Recent drug use, homelessness and increased short-term mortality in HIV-infected persons with alcohol problems

Integrated Care as a Model for Interprofessional Disease Management and the Benefits for People Living with HIV/AIDS

INTRODUCTION

Today, antiretroviral therapy (ART) is effectively used as a lifelong therapy to treat people living with HIV (PLWH) to suppress viral replication. Moreover, PLWH need an adequate care strategy in an interprofessional, networked setting of health care professionals from different disciplines. HIV/AIDS poses challenges to both patients and health care professionals within the framework of care due to frequent visits to physicians, avoidable hospitalizations, comorbidities, complications, and the resulting polypharmacy. The concepts of integrated care (IC) represent sustainable approaches to solving the complex care situation of PLWH.

AIMS

This study aimed to describe the national and international models of integrated care and their benefits regarding PLWH as complex, chronically ill patients in the health care system.

METHODS

We conducted a narrative review of the current national and international innovative models and approaches to integrated care for people with HIV/AIDS. The literature search covered the period between March and November 2022 and was conducted in the databases Cinahl, Cochrane, and Pubmed. Quantitative and qualitative studies, meta-analyses, and reviews were included.

RESULTS

The main findings are the benefits of integrated care (IC) as an interconnected, guideline- and pathway-based multiprofessional, multidisciplinary, patient-centered treatment for PLWH with complex chronic HIV/AIDS. This includes the evidence-based continuity of care with decreased hospitalization, reductions in costly and burdensome duplicate testing, and the saving of overall health care costs. Furthermore, it includes motivation for adherence, the prevention of HIV transmission through unrestricted access to ART, the reduction and timely treatment of comorbidities, the reduction of multimorbidity and polypharmacy, palliative care, and the treatment of chronic pain. IC is initiated, implemented, and financed by health policy in the form of integrated health care, managed care, case and care management, primary care, and general practitioner-centered concepts for the care of PLWH. Integrated care was originally founded in the United States of America. The complexity of HIV/AIDS intensifies as the disease progresses.

CONCLUSIONS

Integrated care focuses on the holistic view of PLWH, considering medical, nursing, psychosocial, and psychiatric needs, as well as the various interactions among them. A comprehensive expansion of integrated care in primary health care settings will not only relieve the burden on hospitals but also significantly improve the patient situation and the outcome of treatment.

Polysubstance Use Patterns Associated With HIV Disease Severity Among Those With Substance Use Disorders: A Latent Class Analysis

OBJECTIVE

Polysubstance use is common among people with HIV infection (PWH) and with substance use disorder (SUD), but its effects are understudied. We aimed to identify polysubstance use patterns over time and assess their associations with HIV disease severity.

METHOD

In 233 PWH with current or past SUD, latent class analysis identified polysubstance use patterns based on the Alcohol Use Disorders Identification Test-Consumption and past-30-day use of cannabis, cocaine, opioids, and tranquilizers at baseline. We categorized changes in use patterns and tested associations between those changes and CD4 count and HIV viral suppression at 12 months in linear and logistic regressions.

RESULTS

Three patterns were identified at baseline: 18% did not use any substance (NONE--a priori defined); 63% used mostly cannabis and alcohol (CA); and 19% used opioids along with other drugs, including cocaine, tranquilizers, cannabis, and alcohol (MULTI). At 12 months, 40% moved from a high to a lower substance use class (MULTI to CA, either to NONE) or remained as NONE, 43% were in CA both times and 17% increased (NONE to CA, either to MULTI) or remained as MULTI. The adjusted mean CD4 count (for baseline covariates and baseline CD4 count) was significantly lower among participants increasing or remaining in MULTI (523, 95% CI [448, 598], cells/mm3) compared with those who decreased/abstained throughout (607, 95% CI [552, 663], p = .02). No significant difference was observed for HIV viral suppression.

CONCLUSIONS

We identified distinct polysubstance use patterns among PWH with SUD: cannabis/alcohol and opioids with alcohol and other drugs. Changes over time toward fewer substances/no use were associated with lower HIV disease severity based on CD4 count but not based on HIV viral suppression.

Characteristics Associated With Unsheltered Status Among Veterans

INTRODUCTION

Unsheltered homelessness is a strongly debated public issue. The study objective is to identify personal and community characteristics associated with unsheltered homelessness in veterans and to test for interactions between these characteristics.

METHODS

In a 2018 national survey of U.S. veterans with homeless experiences; investigators assessed unsheltered time; psychosocial characteristics; and community measures of shelter access, weather, and rental affordability. Associations between these characteristics and unsheltered status were tested in July-August 2020. This study also tested whether the count of personal risk factors interacted with community characteristics in predicting unsheltered status.

RESULTS

Among 5,406 veterans, 481 (8.9%) reported ≥7 nights unsheltered over 6 months. This group was more likely to report criminal justice history, poor social support, medical and drug problems, financial hardship, and being unmarried. Their communities had poorer shelter access and warmer temperatures. The likelihood of unsheltered experience rose with risk factor count from 2.0% (0-1) to 8.4% (2-3) and to 24.2% (4-11). Interaction tests showed that the increase was greater for communities with warmer weather and higher rents (p<0.05).

CONCLUSIONS

Among veterans experiencing homelessness, unsheltered experiences correlate with individual and community risk factors. Communities wishing to address unsheltered homelessness will need to consider action at both levels.

Alcohol Consumption and Hepatitis C Virus (HCV) RNA Levels in HIV/HCV Coinfected Patients

BACKGROUND

The impact of Hepatitis C virus (HCV) RNA levels on the evolution of chronic HCV infection-related liver damage is controversial. Heavy alcohol use is believed to have a deleterious impact on the course of HCV disease, but current knowledge about the possible effect of alcohol use on HCV RNA levels in HIV/HCV coinfected patients is limited.

METHODS

We examined 107 HIV/HCV-infected individuals with current or past unhealthy alcohol use to assess the association between alcohol consumption (any drinking vs. abstinent) and HCV RNA levels.

RESULTS

Participants were 75% male, with a mean age of 43 years, and 63% were on antiretroviral therapy. Mean (SD) log HIV RNA was 3.1 (1.4) and mean (SD) log HCV RNA was 6.1 (0.8). Past-month alcohol use was present in 38% of participants. In a multivariable linear regression analysis we found no significant differences in mean log HCV RNA levels between those reporting alcohol use and those who were abstinent [β (95%CI): -0.04 (-0.34, 0.26), p = 0.79)]. There was no significant association between any heavy drinking day and HCV RNA level (0.07, 95% CI: (-0.24, 0.38), p = 0.66).

CONCLUSIONS

We did not detect significant associations between alcohol use and HCV RNA levels among HIV/HCV coinfected patients.

