Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches

First experience of liver transplantation for HIV-positive patients in Russia

The article presents the results of liver transplantation in five HIV-infected recipients with irreversible liver damage. It is shown that four of them survived in the long-term period and are observed in a stable condition, and the only death in the recipient was not related to the HIV infection. The experience in the treatment of these patients was summarized. Analysis of the first results of liver transplantation in HIV-infection in Russia shows its validity and clinical efficacy. The only lethal case is connected with the initial extremely grave condition of the recipient and his age. Two cases of surgical traumatism, lack of consistent vaccination in the preoperative period, as well as lack of patients with hepatocellular cancer, small number of observations are obvious drawbacks of our first experience and should be corrected in the future. The success of a complex and multidisciplinary program of organ transplantation in HIV infection is impossible without participation of HIV-infectionists in the transplantation team.

Patient and health-care provider experience of a person-centred, multidisciplinary, psychosocial support and harm reduction programme for patients with harmful use of alcohol and drug-resistant tuberculosis in Minsk, Belarus

Background

Tuberculosis (TB) often concentrates in groups of people with complex health and social issues, including alcohol use disorders (AUD). Risk of TB, and poor TB treatment outcomes, are substantially elevated in people who have AUD. Médecins sans Frontières and the Belarus Ministry of Health have worked to improve treatment adherence in patients with multi-drug or rifampicin resistant (MDR/RR)-TB and harmful use of alcohol. In 2016, a person-centred, multidisciplinary, psychosocial support and harm reduction programme delivered by TB doctors, counsellors, psychiatrists, health-educators, and social workers was initiated. In 2020, we described patient and provider experiences within the programme as part of a wider evaluation.

Methods

We recruited 12 patients and 20 health-care workers, using purposive sampling, for in-depth individual interviews and focus group discussions. We used a participant-led, flexible, exploratory approach, enabling participants and the interviewer to shape topics of conversation. Qualitative data were coded manually and analysed thematically. As part of the analysis process, identified themes were shared with health-care worker participants to enable their reflections to be incorporated into the findings.

Results

Key themes related to the patients’ and practitioners experience of having and treating MDRTB with associated complex health and social issues were: fragility and despair and guidance, trust and health. Prejudice and marginalisation were global to both themes. Counsellors and other health workers built a trusting relationship with patients, enabling guidance through a multi-disciplinary approach, which supported patients to achieve their vision of health. This guidance was achieved by a team of social workers, counsellors, doctors and health-educators who provided professional and individualised help for patients’ illnesses, personal or interpersonal problems, administrative tasks, and job searches.

Conclusions

Patients with MDR/RR-TB and harmful use of alcohol faced complex issues during treatment. Our findings describe how person-centred, multi-disciplinary, psychosocial support helped patients in this setting to cope with these challenges and complete the treatment programme. We recommend that these findings are used to: i) inform programmatic changes to further boost the person-centred care nature of this program; and ii) advocate for this type of person-centred care approach to be rolled out across Belarus, and in contexts that face similar challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08525-x.

Integrating Hepatitis C Virus Treatment Programs Within Community Mental Health

Conventional models of health care for the hepatitis C virus (HCV) underserve people with serious mental illness. In a 6-month proof-of-concept study, colocated HCV care coordination was assessed within community mental health settings. The program, which relied on referrals to a visiting hepatologist and was augmented by a part-time nurse practitioner, received 18 referrals for HCV management. From this group, 11 individuals achieved sustained virological response at 12 weeks after direct-acting antiviral therapy. Seven individuals declined treatment or were lost to follow-up. Overall, colocated integrated services may play an important role in HCV health care parity for people with serious mental illness.

COVID ‐19 vaccination coverage and vaccine hesitancy among people with opioid use disorder in Barcelona, Spain

Introduction

People with substance use disorders are considered a priority group for SARS‐CoV‐2 vaccination as they are at elevated risk of COVID‐19 and its severe complications. However, data are scarce about vaccination coverage in a real‐world setting.

Methods

A descriptive study was conducted in people with opioid use disorder (OUD) from three public centres for outpatient drug addiction treatment in Barcelona, Spain, who received brief medical advice and were referred to vaccination clinic sites.

Results

Three hundred and sixty‐two individuals were included: 277 (77%) were men with a mean age of 48.1 ± 8.9 years and 77% were Spanish. Most (90%) participants engaged in polysubstance use and all individuals were on opioid agonist therapy. Psychiatric comorbidity was present in 56% subjects and 32% individuals had ≥1 chronic disease, 30% had HIV and 13% hepatitis C. There were 258 fully vaccinated individuals (71%; 95% confidence interval [CI] 67, 76). Age (odds ratio [OR] 1.04; 95% CI 1.01, 1.08; P < 0.01) and Charlson Comorbidity Index (OR 1.67; 95% CI 1.11, 2.5; P < 0.01) were associated with full vaccination. The vaccination hesitancy causes cited were complacency (53, 51%), convenience (40, 39%) and confidence (11, 10%).

Discussion and Conclusions

More than two‐thirds of our sample of people with OUD were fully vaccinated. Complacency and convenience represented a significant barrier to complete vaccination among people with OUD on opioid agonist therapy referred to vaccination clinic sites. Additional measures are necessary to increase vaccination, especially for younger individuals and those with less medical comorbidity. Integrating vaccination services in drug outpatient centres could be a useful alternative.

Hepatitis C virus in people with serious mental illness: An analysis of the care cascade at a tertiary health service with a pilot 'identify and treat' strategy

BACKGROUND

People with serious mental illness (SMI) are underserved from a hepatitis C Virus (HCV) screening and treatment perspective.

AIMS

To examine the HCV care cascade in people with SMI and to pilot a supported HCV treatment integration program.

METHODS

HCV prevalence was retrospectively analysed from 4,492 consecutive individuals admitted to a tertiary hospital mental health service between January 2017 and December 2018. Sub-cohort analysis of screening patterns and predictors of seropositive infection was performed. Referral pathways and community care integration were analysed for HCV positive individuals, and a prospective community-based 'identify and treat' HCV program was assessed.

RESULTS

Screening for HCV had been performed in 18.6% (835/4,492) of the cohort. Seroprevalence was 4.6% (207/4,492). HCV seropositivity was associated with age > 40-years (OR = 9.30, CI 3.69-23.45, p <0.01), injecting drug use (IDU) (OR = 24.26, CI 8.99-65.43, p <0.01), and previous incarceration (OR = 12.26, 4.51-33.31, p <0.01). In a cohort of treatment-eligible individuals, 43.3% (90/208) had neither been referred to specialist services or general practitioners for HCV management. Amongst those referred to specialist services, 64.7% (57/88) did not attend scheduled follow-up, and 48.3% (15/31) of attendees were lost to follow-up. Through an intensified community access program, 10 people were successfully treated for HCV, though 22 could not be engaged.

