick A Berzon
- Division of Clinical and Health Services Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, 6707 Democracy Blvd., Suite 800, Bethesda, MD 20892, United States of America.
| | - E Jennifer Edelman
- Yale Schools of Medicine and Public Health, 367 Cedar Street, ES Harkness 401, New Haven, CT 06510, United States of America.
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11
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Edelman EJ, Gan G, Dziura J, Esserman D, Morford KL, Porter E, Chan PA, Cornman DH, Oldfield BJ, Yager J, Muvvala SB, Fiellin DA. Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation. J Acquir Immune Defic Syndr 2021; 87:959-970. [PMID: 33675619 PMCID: PMC8192340 DOI: 10.1097/qai.0000000000002666] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/16/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics. SETTING Four HIV clinics in the northeastern United States. METHODS Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups. RESULTS Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork. CONCLUSIONS Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.
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Affiliation(s)
- E. Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Geliang Gan
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Kenneth L. Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Philip A. Chan
- Department of Medicine, Brown University, Providence, RI
| | - Deborah H. Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT
| | | | | | - Srinivas B. Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - David A. Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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12
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Borran M, Dashti-Khavidaki S, Khalili H. The need for an integrated pharmacological response to the treatment of HIV/AIDS and depression. Expert Opin Pharmacother 2021; 22:1179-1192. [PMID: 33586560 DOI: 10.1080/14656566.2021.1882419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: The coexistence of depression and HIV infection affects more than 9 million people worldwide. A literature review revealed a large gap regarding the pharmacotherapy of depression among patients dually diagnosed with HIV and depression.Areas covered:In this review, the authors covered the various dimensions of deploying integrated pharmacological treatment of HIV/AIDS and depression. This topic was addressed in two ways; first, the direct results of integrated pharmacotherapy in syndemic patients; second, the indirect effects of the integrated model on other outcomes of HIV care.Expert opinion: An integrated pharmacological response to the treatment of HIV and depression can bring substantial benefits to HIV outcomes and reduce the burden of both diseases. The direct advantages regarding pharmacological response to the treatment of depression along with HIV care are improving adherence to antiretroviral therapy, optimizing pharmacotherapy, minimizing drug interaction, and prevention of additive adverse drug reactions. Furthermore, in some cases, medication can target both depression and other neuropsychiatric or somatic comorbidities among people living with HIV/AIDS. The integrated pharmacotherapy also has some potential indirect advantages on HIV care outcomes like minimizing loss of care, reducing ongoing HIV transmission, and improving the outcomes of both diseases.
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Affiliation(s)
- Mina Borran
- Department of Internal Medicine, School of Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Simin Dashti-Khavidaki
- Professor of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Professor of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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13
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Schexnayder J, Longenecker CT, Muiruri C, Bosworth HB, Gebhardt D, Gonzales SE, Hanson JE, Hileman CO, Okeke NL, Sico IP, Vedanthan R, Webel AR. Understanding constraints on integrated care for people with HIV and multimorbid cardiovascular conditions: an application of the Theoretical Domains Framework. Implement Sci Commun 2021; 2:17. [PMID: 33579396 PMCID: PMC7881687 DOI: 10.1186/s43058-021-00114-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 01/22/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND People with HIV (PWH) experience increased cardiovascular disease (CVD) risk. Many PWH in the USA receive their primary medical care from infectious disease specialists in HIV clinics. HIV care teams may not be fully prepared to provide evidence-based CVD care. We sought to describe local context for HIV clinics participating in an NIH-funded implementation trial and to identify facilitators and barriers to integrated CVD preventive care for PWH. METHODS Data were collected in semi-structured interviews and focus groups with PWH and multidisciplinary healthcare providers at three academic medical centers. We used template analysis to identify barriers and facilitators of CVD preventive care in three HIV specialty clinics using the Theoretical Domains Framework (TDF). RESULTS Six focus groups were conducted with 37 PWH. Individual interviews were conducted with 34 healthcare providers and 14 PWH. Major themes were captured in seven TDF domains. Within those themes, we identified nine facilitators and 11 barriers to CVD preventive care. Knowledge gaps contributed to inaccurate CVD risk perceptions and ineffective self-management practices in PWH. Exclusive prioritization of HIV over CVD-related conditions was common in PWH and their providers. HIV care providers assumed inconsistent roles in CVD prevention, including for PWH with primary care providers. HIV providers were knowledgeable of HIV-related CVD risks and co-located health resources were consistently available to support PWH with limited resources in health behavior change. However, infrequent medical visits, perceptions of CVD prevention as a primary care service, and multiple co-location of support programs introduced local challenges to engaging in CVD preventive care. CONCLUSIONS Barriers to screening and treatment of cardiovascular conditions are common in HIV care settings and highlight a need for greater primary care integration. Improving long-term cardiovascular outcomes of PWH will likely require multi-level interventions supporting HIV providers to expand their scope of practice, addressing patient preferences for co-located CVD preventive care, changing clinic cultures that focus only on HIV to the exclusion of non-AIDS multimorbidity, and managing constraints associated with multiple services co-location. TRIAL REGISTRATION ClinicalTrials.gov , NCT03643705.
