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Self-efficacy as a mediator of patient navigation interventions to engage persons living with HIV and substance use. Drug Alcohol Depend 2021; 221:108567. [PMID: 33610093 PMCID: PMC8067954 DOI: 10.1016/j.drugalcdep.2021.108567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 11/24/2022]
Abstract
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.
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Irvine MK, Levin B, Robertson MM, Penrose K, Carmona J, Harriman G, Braunstein SL, Nash D. PROMISE (Program Refinements to Optimize Model Impact and Scalability based on Evidence): a cluster-randomised, stepped-wedge trial assessing effectiveness of the revised versus original Ryan White Part A HIV Care Coordination Programme for patients with barriers to treatment in the USA. BMJ Open 2020; 10:e034624. [PMID: 32718922 PMCID: PMC7389516 DOI: 10.1136/bmjopen-2019-034624] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Growing evidence supports combining social, behavioural and biomedical strategies to strengthen the HIV care continuum. However, combination interventions can be resource-intensive and challenging to scale up. Research is needed to identify intervention components and delivery models that maximise uptake, engagement and effectiveness. In New York City (NYC), a multicomponent Ryan White Part A-funded medical case management intervention called the Care Coordination Programme (CCP) was launched at 28 agencies in 2009 in order to address barriers to care and treatment. Effectiveness estimates based on >7000 clients enrolled by April 2013 and their controls indicated modest CCP benefits over 'usual care' for short-term and long-term viral suppression, with substantial room for improvement. METHODS AND ANALYSIS Integrating evaluation findings and CCP service-provider and community-stakeholder input on modifications, the NYC Health Department packaged a Care Coordination Redesign (CCR) in a 2017 request for proposals. Following competitive re-solicitation, 17 of the original CCP-implementing agencies secured contracts. These agencies were randomised within matched pairs to immediate or delayed CCR implementation. Data from three 9-month periods (pre-implementation, partial implementation and full implementation) will be examined to compare CCR versus CCP effects on timely viral suppression (TVS, within 4 months of enrolment) among individuals with unsuppressed HIV viral load newly enrolling in the CCR/CCP. Based on current enrolment (n=933) and the pre-implementation outcome probability (TVS=0.54), the detectable effect size with 80% power is an OR of 2.75 (relative risk: 1.41). ETHICS AND DISSEMINATION This study was approved by the NYC Department of Health and Mental Hygiene Institutional Review Board (IRB, Protocol 18-009) and the City University of New York Integrated IRB (Protocol 018-0057) with a waiver of informed consent. Findings will be disseminated via publications, conferences, stakeholder meetings, and Advisory Board meetings with implementing agency representatives. TRIAL REGISTRATION NUMBER Registered with ClinicalTrials.gov under identifier: NCT03628287, V.2, 25 September 2019; pre-results.
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Affiliation(s)
- Mary K Irvine
- Bureau of HIV, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health (MSPH), Columbia University, New York, New York, USA
| | - McKaylee M Robertson
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Katherine Penrose
- Bureau of HIV, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Jennifer Carmona
- Bureau of HIV, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Graham Harriman
- Bureau of HIV, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Sarah L Braunstein
- Bureau of HIV, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
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Stevens ER, Nucifora KA, Irvine MK, Penrose K, Robertson M, Kulkarni S, Robbins R, Abraham B, Nash D, Braithwaite RS. Cost-effectiveness of HIV care coordination scale-up among persons at high risk for sub-optimal HIV care outcomes. PLoS One 2019; 14:e0215965. [PMID: 31022280 PMCID: PMC6483203 DOI: 10.1371/journal.pone.0215965] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 04/12/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND A study of a comprehensive HIV Care Coordination Program (CCP) showed effectiveness in increasing viral load suppression (VLS) among PLWH in New York City (NYC). We evaluated the cost-effectiveness of a scale-up of the CCP in NYC. METHODS We incorporated observed effects and costs of the CCP into a computer simulation of HIV in NYC, comparing strategy scale-up with no implementation. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression, and was calibrated to NYC HIV epidemiological data from 1997 to 2009. We assessed incremental cost-effectiveness from a health sector perspective using 2017 $US, a 20-year time horizon, and a 3% annual discount rate. We explored two scenarios: (1) two-year average enrollment and (2) continuous enrollment. RESULTS In scenario 1, scale-up resulted in a cost-per-infection-averted of $898,104 and a cost-per-QALY-gained of $423,721. In sensitivity analyses, scale-up achieved cost-effectiveness if effectiveness increased from RR1.11 to RR1.37 or costs decreased by 41.7%. Limiting the intervention to persons with unsuppressed viral load prior to enrollment (RR1.32) attenuated the cost reduction necessary to 11.5%. In scenario 2, scale-up resulted in a cost-per-infection-averted of $705,171 and cost-per-QALY-gained of $720,970. In sensitivity analyses, scale-up achieved cost-effectiveness if effectiveness increased from RR1.11 to RR1.46 or program costs decreased by 71.3%. Limiting the intervention to persons with unsuppressed viral load attenuated the cost reduction necessary to 38.7%. CONCLUSION Cost-effective CCP scale-up would require reduced costs and/or focused enrollment within NYC, but may be more readily achieved in cities with lower background VLS levels.
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Affiliation(s)
- Elizabeth R. Stevens
- Department of Population Health, NYU School of Medicine, New York, NY, United States of America
- * E-mail:
| | - Kimberly A. Nucifora
- Department of Population Health, NYU School of Medicine, New York, NY, United States of America
| | - Mary K. Irvine
- Bureau of HIV/AIDS Prevention & Control, New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Katherine Penrose
- Bureau of HIV/AIDS Prevention & Control, New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - McKaylee Robertson
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, United States of America
- Department of Epidemiology and Biostatistics, School of Public Health, City University of New York, New York, NY, United States of America
| | - Sarah Kulkarni
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, United States of America
| | - Rebekkah Robbins
- Bureau of HIV/AIDS Prevention & Control, New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Bisrat Abraham
- Bureau of HIV/AIDS Prevention & Control, New York City Department of Health and Mental Hygiene, New York, NY, United States of America
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, United States of America
- Department of Epidemiology and Biostatistics, School of Public Health, City University of New York, New York, NY, United States of America
| | - R. Scott Braithwaite
- Department of Population Health, NYU School of Medicine, New York, NY, United States of America
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Hechter RC, Horberg MA, Weisner C, Campbell CI, Contreras R, Chen LH, Yarborough BJH, Lapham GT, Haller IV, Ahmedani BK, Binswanger IA, Kline-Simon AH, Satre DD. Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and drug treatment initiation and engagement among people living with the human immunodeficiency virus (HIV) and patients without an HIV diagnosis. Subst Abus 2019; 40:302-310. [PMID: 30908174 PMCID: PMC6761030 DOI: 10.1080/08897077.2019.1580239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background: Problematic use of alcohol and other drugs (AOD) is highly prevalent among people living with the human immunodeficiency virus (PLWH), and untreated AOD use disorders have particularly detrimental effects on human immunodeficiency virus (HIV) outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) measures of treatment initiation and engagement are important benchmarks for access to AOD use disorder treatment. To inform improved patient care, we compared HEDIS measures of AOD use disorder treatment initiation and engagement and health care utilization among PLWH and patients without an HIV diagnosis. Methods: Patients with a new AOD use disorder diagnosis documented between October 1, 2014, and August 15, 2015, were identified using electronic health records (EHR) and insurance claims data from 7 health care systems in the United States. Demographic characteristics, clinical diagnoses, and health care utilization data were also obtained. AOD use disorder treatment initiation and engagement rates were calculated using HEDIS measure criteria. Factors associated with treatment initiation and engagement were examined using multivariable logistic regression models. Results: There were 469 PLWH (93% male) and 86,096 patients without an HIV diagnosis (60% male) in the study cohort. AOD use disorder treatment initiation was similar in PLWH and patients without an HIV diagnosis (10% vs. 11%, respectively). Among those who initiated treatment, few engaged in treatment in both groups (9% PLWH vs. 12% patients without an HIV diagnosis). In multivariable analysis, HIV status was not significantly associated with either AOD use disorder treatment initiation or engagement. Conclusions: AOD use disorder treatment initiation and engagement rates were low in both PLWH and patients without an HIV diagnosis. Future studies need to focus on developing strategies to efficiently integrate AOD use disorder treatment with medical care for HIV.