CONCLUSION

People with SMI are underserved by traditional models of HCV healthcare. Intensified community-based support can partially bolster the treatment cascade, though investment in innovative screening and management strategies are required to achieve healthcare parity. This article is protected by copyright. All rights reserved.

Correlates of Self-Reported HIV Testing Among Patients in Specialized Substance Abuse Treatment Centers in South Africa

Substance use is a recognized risk factor for HIV acquisition, transmission and progression in South Africa. Persons who use drugs (PWUD) and access specialist substance abuse treatment centers (SSATCs) are a potentially critical target group for HIV services because of the severity of their substance use and associated health risks. SSATCs represent an opportunity for integrated programming, particularly HIV testing services (HTS), to reach PWUD who are at an increased risk of or living with HIV. This analysis of national SSATC admission data explores self-reported HIV testing and associated factors to identify coverage gaps and integration opportunities. The South African Community Epidemiology Network on Drug Use (SACENDU) collects routine surveillance data to monitor national treatment admission trends in alcohol and other drug use. SACENDU data from 2012 to 2017 was analyzed using chi-square test of independence and logistic regression to examine associations between HTS, demographic characteristics and substances of use. Of 87,339 treatment admissions, 47.5% (n = 41,481) of patients had not accessed HTS in the prior 12 months. HTS was reported less frequently by patients whose primary substance of use was cannabis or those with polysubstance use (36.9% and 41.1%, respectively). None of the substance use sub-groups reported a testing rate above 70%. Compared to specific reference groups, logistic regression showed those with lower odds of HTS were: 15-19 years (OR = 0.59); had primary-level education (OR = 0.51); were scholars/learners (OR = 0.27); and primarily cannabis users (OR = 0.64). Patients whose primary drug was heroin had higher odds of testing (OR = 2.45) as did those who injected drugs (OR = 2.86). Given the low coverage and decreased odds of self-reported HTS among sub-groups of patients in SSATCs, the integration of HIV services for PWUD should be a priority in South Africa and a focus of the national HIV strategy.

"It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder

Background

Increasingly, treatment for opioid use disorder (OUD) is offered in integrated treatment models addressing both substance use and other health conditions within the same system. This often includes offering medications for OUD in general medical settings. It remains uncertain whether integrated OUD treatment models are preferred to non-integrated models, where treatment is provided within a distinct treatment system. This study aimed to explore preferences for integrated versus non-integrated treatment models among people with OUD and examine what factors may influence preferences.

Methods

This qualitative study recruited participants (n = 40) through Craigslist advertisements and flyers posted in treatment programs across the United States. Participants were 18 years of age or older and scored a two or higher on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool. Each participant completed a demographic survey and a telephone interview. The interviews were coded and content analyzed.

Results

While some participants preferred receiving OUD treatment from an integrated model in a general medical setting, the majority preferred non-integrated models. Some participants preferred integrated models in theory but expressed concerns about stigma and a lack of psychosocial services. Tradeoffs between integrated and non-integrated models were centered around patient values (desire for anonymity and personalization, fear of consequences), the characteristics of the provider and setting (convenience, perceived treatment effectiveness, access to services), and the patient-provider relationship (disclosure, trust, comfort, stigma).

Conclusions

Among this sample of primarily White adults, preferences for non-integrated versus integrated OUD treatment were mixed. Perceived benefits of integrated models included convenience, potential for treatment personalization, and opportunity to extend established relationships with medical providers. Recommendations to make integrated treatment more patient-centered include facilitating access to psychosocial services, educating patients on privacy, individualizing treatment, and prioritizing the patient-provider relationship. This sample included very few minorities and thus findings may not be fully generalizable to the larger population of persons with OUD. Nonetheless, results suggest a need for expansion of both OUD treatment in specialty and general medical settings to ensure access to preferred treatment for all.

The Hepatitis C-Alcohol Reduction Treatment (Hep ART) intervention: Study protocol of a multi-center randomized controlled trial

INTRODUCTION

Among patients with hepatitis C virus (HCV) infection, alcohol synergistically increases the risk of cirrhosis, hepatocellular carcinoma, and death. Randomized controlled trials of integrated models of HCV-alcohol treatment have been recommended but only performed in patients with severe alcohol use disorders.

OBJECTIVES

This pragmatic randomized controlled trial seeks to compare clinical effectiveness and cost-effectiveness of integrated alcohol treatment compared to enhanced treatment as usual (TAU) on alcohol consumption and economic outcomes among patients ever infected with HCV.

METHODS

Patients recruited from three liver centers who had current or prior chronic HCV and qualifying alcohol screener scores were randomly assigned to enhanced TAU or the Hepatitis C-Alcohol Reduction Treatment (Hep ART) intervention. All patients received enhanced TAU, consisting of a patient-administered alcohol screener and care from medical providers who were trained in Screening, Brief Intervention and Referral to Treatment (SBIRT), including brief motivational interviewing counseling. The Hep ART intervention combined enhanced TAU with up to six months of integrated co-located individual and/or group therapy that provided motivational, cognitive, and behavioral strategies to reduce alcohol consumption. The Timeline Followback (TLFB) Method was used to evaluate alcohol use at baseline, 3, 6, and 12 months. Primary outcomes are alcohol abstinence and fewer heavy drinking days, and for the cost-effectiveness analysis, measures included grams of alcohol consumed.

DISCUSSION

This study will determine whether Hep ART, a six-month integrated alcohol treatment, compared to enhanced TAU, is both clinically effective and cost-effective in patients with a history of comorbid HCV and alcohol use.

A comprehensive assessment of patient reported symptom burden, medical comorbidities, and functional well being in patients initiating direct acting antiviral therapy for chronic hepatitis C: Results from a large US multi-center observational study

BACKGROUND

Symptom burden, medical comorbidities, and functional well-being of patients with chronic hepatitis C virus (HCV) initiating direct acting antiviral (DAA) therapy in real-world clinical settings are not known. We characterized these patient-reported outcomes (PROs) among HCV-infected patients and explored associations with sociodemographic, liver disease, and psychiatric/substance abuse variables.

METHODS AND FINDINGS

PROP UP is a large US multicenter observational study that enrolled 1,600 patients with chronic HCV in 2016-2017. Data collected prior to initiating DAA therapy assessed the following PROs: number of medical comorbidities; neuropsychiatric, somatic, gastrointestinal symptoms (PROMIS surveys); overall symptom burden (Memorial Symptom Assessment Scale); and functional well-being (HCV-PRO). Candidate predictors included liver disease markers and patient-reported sociodemographic, psychiatric, and alcohol/drug use features. Predictive models were explored using a random selection of 700 participants; models were then validated with data from the remaining 900 participants. The cohort was 55% male, 39% non-white, 48% had cirrhosis (12% with advanced cirrhosis); 52% were disabled or unemployed; 63% were on public health insurance or uninsured; and over 40% had markers of psychiatric illness. The median number of medical comorbidities was 4 (range: 0-15), with sleep disorders, chronic pain, diabetes, joint pain and muscle aches being present in 20-50%. Fatigue, sleep disturbance, pain and neuropsychiatric symptoms were present in over 60% and gastrointestinal symptoms in 40-50%. In multivariable validation models, the strongest and most frequent predictors of worse PROs were disability, unemployment, and use of psychiatric medications, while liver markers generally were not.