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Affiliation(s)
- Julie Schexnayder
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106-7343, USA
| | - Chris T Longenecker
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH, USA
| | | | | | | | | | - Jan E Hanson
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106-7343, USA
| | | | | | | | - Rajesh Vedanthan
- New York University Grossman School of Medicine, New York, NY, USA
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106-7343, USA.
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14
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Satre DD, Levine-Hall T, Sterling SA, Young-Wolff K, Lam JO, Alexeeff S, Hojilla JC, Williams A, Justice AC, Sterne J, Cavassini M, Bryant KJ, Williams EC, Horberg MA, Volberding P, Weisner C, Silverberg MJ. The relationship of smoking and unhealthy alcohol use to the HIV care continuum among people with HIV in an integrated health care system. Drug Alcohol Depend 2021; 219:108481. [PMID: 33429295 PMCID: PMC7869693 DOI: 10.1016/j.drugalcdep.2020.108481] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/12/2020] [Accepted: 12/03/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Smoking tobacco and unhealthy alcohol use may negatively influence HIV care continuum outcomes but have not been examined in combination. METHODS Participants were people with HIV (PWH) in Kaiser Permanente Northern California. Predictors included smoking status and unhealthy alcohol use (exceeding daily and/or weekly limits) reported by patients during primary care screening (index date). Outcomes were based on not achieving the following steps in the care continuum: linkage to HIV care (≥1 visit within 90 days of newly identified HIV diagnosis), retention (2+ in-person visits, 60+ days apart) and HIV RNA control (<75 copies/mL). Adjusted odds ratios (ORs) were obtained from separate logistic regression models for each outcome associated with smoking and unhealthy alcohol use independently and combined. RESULTS The overall sample (N = 8958) had a mean age of 48.0 years; was 91.3 % male; 54.0 % white, 17.6 % Latino, 15.1 % black, and 9.6 % other race/ethnicity. Smoking was associated with higher odds of not being linked to HIV care (OR = 1.60 [95 % CI 1.03-2.48]), not retained (OR = 1.30 [95 % CI 1.13-1.50]), and HIV RNA not in control (OR = 1.91 [95 % CI 1.60-2.27]). Alcohol measures were not independently associated with outcomes. The combination of unhealthy alcohol use and smoking (versus neither) was associated with higher odds of not being linked to care (OR = 2.83 [95 % CI 1.40-5.71]), although the interaction did not reach significance (p = 0.18). CONCLUSIONS In this large sample of PWH in an integrated health care system, smoking, both independently and in combination with unhealthy alcohol use, was associated with worse HIV care continuum outcomes.
