Longitudinal patterns of illicit drug use, antiretroviral therapy exposure and plasma HIV-1 RNA viral load among HIV-positive people who use illicit drugs

Bone Tissue Changes in Individuals Living with HIV/AIDS: The Importance of a Hierarchical Approach in Investigating Bone Fragility

Skeletal alterations and their complications can significantly impact the quality of life and overall prognosis of patients living with HIV (PLWHIV). Considering skeletal alterations are often asymptomatic and unapparent during routine clinical evaluation, these conditions are frequently overlooked in the clinical management of PLWHIV. However, since the use of combined antiretroviral therapy (cART) has increased life expectancy in PLWHIV effectively, osteopenia, osteoporosis, and bone fragility are now considered to have a major health impact, with a substantial increase in healthcare costs. This narrative literature review aimed to provide a comprehensive overview of the contemporary literature related to bone changes in PLWHIV, focusing on the importance of taking a multi-scale approach in the assessment of bone hierarchical organization. Even though a low bone mineral density is frequently reported in PLWHIV, numerous ambiguities still remain to be solved. Recent data suggest that assessment of other bone properties (on various levels of the bone structure) could contribute to our understanding of bone fragility determinants in these individuals. Special attention is needed for women living with HIV/AIDS since a postmenopausal status was described as an important factor that contributes to skeletal alterations in this population. Further research on complex etiopathogenetic mechanisms underlying bone alterations in PLWHIV may lead to the development of new therapeutic approaches specifically designed to reduce the health burden associated with skeletal disorders in this population. A major challenge in the clinical management of PLWHIV lies in the adverse skeletal effects of some frequently prescribed cART regimens (e.g., regimens containing tenofovir disoproxil fumarate), which may require a switch to other pharmacological approaches for maintained HIV infection (e.g., regimens containing tenofovir alafenamide). Taken together, the findings are indicative that the HIV/AIDS status should be taken into consideration when designing new guidelines and strategies for individualized prevention, diagnosis, and treatment of increased bone fragility.

Prevalence and Correlates of Heavy Alcohol use among People Living with HIV who use Unregulated Drugs in Vancouver, Canada

Among people living with HIV (PLWH), heavy alcohol use is associated with many negative health consequences. However, the impacts of heavy alcohol use are not well described for PLWH who use drugs. Thus, we investigated the prevalence and correlates of heavy alcohol use among a cohort of people who use drugs (PWUD) living with HIV in Vancouver, Canada. We accessed data from an ongoing community-recruited prospective cohort of PLWH who use drugs with linked comprehensive HIV clinical monitoring data. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods of heavy alcohol use between December 2005 and December 2019. Of the 896 participants included, 291 (32.5%) reported at least one period with heavy alcohol use. Periods of recent incarceration (Adjusted Odds Ratio [AOR] = 1.48, 95% Confidence Interval [CI]: 1.01-2.17), encounters with police (AOR = 1.87, 95% CI: 1.37-2.56), and older age (AOR = 1.05, 95% CI: 1.02-1.07) were positively associated with heavy alcohol use. Engagement in drug or alcohol treatment (AOR = 0.54, 95% CI: 0.42-0.70) and male gender (AOR = 0.46; 95% CI: 0.27-0.78) were negatively associated with heavy alcohol use. We observed that heavy alcohol use was clearly linked to involvement with the criminal justice system. These findings, together with the protective effects of substance use treatment, suggest the need to expand access for drug and alcohol treatment programs overall, and in particular through the criminal justice system to reduce alcohol-related harms among PLWH who use drugs.

Impaired extinction of cocaine seeking in HIV-infected mice is accompanied by peripheral and central immune dysregulation