CONCLUSIONS

This large multi-center cohort study provides a comprehensive and contemporary assessment of the symptom burden and comorbid medical conditions in patients with HCV treated in real world settings. Pain, fatigue, and sleep disturbance were common and often severe. Sociodemographic and psychiatric markers were the most robust predictors of PROs. Future research that includes a rapidly changing population of HCV-infected individuals needs to evaluate how DAA therapy affects PROs and elucidate which symptoms resolve with viral eradication.

TRIAL REGISTRATION

(Clinicaltrial.gov: NCT02601820).

Listening to both sides: A qualitative comparison between patients with hepatitis C and their healthcare professionals' perceptions of the facilitators and barriers to hepatitis C treatment adherence and completion

This qualitative study compares and contrasts the perspectives of healthcare professionals who treat hepatitis C with those of patients in treatment. Comparative analysis of semi-structured interviews with 20 healthcare professionals and 20 patients undergoing treatment for hepatitis C concluded that patients and healthcare professionals disagreed on the source of communication breakdowns, but both felt that individualised clinical information improved adherence. Stigma was recognised as a barrier to treatment adherence by both patients and healthcare professionals. Limitations of the healthcare system, such as patients receiving inconsistent information and long wait times, negatively impacted both patients and providers.

Interventions to optimise the care continuum for chronic viral hepatitis: a systematic review and meta-analyses

BACKGROUND

Advances in therapy for hepatitis B virus (HBV) and hepatitis C virus (HCV) have ushered in a new era in chronic hepatitis treatment. To maximise the effectiveness of these medicines, individuals must be engaged and retained in care. We analysed operational interventions to enhance chronic viral hepatitis testing, linkage to care, treatment uptake, adherence, and viral suppression or cure.

METHODS

We did a systematic review of operational interventions, and did meta-analyses for sufficiently comparable data. We searched PubMed, Embase, WHO library, International Clinical Trials Registry Platform, PsycINFO, and CINAHL for randomised controlled trials and controlled non-randomised studies that examined operational interventions along the chronic viral hepatitis care continuum, published in English up to Dec 31, 2014. We included non-pharmaceutical intervention studies with primary or secondary outcomes of testing, linkage to care, treatment uptake, treatment adherence, treatment completion, treatment outcome, or viral endpoints. We excluded dissertations and studies of children only. Data were extracted by two independent reviewers, with disagreements resolved by a third reviewer. Studies were assessed for bias. Data from similar interventions were pooled and quality of evidence was assessed using GRADE. This study was registered in PROSPERO (42014015094).

FINDINGS

We identified 7583 unduplicated studies, and included 56 studies that reported outcomes along the care continuum (41 for HCV and 18 for HBV). All studies except one were from high-income countries. Lay health worker HBV test promotion interventions increased HBV testing rates (relative risk [RR] 2·68, 95% CI 1·82-3·93). Clinician reminders to prompt HCV testing during clinical visits increased HCV testing rates (3·70, 1·81-7·57). Nurse-led educational interventions improved HCV treatment completion (1·14, 1·05-1·23) and cure (odds ratio [OR] 1·93, 95% CI 1·44-2·59). Coordinated mental health, substance misuse, and hepatitis treatment services increased HCV treatment uptake (OR 3·03, 1·24-7·37), adherence (RR 1·22, 1·05-1·41), and cure (RR 1·21, 1·07-1·38) compared with usual care.

INTERPRETATION

Several simple, inexpensive operational interventions can substantially improve engagement and retention along the chronic viral hepatitis care continuum. Further operational research to inform scale-up of hepatitis services is needed in low-income and middle-income countries.

FUNDING

World Health Organization and US Fulbright Program.

HIV Patients' Preference for Integrated Models of Addiction and HIV Treatment in Vietnam

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.

Low Non-structured Antiretroviral Therapy Interruptions in HIV-Infected Persons Who Inject Drugs Receiving Multidisciplinary Comprehensive HIV Care at an Outpatient Drug Abuse Treatment Center

Continuous HIV treatment is necessary to ensure successful combined antiretroviral therapy (cART). The aim of this study was to evaluate the incidence of patient-initiated non-structured treatment interruptions in HIV-infected persons who inject drugs and who received a multidisciplinary comprehensive program, including medical HIV care, drug-dependence treatment and psychosocial support, at a drug outpatient addiction center. Non-structured treatment interruptions were defined as ≥30 consecutive days off cART without medical indication. During a median follow-up of 53.8 months, 37/132 (28 %) patients experienced the first non-structured treatment interruptions. The cumulative probability of cART interruption at 5 years was 31.2 % (95 % CI 22.4-40.0). Current drug use injection ≥1/day (HR 14.77; 95 % CI 5.90-36.96) and cART naive patients (HR 0.35, 95 % CI 0.14-0.93) were predictive factors for non-structured treatment interruptions. HIV care provided at a drug addiction center is a useful strategy to sustain continuous cART, however, drug abstinence is essential for the long-term maintenance of cART.

Listening to both sides: A qualitative comparison between patients with hepatitis C and their healthcare professionals' perceptions of the facilitators and barriers to hepatitis C treatment adherence and completion

This qualitative study compares and contrasts the perspectives of healthcare professionals who treat hepatitis C with those of patients in treatment. Comparative analysis of semi-structured interviews with 20 healthcare professionals and 20 patients undergoing treatment for hepatitis C concluded that patients and healthcare professionals disagreed on the source of communication breakdowns, but both felt that individualised clinical information improved adherence. Stigma was recognised as a barrier to treatment adherence by both patients and healthcare professionals. Limitations of the healthcare system, such as patients receiving inconsistent information and long wait times, negatively impacted both patients and providers.

Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse

BACKGROUND & AIMS

Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR).

METHODS

We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR.

RESULTS

Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups.

CONCLUSIONS

Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.

The Demand for Antiretroviral Drugs in the Illicit Marketplace: Implications for HIV Disease Management Among Vulnerable Populations

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.

The Hepatitis C treatment experience: Patients' perceptions of the facilitators of and barriers to uptake, adherence and completion

OBJECTIVE

This study explores the perceptions of patients receiving treatment for Hepatitis C to determine what factors influence their decision to commence treatment, ability to maintain adherence and complete their treatment program.

DESIGN

Semi-structured interview techniques were used in a qualitative study of 20 patients undergoing treatment for Chronic Hepatitis C (CHC).

MAIN OUTCOME MEASURES

To explore patients' perceived barriers and facilitators of Hepatitis C treatment adherence and completion.