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Affiliation(s)
- Derek D. Satre
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA,Kaiser Permanente Northern California, Oakland, CA, USA,Corresponding author: Derek D. Satre, Ph.D., Department of Psychiatry and Behavioral Sciences Weill Institute for Neurosciences University of California, San Francisco 401 Parnassus Avenue, Box 0984 San Francisco, CA 94143, , Phone: (415) 476-7382
| | | | | | - Kelly Young-Wolff
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA,Kaiser Permanente Northern California, Oakland, CA, USA
| | | | | | | | | | | | | | | | - Kendall J. Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Emily C. Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, Seattle, WA,Department of Health Services, University of Washington, Seattle, WA
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Paul Volberding
- AIDS Research Institute, University of California, San Francisco, USA
| | - Constance Weisner
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA,Kaiser Permanente Northern California, Oakland, CA, USA
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15
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Ashare RL, Bernstein SL, Schnoll R, Gross R, Catz SL, Cioe P, Crothers K, Hitsman B, Marhefka SL, McClure JB, Pacek LR, Vidrine DJ, Vilardaga R, Kaufman A, Edelman EJ. The United States National Cancer Institute's Coordinated Research Effort on Tobacco Use as a Major Cause of Morbidity and Mortality among People with HIV. Nicotine Tob Res 2021; 23:407-410. [PMID: 32803251 PMCID: PMC7454816 DOI: 10.1093/ntr/ntaa155] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023]
Abstract
The use of antiretroviral therapy for people with HIV (PWH) has improved life expectancy. However, PWH now lose more life-years to tobacco use than to HIV infection. Unfortunately, PWH smoke at higher rates and have more difficulty maintaining abstinence than the general population, compounding their risk for chronic disease. In this Commentary, we describe a United States National Cancer Institute-led initiative to address the relative lack of research focused on developing, testing, and implementing smoking cessation interventions for PWH. This initiative supports seven clinical trials designed to systematically test and/or develop and test adaptations of evidence-based smoking cessation interventions for PWH (eg, combination of behavioral and pharmacological). We summarize each project, including setting/recruitment sites, inclusion/exclusion criteria, interventions being tested, and outcomes. This initiative provides critical opportunities for collaboration and data harmonization across projects. The knowledge gained will inform strategies to assist PWH to promote and maintain abstinence, and ensure that these efforts are adaptable and scalable, thereby addressing one of the major threats to the health of PWH. Reducing smoking behavior may be particularly important during the COVID-19 pandemic given that smokers who become infected with SARS-CoV-2 may be at risk for more severe disease. IMPLICATIONS This Commentary describes a National Cancer Institute-led initiative to advance the science and practice of treating tobacco use among PWH, which is now responsible for more life years lost than HIV. We describe the scope of the problem, the objectives of the initiative, and a summary of the seven funded studies. Harmonization of data across projects will provide information related to treatment mediators and moderators that was not previously possible. Stakeholders interested in tobacco cessation, including researchers, clinicians and public health officials, should be aware of this initiative and the evidence-base it will generate to advance tobacco treatment among this high-risk population.
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Affiliation(s)
- Rebecca L Ashare
- Department of Psychiatry and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale Center for Implementation Science, Yale School of Medicine, New Haven, CT
| | - Robert Schnoll
- Department of Psychiatry and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sheryl L Catz
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA
| | - Patricia Cioe
- Center for Alcohol & Addiction Studies, Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, RI
| | - Kristina Crothers
- Veterans Affairs (VA) Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Brian Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Stephanie L Marhefka
- College of Public Health and Division of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
| | | | - Lauren R Pacek
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Damon J Vidrine
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Roger Vilardaga
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Annette Kaufman
- Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - E Jennifer Edelman
- Yale School of Medicine, New Haven, CT and Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
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16