Substance use disorders (SUDs) are highly comorbid with HIV infection, necessitating an understanding of the interactive effects of drug exposure and HIV. The relationship between HIV infection and cocaine use disorder is likely bidirectional, with cocaine use directly impacting immune function while HIV infection alters addiction-related behavior. To better characterize the neurobehavioral and immune consequences of HIV infection and cocaine exposure, this study utilizes a humanized mouse model to investigate the outcomes of HIV-1 infection on cocaine-related behaviors in a conditioned place preference (CPP) model, and the interactive effects of cocaine and HIV infection on peripheral and central nervous system inflammation. HIV infection selectively impairs cocaine CPP extinction without effecting reinstatement or cocaine seeking under conflict. Behavioral alterations are accompanied by immune changes in HIV infected mice, including increased prefrontal cortex astrocyte immunoreactivity and brain-region specific effects on microglia number and reactivity. Peripheral immune system changes are observed in human cytokines, including HIV-induced reductions in human TNFα, and cocaine and HIV interactions on GM-CSF levels. Together these data provide new insights into the unique neurobehavioral outcomes of HIV infection and cocaine exposure and how they interact to effect immune responses.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Overamped: Stimulant Use and HIV Pathogenesis

PURPOSE OF REVIEW

In the era of HIV treatment as prevention (TasP), more clarity is needed regarding whether people with HIV who use stimulants (i.e., methamphetamine, powder cocaine, and crack cocaine) display elevated HIV viral load and greater immune dysregulation.

RECENT FINDINGS

Although rates of viral suppression have improved in the TasP era, stimulant use was independently associated with elevated viral load in 23 of 28 studies included in our review. In the 12 studies examining other HIV disease markers, there was preliminary evidence for stimulant-associated alterations in gut-immune dysfunction and cellular immunity despite effective HIV treatment. Studies generally focused on documenting the direct associations of stimulant use with biomarkers of HIV pathogenesis without placing these in the context of social determinants of health. Stimulant use is a key barrier to optimizing the effectiveness of TasP. Elucidating the microbiome-gut-brain axis pathways whereby stimulants alter neuroimmune functioning could identify viable targets for pharmacotherapies for stimulant use disorders. Examining interpersonal, neighborhood, and structural determinants that could modify the associations of stimulant use with biomarkers of HIV pathogenesis is critical to guiding the development of comprehensive, multi-level interventions.

Development and internal validation of a risk prediction model for HIV disease severity among people living with HIV and mental illness or substance use disorder

PURPOSE

Mental illness (MI) and substance use disorders (SUD) are highly prevalent among people living with HIV (PLWH), and have been linked to poor HIV clinical outcomes. Innovative tools for early risk identification can facilitate timely interventions for PLWH and MI/SUD to improve their health outcomes, however, this is currently lacking in Texas, a state with the 4th largest population of PLWH in the United States. To address this gap, we developed a predictive model to estimate the risk of suboptimal HIV clinical outcomes among PLWH and MI/SUD in Texas.

METHODS

The Texas Medical Monitoring Project data obtained from June 2015-May 2020 were used to develop and internally validate the predictive model. Univariate descriptive and bivariate inferential statistics were performed to describe the characteristics of the study population and unadjusted associations with HIV clinical outcomes. Multivariable logistic regression was used to develop the prediction model. Internal validation was performed using the bootstrap method.

RESULTS

A total of 518 respondents aged 18 years and above, representing 27,255 adults living with HIV and mental illness or substance use disorders in Texas were included. Most participants were male (77.0%), less than 50 years of age (60.0%), and had mild diagnosed mental illness and substance use disorder (54.8%). The risk predictive model contained eight predictors, which together yielded an area under the receiver operating characteristic (ROC) curve of 0.727. Non-retention in care appeared to be the strongest risk predictor for having suboptimal HIV clinical outcome (adjusted odds ratio (aOR) = 3.27; 95% confidence interval (CI) = 1.45, 7.42).

CONCLUSIONS

The predictive model had good discrimination between persons at risk of poor HIV clinical outcomes and those not at risk.

Impaired extinction of cocaine seeking in HIV-infected mice is accompanied by peripheral and central immune dysregulation

Substance use disorders (SUDs) are highly comorbid with HIV infection, necessitating an understanding of the interactive effects of drug exposure and HIV. The relationship between HIV infection and cocaine use disorder is likely bidirectional, with cocaine use directly impacting immune function while HIV infection alters addiction-related behavior. To better characterize the neurobehavioral and immune consequences of HIV infection and cocaine exposure, this study utilized a humanized mouse model to investigate the outcomes of HIV-1 infection on cocaine-related behaviors in a conditioned place preference (CPP) model, and the interactive effects of cocaine and HIV infection on peripheral and central nervous system inflammation. HIV infection selectively impaired cocaine CPP extinction without effecting reinstatement or cocaine seeking under conflict were observed. Behavioral alterations were accompanied by immune changes in HIV infected mice, including increased prefrontal cortex astrocyte immunoreactivity and brain-region specific effects on microglia number and reactivity. Peripheral immune system changes were observed in both mouse and human cytokines, including HIV-induced reductions in mouse IL-1α and G-CSF and human TNFα, and cocaine induced alterations in mouse GM-CSF. Together these data provide new insights into the unique neurobehavioral outcomes of HIV infection and cocaine exposure and how they interact to effect immune responses.