Socioeconomic, Behavioral, and Clinical Characteristics of Persons Living with HIV Who Experience Homelessness in the United States, 2015-2016

Homelessness is a substantial barrier to consistent, recommended HIV care, access and adherence to antiretroviral therapy (ART), and sustained viral suppression, thus increasing the risk for morbidity and transmission. We used data from the Medical Monitoring Project for June 1, 2015-May 31, 2017 to estimate the weighted prevalence of homelessness among persons with diagnosed HIV (PWH) (N = 7665) overall and by selected sociodemographic, behavioral, and clinical characteristics. Prevalence of homelessness was 8.5%. PWH experiencing homelessness were > 3 times as likely to have needed and not received shelter or housing services (32% vs. 10%), > 4 times as likely to inject drugs (9% vs. 2%), and > 7 times as likely to engage in exchange sex (10% vs. 1%), respectively, compared with PWH who did not experience homelessness. Homelessness was associated with lower HIV care retention, ART dose adherence, and sustained viral suppression. This analysis demonstrates substantial need for enhanced treatment, care, and service delivery for PWH experiencing homelessness. Research has demonstrated that housing assistance programs improve HIV-related outcomes and diminish HIV risk behaviors; therefore, housing assistance for PWH should be prioritized in public health policies and practice.

Longitudinal Determinants of Housing Stability Among People Living With HIV/AIDS Experiencing Homelessness

Objectives. To examine patterns of and factors associated with housing stability over time among people living with HIV (PLWH) experiencing homelessness with co-occurring substance use and mental health disorders enrolled in a patient-centered medical home (PCMH) intervention.Methods. Between September 2013 and February 2017, we ascertained housing trajectories among PLWH in 9 sites in the United States by conducting interviews at baseline, 6, and 12 months after and dichotomized them as improved consistently versus did not improve consistently. We identified covariates affecting housing stability using the socioecological model.Results. Forty-three percent (n = 198) experienced consistent housing improvement. Participants with history of mental health diagnosis (adjusted odds ratio [AOR] = 1.55; 95% confidence interval [CI] = 1.02, 2.35; P = .04) or trauma (AOR = 1.72; 95% CI = 1.22, 2.41; P = .006) had improved housing status; those with recent injecting drug use (AOR = 0.41; 95% CI = 0.19, 0.90; P = .03) had less consistent housing improvement.Conclusions. Improved housing stability may possibly reflect the importance of PCMH interventions that integrate housing, health, and behavioral services with patient navigators to address complex needs of PLWH experiencing homelessness.

Long-term alcohol use patterns and HIV disease severity

OBJECTIVE

We examined the relationship between alcohol use trajectories and HIV disease severity among men and women participating in the Veterans Aging Cohort Study (VACS).

DESIGN

Prospective cohort of HIV-infected persons in care at eight US Veterans Health Administration sites.

METHODS

Between 2002 and 2010, we assessed alcohol consumption annually using the alcohol use disorders identification test-consumption (AUDIT-C). HIV disease severity was ascertained using the VACS index, a validated measure of morbidity and all-cause mortality. We examined the relationship between alcohol use and HIV disease severity patterns using joint trajectory modeling. Alcohol use trajectories were validated using phosphatidylethanol - a biomarker of alcohol consumption - measured between 2005 and 2006 among a subset of participants. We examined associations between membership in alcohol use and VACS index trajectories using multinomial regression.

RESULTS

Among eligible participants, we identified four alcohol consumption trajectories: abstainers (24% of the sample), lower risk (44%), moderate risk (24%), and higher risk drinkers (8%). Alcohol use trajectories were highly correlated with phosphatidylethanol (Cramér's V = 0.465, P < 0.001): mean concentrations were 4.4, 17.8, 57.7, and 167.6 ng/ml in the abstainer, lower risk, moderate risk, and higher risk groups, respectively. Four VACS index trajectories were identified: low (2%), moderate (46%), high (36%), and extreme (16%). Higher risk drinkers were most common in the extreme VACS index group, and were absent in the low index group. In multivariable analysis, the association between alcohol use and VACS index trajectory membership remained significant (P = 0.002).

CONCLUSION

Alcohol use trajectories characterized by persistent unhealthy drinking are associated with more advanced HIV disease severity among HIV-infected veterans in the United States.

Mortality in HIV-Infected Alcohol and Drug Users in St. Petersburg, Russia

In Russia, up to half of premature deaths are attributed to hazardous drinking. The respective roles of alcohol and drug use in premature death among people with HIV in Russia have not been described. Criminalization and stigmatization of substance use in Russia may also contribute to mortality. We explored whether alcohol, drug use and risk environment factors are associated with short-term mortality in HIV-infected Russians who use substances. Secondary analyses were conducted using prospective data collected at baseline, 6 and 12-months from HIV-infected people who use substances recruited between 2007-2010 from addiction and HIV care settings in a single urban setting of St. Petersburg, Russia. We used Cox proportional hazards models to explore associations between 30-day alcohol hazardous drinking, injection drug use, polysubstance use and environmental risk exposures (i.e. past incarceration, police involvement, selling sex, and HIV stigma) with mortality. Among 700 participants, 59% were male and the mean age was 30 years. There were 40 deaths after a median follow-up of 12 months (crude mortality rate 5.9 per 100 person-years). In adjusted analyses, 30-day NIAAA hazardous drinking was significantly associated with mortality compared to no drinking [adjusted Hazard Ratio (aHR) 2.60, 95% Confidence Interval (CI): 1.24-5.44] but moderate drinking was not (aHR 0.95, 95% CI: 0.35-2.59). No other factors were significantly associated with mortality. The high rates of short-term mortality and the strong association with hazardous drinking suggest a need to integrate evidence-based alcohol interventions into treatment strategies for HIV-infected Russians.

Alcohol use disorder and its impact on chronic hepatitis C virus and human immunodeficiency virus infections

Alcohol use disorder (AUD) and hepatitis C virus (HCV) infection frequently co-occur. AUD is associated with greater exposure to HCV infection, increased HCV infection persistence, and more extensive liver damage due to interactions between AUD and HCV on immune responses, cytotoxicity, and oxidative stress. Although AUD and HCV infection are associated with increased morbidity and mortality, HCV antiviral therapy is less commonly prescribed in individuals with both conditions. AUD is also common in human immunodeficiency virus (HIV) infection, which negatively impacts proper HIV care and adherence to antiretroviral therapy, and liver disease. In addition, AUD and HCV infection are also frequent within a proportion of patients with HIV infection, which negatively impacts liver disease. This review summarizes the current knowledge regarding pathological interactions of AUD with hepatitis C infection, HIV infection, and HCV/HIV co-infection, as well as relating to AUD treatment interventions in these individuals.

Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions

Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

Hazardous Alcohol Use Associated with Increased Sexual Risk Behaviors Among People Who Inject Drugs

BACKGROUND

Alcohol is associated with a multitude of severe health consequences. While risk behaviors related to illicit drug use are commonly studied among people who inject drugs (PWID), the role of alcohol use has received substantially less attention in this population. We explored whether drug and sexual risk behaviors as well as experiences of violence were associated with hazardous alcohol use in a cohort of PWID.