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Affiliation(s)
- Rulin C Hechter
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Richard Contreras
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lie-Hong Chen
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Gwen T Lapham
- Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Irina V Haller
- Essentia Institute of Rural Health, Essentia Health, Duluth, Minnesota, USA
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research and Behavioral Health Services, Henry Ford Health System, Detroit, Michigan, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
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Jergesen HE, Thielen ZP, Roever JA, Vashon TT, Wu HH, Yi PH. Primary Hip and Knee Arthroplasty in a Safety Net Hospital: Substance Abuse and Other Factors Affecting Short-term Complications. J Arthroplasty 2018; 33:3003-3008. [PMID: 29853309 DOI: 10.1016/j.arth.2018.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/28/2018] [Accepted: 05/01/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Arthroplasty outcomes and patient risk factors have not been studied in detail in safety net hospital settings. This study examines the relationship between selected risk factors and short-term complications in such a population, including a large subgroup with treated substance abuse. METHODS This retrospective cohort study contains 486 consecutive patients after primary hip and knee arthroplasty. One hundred three of these had a history of substance abuse and completed a 1-year sobriety pathway preoperatively. Primary outcomes included the presence of any complication, deep infection, and reoperation. Bivariable analyses were used to compare outcomes with demographic and health risk factors. A multivariate analysis was performed to identify independent risk factors. RESULTS Adverse outcomes were more common in patients with higher rates of substance abuse, mental illness, and infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Substance abuse alone was not an independent risk factor for the occurrence of complications, but infections with HIV and HCV were. In the substance abuse subgroup, with its higher prevalence of risk factors, complications were more frequent (31.1% vs 16.4%, P = .0009), and, in particular, deep infections (5.8% vs 1.8%, P = .0256). CONCLUSIONS Specific risk factors were associated with short-term complications in safety net arthroplasty patients. Despite having completed a preoperative sobriety pathway, substance abuse patients had more complications than did others. However, substance abuse alone was not an independent risk factor for adverse surgical outcomes. Other factors, notably HCV and HIV infection that were more common in patients with substance abuse, were most closely associated with adverse outcomes.
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Affiliation(s)
- Harry E Jergesen
- Institute for Global Orthopaedics and Traumatology, Zuckerberg San Francisco General Hospital, Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Zachary P Thielen
- Institute for Global Orthopaedics and Traumatology, Zuckerberg San Francisco General Hospital, Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Jay A Roever
- Institute for Global Orthopaedics and Traumatology, Zuckerberg San Francisco General Hospital, Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Toure T Vashon
- Institute for Global Orthopaedics and Traumatology, Zuckerberg San Francisco General Hospital, Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Hao-Hua Wu
- Institute for Global Orthopaedics and Traumatology, Zuckerberg San Francisco General Hospital, Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Paul H Yi
- Institute for Global Orthopaedics and Traumatology, Zuckerberg San Francisco General Hospital, Department of Orthopaedic Surgery, University of California, San Francisco, California
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Lusk SL, Stipp A. Opioid use disorders as an emerging disability. JOURNAL OF VOCATIONAL REHABILITATION 2018. [DOI: 10.3233/jvr-180943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Increased Survival Among HIV-Infected PWID Receiving a Multi-Level HIV Risk and Stigma Reduction Intervention: Results From a Randomized Controlled Trial. J Acquir Immune Defic Syndr 2017; 74:166-174. [PMID: 27861239 DOI: 10.1097/qai.0000000000001245] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In Vietnam, where 58% of prevalent HIV cases are attributed to people who inject drugs, we evaluated whether a multi-level intervention could improve care outcomes and increase survival. METHODS We enrolled 455 HIV-infected males who inject drugs from 32 communes in Thai Nguyen Province. Communes were randomized to a community stigma reduction intervention or standard of care and then within each commune, to an individual enhanced counseling intervention or standard of care, resulting into 4 arms: Arm 1 (standard of care); Arm 2 (community intervention alone); Arm 3 (individual intervention alone); and Arm 4 (community + individual interventions). Follow-up was conducted at 6, 12, 18, and 24 months to assess survival. RESULTS Overall mortality was 23% (n = 103/455) more than 2 years. There were no losses to follow-up for the mortality endpoint. Survival at 24 months was different across arms: Arm 4 (87%) vs Arm 1 (82%) vs Arm 2 (68%) vs Arm 3 (73%); log-rank test for comparison among arms: P = 0.001. Among those with CD4 cell count <200 cells/mm and not on antiretroviral therapy at baseline (n = 162), survival at 24 months was higher in Arm 4 (84%) compared with other arms (Arm 1: 61%; Arm 2: 50%; Arm 3: 53%; P-value = 0.002). Overall, Arm 4 (community + individual interventions) had increased uptake of antiretroviral therapy compared with Arms 1, 2, and 3. CONCLUSIONS This multi-level behavioral intervention seemed to increase survival of HIV-infected participants more than a 2-year period. Relative to the standard of care, the greatest intervention effect was among those with lower CD4 cell counts.
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Irvine MK, Chamberlin SA, Robbins RS, Kulkarni SG, Robertson MM, Nash D. Come as You Are: Improving Care Engagement and Viral Load Suppression Among HIV Care Coordination Clients with Lower Mental Health Functioning, Unstable Housing, and Hard Drug Use. AIDS Behav 2017; 21:1572-1579. [PMID: 27342990 DOI: 10.1007/s10461-016-1460-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Lower mental health functioning, unstable housing, and drug use can complicate HIV clinical management. Merging programmatic and surveillance data, we examined characteristics and outcomes for HIV Care Coordination clients enrolled between December 2009 and March 2013. For clients diagnosed over 12 months before enrollment, we calculated post- versus pre-enrollment relative risks for short-term (12-month) care engagement and viral suppression. Both outcomes significantly improved in all subgroups, including those with lower mental health functioning, unstable housing, or hard drug use. Analyses further stratified within barrier-affected groups showed a tendency toward greater improvement when that barrier was reduced during the follow-up year.