Impaired extinction of cocaine seeking in HIV-infected mice is accompanied by peripheral and central immune dysregulation

Substance use disorders (SUDs) are highly comorbid with HIV infection, necessitating an understanding of the interactive effects of drug exposure and HIV. The relationship between progressive HIV infection and cocaine use disorder is likely bidirectional, with cocaine use having direct effects on immune function while HIV infection can alter addiction-related behavior. To better characterized the neurobehavioral and immune consequences of HIV infection and cocaine exposure, this study utilized a humanized mouse model to investigate the outcomes of progressive HIV infection on cocaine-related behaviors in a cocaine conditioned place preference (CPP) model, and the interactive effects of cocaine and HIV infection on peripheral and central nervous system inflammation. HIV infection did not impact the formation of a cocaine CPP, but did result in resistance to extinction of the CPP. No effects of HIV on yohimbine-primed reinstatement or cocaine seeking under conflict were observed. These behavioral alterations were accompanied by immune changes in HIV infected mice, including increased prefrontal cortex astrocyte immunoreactivity and brain-region specific effects on microglia number and reactivity. Peripheral immune system changes were observed in both mouse and human markers. Among other targets, this included HIV-induced reductions in mouse IL-1α and G-CSF and human TNFα and cocaine-induced alterations in human TNFα and mouse GM-CSF such that cocaine exposure increases both cytokines only in the absence of HIV infection. Together these data provide new insights into the unique neurobehavioral processes underlying HIV infection and cocaine use disorders, and further how they interact to effect immune responses.

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

Background

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

Methods

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

Results

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

Conclusion

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

Contingency Management for Integrated Harm Reduction Among Men Who Have Sex with Men Who Use Methamphetamine in Los Angeles: A Pilot Assessment

Methamphetamine (MA) use is associated with HIV transmission among men who have sex with men (MSM) and lapses in medication adherence. Contingency Management (CM) is effective in reducing MA use, but studies of CM to support adherence to HIV prevention or treatment are limited. We conducted a pilot trial of a CM intervention to reduce MA use and improve PrEP/ART adherence among MSM prescribed a tenofovir (TFV)-based regimen for HIV prevention or treatment. Participants were randomly assigned to receive escalating incentives for either MA abstinence or TFV adherence (based on point-of-care urine testing), and to a monitoring schedule of either 2 or 3 visits/week for 4 weeks. 19 MSM were randomized to either CM for MA use or CM for PrEP/ART adherence (median age: 38; IQR: 28-46) and 15 were living with HIV. Participants attended 95.7% (67/70) of scheduled visits in the 2x/week arm and 74.8% (74/99) in the 3x/week arm. TFV adherence was higher among participants in the TFV adherence arm with 93.5% (n = 72/77) of urine samples positive for TFV, compared to 76.6% (n = 49/64) in the MA abstinence arm (p = 0.007). Participants in the MA abstinence arm had more urine samples negative for MA metabolites (20.3%, n = 13/64) than those receiving CM for TFV adherence (6.5%, n = 5/77; p = 0.021). A CM model for MA abstinence and PrEP/ART adherence using twice-weekly visits and urine testing for MA and TFV for MSM who use MA is feasible and potentially effective as an integrated harm reduction strategy.