METHODS

Analyses were conducted using observational data from a prospective cohort of community-recruited HIV-negative PWID in Vancouver, Canada. We used the U.S. National Institute on Alcohol Abuse and Alcoholism definition of hazardous alcohol use (i.e., >14 drinks/wk or >4 drinks on 1 occasion for men, and >7 drinks/wk or >3 drinks on 1 occasion for women). We used multivariable generalized estimating equations (GEE) to identify the factors associated with hazardous alcohol use.

RESULTS

Between 2006 and 2012, 1,114 HIV-negative individuals were recruited, and 186 (16.7%) reported hazardous alcohol use in the previous 6 months at baseline. In multivariable GEE analyses, having multiple sex partners (adjusted odds ratio [AOR] = 1.25), history of sexually transmitted infection (AOR = 1.50), experiencing violence (AOR = 1.36), and incarceration (AOR = 1.29) were each independently associated with hazardous alcohol use. Caucasian ethnicity (AOR = 0.56), ≥ daily heroin injection (AOR = 0.81), and engagement in addiction treatment (AOR = 0.84) were negatively associated with hazardous alcohol use (all p < 0.05).

CONCLUSIONS

A considerable proportion of PWID reported hazardous alcohol use, which was independently associated with reporting sexual, but not drug-related, HIV risk behaviors and experiencing recent violence. Findings suggest a need to integrate regular screening and evidence-based alcohol interventions into treatment efforts for PWID.

Pain and Mortality Risk in a Cohort of HIV-Infected Persons with Alcohol Use Disorders

Pain has been associated with increased risk for mortality in some studies. We analyzed data from a cohort study [HIV-longitudinal interrelationships of viruses and ethanol (HIV-LIVE)] of HIV-infected persons with alcohol use disorders enrolled 2001-2003 to explore whether reporting moderate or greater pain interference was associated with mortality. The main independent variable was pain that at least moderately interfered with work based on a single question from the SF-12. Primary analyses dichotomized at "moderately" or above. Cox proportional hazards models assessed the association between pain interference and death adjusting for demographics, substance use, CD4 count, HIV viral load and co-morbidities. Although significant in unadjusted models (HR = 1.58 (95 % CI 1.03-2.41; p value = 0.04)), after adjusting for confounders, ≥moderate pain interference was not associated with an increased risk of death [aHR = 1.30 (95 % CI 0.81-2.11, p value = 0.28)]. Among HIV-infected persons with alcohol use disorders, we did not detect a statistically significant independent association between pain interference and risk of death after adjustment for potential confounders.

Characteristics of Homeless Adults Who Died of Drug Overdose: A Retrospective Record Review

Drug overdose is a major cause of death among homeless people, but little is known about the characteristics of homeless overdose decedents. We conducted a retrospective record review of 219 adult patients of Boston Health Care for the Homeless Program (BHCHP) who died of drug overdose in 2003-2008. We assessed the substances implicated in overdose and the health and service use characteristics of decedents prior to death. Eighty-one percent of overdose deaths involved opioids and 40% involved multiple drugs. Problem substance use (85%), psychiatric illness (61%), and chronic pain (45%) were common, and 32% had documentation of all three. Half were well-connected to BHCHP, and 35% had a clinic visit within 90 days of death. The complex health histories and frequent health care contacts of homeless drug overdose decedents suggest that clinical facilities may be an important frontline venue for overdose education, naloxone distribution, and integrated substance use treatment programming.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review

BACKGROUND

Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide.

OBJECTIVES

We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation.

SEARCH METHODS

We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature.

SELECTION CRITERIA

We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure.

DATA COLLECTION AND ANALYSIS

Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding.

RESULTS

Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics.

CONCLUSIONS

Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

Twelve-year mortality in HIV-infected patients receiving antiretroviral therapy: the role of social vulnerability. The ANRS CO8 APROCO-COPILOTE cohort

BACKGROUND

Although the role of clinical/biological factors associated with mortality has already been explored in HIV-infected patients on antiretroviral therapy (ART), to date little attention has been given to the potential role of social vulnerability. This study aimed to construct an appropriate measure of social vulnerability and to evaluate whether this measure is predictive of increased mortality risk in ART-treated patients followed up in the ANRS CO8 APROCO-COPILOTE cohort.

METHODS

The cohort enrolled 1,281 patients initiating a protease inhibitor-based regimen in 1997-1999. Clinical/laboratory data were collected every 4 months. Self-administered questionnaires collected psycho-social/behavioural characteristics at enrolment (month [M] 0), M4 and every 8-12 months thereafter. A multiple correspondence analysis using education, employment and housing indicators helped construct a composite indicator measuring social vulnerability. The outcome studied was all-cause deaths occurring after M4. The relationship between social vulnerability and mortality, after adjustment for other predictors, was studied using a shared-frailty Cox model, taking into account informative study dropout.

RESULTS

Over a median (IQR) follow-up of 7.9 (3.0-11.2) years, 121 deaths occurred among 1,057 eligible patients, corresponding to a mortality rate (95% CI) of 1.64 (1.37, 1.96)/100 person-years. Leading causes of death were non-AIDS defining cancers (n=26), AIDS (n=23) and cardiovascular diseases (n=12). Social vulnerability (HR [95% CI] =1.2 [1.0, 1.5]) was associated with increased mortality risk, after adjustment for other known behavioural and bio-medical predictors.

CONCLUSIONS

Social vulnerability remains a major mortality predictor in ART-treated patients. A real need exists for innovative interventions targeting individuals cumulating several sources of social vulnerability, to ensure that social inequalities do not continue to lead to higher mortality.

Complex care needs of patients with late-stage HIV disease: a retrospective study

This retrospective chart review provides a profile of an emerging population of vulnerable HIV patients with complex comorbidities. Data were abstracted from all 83 patients admitted in 2008 to Casey House, a community-based hospital dedicated to supportive and palliative care for persons with HIV in Toronto, Canada. We describe patient characteristics, including medical and psychiatric conditions, and use a Venn diagram and case study to illustrate the frequency and reality of co-occurring conditions that contribute to the complexity of patients' health and health care needs. The mean age at admission was 49.2 years (SD = 10.5). Sixty-seven patients (80.7%) were male. Patients experienced a mean of 5.9 medical comorbidities (SD = 2.3) and 1.9 psychiatric disorders (lifetime Axis I diagnoses). Forty patients (48.2%) experienced cognitive impairment including HIV-associated dementia. Patients were on a mean of 11.5 (SD = 5.3) medications at admission; 74.7% were on antiretroviral medications with 55.0% reporting full adherence. Current alcohol and drug use was common with 50.6% reporting active use at admission. Our Venn diagram illustrates the breadth of complexity in the clients with 8.4% of clients living in unstable housing with three or more medical comorbidities and two or more psychiatric diagnoses. Comprehensive HIV program planning should include interventions that can flexibly adapt to meet the multidimensional and complex needs of this segment of patients. Researchers, policy-makers, and clinicians need to have greater awareness of overlapping medical, psychiatric and psychosocial comorbidities. Inclusion of the needs of these most vulnerable patients in the development of evidence-based guidelines is an important step for effectively treating, preventing, and planning for the future of HIV/AIDS care.