RESULTS

Analysis of patient interviews identified four key themes: (1) motivations for commencing CHC treatment - fear of death and ridding themselves of stigma and shame; (2) the influential role of provider communication - patients reported that information and feedback that was personalised to their needs and lifestyles was the most effective for improving adherence to treatment; (3) facilitators of treatment adherence and completion - social, emotional and practical support improved adherence and completion, as did temporarily ceasing employment; (4) barriers to treatment adherence and completion - these included side effects, stigma, a complicated dosing schedule and limitations of the public healthcare system.

CONCLUSION

To increase treatment adherence and completion rates, a patient-centred approach is required that addresses patients' social, practical, and emotional support needs and adaptive coping strategies.

Instrumental support to facilitate hepatitis C treatment adherence: working around shortfalls in shared-care

Adherence to treatment for hepatitis C virus (HCV) infection is associated with the successful eradication of infection. However, patients often have difficulty adhering to HCV treatment because of factors such as the psychiatric side effects of regimens and social disadvantage. Commonly, health professionals including specialist physicians, nurses, social workers and psychologists work together under a multidisciplinary model of shared-care to support patients' adherence to HCV treatment. In some HCV treatment clinics, shared-care is not always available, or only partially implemented and this has implications for patient adherence. To explore the facilitators of adherence, an interview-based study was conducted in 2012 with a purposive sample of Australian physicians and nurses (N = 20). The findings reveal that when comprehensive shared-care was limited or unavailable, physicians and nurses filled in the gaps by assuming roles outside of their expertise to help patients adhere to HCV treatment. Physicians and nurses applied instrumental support strategies based on psychosocial interventions, namely patient advocacy, pragmatic problem-solving, treatment engagement and emotional support. These strategies were provided by dedicated physicians and nurses to address shortfalls in multidisciplinary shared-care. Although these interventions were reported to assist adherence, there is an increased risk of complications when physicians and nurses move beyond the bounds of their disciplinary training, for example, to assess and manage patients' psychiatric side effects or advocate on their behalf for social services. Future research should measure the effectiveness of instrumental support strategies on HCV treatment adherence, and explore the costs associated with physicians and nurses providing instrumental support in the absence of comprehensive multidisciplinary shared-care.

The treatment journey of a patient with multidrug-resistant tuberculosis in South Africa: is it patient-centred?

To improve the treatment of patients co-infected with multidrug-resistant tuberculosis (MDR-TB) and the human immunodeficiency virus, we measured the relationship between treatment outcomes and hospital performance at four decentralised MDR-TB sites in South Africa. We describe hospital performance from the patient's perspective by the use of a graphic that visually represents a patient's treatment journey. The graphic was used to report study findings to study sites and as a catalyst for a quality improvement process.

Association between health systems performance and treatment outcomes in patients co-infected with MDR-TB and HIV in KwaZulu-Natal, South Africa: implications for TB programmes

OBJECTIVE

To improve the treatment of MDR-TB and HIV co-infected patients, we investigated the relationship between health system performance and patient treatment outcomes at 4 decentralised MDR-TB sites.

METHODS

In this mixed methods case study which included prospective comparative data, we measured health system performance using a framework of domains comprising key health service components. Using Pearson Product Moment Correlation coefficients we quantified the direction and magnitude of the association between health system performance and MDR-TB treatment outcomes. Qualitative data from participant observation and interviews analysed using systematic text condensation (STC) complemented our quantitative findings.

FINDINGS

We found significant differences in treatment outcomes across the sites with successful outcomes varying from 72% at Site 1 to 52% at Site 4 (p<0.01). Health systems performance scores also varied considerably across the sites. Our findings suggest there is a correlation between treatment outcomes and overall health system performance which is significant (r = 0.99, p<0.01), with Site 1 having the highest number of successful treatment outcomes and the highest health system performance. Although the 'integration' domain, which measured integration of MDR-TB services into existing services appeared to have the strongest association with successful treatment outcomes (r = 0.99, p<0.01), qualitative data indicated that the 'context' domain influenced the other domains.

CONCLUSION

We suggest that there is an association between treatment outcomes and health system performance. The chance of treatment success is greater if decentralised MDR-TB services are integrated into existing services. To optimise successful treatment outcomes, regular monitoring and support are needed at a district, facility and individual level to ensure the local context is supportive of new programmes and implementation is according to guidelines.

All-cause mortality and liver-related outcomes following successful antiviral treatment for chronic hepatitis C

BACKGROUND

Antiviral therapy for the hepatitis C virus (HCV) reduces all-cause and liver-related morbidity and mortality. Few studies are available from populations with multiple medical and psychiatric comorbidities where the impact of successful antiviral therapy might be limited.

AIM

The purpose of this study was to determine the effect of sustained virologic response (SVR) on all-cause and liver-related mortality in a cohort of HCV patients treated in an integrated hepatitis/mental health clinic.

METHODS

This was a retrospective review of all patients who initiated antiviral treatment for chronic HCV between January 1, 1997 and December 31, 2009. Cox regression analysis was used to determine factors involved in all-cause mortality, liver-related events and hepatocellular carcinoma.

RESULTS

A total of 536 patients were included in the analysis. Median follow-up was 7.5 years. Liver and non-liver-related mortality occurred in 2.7 and 5.0 % of patients with SVR and in 17.8 and 6.4 % of patients without SVR. In a multivariate analysis, SVR was the only factor associated with reduced all-cause mortality (HR 0.47; 95 % CI 0.26-0.85; p = 0.012) and reduced liver-related events (HR 0.23; 95 % CI 0.08-0.66, p = 0.007). Having stage 4 liver fibrosis increased all-cause mortality (HR 2.50; 95 % CI 1.23-5.08; p = 0.011). Thrombocytopenia at baseline (HR 2.66; 95 % CI 1.22-5.79; p = 0.014) and stage 4 liver fibrosis (HR 4.87; 95 % CI 1.62-14.53; p = 0.005) increased liver-related events.

CONCLUSIONS

Despite significant medical and psychiatric comorbidities, SVR markedly reduced liver-related outcomes without a significant change in non-liver-related mortality after a median follow-up of 7.5 years.

Effectiveness of alcohol treatment interventions integrated into routine tuberculosis care in Tomsk, Russia

AIMS

To test the feasibility and effectiveness of brief counseling intervention (BCI) and naltrexone integrated into tuberculosis (TB) care in Tomsk, Russia.

DESIGN

Using a factorial randomized controlled trial design, patients were randomized into: naltrexone (NTX), brief behavioral compliance enhancement therapy (BBCET), treatment as usual (TAU) and BCI.

SETTING AND PARTICIPANTS

In the Tomsk Oblast, hospitalized TB patients diagnosed with alcohol use disorders (AUDs) by the DSM-IV were referred at the start of TB treatment. Of the 196 participants, the mean age was 41 years and 82% were male. Severe TB (84.7% had cavitary disease) and smoking (92.9%) were common. The majority had a diagnosis of an AUD (63.0%); 27.6% reported nearly daily drinking and consumed a median of 16 standard drinks per day.