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Affiliation(s)
- Mary K Irvine
- The Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 42-09 28th Street, Queens, New York, NY, 11101-4132, USA
| | - Stephanie A Chamberlin
- The Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 42-09 28th Street, Queens, New York, NY, 11101-4132, USA.
| | - Rebekkah S Robbins
- The Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 42-09 28th Street, Queens, New York, NY, 11101-4132, USA
| | - Sarah G Kulkarni
- Graduate School of Public Health and Health Policy, The City University of New York, 55 West 125th Street, New York, 10027, NY, USA
- Institute for Implementation Science in Population Health, The City University of New York, 55 West 125th Street, New York, 10027, NY, USA
| | - McKaylee M Robertson
- Graduate School of Public Health and Health Policy, The City University of New York, 55 West 125th Street, New York, 10027, NY, USA
| | - Denis Nash
- Graduate School of Public Health and Health Policy, The City University of New York, 55 West 125th Street, New York, 10027, NY, USA
- Institute for Implementation Science in Population Health, The City University of New York, 55 West 125th Street, New York, 10027, NY, USA
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Lake S, Kerr T, Capler R, Shoveller J, Montaner J, Milloy MJ. High-intensity cannabis use and HIV clinical outcomes among HIV-positive people who use illicit drugs in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 42:63-70. [PMID: 28336000 DOI: 10.1016/j.drugpo.2017.02.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 02/03/2017] [Accepted: 02/24/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reforms to the legal status of medical and non-medical cannabis are underway in many jurisdictions, including Canada, as are renewed efforts to scale-up HIV treatment-as-prevention (TasP) initiatives. It has been suggested that high-intensity cannabis use may be associated with sub-optimal HIV treatment outcomes. Thus, using data from a setting with a community-wide treatment-as-prevention (TasP) initiative coinciding with increasing access to medical cannabis, we sought to investigate the possible impact of high-intensity cannabis use on HIV clinical outcomes. METHODS Data was derived from the ACCESS study, a prospective cohort of HIV-positive people who use illicit drugs (PWUD) in Vancouver, Canada. Cohort data was confidentially linked to comprehensive clinical profiles, including records of all antiretroviral therapy (ART) dispensations and longitudinal plasma HIV-1 RNA viral load (VL) monitoring. We used generalized estimating equations (GEEs) to estimate the longitudinal bivariable and multivariable relationships between at least daily cannabis use and two key clinical outcomes: overall engagement in ART care, and achieving a non-detectable VL among ART-exposed participants. RESULTS Between December 2005 and June 2015, 874 HIV-positive PWUD (304 [35%] non-male) were included in this study. In total, 788 (90%) were engaged in HIV care at least once over the study period, of whom 670 (85%) achieved non-detectable VL at least once. In multivariable analyses, ≥ daily cannabis use did not predict lower odds of ART care (Adjusted Odds Ratio [AOR]: 1.02, 95% confidence interval [CI]: 0.77-1.36) or VL non-detectability among ART-exposed (AOR: 0.96, 95% CI: 0.75-1.21). Upon testing for potential interactions, ≥ daily cannabis use was found to be negatively associated with ART engagement during periods of binge alcohol use (p<0.05). CONCLUSION With the exception of frequent cannabis use during periods of binge alcohol use, our results showed no statistically significant impact of daily cannabis use on the likelihood of ART care or VL non-detectability among ART-exposed HIV-positive PWUD. These findings are reassuring in light of the impending legalization of cannabis in Canada and ongoing efforts to expand TasP initiatives.
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Affiliation(s)
- Stephanie Lake
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Rielle Capler
- Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada
| | - Jeannie Shoveller
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
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Lake S, Kerr T, Buxton J, Guillemi S, Parashar S, Montaner J, Wood E, Milloy MJ. Prescription Opioid Injection Among HIV-Positive People Who Inject Drugs in a Canadian Setting. AIDS Behav 2016; 20:2941-2949. [PMID: 27146887 DOI: 10.1007/s10461-016-1369-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prescription opioids (POs) are commonly prescribed to patients living with HIV/AIDS, while the illicit use of POs remains a major public health concern throughout Canada and the United States. We sought to identify the prevalence and correlates of PO injection among HIV-positive people who inject drugs (PWID) in Vancouver, Canada, where HIV/AIDS treatment and care is offered at no cost. We examined data from 634 individuals from an ongoing prospective cohort of HIV-positive PWID. Between December 2005 and November 2013, the median prevalence of recent PO injection was 24.2 % [interquartile range (IQR): 21.5-25.8 %]. In a multivariable generalized estimating equation model, Caucasian ethnicity, heroin injection, and drug dealing were positively associated with PO injection, while older age and methadone maintenance treatment were negatively associated with PO injection (all p < 0.05). Engagement on antiretroviral therapy was inversely associated with PO injection in a bivariable analysis, but did not remain significant after adjusting for heroin injection. These findings describe a particularly vulnerable sub-group of PWID who may benefit from targeted efforts to both minimize drug-related risk behaviors and support HIV/AIDS treatment.
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Affiliation(s)
- Stephanie Lake
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada
| | - Silvia Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Surita Parashar
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Sacamano PL, Farley JE. Behavioral and Other Characteristics Associated with HIV Viral Load in an Outpatient Clinic. PLoS One 2016; 11:e0166016. [PMID: 27806109 PMCID: PMC5091742 DOI: 10.1371/journal.pone.0166016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/21/2016] [Indexed: 11/18/2022] Open
Abstract
Persons living with HIV (PLWH) who are engaged in care, yet not virally suppressed, represent a risk for transmission and opportunity for risk reduction interventions. This study describes characteristics of an outpatient clinic cohort of PLWH by laboratory confirmed viral suppression status and examines associations with demographics and sexual and drug use behaviors gathered through questionnaire. From a sample of 500 clinic patients, 438 were prescribed antiretroviral treatment (ART) and 62 were not. Among the 438 on ART, 72 (16.4%) were not virally suppressed at the most recent lab draw. Compared to individuals with a suppressed viral load, those that were unsuppressed were more likely to: be black (79.2% vs. 64.2%; p = 0.014); earn below $25,000/year (88.9% vs. 65.0%; p < 0.001); be of a younger age (47.8 vs. 50.0 mean years; p = 0.009); be on opiate substitution (14.1% vs. 6.3%; p = 0.023); and acknowledge poly-substance (38.9% vs. 24.4%; p = 0.012) and excessive alcohol use (13.9% vs. 6.0%; p = 0.019). Conversely, a smaller proportion of those with an unsuppressed viral load had multiple sex partners in the previous 30 days (39.8% vs. 58.5%; p = 0.003). In multivariable regression of those on ART, the prevalence of an unsuppressed viral load was 3% lower with each increasing year of age (aPR: 0.97; 95% CI: 0.95, 0.99) and 47% lower with income over $25,000/year (aPR: 0.33; 95% CI: 0.16, 0.70). In a separate analysis of all 500 subjects, ART was less frequently prescribed to blacks compared to whites, heterosexuals, those with lower education and income, and persons with active substance use. Findings confirm that a large proportion of PLWH and engaged in care were not virally suppressed and continued behaviors that risk transmission, indicating the need for screening, prevention counseling and access to ancillary services to lower the incidence of HIV infections.