Cost of Care for HIV-Infected Patients with Co-Occurring Substance Use Disorder or Psychiatric Disease: Report from a Large, Integrated Health Plan

Background. The costs of providing care to HIV-infected (HIV+) patients with co-occurring diagnoses of substance use (SU) disorder or psychiatric disease (PD) are not well documented. It is our objective to evaluate costs in these HIV+ patients receiving care in a large health plan. Methods. We conducted a retrospective cohort study from 1995 to 2010 to compare costs of healthcare in HIV+ patients with and without co-occurring SU disorder and/or PD diagnoses. Estimates of proportional differences in costs (rate ratios) were obtained from repeated measures generalized linear regression. Models were stratified by cost category (e.g., inpatient, outpatient). Results. Mean total healthcare costs per patient per year were higher in HIV+ patients diagnosed with SU disorder or PD compared to HIV+ patients without these comorbid conditions. After controlling for confounders, total mean costs remained significantly higher in patients diagnosed with SU disorder (RR = 1.24, 95% CI = 1.18-1.31) or PD (RR = 1.19, 95% CI = 1.15-1.24). Mean outpatient care costs were significantly greater in patients with both SU disorder and PD (RR = 1.52, 95% CI = 1.41-1.64). Conclusions. Given these higher expenditures in the care of HIV+ patients with comorbid SU disorder and/or PD, greater efforts to facilitate SU disorder or PD treatment initiation and persistence could provide substantial savings.

Inflammatory cytokines and mortality in a cohort of HIV-infected adults with alcohol problems

BACKGROUND

HIV infection leads to chronic inflammation and alterations in levels of inflammatory cytokines. The association between cytokine levels and mortality in HIV infection is not fully understood.

METHODS

We analyzed data from a cohort of HIV-infected adults with alcohol problems who were recruited in 2001-2003, and were prospectively followed until 2010 for mortality using the National Death Index. The main independent variables were inflammatory biomarkers [interleukin-6 (IL-6), IL-10, tumor necrosis factor-α, C-reactive protein, serum amyloid A, monocyte chemotactic protein-1, and cystatin-C], measured at baseline in peripheral blood and categorized as high (defined as being in the highest quartile) vs. low. A secondary analysis was conducted using inflammatory burden score, defined as the number of biomarkers in the highest quartile (0, 1, 2 or ≥ 3). Cox models were used to assess the association between both biomarker levels and inflammatory burden with mortality adjusting for potential confounders.

RESULTS

Four hundred HIV-infected patients were included (74.8% men, mean age 42 years, 50% hepatitis C virus-infected). As of 31 December 2009, 85 patients had died. In individual multivariable analyses for each biomarker, high levels of IL-6 and C-reactive protein were significantly associated with mortality [hazard ratio=2.49 (1.69-5.12), P<0.01] and [hazard ratio=1.87 (1.11-3.15), P=0.02], respectively. There was also a significant association between inflammatory burden score and mortality [hazard ratio=2.18 (1.29-3.66) for ≥ 3 vs. 0, P=0.04]. In the fully adjusted multivariable analysis, high levels of IL-6 remained independently associated with mortality [hazard ratio=2.57 (1.58-4.82), P<0.01].

CONCLUSION

High IL-6 levels and inflammatory burden score were associated with mortality in a cohort of HIV-infected adults with alcohol problems.

Chronic hepatitis C virus infection is associated with all-cause and liver-related mortality in a cohort of HIV-infected patients with alcohol problems

AIMS

To assess the association between hepatitis C virus (HCV) infection and overall and liver-related death in human immunodeficiency virus (HIV)-infected patients with alcohol problems.

DESIGN

We analyzed data from a cohort of HIV-infected adults with current or past alcohol problems enrolled between 2001 and 2003, searching for causes of death until 2010 using the National Death Index.

SETTING AND PARTICIPANTS

Participants were HIV-infected adults with current or past alcohol problems, recruited in Boston, MA from HIV clinics at two hospitals, homeless shelters, drug treatment programs, subject referrals, flyers and another cohort study with comparable recruitment sites.

MEASUREMENTS

The primary and secondary outcomes were all-cause and liver-related mortality, respectively. The main independent variable was hepatitis C virus (HCV) RNA status (positive versus negative). Mortality rates and Kaplan-Meier survival curves were calculated by HCV status for both overall and liver-related mortality. Cox proportional hazards models were used to assess the association between HCV infection and overall and liver-related death, adjusting for alcohol and drug use over time.

FINDINGS

A total of 397 adults (50% HCV-infected) were included. As of 31 December 2009, 83 cohort participants had died (60 HCV-infected, 23 HCV-uninfected; log-rank test P < 0.001), and 26 of those deaths were liver-related (21 HCV-infected, five HCV-uninfected; log-rank test P < 0.001). All-cause and liver-related mortality rates were 4.68 and 1.64 deaths per 100 person-years for HCV-infected patients and 1.65 and 0.36 per 100 person-years for those without HCV, respectively. In the fully adjusted Cox model, HCV infection was associated with both overall [hazard ratio (HR) = 2.55, 95% confidence interval (CI) = 1.50-4.33, P < 0.01], and liver-related mortality (HR = 3.24, 95% CI = 1.18-8.94, P = 0.02].

CONCLUSION

Hepatitis C virus infection is associated independently with all-cause and liver-related mortality in human immunodeficiency virus-infected patients with alcohol problems, even when accounting for alcohol and other drug use.

Latent class analysis of polysubstance use, sexual risk behaviors, and infectious disease among South African drug users

BACKGROUND

HIV transmission risk among non-injection drug users is high due to the co-occurrence of drug use and sexual risk behaviors. The purpose of the current study was to identify patterns of drug use among polysubstance users within a high HIV prevalence population.

METHODS

The study sample included 409 substance users from the Pretoria region of South Africa. Substances used by 20% or more the sample included: cigarettes, alcohol, marijuana and heroin in combination, marijuana and cigarettes in combination, and crack cocaine. Latent class analysis was used to identify patterns of polysubstance use based on types of drugs used. Multivariate logistic regression analyses compared classes on demographics, sexual risk behavior, and disease status.