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Ríos SC, Colón Sáez JO, Quesada O, Figueroa KQ, Lasalde Dominicci JA. Disruption of the cholinergic anti-inflammatory response by R5-tropic HIV-1 protein gp120 JRFL. J Biol Chem 2021; 296:100618. [PMID: 33811859 PMCID: PMC8102909 DOI: 10.1016/j.jbc.2021.100618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 01/13/2023] Open
Abstract
Despite current pharmacological intervention strategies, patients with HIV still suffer from chronic inflammation. The nicotinic acetylcholine receptors (nAChRs) are widely distributed throughout the nervous and immune systems. In macrophages, activation of alpha7-nAChR (α7-nAChR) controls inflammatory processes through the cholinergic anti-inflammatory response (CAR). Given that this innate immune response controls inflammation and α7-nAChR plays a critical role in the regulation of systemic inflammation, we investigated the effects of an R5-tropic HIV soluble component, gp120JRFL, on the CAR functioning. We previously demonstrated that X4-tropic HIV-1 gp120IIIB disrupts the CAR as well as inducing upregulation of the α7-nAChR in vitro in monocyte-derived macrophages (MDMs), which correlates with the upregulation observed in monocytes, T-lymphocytes, and MDMs recovered from HIV-infected people. We demonstrate here using imaging and molecular assays that the R5-tropic HIV-1 glycoprotein gp120JRFL upregulates the α7-nAChR in MDMs dependent on CD4 and/or CCR5 activation. This upregulation was also dependent on MEK1 since its inhibition attenuates the upregulation of α7-nAChR induced by gp120JRFL and was concomitant with an increase in basal calcium levels, which did not result in apoptosis. Moreover, the CAR was determined to be disrupted, since α7-nAChR activation in MDMs did not reduce the production of the proinflammatory cytokines IL-6, GRO-α, or I-309. Furthermore, a partial antagonist of α7-nAChR, bupropion, rescued IL-6 but not GRO-α or I-309 production. Together, these results demonstrate that gp120JRFL disrupts the CAR in MDMs. Other medications targeting the α7-nAChR need to be tested to reactivate the CAR to ameliorate inflammation in HIV-infected subjects.
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Affiliation(s)
- Sonnieliz Cotto Ríos
- Department of Chemistry, University of Puerto Rico, Río Piedras Campus, San Juan, Puerto Rico, USA
| | - José O Colón Sáez
- Department of Pharmaceutical Sciences, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Orestes Quesada
- Department of Physical Sciences, University of Puerto Rico, Río Piedras Campus, San Juan, Puerto Rico, USA
| | | | - José A Lasalde Dominicci
- Department of Chemistry, University of Puerto Rico, Río Piedras Campus, San Juan, Puerto Rico, USA; Department of Biology, University of Puerto Rico, Río Piedras Campus, San Juan, Puerto Rico, USA; Institute of Neurobiology, University of Puerto Rico Medical Science Campus, San Juan, Puerto Rico, USA; Molecular Sciences Research Center, University of Puerto Rico, San Juan, Puerto Rico, USA.
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17
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Edelman EJ, Dziura J, Esserman D, Porter E, Becker WC, Chan PA, Cornman DH, Rebick G, Yager J, Morford K, Muvvala SB, Fiellin DA. Working with HIV clinics to adopt addiction treatment using implementation facilitation (WHAT-IF?): Rationale and design for a hybrid type 3 effectiveness-implementation study. Contemp Clin Trials 2020; 98:106156. [PMID: 32976995 PMCID: PMC7511156 DOI: 10.1016/j.cct.2020.106156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tobacco, alcohol and opioid misuse are associated with substantial morbidity and mortality among people with HIV (PWH). Despite existence of evidence-based counseling and medications for addiction, these treatments are infrequently offered in HIV clinics. The Working with HIV clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study was conducted to address this implementation challenge. The study's goals were to conduct a formative evaluation of barriers to and facilitators of implementing addiction treatment for PWH followed by an evaluation of the impact of Implementation Facilitation (IF) on promoting adoption of addiction treatments and clinical outcomes. METHODS The study was conducted at four HIV clinics in the northeast United States, using a hybrid type 3 effectiveness-implementation stepped wedge design and guided by the Promoting Action on Research Implementation in Health Services Research (PARiHS) framework. A mixed-methods approach was used to identify evidence, context, and facilitation-related barriers to and facilitators of integration of addiction treatments into HIV clinics and to help tailor IF for each clinic. An evaluation was then conducted of the impact of IF on implementation outcomes, including provision of addiction treatment (primary outcome), organizational and clinician and staff readiness to adopt addiction treatment, and changes in organizational models of care used to deliver addiction treatment. The evaluation also included IF's impact on effectiveness outcomes, specifically HIV-related outcomes among patients eligible for addiction treatment. CONCLUSIONS Results will generate important information regarding the impact of IF as a reproducible strategy to promote addiction treatment in HIV clinics.