Perceived Mistreatment in Health Care Settings and its Relationship with HIV Clinical Outcomes in HIV-positive People who Use Drugs in Vancouver, Canada

People living with HIV (PLWH) often experience stigma and discrimination by health care professionals. We investigated the prevalence of perceived mistreatment in health care settings and its associations with HIV clinical outcomes and health care-seeking behaviour using data from a long-running prospective cohort of PLWH who use drugs. Of the 857 participants included, 19% reported at least one instance of perceived mistreatment during the study period. In adjusted longitudinal analyses, perceived mistreatment was positively associated with not being on ART in the same follow-up period, and participants who reported perceived mistreatment were less likely to report seeing a physician in the subsequent follow-up period. Daily use of injection drugs was positively associated with reporting perceived mistreatment. These findings demonstrate the implications of negative health care interactions in a population that must consistently engage with the health care system, and the need for stigma-reducing educational interventions for health care professionals.

The effect of substance uses on antiretroviral treatment adherence in primary health care

BACKGROUND

Adherence to antiretroviral treatment (ART) is the primary factor determining how an individual responds to their treatment. Unfortunately, individuals who use substances experience suboptimal adherence to their treatment, but little is known about the exact effects of their use on ART adherence in primary health care settings.

METHODS

The authors used a prospective cohort study to evaluate substance use's effects on ART adherence among people living with HIV (PLWH) who attend primary health care services in the Mthatha region of South Africa.

RESULTS

During the study period, 601 PLWH were followed up for 6 months. The participant's mean age was 38.5 (standard deviation [s.d.] = 11) years, with a mean CD4 count of 491.7 (s.d. = 241). Suboptimal ART adherence and default rates were 20.2% and 9.3%, respectively. Among the substance users, suboptimal adherence to ART was statistically significantly higher than non-users (24.6% and 15.9%, respectively, p = 0.007). The authors also observed suboptimum ART adherence among people who presented with clinical comorbidities.

CONCLUSION

Substance use has negatively affected ART adherence among PLWH who attend primary health care services in the Eastern Cape province of South Africa. Therefore, an integrated substance use management strategy in primary health care is recommended to achieve optimal adherence to ART.Contribution: Substance use disorder significantly affected the adherence to ART in primary health care. This is important since primary care is the gateway to the HIV care continuum. The study highlighted the role of integration of substance use management in primary care.

Effectiveness and Safety of Bictegravir/Emtricitabine/Tenofovir Alafenamide in Patients With HIV-1 Infection and Ongoing Substance Use Disorder: The BASE Study

Background

People with human immunodeficiency virus (HIV) and substance use disorder (PWH/SUD) are at higher risk of nonadherence to antiretroviral therapy. Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) exhibits high rates of efficacy with a favorable adverse event profile. The BASE study (NCT03998176) is a phase 4, single-arm study evaluating the effectiveness and safety of B/F/TAF among PWH/SUD.

Methods

Viremic (HIV RNA >1000 copies/mL) PWH/SUD initiated B/F/TAF once daily for 48 weeks (W). The primary endpoint was proportion of participants with HIV RNA <50 copies/mL at W24. Secondary endpoints were proportion of participants with HIV-1 RNA <50 copies/mL at W48, safety, B/F/TAF adherence (dried blood spot [DBS] concentrations of emtricitabine triphosphate and tenofovir diphosphate [TFV-DP]), substance use (NIDA-ASSIST), and quality of life (SF-12).

Results

Forty-three participants were enrolled; 95% reported methamphetamine use. Median age was 38 (range, 21-62) years; 21% were female, 81% White, 14% Black, and 16% Hispanic. Thirty-two (74%) and 21 (49%) participants had HIV RNA <50 copies/mL (intention-to-treat) at W24 and W48, respectively. Seven participants (16%) experienced confirmed virologic failure through W48; 1 developed emergent drug resistance (M184V). Fifteen participants (35%) experienced grade ≥3 adverse events. Five participants (12%) reported suicidal ideation; none resulted in discontinuation. Median DBS concentrations were representative of 5-6 doses/week (TFV-DP, 1603 fmol/punches). NIDA-ASSIST scores declined from baseline to W48 with methamphetamine use decreasing most (-7.9 points; -29%), and SF-12 physical/mental scores increased 1.2 and 7.6 points, respectively.

Conclusions

B/F/TAF among a high-risk population of PWH/SUD resulted in an initial 72% viral suppression rate at W24 before dropping to 49% at W48 as retention declined. One participant developed emergent drug resistance (M184V).