MEASUREMENTS

Primary outcomes were 'favorable' TB outcome (cured, completed treatment) and change in mean number of abstinent days in the last month of study compared with baseline. Change in mean number of heavy drinking days, defined as four drinks per day and five drinks per day for women and men, respectively, and TB adherence, measured as percentage of doses taken as prescribed under direct observation, were secondary outcomes. Analysis based on 'intention-to-treat' was performed for multivariable analysis.

FINDINGS

Primary TB and alcohol end-points between naltrexone and no-naltrexone or BCI and no-BCI groups did not differ significantly. TB treatment adherence and change in number of heavy drinking days also did not differ significantly among treatment arms. Among individuals with a prior quitting attempt (n = 111), naltrexone use was associated with an increased likelihood of favorable TB outcomes (92.3% versus 75.9%, P = 0.02).

CONCLUSIONS

In Tomsk Oblast, Russia, tuberculosis patients with severe alcohol use disorders who were not seeking alcohol treatment did not respond to naltrexone or behavioral counselling integrated into tuberculosis care; however, those patients with past attempts to quit drinking had improved tuberculosis outcomes.

Investigation of hepatitis B virus and human immunodeficiency virus transmission among severely mentally ill residents at a long term care facility

Background

A high prevalence of hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections have been reported among persons with severe mental illness. In October, 2009, the Cook County Department of Public Health (CCDPH) initiated an investigation following notification of a cluster of HBV infections among mentally ill residents at a long term care facility (LTCF).

Methods

LTCF staff were interviewed and resident medical records were reviewed. Residents were offered testing for HBV, HCV, and HIV. Serum specimens from residents diagnosed with HBV or HIV infection were sent to the Centers for Disease Control and Prevention (CDC) for analysis.

Results

Eleven newly diagnosed HBV infections were identified among mentally ill residents at the LTCF. Of these 11 infections, 4 serum specimens were available for complete HBV genome sequencing; all 4 genomes were found to be closely related. Four newly diagnosed HIV infections were identified within this same population. Upon molecular analysis, 2 of 4 HIV sequences from these new infections were found to be nearly identical and formed a tight phylogenetic cluster.

Conclusions

HBV and HIV transmission was identified among mentally ill residents of this LTCF. Continued efforts are needed to prevent bloodborne pathogen transmission among mentally ill residents in LTCFs.

Chronic hepatitis C and antiviral treatment regimens: where can psychology contribute?

OBJECTIVE

Our goal was to evaluate the existing literature on psychological, social, and behavioral aspects of chronic hepatitis C viral (HCV) infection and antiviral treatment; provide the state of the behavioral science in areas that presently hinder HCV-related health outcomes; and make recommendations for areas in which clinical psychology can make significant contributions.

METHOD

The extant literature on HCV and antiviral therapy was reviewed as related to biopsychosocial factors such as mental health, substance/alcohol use, quality of life, coping, stigma, racial disparities, side effects, treatment adherence, integrated care, and psychological interventions.

RESULTS

For reasons that have not been well elucidated, individuals infected with HCV experience psychological and somatic problems and report poor health-related quality of life. Preexisting conditions, including poor mental health and alcohol/substance use, can interfere with access to and successful completion of HCV treatment. Perceived stigma is highly prevalent and associated with psychological distress. Racial disparities exist for HCV prevalence, treatment uptake, and treatment success. During HCV treatment, patients experience exacerbation of symptoms, treatment side effects, and poorer quality of life, making it difficult to complete treatment. Despite pharmacological advances in HCV treatment, improvements in clinical and public health outcomes have not been realized. The reasons for this lack of impact are multifactorial, but include suboptimal referral and access to care for many patients, treatment-related side effects, treatment nonadherence, and lack of empirically based approaches.

CONCLUSIONS

Biomedical advances in HCV and antiviral treatment have created a fertile field in which psychologists are uniquely positioned to make important contributions to HCV management and treatment.

How unique is continuity of care? A review of continuity and related concepts

BACKGROUND

The concept of 'continuity of care' has changed over time and seems to be entangled with other care concepts, for example coordination and integration of care. These concepts may overlap, and differences between them often remain unclear.

OBJECTIVE

In order to clarify the confusion of tongues and to identify core values of these patient-centred concepts, we provide a historical overview of continuity of care and four related concepts: coordination of care, integration of care, patient-centred care and case management.

METHODS

We identified and reviewed articles including a definition of one of these concepts by performing an extensive literature search in PubMed. In addition, we checked the definition of these concepts in the Oxford English Dictionary.

RESULTS

Definitions of continuity, coordination, integration, patient-centred care and case management vary over time. These concepts show both great entanglement and also demonstrate differences. Three major common themes could be identified within these concepts: personal relationship between patient and care provider, communication between providers and cooperation between providers. Most definitions of the concepts are formulated from the patient's perspective.

CONCLUSIONS

The identified themes appear to be core elements of care to patients. Thus, it may be valuable to develop an instrument to measure these three common themes universally. In the patient-centred medical home, such an instrument might turn out to be an important quality measure, which will enable researchers and policy makers to compare care settings and practices and to evaluate new care interventions from the patient perspective.

Time to rethink antiviral treatment for hepatitis C in patients with coexisting mental health/substance abuse issues

BACKGROUND

A new era has dawned in the treatment of chronic hepatitis C (HCV) virus with the use of direct-acting antiviral medications augmenting combination therapy. Unfortunately, the significant impact of improvements may not be realized if antiviral treatment is not expanded to include a larger proportion of patients, many of whom have coexisting mental health and/or substance abuse issues and have been historically deferred from treatment.

METHODS

We reviewed the extent literature on HCV treatment for individuals with co-occurring mental health and/or substance abuse issues.

RESULTS

A number of empirically-based arguments exist in favor of treating HCV-infected individuals with mental health and/or substance abuse issues within the context of multidisciplinary team approaches. Integrated, collaborative, or hybrid models of care are just a few examples of multidisciplinary approaches that can combine the care of HCV treating providers with mental health and/or addictions providers to safely and effectively treat these patients. Collectively, these arguments and the empirical evidence that supports them, provides a strong rationale for why expanding antiviral therapy to these patients is critical and timely.

CONCLUSIONS

A decade of evidence suggests that HCV-infected individuals with mental health and/or substance abuse issues can safely and effectively undergo antiviral treatment when delivered through multidisciplinary care settings. Multidisciplinary approaches that combine HCV treating providers with mental health, addictions, and other support systems can facilitate preparation and successful treatment of these patients on antiviral therapy.

Social support and clinical outcomes during antiviral therapy for chronic hepatitis C

OBJECTIVE

To determine if social support (SS) is associated with clinical outcomes during antiviral therapy for chronic hepatitis C virus (HCV).