RESULTS

Four classes of substance use were found: MJ+Cig (40.8%), MJ+Her (30.8%), Crack (24.7%), and Low Use (3.7%). The MJ+Cig class was 6.7 times more likely to use alcohol and 3 times more likely to use drugs before/during sex with steady partners than the Crack class. The MJ+Cig class was 16 times more likely to use alcohol before/during sex with steady partners than the MJ+Her class. The Crack class was 6.1 times more likely to engage in transactional sex and less likely to use drugs before/during steady sex than the MJ+Her class.

CONCLUSIONS

Findings illustrate patterns of drug use among a polysubstance using population that differ in sexual risk behavior. Intervention strategies should address substance use, particularly smoking as a route of administration (ROA), and sexual risk behaviors that best fit this high-risk population.

Interleukin-6 is associated with noninvasive markers of liver fibrosis in HIV-infected patients with alcohol problems

Both HIV and hepatitis C virus (HCV) cause chronic inflammation and alterations in serum inflammatory cytokines. The impact of inflammatory cytokines on liver fibrosis is not well understood. We studied the association between interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α and liver fibrosis in HIV-infected patients with current or past alcohol problems (CAGE ≥2 or physician investigator diagnosis). Liver fibrosis was estimated with FIB-4 (FIB-4 <1.45 defined the absence of liver fibrosis and FIB-4 >3.25 defined advanced fibrosis). Logistic regression was used to assess the association between cytokines and fibrosis, adjusting for age, sex, CD4, HIV RNA, current antiretroviral therapy, body mass index, and HCV. Secondary analyses explored whether the association between HCV and liver fibrosis was mediated by these cytokines. Participants (n=308) were all HIV-infected; 73% were male with a mean age of 42 years; half had detectable HCV-RNA, 60.7% had an absence of liver fibrosis, and 10.1% had advanced fibrosis. In models that adjusted for each cytokine separately, higher levels of IL-6 were significantly associated with an absence of fibrosis [adjusted OR (95% CI): 0.43 (0.19, 0.98), p=0.05] and were borderline significant for advanced fibrosis [adjusted OR (95% CI): 8.16 (0.96, 69.54), p=0.055]. In the final model, only higher levels of IL-6 remained significantly associated with advanced liver fibrosis [adjusted OR (95% CI): 11.78 (1.17, 118.19), p=0.036]. Adjustment for inflammatory cytokines attenuated the adjusted OR for the association between HCV and fibrosis in the case of IL-6 [for the absence of fibrosis from 0.32 (0.17, 0.57) p<0.01 to 0.47 (0.23, 0.96) p=0.04; and for advanced fibrosis from 7.22 (2.01, 25.96) p<0.01 to 6.62 (1.20, 36.62) p=0.03], suggesting IL-6 may be a partial mediator of the association between HCV and liver fibrosis. IL-6 was strongly and significantly associated with liver fibrosis in a cohort of HIV-infected patients with alcohol problems. IL-6 may be a useful predictive marker for liver fibrosis for HIV-infected patients.

Impact of lifetime alcohol use on liver fibrosis in a population of HIV-infected patients with and without hepatitis C coinfection

BACKGROUND

The effect of alcohol on liver disease in HIV infection has not been well characterized.

METHODS

We performed a cross-sectional multivariable analysis of the association between lifetime alcohol use and liver fibrosis in a longitudinal cohort of HIV-infected patients with alcohol problems. Liver fibrosis was estimated with 2 noninvasive indices, "FIB-4," which includes platelets, liver enzymes, and age; and aspartate aminotransferase/platelet ratio index ("APRI"), which includes platelets and liver enzymes. FIB-4 <1.45 and APRI <0.5 defined the absence of liver fibrosis. FIB-4 >3.25 and APRI >1.5 defined advanced liver fibrosis. The main independent variable was lifetime alcohol consumption (<150 kg, 150 to 600 kg, >600 kg).

RESULTS

Subjects (n = 308) were 73% men, mean age 43 years, 49% with hepatitis C virus (HCV) infection, 60% on antiretroviral therapy, 49% with an HIV RNA load <1,000 copies/ml, and 18.7% with a CD4 count <200 cells/mm(3) . Forty-five percent had lifetime alcohol consumption >600 kg, 32.7% 150 to 600 kg, and 22.3% <150 kg; 33% had current heavy alcohol use, and 69% had >9 years of heavy episodic drinking. Sixty-one percent had absence of liver fibrosis and 10% had advanced liver fibrosis based on FIB-4. In logistic regression analyses, controlling for age, gender, HCV infection, and CD4 count, no association was detected between lifetime alcohol consumption and the absence of liver fibrosis (FIB-4 <1.45) (adjusted odds ratio [AOR] = 1.12 [95% CI: 0.25 to 2.52] for 150 to 600 kg vs. <150 kg; AOR = 1.11 [95% CI: 0.52 to 2.36] for >600 kg vs. <150 kg; global p = 0.95). Additionally, no association was detected between lifetime alcohol use and advanced liver fibrosis (FIB-4 >3.25). Results were similar using APRI, and among those with and without HCV infection.

CONCLUSIONS

In this cohort of HIV-infected patients with alcohol problems, we found no significant association between lifetime alcohol consumption and the absence of liver fibrosis or the presence of advanced liver fibrosis, suggesting that alcohol may be less important than other known factors that promote liver fibrosis in this population.

Key drug use, health and socio-economic characteristics of young crack users in two Brazilian cities

BACKGROUND

Crack use constitutes a major problem in cities across Brazil. While existing data suggest that crack use is generally concentrated among disenfranchised young people with extensive health problems and crime involvement, extensive data gaps exist. To address this issue, this study aimed to assess key characteristics of young crack users in two Brazilian cities.

METHODS

N=160 regular and young adult (ages 18-24) crack users were recruited by community-based methods in the cities of Rio de Janeiro (Southeast) and Salvador (Northeast). Assessments included an interviewer-administered questionnaire on key social, drug use, health and service use characteristics, as well as serological testing of HBV, HCV and HIV status, and were conducted anonymously between November 2010 and June 2011. Participants provided informed consent and received transportation vouchers following assessment completion. The study was approved by institutional ethics review boards.

RESULTS

The majority of participants were: male, with less than high school education, unstably housed (Rio only); gained income from legal or illegal work; arrested by police in past year (Salvador only); had numerous daily crack use episodes and shared paraphernalia (Salvador only); co-used alcohol, tobacco, cannabis and cocaine; had no injection history; rated physical and mental health as 'fair' or lower (Salvador only); had unprotected sex; were never HIV tested; were not HIV, HBV or HCV positive; and did not use existing social or health services, but desired access to crack user specific services.

CONCLUSION

Crack users in the two Brazilian sites featured extensive socio-economic marginalization, crack and poly-drug use as well as sexual risk behaviours, and compromised health status. Social and health service utilization are low, yet needs are high. There is an urgent need for further research and for targeted interventions for crack use in Brazil.