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Affiliation(s)
- Paul L. Sacamano
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Jason E. Farley
- Department of Community and Public Health, Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
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12
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Zelaya CE, Le Minh N, Lau B, Latkin CA, Viet Ha T, Minh Quan V, Mo TT, Sripaipan T, Davis WW, Celentano DD, Frangakis C, Go VF. The Effect of a Multi-Level Intervention on the Initiation of Antiretroviral Therapy (ART) among HIV-Infected Men Who Inject Drugs and Were Diagnosed Late in Thai Nguyen, Vietnam. PLoS One 2016; 11:e0161718. [PMID: 27579772 PMCID: PMC5007027 DOI: 10.1371/journal.pone.0161718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 08/09/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Vietnam, an estimated 256,000 people are living with HIV, and 58% of HIV-infections reported are among people who inject drugs (PWID). While antiretroviral therapy (ART) is widely available in Vietnam, marginalized hard-to-reach male PWID, demonstrate significantly reduced and delayed access to ART. METHODS We investigated the effect of a randomized four-arm multi-level intervention trial on ART initiation among male PWID. Our analysis was conducted among a subset of trial participants (n = 136), who were newly diagnosed as HIV-infected, treatment naïve, and eligible for ART (baseline late diagnosis). The trial arms included: 1, standard of care (HIV testing and counseling); 2, structural-level intervention (door-to-door communications and community video screenings); 3, individual-level intervention (counseling plus group support); and 4, individual-level plus structural-level intervention. In a time-to-event analysis, we used a non-parametric approach for competing risks to estimate cumulative incidence function (CIF) for ART initiation (event of interest) by arm and the difference in CIF for each trial arm as compared to Arm 1. Follow-up was conducted at 6, 12, 18 and 24 months. Data collection occurred from 2009 to 2013. FINDINGS By 24-months, 61.0% initiated ART, and 30.9% had died prior to ART initiation. In the first 6 months, participants in arm 4 (individual plus community intervention) had a 28% (95% confidence interval (CI): 6-50%) increased probability of initiating ART. Despite increasing coverage of ART in all arms throughout follow-up, participants in arm 4 retained a 31% (95% CI: 5-56%) increased probability of initiating ART. The individual and community components of the intervention were only effective when delivered together. CONCLUSIONS Marginalized, hard-to-reach men, who do not routinely engage in HIV services, and therefore come into care late, may benefit significantly from both individual counseling and group support, in combination with community-focused stigma reduction, when being referred and attempting to initiate urgently needed ART.
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Affiliation(s)
- Carla E. Zelaya
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, Maryland 21205, United States of America
- * E-mail:
| | - Nguyen Le Minh
- Centre for Preventive Medicine of Thai Nguyen, 971 Duong Tu Minh Road, Thai Nguyen City, Vietnam
| | - Bryan Lau
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, Maryland 21205, United States of America
| | - Carl A. Latkin
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior, and Society, 624 N. Broadway, Hampton House 737, Baltimore, Maryland 21205, United States of America
| | - Tran Viet Ha
- University of North Carolina, No 6, Lane 76, Linh Lang Street, Hanoi, Vietnam
| | - Vu Minh Quan
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, Maryland 21205, United States of America
| | - Thi Tran Mo
- University of North Carolina, No 6, Lane 76, Linh Lang Street, Hanoi, Vietnam
| | - Teerada Sripaipan
- University of North Carolina at Chapel Hill Gillings School of Global Public Health, Department of Health Behavior, 361 Rosenau Hall, Campus Box 7440, Chapel Hill, NC 27599, United States of America
| | - Wendy W. Davis
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, Maryland 21205, United States of America
| | - David D. Celentano
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, Maryland 21205, United States of America
| | - Constantine Frangakis
- Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics, 615 N. Wolfe Street, Room E3642, Baltimore, Maryland 21205, United States of America
| | - Vivian F. Go
- University of North Carolina at Chapel Hill Gillings School of Global Public Health, Department of Health Behavior, 361 Rosenau Hall, Campus Box 7440, Chapel Hill, NC 27599, United States of America
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13
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Nguyen Bich D, Korthuis PT, Nguyen Thu T, Van Dinh H, Le Minh G. HIV Patients' Preference for Integrated Models of Addiction and HIV Treatment in Vietnam. J Subst Abuse Treat 2016; 69:57-63. [PMID: 27568511 DOI: 10.1016/j.jsat.2016.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/29/2016] [Accepted: 07/13/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Integrated care models for HIV and substance use disorder (SUD) care are proposed as a strategy for closing gaps in the HIV care continuum and decreasing HIV transmission. We examined attitudes regarding integration of HIV and SUD treatment among HIV-infected patients with illicit drug and unhealthy alcohol use. METHOD We conducted a cross-sectional survey of HIV-infected patients receiving care at 5 HIV clinics in Hanoi, Vietnam, regarding substance use and attitudes toward HIV and SUD treatment integration. We used multivariate logistic regression to identify correlates of integrated care preference. RESULT Among 312 participants with current or past illicit drug use or unhealthy alcohol use, 81.4% preferred integrated treatment for HIV and SUD. In multivariate analysis, completing a college education (aOR 0.22, 95% CI 0.08, 0.65), risk of depression (aOR 3.51, 95% CI 1.57, 7.87), ever having received medication-assisted treatment for opioid use disorder (aOR 4.20, 95% CI 1.65, 10.69), being comfortable discussing substance use with counselors/nurses (aOR 3.86, 95% CI 1.38, 10.81) and having discussed alcohol use with their health providers (aOR 2.34, 95% CI 1.09, 4.99) were associated with patients' preference for integrated care, after adjusting for age and gender. CONCLUSION Most, but not all, HIV-infected patients with substance use preferred integrated HIV and SUD treatment. Our findings suggest that policies to expand integration of HIV and SUD treatment will be well received by most patients, and that stand-alone treatment options should be preserved for a significant minority.
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Go VF, Morales GJ, Mai NT, Brownson RC, Ha TV, Miller WC. Finding what works: identification of implementation strategies for the integration of methadone maintenance therapy and HIV services in Vietnam. Implement Sci 2016; 11:54. [PMID: 27097726 PMCID: PMC4837557 DOI: 10.1186/s13012-016-0420-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 04/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background Integration of methadone maintenance therapy (MMT) and HIV services is an evidence-based intervention (EBI) that benefits HIV care and reduces costs. While MMT/HIV integration is recommended by the World Health Organization and the Centers for Disease Control and Prevention, it is not widely implemented, due to organizational and operational barriers. Our study applied an innovative process to identify implementation strategies to address these barriers. Methods Our process was adapted from the Expert Recommendations for Implementing Change (ERIC) protocol and consisted of two main phases. In Phase 1, we conducted 16 in-depth interviews with stakeholders and developed matrices to display barriers to integration. In Phase 2, we selected implementation strategies that addressed the barriers identified in Phase 1 and conducted a poll to vote on the most important and feasible strategies among a panel with expertise in cultural context and implementation science. Results Barriers fell into two broad categories: policy and programmatic. At the policy level, barriers included lack of a national mandate, different structures (MMT vs. HIV clinic) for cost reimbursement and staff salaries, and resistance on the part of staff to take on additional tasks without compensation. Programmatic barriers included the need for cross-training in MMT and HIV tasks, staff accountability, and commitment from local leaders. In Phase 2, we focused on programmatic challenges. Based on voting results and iterative dialogue with our expert panel, we selected several implementation strategies in the domains of technical assistance, staff accountability, and local commitment that targeted these barriers. Conclusions Key programmatic barriers to MMT/HIV integration in Vietnam may be addressed through implementation strategies that focus on technical assistance, staff accountability, and local commitment. Our process of identifying implementation strategies was simple, low cost, and potentially replicable to other settings. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0420-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vivian F Go
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA.