Association of Substance Use with Immunological Response to Antiretroviral Therapy in HIV-Positive Patients from Southwest Ethiopia: A Prospective Observational Study

Background

Use of psychoactive substances by HIV-positive patients in the course of antiretroviral drug treatment has become a public health problem globally. Substance use (alcohol, nicotine, and khat) during the course of treatment results in interactions with drugs that lead to undesired treatment outcomes. This condition is understudied, and the consequences of substance use among patients on antiretroviral treatment are not well explored.

Methods

A prospective observational study was conducted among people on antiretroviral therapy (ART) at Jimma University Medical Center in southwest Ethiopia from April 20 to November 27, 2019. Data were collected using the World Health Organization's alcohol, smoking, and substance involvement screening test among adults who have followed antiretroviral therapy for a minimum of 6 months. Logistic regression analysis was done to identify factors associated with immunological response. The inadequate immunological response was defined as patients who were unable to achieve or maintain a CD4 cell count of >350 cells/mm³ after the 6-months of follow-up.

Results

Of the 332 patients enrolled, a majority (64.2%) of the respondents were females. The mean (±SD) age of the patients was 38.5 ± 9.5 years. The proportion of participants with a high level of health risk due to alcohol use was 8.4%, while 63.8% of them were non-alcohol users with no health risk. In multivariable logistic regression analysis, moderate and high levels of health risks from alcohol use were significantly associated with increased odds of inadequate immunological response (AOR: 2.9; 95% CI, 1.1-7.4) and (AOR: 4.3; 95% CI, 1.2-14.8), respectively, but the level of health risk from khat and cigarette use showed no association with inadequate immunological response in this study.

Conclusion

Moderate and high levels of health risk from alcohol use were independently associated with inadequate immunological response. People living with HIV/AIDS should regularly be screened for and be educated about substance use and its potential negative impact on CD4 cell recovery.

Crack cocaine use frequency is associated with HIV disease severity independent of antiretroviral therapy exposure: a prospective cohort study

We sought to evaluate the effect of crack cocaine use frequency on HIV disease severity among HIV-positive people who use unregulated drugs (PWUD). We analyzed data from the ACCESS study, an open prospective cohort of HIV-positive PWUD including comprehensive HIV clinical monitoring in a setting with no-cost healthcare. Multivariable generalized linear mixed-effects models were used to estimate the independent effect of time-updated crack cocaine use frequency on HIV disease severity, adjusting for ART exposure and relevant confounders. In multivariable adjusted models, daily or greater frequency of crack cocaine use was significantly associated with higher VACS Index scores (β = 0.8, 95% confidence interval: 0.1, 1.5) as compared to none. Our finding suggests that daily or greater frequency of crack cocaine use exacerbates HIV disease severity independent of ART exposure. The observed effect may reflect an underlying biological mechanism or other factors linked with crack cocaine use; further investigation is warranted.

Periods of Homelessness Linked to Higher VACS Index Among HIV-Positive People Who Use Drugs

We sought to evaluate the impact of homelessness on HIV disease progression among people who use unregulated drugs (PWUD) living with HIV and test if this association was mediated by adherence to antiretroviral therapy (ART). We applied general linear mixed-effects modeling to estimate the longitudinal relationship between homelessness and the Veterans Aging Cohort Study (VACS) Index, a validated measure of HIV disease progression that predicts all-cause mortality, among a prospective cohort of PWUD. In a longitudinal model adjusted for ART adherence, homelessness was significantly associated with increased VACS Index scores and 16% of the association was mediated by ART adherence. These findings indicate that homelessness was a significant risk factor for HIV disease progression and this association was marginally mediated by ART adherence. Future studies are needed to quantify the other mechanisms (e.g., food insecurity, mental health) by which homelessness increases mortality risk among PWUD living with HIV.

Associations amongst form of cocaine used (powder vs crack vs both) and HIV-related outcomes

•

Among PWH, cocaine use vs no-use was associated with worse HIV treatment outcomes.

•

Powder cocaine only users were more likely to be younger, Hispanic, and employed.

•

Users of powder + crack cocaine had lower viral suppression than users of either alone.

•

Harm reduction efforts addressing substance use should be a key component of HIV care.