Housing status and the health of people living with HIV/AIDS

Individuals who are homeless or living in marginal conditions have an elevated burden of infection with HIV. Existing research suggests the HIV/AIDS pandemic in resource-rich settings is increasingly concentrated among members of vulnerable and marginalized populations, including homeless/marginally-housed individuals, who have yet to benefit fully from recent advances in highly-active antiretroviral therapy (HAART). We reviewed the scientific evidence investigating the relationships between inferior housing and the health status, HAART access and adherence and HIV treatment outcomes of people living with HIV/AIDS (PLWHA.) Studies indicate being homeless/marginally-housed is common among PLWHA and associated with poorer levels of HAART access and sub-optimal treatment outcomes. Among homeless/marginally-housed PLWHA, determinants of poorer HAART access/adherence or treatment outcomes include depression, illicit drug use, and medication insurance status. Future research should consider possible social- and structural-level determinants of HAART access and HV treatment outcomes that have been shown to increase vulnerability to HIV infection among homeless/marginally-housed individuals. As evidence indicates homeless/marginally-housed PLWHA with adequate levels of adherence can benefit from HAART at similar rates to housed PLWHA, and given the individual and community benefits of expanding HAART use, interventions to identify HIV-seropositive homeless/marginally-housed individuals, and engage them in HIV care including comprehensive support for HAART adherence are urgently needed.

Service priorities and unmet service needs among people living with HIV/AIDS: results from a nationwide interview of HIV/AIDS housing organizations

Housing for people living with HIV/AIDS (PLWHA) has been linked to a number of positive physical and mental health outcomes, in addition to decreased sexual and drug-related risk behavior. The current study identified service priorities for PLWHA, services provided by HIV/AIDS housing agencies, and unmet service needs for PLWHA through a nationwide telephone survey of HIV/AIDS housing agencies in the USA. Housing, alcohol/drug treatment, and mental health services were identified as the three highest priorities for PLWHA and assistance finding employment, dental care, vocational assistance, and mental health services were the top needs not being met. Differences by geographical region were also examined. Findings indicate that while housing affords PLWHA access to services, there are still areas (e.g., mental health services) where gaps in linkages to care exist.

Sticking to it: the effect of maximally assisted therapy on antiretroviral treatment adherence among individuals living with HIV who are unstably housed

Housing is a known determinant of health behaviors, which includes adherence to Antiretroviral Therapy (ART). Within the Longitudinal Investigations into Supportive and Ancillary Health Services (LISA) study, unstable housing is inversely associated with adherence. Several comprehensive adherence support services have emerged to improve adherence for unstably housed or otherwise vulnerable populations. The Maximally Assisted Therapy (MAT) program in Vancouver, British Columbia uses a multidisciplinary approach to support HIV-positive clients with a history of addictions or mental illness, many of whom also experience episodic homelessness. This study investigated the association between antiretroviral adherence and use of support services, including the MAT program, amongst people living with HIV and AIDS who are unstably housed in the LISA sample. Of the 212 unstably housed participants, those who attended the MAT program were 4.76 times more likely to be ≥95% adherent (95% CI 1.72-13.13; P = 0.003) than those who did not. The findings suggest that in the absence of sustainable housing solutions, programs such as MAT play an important role in supporting treatment adherence in this population.

Association of ongoing drug and alcohol use with non-adherence to antiretroviral therapy and higher risk of AIDS and death: results from ACTG 362

Drug and alcohol use have been associated with a worse prognosis in short-term and cross-sectional analyses of HIV-infected populations, but longitudinal effects on adherence to antiretroviral therapy (ART) and clinical outcomes in advanced AIDS are less well characterized. We assessed self-reported drug and alcohol use in AIDS patients, and examined their association with non-adherence and death or disease progression in a multicenter observational study. We defined non-adherence as reporting missed ART doses in the 48 hours before study visits. The association between drug use and ART non-adherence was evaluated using repeated measures generalized estimating equation (GEE) models. The association between drug and alcohol use and time to new AIDS diagnosis or death was evaluated via Cox regression models, controlling for covariates including ART adherence. Of 643 participants enrolled between 1997 and 1999 and followed through 2007, at entry 39% reported ever using cocaine, 24% amphetamines, and 10% heroin. Ongoing drug use during study follow-up was reported by 9% using cocaine, 4% amphetamines, and 1% heroin. Hard drug (cocaine, amphetamines, or heroin) users had 2.1 times higher odds (p=0.001) of ART non-adherence in GEE models and 2.5 times higher risk (p=0.04) of AIDS progression or death in Cox models. Use of hard drugs was attenuated as a risk factor for AIDS progression or death after controlling for non-adherence during follow-up (HR = 2.11, p=0.08), but was still suggestive of a possible adherence-independent mechanism of harm. This study highlights the need to continuously screen and treat patients for drug use as a part of ongoing HIV care.

Homelessness and adherence to antiretroviral therapy among a cohort of HIV-infected injection drug users

Homelessness is prevalent among HIV-infected injection drug users (IDU) and may adversely affect access and adherence to antiretroviral therapy (ART). There are limited descriptions of the effect of homelessness on adherence to ART in long-term cohorts of HIV-infected IDU. We used data from a community-recruited prospective cohort of HIV-infected IDU, including comprehensive ART dispensation records, in a setting where HIV care is free. We examined the relationship between the homelessness measured longitudinally, and the odds of ≥95% adherence to ART using generalized estimating equations logistic regression modeling adjusting for sociodemographics, drug use, and clinical variables. Between May 1996 and September 2008, 545 HIV-infected IDU were recruited and eligible for the present study. The median follow-up duration was 23.8 months (IQR 8.5-91.6 months) contributing 2,197 person-years of follow-up. At baseline, homeless participants were slightly younger (35.8 vs. 37.9 years, p = 0.01) and more likely to inject heroin at least daily (37.1% vs. 24.6%. p = 0.004) than participants who had housing. The multivariate model revealed that homelessness (adjusted odds ratio [AOR] 0.66; 95% CI: 0.53-0.84) and frequent heroin use (AOR 0.40; 95% CI: 0.30-0.53) were significantly and negatively associated with ART adherence, whereas methadone maintenance was positively associated (AOR 2.33; 95% CI: 1.86-2.92). Sub-optimal ART adherence was associated with homelessness and daily injection heroin use among HIV-infected IDU. Given the survival benefit of ART, it is critical to develop and evaluate innovative strategies such as supportive housing and methadone maintenance to address these risk factors to improve adherence.