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Affiliation(s)
- E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America.
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America; Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States of America
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - William C Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Philip A Chan
- Department of Medicine, Brown University, Providence, RI, United States of America
| | - Deborah H Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT, United States of America
| | - Gabriel Rebick
- New York University, New York, NY, United States of America
| | - Jessica Yager
- SUNY Downstate, Brooklyn, NY, United States of America
| | - Kenneth Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Srinivas B Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
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Chang L, Liang H, Kandel SR, He JJ. Independent and Combined Effects of Nicotine or Chronic Tobacco Smoking and HIV on the Brain: A Review of Preclinical and Clinical Studies. J Neuroimmune Pharmacol 2020; 15:658-693. [PMID: 33108618 DOI: 10.1007/s11481-020-09963-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 02/07/2023]
Abstract
Tobacco smoking is highly prevalent among HIV-infected individuals. Chronic smokers with HIV showed greater cognitive deficits and impulsivity, and had more psychopathological symptoms and greater neuroinflammation than HIV non-smokers or smokers without HIV infection. However, preclinical studies that evaluated the combined effects of HIV-infection and tobacco smoking are scare. The preclinical models typically used cell cultures or animal models that involved specific HIV viral proteins or the administration of nicotine to rodents. These preclinical models consistently demonstrated that nicotine had neuroprotective and anti-inflammatory effects, leading to cognitive enhancement. Although the major addictive ingredient in tobacco smoking is nicotine, chronic smoking does not lead to improved cognitive function in humans. Therefore, preclinical studies designed to unravel the interactive effects of chronic tobacco smoking and HIV infection are needed. In this review, we summarized the preclinical studies that demonstrated the neuroprotective effects of nicotine, the neurotoxic effects of the HIV viral proteins, and the scant literature on nicotine or tobacco smoke in HIV transgenic rat models. We also reviewed the clinical studies that evaluated the neurotoxic effects of tobacco smoking, HIV infection and their combined effects on the brain, including studies that evaluated the cognitive and behavioral assessments, as well as neuroimaging measures. Lastly, we compared the different approaches between preclinical and clinical studies, identified some gaps and proposed some future directions. Graphical abstract Independent and combined effects of HIV and tobacco/nicotine. Left top and bottom panels: Both clinical studies of HIV infected persons and preclinical studies using viral proteins in vitro or in vivo in animal models showed that HIV infection could lead to neurotoxicity and neuroinflammation. Right top and bottom panels: While clinical studies of tobacco smoking consistently showed deleterious effects of smoking, clinical and preclinical studies that used nicotine show mild cognitive enhancement, neuroprotective and possibly anti-inflammatory effects. In the developing brain, however, nicotine is neurotoxic. Middle overlapping panels: Clinical studies of persons with HIV who were smokers typically showed additive deleterious effects of HIV and tobacco smoking. However, in the preclinical studies, when nicotine was administered to the HIV-1 Tg rats, the neurotoxic effects of HIV were attenuated, but tobacco smoke worsened the inflammatory cascade.
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Affiliation(s)
- Linda Chang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 670 W. Baltimore Street, HSF III, Baltimore, MD, 21201, USA.
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA.
| | - Huajun Liang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 670 W. Baltimore Street, HSF III, Baltimore, MD, 21201, USA
| | - Suresh R Kandel
- Department of Microbiology and Immunology, Chicago Medical School, Center for Cancer Cell Biology, Immunology and Infection, Rosalind Franklin University, 3333 Green Bay Road, Basic Science Building 2.300, North Chicago, IL, 60064, USA
| | - Johnny J He
- Department of Microbiology and Immunology, Chicago Medical School, Center for Cancer Cell Biology, Immunology and Infection, Rosalind Franklin University, 3333 Green Bay Road, Basic Science Building 2.300, North Chicago, IL, 60064, USA.
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