| | - Giuliana J Morales
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Nguyen Tuyet Mai
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University, St. Louis, MO, USA.,Division of Public Health Sciences and Alvin J. Siteman Cancer Center, School of Medicine, Washington University, St. Louis, MO, USA
| | - Tran Viet Ha
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - William C Miller
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA.,Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Current affiliation: Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
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15
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Nosyk B, Min JE, Evans E, Li L, Liu L, Lima VD, Wood E, Montaner JSG. The Effects of Opioid Substitution Treatment and Highly Active Antiretroviral Therapy on the Cause-Specific Risk of Mortality Among HIV-Positive People Who Inject Drugs. Clin Infect Dis 2015; 61:1157-65. [PMID: 26113656 DOI: 10.1093/cid/civ476] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 04/29/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prior studies indicated opioid substitution treatment (OST) reduces mortality risk and improves the odds of accessing highly active antiretroviral therapy (HAART); however, the relative effects of these treatments for human immunodeficiency virus (HIV)-positive people who inject drugs (PWID) are unclear. We determine the independent and joint effects of OST and HAART on mortality, by cause, within a population of HIV-positive PWID initiating HAART. METHODS Using a linked population-level database for British Columbia, Canada, we used time-to-event analytic methods, including competing risks models, proportional hazards models with time-varying covariates, and marginal structural models, to identify the independent and joint effects of OST and HAART on all-cause as well as drug- and HIV-related mortality, controlling for covariates. RESULTS Among 1727 HIV-positive PWID, 493 (28.5%) died during a median 5.1 years (interquartile range, 2.1-9.1) of follow-up: 18.7% due to drug-related causes, 55.8% due to HIV-related causes, and 25.6% due to other causes. Standardized mortality ratios were 12.2 (95% confidence interval [CI], 9.8, 15.0) during OST and 30.0 (27.1, 33.1) during periods out of OST. Both OST (adjusted hazard, 0.34; 95% CI, .23, .49) and HAART (0.39 [0.31, 0.48]) decreased the hazard of all-cause mortality; however, individuals were at lowest risk of death when these medications were used jointly (0.16 [0.10, 0.26]). Both OST and HAART independently protected against HIV-related death, drug-related death and death due to other causes. CONCLUSIONS While both OST and HAART are life-saving treatments, joint administration is urgently needed to protect against both drug- and HIV-related mortality.
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Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | - Elizabeth Evans
- University of California-Los Angeles Integrated Substance Abuse Programs
| | - Libo Li
- University of California-Los Angeles Integrated Substance Abuse Programs
| | - Lei Liu
- Department of Preventative Medicine, Northwestern University, Chicago, Illinois
| | - Viviane D Lima
- BC Centre for Excellence in HIV/AIDS, Vancouver Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Evan Wood
- BC Centre for Excellence in HIV/AIDS, Vancouver Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, Vancouver Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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16
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Tsuyuki K, Surratt HL, Levi-Minzi MA, O'Grady CL, Kurtz SP. The Demand for Antiretroviral Drugs in the Illicit Marketplace: Implications for HIV Disease Management Among Vulnerable Populations. AIDS Behav 2015; 19:857-68. [PMID: 25092512 PMCID: PMC4318775 DOI: 10.1007/s10461-014-0856-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The diversion of antiretroviral medications (ARVs) has implications for the integrity and success of HIV care, however little is known about the ARV illicit market. This paper aimed to identify the motivations for buying illicit ARVs and to describe market dynamics. Semi-structured interviews (n = 44) were conducted with substance-involved individuals living with HIV who have a history of purchasing ARVs on the street. Grounded theory was used to code and analyze interviews. Motivations for buying ARVs on the illicit market were: to repurchase ARVs after having diverted them for money or drugs; having limited access or low quality health care; to replace lost or ruined ARVs; and to buy a back-up stock of ARVs. This study identified various structural barriers to HIV treatment and ARV adherence that incentivized ARV diversion. Findings highlight the need to improve patient-provider relationships, ensure continuity of care, and integrate services to engage and retain high-needs populations.
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Affiliation(s)
- Kiyomi Tsuyuki
- Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, 2 NE 40th Street, Suite 404, Miami, FL, 33137, USA,
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17
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Merlin JS, Walcott M, Kerns R, Bair MJ, Burgio KL, Turan JM. Pain self-management in HIV-infected individuals with chronic pain: a qualitative study. PAIN MEDICINE 2015; 16:706-14. [PMID: 25645646 DOI: 10.1111/pme.12701] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Chronic pain in individuals with HIV is a common, impairing condition. Behavioral interventions for chronic pain specifically tailored to this population have yet to be developed. We assert that understanding self-management strategies already used by persons living with these conditions is an essential first step, and is the objective of this investigation. DESIGN We conducted a thematic analysis of qualitative data from 25 in-depth interviews with individuals with HIV and chronic pain. RESULTS The primary pain self-management strategies articulated by participants were: physical activity; cognitive and spiritual strategies; spending time with family and friends and social support; avoidance of physical/social activity; medication-centric pain management; and substance use. CONCLUSIONS Some of these strategies may be viewed as beneficial and overlap with known HIV self-management strategies (cognitive strategies), whereas others may have negative health consequences (substance use). Interventions that incorporate healthy self-management strategies may be particularly effective in improving both HIV and pain outcomes.
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Affiliation(s)
- Jessica S Merlin
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
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18
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Landovitz RJ, Fletcher JB, Shoptaw S, Reback CJ. Contingency management facilitates the use of postexposure prophylaxis among stimulant-using men who have sex with men. Open Forum Infect Dis 2015; 2:ofu114. [PMID: 25884003 PMCID: PMC4396429 DOI: 10.1093/ofid/ofu114] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2014] [Indexed: 12/04/2022] Open
Abstract
Compared to a control behavioral intervention, Contingency Management, an escalating voucher-based incentive system to reinforce stimulant abstinence, better supported MSM stimulant users in PEP course completion, decreased stimulant use, and a trend toward fewer condomless sexual acts. Background. Stimulant-using men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) acquisition. Contingency Management (CM) is a robust substance abuse intervention that provides voucher-based incentives for stimulant-use abstinence. Methods. We conducted a randomized controlled trial of CM with postexposure prophylaxis (PEP) among stimulant-using MSM. Participants were randomized to CM or a noncontingent “yoked” control (NCYC) intervention and observed prospectively. Generalized linear models were used to estimate the effect of CM on PEP course completion, medication adherence, stimulant use, and sexual risk behaviors. Results. At a single site in Los Angeles, 140 MSM were randomized to CM (n = 70) or NCYC (n = 70). Participants were 37% Caucasian, 37% African American, and 18% Latino. Mean age was 36.8 (standard deviation = 10.2) years. Forty participants (29%) initiated PEP after a high-risk sexual exposure, with a mean exposure-to-PEP time of 32.9 hours. PEP course completion was greater in the CM group vs the NCYC group (adjusted odds ratio [AOR] 7.2; 95% confidence interval {CI}, 1.1–47.9), with a trend towards improved medication adherence in the CM group (AOR, 4.3; 95% CI, 0.9–21.9). Conclusions. CM facilitated reduced stimulant use and increased rates of PEP course completion, and we observed a trend toward improved adherence. Participants in the CM group reported greater reductions in stimulant use and fewer acts of condomless anal intercourse than the control group. This novel application of CM indicated the usefulness of combining a CM intervention with PEP to produce a synergistic HIV prevention strategy that may reduce substance use and sexual risk behaviors while improving PEP parameters.