Harmful alcohol consumption and patterns of substance use in HIV-infected patients receiving antiretrovirals (ANRS-EN12-VESPA Study): relevance for clinical management and intervention

Alcohol abuse affects secondary prevention and disease progression in HIV-infected patients, and adherence and response to treatment in those chronically treated. The objective of this study was to estimate the prevalence of harmful alcohol consumption (HAC) using various indicators and identify which groups of patients may require specific targeted interventions for HAC risk reduction. A cross-sectional survey, based on a random sample representative of people living with HIV/AIDS (PLWHA) was carried out in 102 French hospital departments delivering HIV care. As alcohol abuse is particularly detrimental to patients receiving highly active antiretroviral therapy (HAART), we focused only on those individuals receiving HAART with complete alcohol assessment (CAGE, AUDIT-C, regular binge drinking, N=2340). Collected information included medical and socio-demographic data, HIV risk behaviors, adherence to treatment and substance and alcohol use, together with depression, anxiety, and experience of attempted suicide or sex work. HAC prevalence was evaluated as follows: 12% (CAGE score > or =2), 27% (AUDIT-C), and 9% (regular binge drinking). Three groups were at higher risk of HAC: men who have sex with men using stimulants, polydrug users, and to a lesser degree, ex-drug users. Innovative intervention strategies to reduce HAC and improve HIV prevention and HAART adherence in various PLWHA populations need urgent testing and implementation. Such interventions for alcohol risk reduction remain central to promoting improved HIV prevention and assuring HAART effectiveness in these populations.

Differences in Mortality among Heroin, Cocaine, and Methamphetamine Users: A Hierarchical Bayesian Approach

Studies examining differences in mortality among long-term drug users have been limited. In this paper, we introduce a Bayesian framework that jointly models survival data using a Weibull proportional hazard model with frailty, and substance and alcohol data using mixed-effects models, to examine differences in mortality among heroin, cocaine, and methamphetamine users from five long-term follow-up studies. The traditional approach to analyzing combined survival data from numerous studies assumes that the studies are homogeneous, thus the estimates may be biased due to unobserved heterogeneity among studies. Our approach allows us to structurally combine the data from different studies while accounting for correlation among subjects within each study. Markov chain Monte Carlo facilitates the implementation of Bayesian analyses. Despite the complexity of the model, our approach is relatively straightforward to implement using WinBUGS. We demonstrate our joint modeling approach to the combined data and discuss the results from both approaches.

Excess mortality among HIV-infected patients diagnosed with substance use dependence or abuse receiving care in a fully integrated medical care program

BACKGROUND

We examined the association between substance use (SU) disorder and mortality among HIV-infected patients in a large, private medical care program.

METHODS

In a retrospective cohort design, HIV-infected patients (≥14 years old) from a large health plan (Northern California) were studied to examine mortality associated with diagnosis of SU dependence or abuse over an 11-year period.

RESULTS

At study entry or during follow-up, 2,279 (25%) of 9,178 HIV-infected patients had received a diagnosis of SU disorder. Diagnoses were categorized as alcohol dependence/abuse only, illicit drugs only, or both. Cause of death differed by the category of SU diagnosis. Mortality rates ranged from 35.5 deaths per 1,000 person-years in patients with an SU disorder to 17.5 deaths among patients without an SU disorder. Regression results indicated mortality risk was significantly higher in all categories of SU disorder compared to no SU diagnosis (hazard ratios ranging from 1.65 to 1.67) after adjustment for SU treatment and confounders.

CONCLUSIONS

A diagnosis of SU dependence/abuse is associated with higher mortality among HIV-infected patients for whom access to medical services is not a significant factor.

Mortality after diagnosis of psychiatric disorders and co-occurring substance use disorders among HIV-infected patients

We examined the associations between psychiatric diagnoses, substance use disorders, health services, and mortality among 9751 HIV-infected patients (≥14 years old) in a large, private medical care program, in a retrospective cohort design over a 12-year period. All study data were extracted from computerized clinical and administrative databases. Results showed that 25.4% (n = 2472) of the 9751 study subjects had received a psychiatric diagnosis (81.1% had major depression, 17.1% had panic disorder, 14.2% had bipolar disorder, and 8.1% had anorexia/bulimia); and 25.5% (n = 2489) had been diagnosed with substance use disorder; 1180 (12.1%) patients had received both psychiatric and substance diagnoses. In comparison to patients with neither a psychiatric diagnosis nor a SU diagnosis, the highest risk of death was found among patients with dual psychiatric and substance use diagnoses who had no psychiatric treatment visits and no substance treatment (relative hazards [RH] = 4.17, 95% confidence interval [CI] = 2.35 to 7.40). Among dually diagnosed patients, receiving psychiatric and/or substance use disorder treatment somewhat reduced the risk of death compared to patients with neither diagnosis. The lowest risks of death were observed among patients with a single diagnosis who had received corresponding treatment. Our study findings suggest that screening for psychiatric and substance problems at the initiation and during the course of HIV/AIDS treatment and providing psychiatric and substance use disorder treatment may extend life for these vulnerable patients.

Addiction treatment and stable housing among a cohort of injection drug users

Background

Unstable housing and homelessness is prevalent among injection drug users (IDU). We sought to examine whether accessing addiction treatment was associated with attaining stable housing in a prospective cohort of IDU in Vancouver, Canada.

Methods

We used data collected via the Vancouver Injection Drug User Study (VIDUS) between December 2005 and April 2010. Attaining stable housing was defined as two consecutive “stable housing” designations (i.e., living in an apartment or house) during the follow-up period. We assessed exposure to addiction treatment in the interview prior to the attainment of stable housing among participants who were homeless or living in single room occupancy (SRO) hotels at baseline. Bivariate and multivariate associations between the baseline and time-updated characteristics and attaining stable housing were examined using Cox proportional hazard regression models.

Principal Findings

Of the 992 IDU eligible for this analysis, 495 (49.9%) reported being homeless, 497 (50.1%) resided in SRO hotels, and 380 (38.3%) were enrolled in addiction treatment at the baseline interview. Only 211 (21.3%) attained stable housing during the follow-up period and of this group, 69 (32.7%) had addiction treatment exposure prior to achieving stable housing. Addiction treatment was inversely associated with attaining stable housing in a multivariate model (adjusted hazard ratio [AHR]  = 0.71; 95% CI: 0.52–0.96). Being in a partnered relationship was positively associated with the primary outcome (AHR  = 1.39; 95% CI: 1.02–1.88). Receipt of income assistance (AHR  = 0.65; 95% CI: 0.44–0.96), daily crack use (AHR  = 0.69; 95% CI: 0.51–0.93) and daily heroin use (AHR  = 0.63; 95% CI: 0.43–0.92) were negatively associated with attaining stable housing.

Conclusions

Exposure to addiction treatment in our study was negatively associated with attaining stable housing and may have represented a marker of instability among this sample of IDU. Efforts to stably house this vulnerable group may be occurring in contexts outside of addiction treatment.

Missed opportunities for HIV testing among high-risk heterosexuals

BACKGROUND

HIV testing is an important HIV prevention strategy, yet heterosexuals at high risk do not test as frequently as other groups. We examined the association of past year HIV testing and encounters with institutional settings where the Centers for Disease Control and Prevention recommends annual testing for high-risk heterosexuals.