METHODS

Data from 394 patients who participated in the prospective, longitudinal VIRAHEP-C study were examined. VIRAHEP-C enrolled 401 adults with HCV to evaluate factors associated with antiviral treatment response. Perceived SS was measured using the Medical Outcome Study Social Support Survey (MOS-SSS) at baseline and treatment week 24. Scores were calculated as a continuous variable ranging from 0% to 100% with higher scores indicating greater support. Two SS variables were created: (1) baseline SS (BL-SS) and (2) change in SS from baseline to treatment week 24 (CH-SS). The primary endpoint was sustained virological response (SVR) six months post-treatment. Intermediate outcomes included: symptom-reporting; virological response at treatment week 24; medication adherence; neuropsychiatric adverse events; and dose reductions and premature medication discontinuation. The relative risk of each outcome was estimated using modified Poisson regression models or linear mixed models.

RESULTS

BL-SS was relatively high (mean=79%). Overall, SS declined from baseline to treatment week 24 (median change: -1.3%; p<.01). Neither BL-SS nor CH-SS was associated with SVR. However, BL-SS was associated with multiple symptoms (fatigue, headache, irritability, aches/pains) during treatment, even after adjusting for baseline depression, which was significantly associated with symptom-reporting.

CONCLUSIONS

SS was not directly associated with efficacy measures, such as SVR. However, baseline SS predicted an increase in symptomatology over the course of antiviral therapy. Baseline depression was also significantly associated with symptom-reporting.

A randomized controlled trial of an integrated care intervention to increase eligibility for chronic hepatitis C treatment

OBJECTIVES

Mental health and substance abuse (MH/SA) comorbidities are the most oft-cited reasons for deferral from peginterferon (PegIFN) therapy for chronic hepatitis C virus (HCV). We sought to determine whether an integrated care intervention (INT) for patients deferred from PegIFN owing to MH/SA could improve subsequent treatment eligibility rates.

METHODS

In this randomized controlled trial, 101 HCV patients who were evaluated at two hepatology centers and deferred from antiviral therapy owing to MH/SA were enrolled. Participants were randomized to an INT (N=50) or standard of care (SC; N=51). The INT group received counseling and case management for up to 9 months. All participants underwent 3-, 6-, and 9-month clinical follow-up visits, where hepatologists, masked to group, re-evaluated patients for treatment eligibility. Standardized mood and alcohol use instruments were administered to all participants to aid clinicians in treatment decisions.

RESULTS

Of 101 participants, the mean age was 48 years and 50% were men, 61% Caucasian, and 77% genotype 1. Patients were initially deferred owing to psychiatric issues (35%), alcohol abuse (31%), drug abuse (9%), or more than one of these reasons (26%). In an intent-to-treat analysis, 42% (21/50) of INT participants became eligible for therapy compared to 18% (9/51) of SC participants (P=0.009, relative risk (RR)=2.38, 95% confidence interval (CI) (1.21, 4.68)). When baseline predictors significant at P<0.10 in univariate models were entered into multivariate models adjusted for treatment group, only baseline depression remained significant (P=0.05, RR=0.98, 95% CI (0.96, 1.00)). With the exception of a model adjusted for genotype, treatment group remained significant in all models.

CONCLUSIONS

This trial suggests that INTs can increase eligibility for HCV treatment and expand treatment to the underserved population with MH/SA comorbidities.

Prevalence of liver disease in veterans with bipolar disorder or schizophrenia

OBJECTIVE

To assess the prevalence of three liver diseases [hepatitis C virus (HCV), nonalcoholic fatty liver disease and alcohol-induced cirrhosis] in patients (veterans) with/without schizophrenia/schizoaffective disorder and bipolar disorder.

METHODS

A retrospective electronic chart review of Veterans Integrated Services Network 20 facilities from January 1, 2001 to December 21, 2006 selected patients to one of two groups: schizophrenia/schizoaffective disorder or bipolar disorder. Patients in both groups were compared with veterans in an equal-sized random sample from the same data set of veterans without psychiatric diagnoses. Logistic regression models evaluated risk for overall liver diseases as well as HCV, nonalcoholic fatty liver disease and alcoholic-induced cirrhosis.

RESULTS

Patients with schizophrenia (n=6521) had a higher prevalence of liver disease [22.4% versus 3.2%; odds ratio (OR)=8.73]; HCV (16.5% versus 1.9%; OR=10.21); and alcohol-related cirrhosis (1.6% versus 0.4%; OR=4.09) than matched controls. Patients with bipolar disorder (n=5319) had a higher prevalence of liver disease (21.5% versus 3.5%; OR=7.58); HCV (15.5% versus 2.1%; OR=8.60); and alcohol-related cirrhosis (1.6% versus 0.4%; OR=3.82) than matched controls. Risk factors for liver disease in patients with schizophrenia (versus matched controls) included diabetes (OR=1.29), hypertension (OR=1.27), HIV (OR=3.54), substance use disorder (SUD) (OR=2.28), alcohol use disorder (OR=3.05) and schizophrenia (OR=2.74). Risk factors for development of liver disease for patients with bipolar disorder: diabetes (OR=1.40), HIV (OR=3.66), SUD (OR=2.68), alcohol use disorder (OR=3.22) and bipolar disorder (OR=2.27).

CONCLUSIONS

This study in veterans shows that the presence of mental illness and its comorbidities represents a significant risk factor for the diagnosis of liver disease, including HCV and alcohol-related cirrhosis.

TB and HIV integration: obstacles and possible solutions to implementation in South Africa

OBJECTIVES

To identify key obstacles to operational integration of TB and HIV services and to suggest strategies to promote integration in the prevention, treatment and care of patients with TB and HIV.

METHODS

This is a health systems research case study of operational integration of TB and HIV in South Africa. Peer-reviewed and grey literature together with the experiences of the authors were used to identify key obstacles to integration in service implementation practices and community-level care. Relevant legislation, policies and guidelines were analysed to determine whether they facilitated or undermined the integration of TB and HIV services.

RESULTS

Obstacles to integration exist at contextual and epidemiological levels as well as at intervention design and implementation levels. Importantly, integration at an operational level is undermined by fundamentally different principles underpinning the design of TB and HIV programmes and national policies and legislation which mitigate against integration.

CONCLUSION

South Africa has an opportunity to effect changes that will facilitate TB/HIV integration and improve care for all those infected with TB, HIV or both conditions. An analytic approach necessary to understand the obstacles to and ensure effective strategies facilitating integration is required. This needs to be followed by mobilisation of clinical and health systems expertise, health infrastructure, commitment and experience in creative and appropriate ways for the variety of health care settings.

Strategies to improve access to and utilization of health care services and adherence to antiretroviral therapy among HIV-infected drug users

We review five innovative strategies to improve access, utilization, and adherence for HIV-infected drug users and suggest areas that need further attention. In addition, we highlight two innovative programs. The first increases access and utilization through integrated HIV and opioid addiction treatment with buprenorphine in a community health center, and the second incorporates adherence counseling for antiretroviral therapy in methadone programs. Preliminary evaluations demonstrated that these strategies may improve both HIV and opioid addiction outcomes and may be appropriate for wider dissemination. Further refinement and expansion of strategies to improve outcomes of HIV-infected drug users is warranted.