Introduction

Cocaine (including powder and crack) use is common among people with HIV (PWH). We identified socio-demographic and behavioral factors associated with cocaine use (overall and various forms) among PWH; we also examined differences in HIV treatment outcomes across cocaine exposure groups.

Methods

The study sample (N = 1166) was derived from two cohorts of PWH in Florida between 2014 and 2020. Baseline data were linked to the Enhanced HIV/AIDS Reporting System (eHARS) which tracks HIV viral load. Socio-demographics and polysubstance use were compared by cocaine use and the three cocaine use groups (powder only n = 101, crack only n = 91, or both n = 65). The association between the three cocaine use groups, ART adherence, and HIV viral suppression (<200 copies/mL) in the following year was assessed by multivariate logistic regression.

Results

People who used cocaine had lower HIV treatment adherence and viral suppression than those who did not use. People who used powder cocaine only were more likely to be younger, Hispanic/Latinx, and employed than those who used crack only or both. Compared to people who used both powder and crack cocaine, those who used one form of cocaine had 3 + odds of having durable viral suppression in the following year.

Conclusion

The dual use of both powder and crack cocaine was associated with significantly worse HIV outcomes compared to use of only one form of cocaine. Screening for powder and crack cocaine use and timely intervention are needed to improve HIV treatment outcomes among this high-risk population.

Epidemiological risk factors associated with primary infection by Epstein-Barr virus in HIV-1-positive subjects in the Brazilian Amazon region

To identify the prevalence and risk factors for primary Epstein–Barr virus (EBV) infection in human immunodeficiency virus (HIV)-1-positive adult treatment-naïve patients between January 2018 and December 2019 in a state of the Brazilian Amazon region. A total of 268 HIV-1 positive patients and 65 blood donors participated in the study. Epidemiological data were obtained from medical records and through a designed questionnaire. EBV infection was screened by the semiquantitative detection of anti-viral capsid antigen (VCA) EBV IgM and IgG, followed by molecular detection of the EBNA-3C gene. The plasma viral loads of HIV-1 and EBV were quantified using a commercial kit. The prevalence of primary coinfection was 7.12%. The associated risk factors were education level, family income, history of illicit drug use and sexually transmitted infections, homosexual contact and condom nonuse. Approximately 58.5% had late initiation of highly active antiretroviral therapy, which influenced the risk of HIV-EBV 1/2 multiple infection (odds ratio (OR): 4.76; 95% CI 1.51–15.04) and symptom development (p = 0.004). HIV viral load was associated with patient age (OR: 2.04; 95% CI 2.01–2.07; p = 0.026) and duration of illicit drug use (OR: 1.57; 95% CI 1.12–2.22; p = 0.0548). EBV viral load was associated with younger age (OR: 0.82; 95% CI 0.79–1.03; p = 0.0579). The replication of both viruses was associated with symptom development (HIV = OR: 2.06; 95% CI 1.22–3.50; p = 0.0073; EBV = OR: 8.81; 95% CI 1–10; p = 0.0447). The prevalence of HIV/EBV coinfection was lower than that observed in other studies, and social vulnerability and promiscuous sexual behavior were associated risk factors. A long time of HIV-1 infection, without therapy, influenced the risk of coinfection and disease progression. The viral loads of both viruses may be associated with some epidemiological aspects of the population.

A "Drug-Dependent" Immune System Can Compromise Protection against Infection: The Relationships between Psychostimulants and HIV

Psychostimulant use is a major comorbidity in people living with HIV, which was initially explained by them adopting risky behaviors that facilitate HIV transmission. However, the effects of drug use on the immune system might also influence this phenomenon. Psychostimulants act on peripheral immune cells even before they reach the central nervous system (CNS) and their effects on immunity are likely to influence HIV infection. Beyond their canonical activities, classic neurotransmitters and neuromodulators are expressed by peripheral immune cells (e.g., dopamine and enkephalins), which display immunomodulatory properties and could be influenced by psychostimulants. Immune receptors, like Toll-like receptors (TLRs) on microglia, are modulated by cocaine and amphetamine exposure. Since peripheral immunocytes also express TLRs, they may be similarly affected by psychostimulants. In this review, we will summarize how psychostimulants are currently thought to influence peripheral immunity, mainly focusing on catecholamines, enkephalins and TLR4, and shed light on how these drugs might affect HIV infection. We will try to shift from the classic CNS perspective and adopt a more holistic view, addressing the potential impact of psychostimulants on the peripheral immune system and how their systemic effects could influence HIV infection.