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Affiliation(s)
- Raphael J Landovitz
- UCLA Center for Clinical AIDS Research and Education, David Geffen School of Medicine , University of California
| | | | | | - Cathy J Reback
- Friends Research Institute, Inc., ; UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine , University of California , Los Angeles
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Surratt HL, O'Grady CL, Levi-Minzi MA, Kurtz SP. Medication adherence challenges among HIV positive substance abusers: the role of food and housing insecurity. AIDS Care 2014; 27:307-14. [PMID: 25314042 DOI: 10.1080/09540121.2014.967656] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study examines the prevalence of food/housing insecurity and its association with psychological, behavioral, and environmental factors impacting antiretroviral (ARV) medication adherence and diversion among substance using HIV+ patients in South Florida. Five hundred and three HIV+ substance abusers were recruited through targeted sampling. Participants completed a standardized instrument assessing demographics, mental health status, sex risk behaviors, HIV diagnosis, treatment history and access, ARV adherence and diversion, and attitudes toward health-care providers. Chi-square and t-tests were used to examine differences by food/housing status and a multivariate linear regression model examined food/housing insecurity and its associations to ARV adherence. Food/housing insecurity was reported by 43.3% of the sample and was associated with higher likelihood of severe psychological distress and substance dependence. Nearly 60% reported recent ARV diversion; only 47.2% achieved 95% medication adherence over one week. Food/housing insecure participants had deficits in their HIV care, including less time in consistent care, lower access to medical care, and less favorable attitudes toward care providers. Multivariate linear regression showed food/housing insecurity demonstrated significant main effects on adherence, including lower past week adherence. Medication diversion was also associated with reduced adherence. Our findings suggest that food/housing insecurity operates as a significant driver of ARV non-adherence and diversion in this population. In the pursuit of better long-term health outcomes for vulnerable HIV+ individuals, it is essential for providers to understand the role of food and housing insecurity as a stressor that negatively impacts ARV adherence and treatment access, while also significantly contributing to higher levels of distress and substance dependence.
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Affiliation(s)
- Hilary L Surratt
- a Center for Applied Research on Substance Use & Health Disparities , Nova Southeastern University , Miami , FL , USA
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20
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Vallecillo G, Mojal S, Torrens M, Muga R. Antiretroviral Therapy (ART) Use, Human Immunodeficiency Virus (HIV)-1 RNA Suppression, and Medical Causes of Hospitalization Among HIV-Infected Intravenous Drug Users in the Late ART Era. Open Forum Infect Dis 2014; 1:ofu010. [PMID: 25734084 PMCID: PMC4324207 DOI: 10.1093/ofid/ofu010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/26/2014] [Indexed: 12/04/2022] Open
Abstract
HIV-infected intravenous drug users are admitted to hospital mainly for non-HIV related illnesses in the late ART era. However , current ART use at admission is low and determines hospital discharge diagnoses. Background. Antiretroviral therapy (ART) has reduced the rates and changed the causes of hospital admission. However, human immunodeficiency virus-positive intravenous drug users (HIV-IDU) continue to have increased hospitalizations and discharge diagnosis are less defined in the late ART era. Our aim was to examine ART use, HIV-1 RNA suppression, and hospital discharge diagnoses among HIV-IDU admitted to an urban hospital. Methods. A retrospective analysis was made of HIV-IDU admitted for medical causes for the first time (2006–2010). Surgical, obstetric, or mental (except HIV-associated neurocognitive disorder) diagnoses were excluded. Clinical characteristics, number of admissions, and primary discharge diagnoses were determined for each patient. Results. Three hundred and seventy-five admissions were recorded among 197 hospitalized HIV-IDU. Lifetime prevalence of ART use was 83.2% (164 of 197) and the rate of HIV-1 RNA <50 copies/mL was 38.1% (75 of 197). Primary discharge diagnosis groups were as follows: bacterial infections (59.2%), chronic end-organ damage (16.8%), complications derived from injected drug use (16.8%), malignancies (9.1%), and opportunistic infections (6.6%). Chronic end-organ damage was diagnosed more frequently in patients with HIV-1 RNA <50 copies/mL (36% vs 4.9%; P < .000), and complications derived from injected drug use (23.8% vs 5.3%; P < .0008) and acquired immune deficiency syndrome (AIDS) opportunistic infections (19.8% vs 1.3% P < .019) were usually diagnosed in patients with HIV-1 RNA detectable viral load. Conclusions. Human immunodeficiency virus-positive intravenous drug users are admitted to hospitals mainly for non-AIDS-related illnesses; however, sustained HIV-1 RNA viral load suppression is poor and determines hospital discharge diagnoses. Providers need to be aware of the management of HIV-related comorbidities and reinforce strategies to improve ART retention in this population.
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Affiliation(s)
| | - Sergio Mojal
- Department of Statistics and Operations Research, Parc de Recerca Biomédica de Barcelona, Barcelona, Spain
| | - Marta Torrens
- Drug Addiction Unit of Psychiatry, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Roberto Muga
- Departments of Internal Medicine and Drug Addiction Unit of Psychiatry
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Cao X, Wu Z, Li L, Pang L, Rou K, Wang C, Luo W, Yin W, Li J, McGoogan JM. Mortality among methadone maintenance clients in China: a six-year cohort study. PLoS One 2013; 8:e82476. [PMID: 24349294 PMCID: PMC3861403 DOI: 10.1371/journal.pone.0082476] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 11/02/2013] [Indexed: 11/24/2022] Open
Abstract
Objective To assess the overall mortality of methadone maintenance treatment (MMT) clients in China and its associated factors. Methods A total of 1,511 MMT clients, all of whom enrolled in China's first eight MMT clinics between March and December 2004, were included in this cohort study and followed for approximately six years, until June 2010. Mortality and its predictors were examined using Cox proportional hazards regression models. Results A total of 154 deaths were observed within 5,391 person-years (PY) of follow-up for an all-cause mortality rate of 28.6 per 1,000 PY. The leading causes of death were drug overdose (33.8%), HIV/AIDS-unrelated disease (21.4%), and HIV/AIDS (16.9%). The all-cause mortality rate of clients engaged in MMT for one year or less was roughly three times that of clients who stayed in MMT for four years or more (14.0 vs. 4.6, p<0.0001), HIV-positive subjects was nearly four times mortality rate than that of HIV-negative individuals (28.1 vs.6.8, p<0.0001). ART-naive HIV-positive subjects had approximately two times higher mortality rate than those receiving ART (31.2 vs. 17.3, <0.0001). After adjusting for confounding variables, we found that being male (HR = 1.63, CI: 1.03–2.57, p = 0.0355) and being HIV-positive (HR = 5.16, CI: 3.70–7.10, p<0.0001) were both associated with higher risk of death whereas increased durations of methadone treatment were associated with a lower risk of death (HR = 0.26, CI: 0.18–0.38, p<0.0001 for two to three years, HR = 0.08, CI: 0.05–0.14, p<0.0001 for four or more years). Conclusion Overall mortality was high among MMT clients in China. Specific interventions aimed at decreasing mortality among MMT clients are needed. Our study supports the need for keeping client at MMT longer and for expanding ART coverage and suggests the potential benefits of integrated MMT and ART services for drug users in China.