METHODS

We recruited high-risk heterosexuals in New York City in 2006 to 2007 through respondent-driven sampling. Respondents were asked the date of their most recent HIV test and any potential encounters with 4 testing settings (homeless shelters, jails/prisons, drug treatment programs, and health care providers). Analyses were stratified by gender.

RESULTS

Of the 846 respondents, only 31% of men and 35% of women had a past year HIV test, but over 90% encountered at least one testing setting. HIV seroprevalence was 8%. In multiple logistic regression, recent HIV testing was significantly associated with recent encounters with homeless shelters and jails/prisons for men, and encounters with health care providers for both men and women.

CONCLUSIONS

HIV testing was low overall but higher for those with exposures to potential routine testing settings. Further expansion of testing in these settings would likely increase testing rates and may decrease new HIV infections among high-risk heterosexuals.

Predictors of death and survival duration among a sample of persons living With HIV/AIDS

A follow-up study was conducted on a sample of 120 ethnically diverse HIV-positive men and women first interviewed in 2000. Participant survival and death rates were ascertained from death records and analyses were performed to identify demographic and psychosocial predictors of survival from the original data. Consistent with past studies, factors associated with survival were age, CD4 count, years HIV positive, and lower alcohol use. Two analyses identified use of professional counseling as a unique factor associated with reduced risk of death. Contrary to our hypotheses, the results from these analyses did not suggest that social groups with fewer economic and institutional resources or those with limited access to highly active retroviral therapy (HAART) therapies were at reduced risk of survival.

Micoses sistêmicas: fatores associados ao óbito em pacientes com infecção pelo vírus da imunodeficiência humana, Cuiabá, Estado de Mato Grosso, 2005-2008

A prevalência de micose sistêmica entre 1.300 pacientes portadores de HIV/Aids de Cuiabá, Mato Grosso foi de 4,6%, no período de 2005-2008. As espécies de fungos isoladas foram o Cryptococcus neoformans (50%), Cryptococcus gattii (1,6%), Cryptococcus spp (6,6%), Histoplasma capsulatum (38,3%) e Paracoccidioides brasiliensis (3,3%). Óbito foi registrado em 32 (53,3%) pacientes, sendo a criptococose a principal causa. A contagem de linfócitos T CD4+ foi baixa e semelhante entre os pacientes que sobreviveram ou faleceram por micose sistêmica. O etilismo (OR:8,2; IC95%: 1,4-62,1; p=0,005) e o nível médio de desidrogenase lática [758 (182) U/L vs 416 (268) U/L; p<0,001] foram as características independentemente associadas ao óbito dos pacientes do estudo. Os resultados mostram alta letalidade por micoses sistêmicas em pacientes portadores de HIV/Aids de Cuiabá e sugerem que características clínico-laboratoriais tais como o etilismo e a elevação precoce da desidrogenase lática podem ser fatores relacionados ao pior prognóstico nessas condições.

Impact of housing on the survival of persons with AIDS

BACKGROUND

Homeless persons with HIV/AIDS have greater morbidity and mortality, more hospitalizations, less use of antiretroviral therapy, and worse medication adherence than HIV-infected persons who are stably housed. We examined the effect of homelessness on the mortality of persons with AIDS and measured the effect of supportive housing on AIDS survival.

METHODS

The San Francisco AIDS registry was used to identify homeless and housed persons who were diagnosed with AIDS between 1996 and 2006. The registry was computer-matched with a housing database of homeless persons who received housing after their AIDS diagnosis. The Kaplan-Meier product limit method was used to compare survival between persons who were homeless at AIDS diagnosis and those who were housed. Proportional hazards models were used to estimate the independent effects of homelessness and supportive housing on survival after AIDS diagnosis.

RESULTS

Of the 6,558 AIDS cases, 9.8% were homeless at diagnosis. Sixty-seven percent of the persons who were homeless survived five years compared with 81% of those who were housed (p < 0.0001). Homelessness increased the risk of death (adjusted relative hazard [RH] 1.20; 95% confidence limits [CL] 1.03, 1.41). Homeless persons with AIDS who obtained supportive housing had a lower risk of death than those who did not (adjusted RH 0.20; 95% CL 0.05, 0.81).

CONCLUSION

Supportive housing ameliorates the negative effect of homelessness on survival with AIDS.

Engaging homeless persons in end of life preparations

BACKGROUND

There are no prospective studies that have investigated the effects of an intervention to improve end of life (EOL) care in an underserved population.

OBJECTIVE

To determine whether homeless persons will complete an advance directive (AD).

DESIGN

Randomized trial comparing two modes of providing an opportunity for homeless persons to complete an AD. Half of the subjects were randomized to a self-guided group (SG) who were given an AD and written instructions; the other half were given the same material but, in addition, were offered the opportunity to receive guidance to complete the AD (CG).

PARTICIPANTS

Fifty-nine homeless persons recruited from a drop-in center.

MEASURES

Rate of AD completion and baseline and 3-month follow-up EOL-related knowledge, attitudes, and behaviors.

RESULTS

The overall AD completion rate was 44%, with a statistically significant higher completion rate of 59% in the CG group compared to 30% in the self-guided only group. Frequency of worry about death decreased among those who filled out an AD from 50% to 12.5%, and also among those who did not (25% to 12.5%) (p < .05). Among those who filled out an AD, there were increases in plans to write down EOL wishes (56% to 100%; p < .05) and plans to talk about these wishes with someone (63% to 94%; p < .05).

CONCLUSION

This study demonstrates that people living in dire economic and social situations will complete an AD when offered the opportunity. While offering guidance resulted in higher rates of completion; even a simple self-guided AD process can achieve completion of ADs in this population.

Reducing risky sexual behavior and substance use among currently and formerly homeless adults living with HIV

OBJECTIVES

We examined the efficacy of the Healthy Living Program in reducing risky sexual behavior and substance use among adults with HIV infection who were marginally housed (i.e., homeless at some point over a 37-month period).

METHODS

We had previously conducted a randomized controlled trial with 936 adults living with HIV infection. In that study, 3 intervention modules of 5 sessions each addressed different goals: reducing risky sexual acts and drug use, improving the quality of life, and adhering to healthful behaviors. Participants were interviewed at baseline and at 5, 10, 15, 20, and 25 months; 746 completed 4 or more assessments. In this study, we analyzed sexual behavior and drug use outcomes for the 35% (n = 270 of 767) of participants who were considered marginally housed.

RESULTS

Among the marginally housed participants, there were significantly greater reductions in unprotected risky sexual acts, the number of sexual partners of HIV negative or unknown serostatus, alcohol or marijuana use, and hard drug use among the intervention group than among the control group.

CONCLUSIONS

Intensive, skill-focused intervention programs may improve the lives of marginally housed adults living with HIV infection.