Addressing the HIV-related needs of substance misusers in New York State: the benefits and barriers to implementing a "one-stop shopping" model

Substance misusers are at risk for contracting HIV/AIDS, and substance user treatment programs (SUTPs) are uniquely situated to address their HIV-related needs. In New York State, some SUTPs have implemented a centralized model of substance user treatment and HIV care. We synthesize past literature and use data from semistructured interviews with SUTP staff, analyzed with qualitative software, to describe implementation barriers. These interviews were conducted in 2003-2004 at three SUTPs in Texas and New York as part of a study funded by the National Institutes of Health. With study limitations noted, main implications include a need for a combined medical-addiction treatment philosophy to facilitate multidisciplinary care.

A cross-site, comparative effectiveness study of an integrated HIV and substance use treatment program

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.

Update on mental health issues in patients with HIV infection

HIV infection remains a major world health problem more than 20 years after discovery of the virus. Mental disorders make individuals more vulnerable to behaviors that transmit HIV and interfere with HIV treatment adherence. The evidence supporting the need for optimal provision of mental health care in HIV clinics is mounting, along with evidence that these disorders can be treated successfully. Disorders of mental life include brain diseases (eg, depression, bipolar disorder, schizophrenia, and dementia), personality disorders, addictions, and psychologic disruptions, which contribute to the spread of the virus through their influence on behavior. However, although evidence exists that successful treatment of co-occurring mental disorders leads to improved HIV outcomes, integrated mental health care in HIV clinics remains grossly suboptimal.

Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients: Design and Implementation

BACKGROUND

While the integration of alcohol screening, treatment, and referral in primary care and other medical settings in the U.S. and worldwide has been recognized as a key health care priority, it is not routinely done. In spite of the high co-occurrence and excess mortality associated with alcohol use disorders (AUDs) among individuals with tuberculosis (TB), there are no studies evaluating effectiveness of integrating alcohol care into routine treatment for this disorder.

METHODS

We designed and implemented a randomized controlled trial (RCT) to determine the effectiveness of integrating pharmacotherapy and behavioral treatments for AUDs into routine medical care for TB in the Tomsk Oblast Tuberculosis Service (TOTBS) in Tomsk, Russia. Eligible patients are diagnosed with alcohol abuse or dependence, are newly diagnosed with TB, and initiating treatment in the TOTBS with Directly Observed Therapy-Short Course (DOTS) for TB. Utilizing a factorial design, the Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients (IMPACT) study randomizes eligible patients who sign informed consent into 1 of 4 study arms: (1) Oral Naltrexone + Brief Behavioral Compliance Enhancement Therapy (BBCET) + treatment as usual (TAU), (2) Brief Counseling Intervention (BCI) + TAU, (3) Naltrexone + BBCET + BCI + TAU, or (4) TAU alone.

RESULTS

Utilizing an iterative, collaborative approach, a multi-disciplinary U.S. and Russian team has implemented a model of alcohol management that is culturally appropriate to the patient and TB physician community in Russia. Implementation to date has achieved the integration of routine alcohol screening into TB care in Tomsk; an ethnographic assessment of knowledge, attitudes, and practices of AUD management among TB physicians in Tomsk; translation and cultural adaptation of the BCI to Russia and the TB setting; and training and certification of TB physicians to deliver oral naltrexone and brief counseling interventions for alcohol abuse and dependence as part of routine TB care. The study is successfully enrolling eligible subjects in the RCT to evaluate the relationship of integrating effective pharmacotherapy and brief behavioral intervention on TB and alcohol outcomes, as well as reduction in HIV risk behaviors.

CONCLUSIONS

The IMPACT study utilizes an innovative approach to adapt 2 effective therapies for treatment of alcohol use disorders to the TB clinical services setting in the Tomsk Oblast, Siberia, Russia, and to train TB physicians to deliver state of the art alcohol pharmacotherapy and behavioral treatments as an integrated part of routine TB care. The proposed treatment strategy could be applied elsewhere in Russia and in other settings where TB control is jeopardized by AUDs. If demonstrated to be effective, this model of integrating alcohol interventions into routine TB care has the potential for expanded applicability to other chronic co-occurring infectious and other medical conditions seen in medical care settings.

Adaptations across clinical sites of an integrated treatment model for persons with HIV and substance abuse

Substance use disorders are common among people living with HIV (PLWHA), and PLWHA with untreated substance use are less likely to receive antiretroviral therapy (ART) or achieve viral suppression when ART is prescribed. Integrated behavioral and medical interventions are one approach used to treat complex chronic illnesses, including HIV and substance abuse (SA). As the potential benefit for integrated HIV-substance abuse treatment is recognized, the number of providers attempting to integrate care is growing. Integrated care models can range from coordinated to colocated to fully integrated models. Providers need a better understanding of these implementation options for HIV-substance abuse treatment and how they impact providers of different disciplines. Between April and November 2006, interviews exploring the process of implementing an integrated HIV-substance abuse intervention were completed with clinic staff at three diverse HIV clinics in North Carolina. Key differences in implementation between sites were found. The degree of integrated care between sites ranged from colocated to integrated, and clinic staff perceived each integrated model to have advantages and disadvantages. Recommendations for implementing HIV-SA integrated care are made.

Psychiatric and substance use disorders comorbidities in veterans with hepatitis C virus and HIV coinfection

PURPOSE OF REVIEW

A growing number of veterans in the Veterans Health Administration are coinfected with HIV and hepatitis C virus. This review covers timely research relative to comorbid conditions that are common in this population including psychiatric diagnoses, substance use disorders and neurocognitive problems.

RECENT FINDINGS

Current literature on the psychiatric, substance use disorders and cognitive problems of the coinfected population show that not only are rates of morbidity higher in the coinfected population but that this affects antiviral treatments as well. There is new evidence that brain injuries and infiltration of the virus into the central nervous system may be responsible for cognitive dysfunction. Cotesting, particularly in hepatitis C infected individuals, is not done routinely despite shared risk factors.

SUMMARY

With this understanding of the comorbidities of the coinfected population, integrated healthcare models involving mental health, internal medicine, substance abuse treatment and internal medicine are crucial to work with these medically and psychologically complex patients.

Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates

AIMS

Through a novel synthesis of the literature and our own clinical experience, we have derived a set of evidence-based recommendations for consideration as guidance in the management of opioid-dependent pregnant women and infants.

METHODS

PubMed literature searches were carried out to identify recent key publications in the areas of pregnancy and opioid dependence, neonatal abstinence syndrome (NAS) prevention and treatment, multiple substance abuse and psychiatric comorbidity.

RESULTS

Pregnant women dependent on opioids require careful treatment to minimize harm to the fetus and neonate and improve maternal health. Applying multi-disciplinary treatment as early as possible, allowing medication maintenance and regular monitoring, benefits mother and child both in the short and the long term. However, there is a need for randomized clinical trials with sufficient sample sizes.