Comparative impact of methamphetamine and other drug use on viral suppression among sexual minority men on antiretroviral therapy

BACKGROUND

Substance use decreases the likelihood of achieving undetectable HIV viremia; however, the comparative effects by drug have not been fully described. In this study, we compare the effects of methamphetamine use versus other drugs on viremia in sexual minority men on antiretroviral therapy (ART).

METHODS

HIV-positive participants currently on ART (N = 230) were selected from an ongoing cohort of diverse young sexual minority men (mSTUDY) enrolled from August 2014 to May 2018. Substance use and sociodemographic factors associated with viremia outcomes were assessed using ordinal regression analysis with generalized estimating equations. Viremia outcomes were grouped as undetectable (<20 copies/mL), low level suppressed (21-200 copies/mL), or not suppressed (>200 copies/mL).

RESULTS

The prevalence of drug use across 825 study visits was 73 %, with methamphetamine use most prevalent (50 %). After adjusting for unstable housing and ART adherence, methamphetamine use, either alone (adjusted OR = 1.87; 95 % CI 1.03-3.40) or with other drugs (adjusted OR = 1.82; 95 % CI 1.12-2.95), was associated with higher odds of increasing viremia compared to no drug use. Other drug use excluding methamphetamine did not show a similar association (adjusted OR = 1.29; 95 % CI 0.80-2.09). Among our study population, nearly half the instances of viremia could be reduced if methamphetamine was discontinued (attributable fraction = 46 %; 95 % CI 3-71 %).

CONCLUSIONS

Methamphetamine use, either alone or in combination with other drugs, is associated with failure of viral suppression among sexual minority men on ART independent of adherence and sociodemographic factors. This accounts for nearly half of the observed instances of unsuppressed viremia in this study.

Natural Language Processing of Clinical Notes to Identify Mental Illness and Substance Use Among People Living with HIV: Retrospective Cohort Study

Background

Mental illness and substance use are prevalent among people living with HIV and often lead to poor health outcomes. Electronic medical record (EMR) data are increasingly being utilized for HIV-related clinical research and care, but mental illness and substance use are often underdocumented in structured EMR fields. Natural language processing (NLP) of unstructured text of clinical notes in the EMR may more accurately identify mental illness and substance use among people living with HIV than structured EMR fields alone.

Objective

The aim of this study was to utilize NLP of clinical notes to detect mental illness and substance use among people living with HIV and to determine how often these factors are documented in structured EMR fields.

Methods

We collected both structured EMR data (diagnosis codes, social history, Problem List) as well as the unstructured text of clinical HIV care notes for adults living with HIV. We developed NLP algorithms to identify words and phrases associated with mental illness and substance use in the clinical notes. The algorithms were validated based on chart review. We compared numbers of patients with documentation of mental illness or substance use identified by structured EMR fields with those identified by the NLP algorithms.

Results

The NLP algorithm for detecting mental illness had a positive predictive value (PPV) of 98% and a negative predictive value (NPV) of 98%. The NLP algorithm for detecting substance use had a PPV of 92% and an NPV of 98%. The NLP algorithm for mental illness identified 54.0% (420/778) of patients as having documentation of mental illness in the text of clinical notes. Among the patients with mental illness detected by NLP, 58.6% (246/420) had documentation of mental illness in at least one structured EMR field. Sixty-three patients had documentation of mental illness in structured EMR fields that was not detected by NLP of clinical notes. The NLP algorithm for substance use detected substance use in the text of clinical notes in 18.1% (141/778) of patients. Among patients with substance use detected by NLP, 73.8% (104/141) had documentation of substance use in at least one structured EMR field. Seventy-six patients had documentation of substance use in structured EMR fields that was not detected by NLP of clinical notes.

Conclusions

Among patients in an urban HIV care clinic, NLP of clinical notes identified high rates of mental illness and substance use that were often not documented in structured EMR fields. This finding has important implications for epidemiologic research and clinical care for people living with HIV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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