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Affiliation(s)
- Xiaobin Cao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- * E-mail:
| | - Li Li
- Semel Institute Center for Community Health, University of California Los Angeles, Los Angeles, California, United States of America
| | - Lin Pang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Keming Rou
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Changhe Wang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Wei Luo
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Wenyuan Yin
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jianhua Li
- Yunnan Institute of Drug Abuse, Kunming, Yunnan, China
| | - Jennifer M. McGoogan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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22
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Langkilde A, Petersen J, Klausen HH, Henriksen JH, Eugen-Olsen J, Andersen O. Inflammation in HIV-infected patients: impact of HIV, lifestyle, body composition, and demography - a cross sectional cohort study. PLoS One 2012; 7:e51698. [PMID: 23251607 PMCID: PMC3519691 DOI: 10.1371/journal.pone.0051698] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 11/05/2012] [Indexed: 01/04/2023] Open
Abstract
Objectives To examine mechanisms underlying the increased inflammatory state of HIV-infected patients, by investigating the association of HIV-related factors, demography, lifestyle, and body composition with the inflammatory marker soluble urokinase plasminogen activator receptor (suPAR). Methods suPAR was measured in EDTA-plasma and associated with HIV-related factors (HIV-duration, combination antiretroviral treatment (cART), nadir CD4+ cell count, CD4+ cell count, and HIV RNA); demography; lifestyle; and body composition determined by Dual energy X-ray Absorptiometry (DXA) scan, in multiple linear regression analyses adjusted for biological relevant covariates, in a cross-sectional study of 1142 HIV-infected patients. Results Increased suPAR levels were significantly associated with age, female sex, daily smoking, metabolic syndrome and waist circumference. cART was associated with 17% lower suPAR levels. In cART-treated patients 10-fold higher HIV RNA was associated with 21% higher suPAR, whereas there was no association in untreated patients. Patients with CD4+ cell count<350 cells/µL had 7% higher suPAR, but we found no association with nadir CD4+ cell count or with duration of HIV-infection. Finally, suPAR was not associated with adipose tissue distribution, but strongly associated with low muscle mass. In patients infected through intravenous drug use (IDU), CD4+ cell counts<350 cells/µL were associated with 27% lower suPAR (p = 0.03), and suPAR was 4% lower pr. year during treatment (p = 0.05); however, there was no association with HIV RNA, duration of HIV-infection, nor cART. Conclusion We found elevated suPAR levels in untreated patients compared to patients on cART. Moreover, we observed a significant positive association between suPAR and HIV RNA levels in cART-treated patients. Age, HIV-transmission through IDU, metabolic syndrome, smoking, and low leg muscle mass were also significantly associated with suPAR levels. Our study therefore indicates, that also other aspects of living with HIV than virologic and immunologic markers add to the increased inflammation in HIV-infected patients.
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Affiliation(s)
- Anne Langkilde
- Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark.
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23
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Landovitz RJ, Fletcher JB, Inzhakova G, Lake JE, Shoptaw S, Reback CJ. A novel combination HIV prevention strategy: post-exposure prophylaxis with contingency management for substance abuse treatment among methamphetamine-using men who have sex with men. AIDS Patient Care STDS 2012; 26:320-8. [PMID: 22680280 DOI: 10.1089/apc.2011.0432] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Methamphetamine use has been associated with HIV transmission among men who have sex with men (MSM). However, providers have been hesitant to utilize post-exposure prophylaxis (PEP) in populations of stimulant users. This single-arm, open label pilot study sought to demonstrate the safety, feasibility, and acceptability of PEP combined with the drug abstinence intervention of contingency management (CM) in methamphetamine-using MSM. HIV-uninfected MSM reporting recent methamphetamine use were recruited to a CM intervention. Those who reported a recent high-risk sexual or injection drug exposure to an HIV-infected or serostatus unknown source were initiated on tenofovir/emtricitabine (Truvada)-based PEP. Participants were followed over 3 months for infectious/biologic, behavioral, and drug use outcomes. Fifty-three participants enrolled in the study; 35 participants (66%) initiated PEP after a high-risk exposure. The median time from exposure to medication administration was 37.8 h (range 12.5-68.0 h). Twenty-five (71.4%) PEP initiators successfully completed the treatment course. Median medication adherence was 96% (IQR 57-100%), and medication was generally well tolerated. Methamphetamine abstinence during CM treatment increased PEP adherence (2% [95% CI +1-+3%]) per clean urine toxicology sample provided), and increased the odds of PEP course completion (OR 1.17, 95% CI 1.04-1.31). One incident of HIV seroconversion was observed in a participant who did not complete PEP treatment, and reported multiple subsequent exposures. Findings demonstrate that PEP, when combined with CM, is safe, feasible, and acceptable as an HIV prevention strategy in methamphetamine-using MSM.
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Affiliation(s)
- Raphael J. Landovitz
- UCLA Center for Clinical AIDS Research & Education, David Geffen School of Medicine, University of California, Los Angeles, California
| | | | | | - Jordan E. Lake
- UCLA Center for Clinical AIDS Research & Education, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Steven Shoptaw
- Department of Family Medicine, University of California, Los Angeles, California
| | - Cathy J. Reback
- Friends Research Institute, Inc., Los Angeles, California
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, California
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24
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Wiederin JL, Yu F, Donahoe RM, Fox HS, Ciborowski P, Gendelman HE. Changes in the plasma proteome follows chronic opiate administration in simian immunodeficiency virus infected rhesus macaques. Drug Alcohol Depend 2012; 120:105-12. [PMID: 21821369 PMCID: PMC3245805 DOI: 10.1016/j.drugalcdep.2011.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 07/06/2011] [Accepted: 07/07/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Substantive plasma proteomic changes follow lentiviral infection and disease pathobiology. We posit that such protein alterations are modified during drug abuse, further serving to affect the disease. To this end, we investigated the effect of opiate administration on the plasma proteome of Indian-strain rhesus monkeys infected with simian immunodeficiency virus (SIV) strain smm9. METHODS Whole blood was collected at 7 weeks prior to and 1.4 and 49 weeks after viral infection. Viral load, CD4(+) T cell subsets, and plasma protein content were measured from monkeys that did or did not receive continuous opiate administrations. The plasma proteome was identified and quantified by isobaric tags for relative and absolute quantitation labeling (iTRAQ) and mass spectrometry. RESULTS While substantive changes in plasma proteins were seen during SIV infection, the addition of opiates led to suppression of these changes as well as increased variance of the proteome. These changes demonstrate that opiates induce broad but variant immune suppression in SIV-infected monkeys. CONCLUSION The broad suppressive changes seen in plasma of SIV-infected monkeys likely reflect reduced multisystem immune homeostatic responses induced by opiates. Such occur as a consequence of complex cell-to-cell interactions operative between the virus and the host. We conclude that such changes in plasma proteomic profiling may be underappreciated and as such supports the need for improved clinical definitions.
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Affiliation(s)
- Jayme L. Wiederin
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
| | - Fang Yu
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
| | - Robert M. Donahoe
- Department of Pathology, University of Utah Medical Center, Salt Lake City, Utah USA 84112-5650
| | - Howard S. Fox
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
| | - Pawel Ciborowski
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
- Corresponding author: Pawel Ciborowski, Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, 985800 Nebraska Medical Center, Omaha, NE 68198-5880, Phone: 402 559 8920; FAX 402 559 3744;
| | - Howard E. Gendelman
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
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25
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Kipp AM, Desruisseau AJ, Qian HZ. Non-injection drug use and HIV disease progression in the era of combination antiretroviral therapy. J Subst Abuse Treat 2011; 40:386-96. [PMID: 21353444 DOI: 10.1016/j.jsat.2011.01.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Revised: 10/11/2010] [Accepted: 01/06/2011] [Indexed: 11/18/2022]
Abstract
Little is known about the effects of non-injection drug use (NIDU) on HIV antiretroviral treatment outcomes. We conducted a systematic literature search and identified nine publications from prospective cohort studies investigating the relationship between NIDU and clinical HIV disease progression. Hazard ratios from studies estimating the effect of drug use on time to AIDS-related mortality ranged from 0.89 to 3.61, and only two of these were statistically significant. Hazard ratios from studies assessing time to an AIDS-defining event ranged from 1.19 to 2.51, with 8 of the 14 estimates falling between 1.55 and 1.65 regardless of drug use definition and measurement of use or frequency. It is suggested that NIDU may have a moderate effect of increasing the risk of progression to AIDS, but its impact on AIDS-related mortality is uncertain. NIDU may affect HIV antiretroviral treatment outcomes primarily through interaction with antiretroviral therapy and, to a lesser extent, through immune modulation and deterioration of general health. The limitations about published studies are discussed, and future perspectives on research on this topic are provided.