RECOMMENDATIONS

Opioid maintenance therapy is the recommended treatment approach during pregnancy. Treatment decisions must encompass the full clinical picture, with respect to frequent complications arising from psychiatric comorbidities and the concomitant consumption of other drugs. In addition to standardized approaches to pregnancy, equivalent attention must be given to the treatment of NAS, which occurs frequently after opioid medication.

CONCLUSION

Methodological flaws and inconsistencies confound interpretation of today's literature. Based on this synthesis of available evidence and our clinical experience, we propose recommendations for further discussion.

Management of chronic hepatitis C in veterans: the potential of integrated care models

The prevalence of hepatitis C virus (HCV) infection is higher among veterans than nonveterans, but only about 14% of all identified infected veterans have ever received antiviral therapy. High rates of comorbid psychiatric and substance use disorders are major barriers to receiving antiviral treatment for veterans, and characteristics associated with poor virologic response are more common in this population. However, accumulating evidence indicates that patients with psychiatric and substance use disorders can successfully receive interferon-based antiviral therapies in an integrated or multidisciplinary health-care setting. The broad aims of integrated care models include reducing fragmentation and improving continuity and coordination of care. Although, to date, there are no randomized controlled trials of specific care models for patients with HCV, studies of integrated care for other chronic diseases suggest several strategies for optimizing outcomes for patients with HCV. Components of an HCV clinic incorporating these principles have been tested in a nonrandomized setting and include routine screening of all patients for psychiatric and substance use disorder risk factors, collaboration with mental health providers within the HCV clinic, following a defined integrated medical/psychiatric clinical protocol, provision of ongoing integrated support during antiviral treatment or retreatment, and educating patients on principles of chronic disease self-management.

Managing addiction as a chronic condition

This article reviews progress in adapting addiction treatment to respond more fully to the chronic nature of most patients' problems. After reviewing evidence that the natural history of addiction involves recurrent cycles of relapse and recovery, we discuss emerging approaches to recovery management, including techniques for improving the continuity of care, monitoring during periods of abstinence, and early reintervention; recent developments in the field related to self-management, mutual aid, and other recovery supports; and system-level interventions. We also address the importance of adjusting treatment funding and organizational structures to better meet the needs of individuals with a chronic disease.

Hepatitis C in schizophrenia: screening experience in a community-dwelling clozapine cohort

Hepatitis C virus (HCV) infection occurs in up to 20% of patients with chronic mental illnesses. To determine the prevalence of hepatitis C in a diagnostically well-defined sample, the authors screened all schizophrenia outpatients in a clozapine clinic (N=98) for HCV antibodies. Eight patients were positive for hepatitis C antibodies (antibody-positive prevalence: 8.2%); of those, 50% had detectable viral loads (viremia-positive prevalence: 4.1%). Screening for HCV infection should be considered for outpatients with schizophrenia. However, clinical experience treating HCV in schizophrenia patients is limited; in this cohort, 2 years after screening, no patient had received interferon/ribavirin treatment.

Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: non-adherence, default and the acquisition of multidrug resistance

OBJECTIVE

To identify barriers to successful tuberculosis (TB) treatment in Tomsk, Siberia, by analysing individual and programmatic risk factors for non-adherence, default and the acquisition of multidrug resistance in a TB treatment cohort in the Russian Federation.

METHODS

We conducted a retrospective cohort study of consecutively enrolled, newly detected, smear and/or culture-positive adult TB patients initiating therapy in a DOTS programme in Tomsk between 1 January and 31 December 2001.

FINDINGS

Substance abuse was strongly associated with non-adherence [adjusted odds ratio (OR): 7.3; 95% confidence interval (CI): 2.89-18.46] and with default (adjusted OR: 11.2; 95% CI: 2.55-49.17). Although non-adherence was associated with poor treatment outcomes (OR: 2.4; 95% CI: 1.1-5.5), it was not associated with the acquisition of multi-drug resistance during the course of therapy. Patients who began treatment in the hospital setting or who were hospitalized later during their treatment course had a substantially higher risk of developing multidrug-resistant TB than those who were treated as outpatients (adjusted HRs: 6.34; 95% CI: 1.35-29.72 and 6.26; 95% CI: 1.02-38.35 respectively).

CONCLUSION

In this cohort of Russian TB patients, substance abuse was a strong predictor of non-adherence and default. DOTS programmes may benefit from incorporating measures to diagnose and treat alcohol misuse within the medical management of patients undergoing TB therapy. Multidrug-resistant TB occurred among adherent patients who had been hospitalized in the course of their therapy. This raises the possibility that treatment for drug-sensitive disease unmasked a pre-existing population of drug-resistant organisms, or that these patients were reinfected with a drug-resistant strain of TB.

Medical/psychiatric comanagement by nurse practitioners in chronic hepatitis C treatment: a case study

This article aims to increase access to care for patients with chronic hepatitis C who have medical and psychiatric comorbidities by reporting on a clinical advanced practice nursing comanagement model for evaluation, treatment, and follow-up care.

HIV/AIDS: testing and risk behaviors among British Columbia's rural Aboriginal population

OBJECTIVES

Over the last decade, there has been growing concern in the public health sector over the spread of Human Immunodeficiency Virus (HIV) in Canada's Aboriginal population. However, there continues to be a general lack of HIV awareness and its risk factors in Aboriginal communities.

STUDY DESIGN AND METHODS

This study investigated HIV testing patterns, perceptions and risk factors within 7 community organizations through the use of face-to-face interviews. The objectives of this research project were to 1) describe the prevalence of HIV testing; 2) describe issues concerning confidentiality related to the HIV testing; 3) identify the prevalence of risk factors for HIV transmission; and, 4) build research capacity in the Aboriginal community.

RESULTS

Two hundred and nineteen Aboriginal persons participated in interviews. Off-reserve residents (pOR: 0.48, 95% CI: 0.29 - 0.80) were significantly more likely to use illicit drugs than reserve residents. Sixty percent of participants had reported undergoing HIV testing at some point. Two-spirited participants (pOR: 16.1, 95% CI: 2.13-121.06), those who previously tested for a Sexually Transmitted Disease (pOR: 2.94, 95% CI: 1.73-4.98), those currently using cocaine (pOR: 3.88, 95% CI: 1.25 - 12.0), and those who reported to "never", or "some of the time" use clean needles (pOR: 11.0, 95% CI: 1.36- 88.66) were significantly more likely to undergoing HIV testing. On-reserve residents (pOR: 0.55, 95% CI: 0.35-0.87) and respondents older than 40 years of age (pOR: 0.40, 95% CI: 0.19 - 0.86) were less likely to undergo HIV testing.

CONCLUSIONS

Participants with HIV risk factors are more likely to be tested for HIV in rural areas and confidentiality issues were not a barrier to testing for most participants. Off-reserve residents were more likely to undergo HIV testing, the reasons for which require additional research. Finally, public health units are often under-utilized as locations to seek testing.