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Affiliation(s)
- Aaron M Kipp
- Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37203, USA
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26
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Proeschold-Bell RJ, Heine A, Pence BW, McAdam K, Quinlivan EB. A cross-site, comparative effectiveness study of an integrated HIV and substance use treatment program. AIDS Patient Care STDS 2010; 24:651-8. [PMID: 20846009 DOI: 10.1089/apc.2010.0073] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Co-occurrence of HIV and substance abuse is associated with poor outcomes for HIV-related health and substance use. Integration of substance use and medical care holds promise for HIV patients, yet few integrated treatment models have been reported. Most of the reported models lack data on treatment outcomes in diverse settings. This study examined the substance use outcomes of an integrated treatment model for patients with both HIV and substance use at three different clinics. Sites differed by type and degree of integration, with one integrated academic medical center, one co-located academic medical center, and one co-located community health center. Participants (n=286) received integrated substance use and HIV treatment for 12 months and were interviewed at 6-month intervals. We used linear generalized estimating equation regression analysis to examine changes in Addiction Severity Index (ASI) alcohol and drug severity scores. To test whether our treatment was differentially effective across sites, we compared a full model including site by time point interaction terms to a reduced model including only site fixed effects. Alcohol severity scores decreased significantly at 6 and 12 months. Drug severity scores decreased significantly at 12 months. Once baseline severity variation was incorporated into the model, there was no evidence of variation in alcohol or drug score changes by site. Substance use outcomes did not differ by age, gender, income, or race. This integrated treatment model offers an option for treating diverse patients with HIV and substance use in a variety of clinic settings. Studies with control groups are needed to confirm these findings.
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Affiliation(s)
| | - Amy Heine
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Brian Wells Pence
- Department of Community and Family Medicine, Global Health Institute, Duke University, Durham, North Carolina
| | - Keith McAdam
- Department of Psychiatry, Duke University, Durham, North Carolina
| | - Evelyn Byrd Quinlivan
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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27
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Larsen MV, Omland LH, Gerstoft J, Røge BT, Larsen CS, Pedersen G, Obel N, Kronborg G. Impact of injecting drug use on response to highly active antiretroviral treatment in HIV-1-infected patients: a nationwide population-based cohort study. ACTA ACUST UNITED AC 2010; 42:917-23. [PMID: 20840000 DOI: 10.3109/00365548.2010.511258] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The objective of this study was to determine the effect of highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV)-infected patients infected through injecting drug use (injecting drug users, IDUs) compared to patients infected via other routes (non-IDUs). We conducted a nationwide population-based cohort study of all HIV-infected patients who initiated HAART during the study period of 1 January 1995 to 31 December 2007. We compared changes in CD4(+) cell counts, percentage of full viral suppression (< 500 copies/ml) and mortality from start of HAART, as well as differences in initial HAART regimen. Three thousand six hundred and fifteen patients were included in the study, representing 22,804 person-y of observation. A total of 346 (9.6%) were categorized as IDUs. Of IDUs, 55% gained full viral control within the first y after HAART compared to 76% of non-IDUs (p = 0.0002). Absolute CD4(+) cell count and survival were lower for IDUs compared to non-IDUs (adjusted mortality rate ratio 3.6 (95% CI 2.9-4.3)). IDUs were more likely to receive a first regimen based on protease inhibitors (PIs) compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens for non-IDUs, and IDUs initiated HAART later than non-IDUs. In conclusion, more than half of the HIV-infected patients in Denmark infected through injecting drug use gained full viral suppression after initiating HAART. Absolute CD4(+) cell count was lower and mortality higher among IDUs than non-IDUs.
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Affiliation(s)
- Mette Vang Larsen
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark.
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28
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Nijhawan A, Kim S, Rich JD. Management of HIV infection in patients with substance use problems. Curr Infect Dis Rep 2010; 10:432-8. [PMID: 18687208 DOI: 10.1007/s11908-008-0068-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although highly active antiretroviral therapy (HAART) has greatly reduced overall morbidity and mortality in patients with HIV, patients with substance use issues have been less likely than other patients with HIV to realize these benefits. Social obstacles (eg, lack of housing, minimal social support), and medical comorbidities (eg, mental illness, hepatitis), complicate the management of this group of patients. Not only are drug and alcohol users less likely to access medical care, initiation of HAART may be delayed due to concerns for adherence and the potential development of drug resistance. Ultimately, a multidisciplinary comprehensive approach is needed to both engage and retain this population in care. Through the integration of case management, addiction therapy, and medical treatment of HIV, we may be able to improve outcomes for patients with HIV and addiction.
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Affiliation(s)
- Ank Nijhawan
- Brown Medical School, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA
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29
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Larsen MV, Omland LH, Gerstoft J, Larsen CS, Jensen J, Obel N, Kronborg G. Impact of injecting drug use on mortality in Danish HIV-infected patients: a nation-wide population-based cohort study. Addiction 2010; 105:529-35. [PMID: 20402997 DOI: 10.1111/j.1360-0443.2009.02827.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To estimate the impact of injecting drug use (IDU) on mortality in HIV-infected patients in the highly active antiretroviral therapy (HAART) era. DESIGN Population-based, nation-wide prospective cohort study in Denmark (the Danish HIV Cohort Study). METHODS A total of 4578 HIV-infected patients were followed from 1 January 1997 or date of HIV diagnosis. We calculated mortality rates stratified on IDU. One-, 5- and 10-year survival probabilities were estimated by Kaplan-Meier methods, and Cox regression analyses were used to estimate mortality rate ratios (MRR). RESULTS Of the patients, 484 (10.6%) were categorized as IDUs and 4094 (89.4%) as non-IDUs. IDUs were more likely to be women, Caucasian, hepatitis C virus (HCV) co-infected and younger at baseline; 753 patients died during observation (206 IDUs and 547 non-IDUs). The estimated 10-year survival probabilities were 53.2% [95% confidence interval (CI): 48.1-58.3] in the IDU group and 82.1% (95% CI: 80.7-83.6) in the non-IDU group. IDU as route of HIV infection more than tripled the mortality in HIV-infected patients (MRR: 3.2; 95% CI: 2.7-3.8). Adjusting for potential confounders did not change this estimate substantially. The risk of HIV-related death was not increased in IDUs compared to non-IDUs (MRR 1.1; 95% CI 0.7-1.7). CONCLUSIONS Although Denmark's health care system is tax paid and antiretroviral therapy is provided free of charge, HIV-infected IDUs still suffer from substantially increased mortality in the HAART era. The increased risk of death seems to be non-HIV-related and is due probably to the well-known risk factors associated with intravenous drug abuse.
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Affiliation(s)
- Mette V Larsen
- Department of Infectious Diseases, Copenhagen University Hospital, DK - 2650 Hvidovre, Denmark.
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30
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Current World Literature. Curr Opin Allergy Clin Immunol 2008; 8:590-3. [DOI: 10.1097/aci.0b013e32831ceb82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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