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

Substance Use Disorders in Global Mental Health Delivery: Epidemiology, Treatment Gap, and Implementation of Evidence-Based Treatments

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Assess the treatment gap for patients with substance use disorders• Evaluate treatments and models of implementation for substance use disorders ABSTRACT: Substance use disorders (SUDs) account for substantial global morbidity, mortality, and financial and social burden, yet the majority of those suffering with SUDs in both low- and middle-income (LMICs) and high-income countries (HICs) never receive SUD treatment. Evidence-based SUD treatments are available, but access to treatment is severely limited. Stigma and legal discrimination against persons with SUDs continue to hinder public understanding of SUDs as treatable health conditions, and to impede global health efforts to improve treatment access and to reduce SUD prevalence and costs. Implementing SUD treatment in LMICs and HICs requires developing workforce capacity for treatment delivery. Capacity building is optimized when clinical expertise is partnered with regional community stakeholders and government in the context of a unified strategy to expand SUD treatment services. Workforce expansion for SUD treatment delivery harnesses community stakeholders to participate actively as family and peer supports, and as trained lay health workers. Longitudinal supervision of the workforce and appropriate incentives for service are required components of a sustainable, community-based model for SUD treatment. Implementation would benefit from research investigating the most effective and culturally adaptable models that can be delivered in diverse settings.

Contemporary Trends in Hospitalizations for Comorbid Chronic Liver Disease and Substance Use Disorders

INTRODUCTION

Chronic liver diseases (CLDs) and substance use disorders (SUDs) are increasingly prevalent and often coexist. Contemporary studies describing the characteristics and hospitalization trends of those with comorbid CLD-SUD are lacking. We aimed to characterize a population-based cohort with comorbid CLD-SUD and describe trends in these hospitalizations over time by individual-level characteristics.

METHODS

We performed a cross-sectional analysis of the National Inpatient Sample from 2005 through 2017. Diagnosis codes were used to identify adult hospitalizations with CLD, SUD, or both. Bivariate and multivariate analyses were used to make comparisons between diagnosis categories. Unadjusted and age-adjusted trends in these hospitalizations were described over time.

RESULTS

Of 401,867,749 adult hospital discharges, 3.2% had CLD-only and 1.7% had comorbid CLD-SUD. Compared with CLD-only, comorbid CLD-SUD hospitalizations resulted in higher inpatient mortality (3.1% vs 2.4%, P < 0.001) and were associated with younger age, male sex, Native American race, and urban and Western US location. Over time, comorbid hospitalizations grew 34%, and the demographics shifted with larger increases in hospitalization rates seen in younger individuals, women, Native Americans, and those publicly insured. In comorbid hospitalizations, alcoholic SUD and CLD decreased, but drug SUDs and nonalcoholic fatty liver diseases are fast-growing contributors.

DISCUSSION

In this comprehensive analysis of US hospitalizations, comorbid CLD-SUD hospitalizations are increasing over time and lead to higher inpatient mortality than CLD alone. We further characterize the changing demographics of these hospitalizations, providing a contemporary yet inclusive look at comorbid CLD-SUD hospitalizations. These data can guide interventions needed to improve the poor outcomes suffered by this growing population.

Effectiveness and safety of direct-acting antivirals in hepatitis C infected patients with mental disorders: Results in real clinical practice

The aim of this study is to analyze the effectiveness and safety of direct-acting antivirals (DAAs) in psychiatric patients with chronic hepatitis C (CHC). Secondary objectives included adherence and drug-drug interaction (DDIs) evaluations. Prospective observational comparative study carried out during 3 years. Psychiatric patients were included and mental illness classified by a psychiatric team based on clinical records. Main effectiveness and safety variables were sustained virologic response (SVR) at posttreatment week 12 (SVR12) and rate of on-treatment serious drug-related adverse events (AEs), respectively. A total of 242 psychiatric and 900 nonpsychiatric patients were included. SVR12 by intention-to-treat (ITT) analysis of psychiatric vs nonpsychiatric patients was 92.6% (95% confidence interval [CI], 89.1-96.1) vs 96.2% (95% CI, 94.9-97.5) (P = .02). SVR12 by modified-ITT analysis was 97.8% (95% CI, 95.0-99.3) vs 98.4% (95% CI, 97.5-99.3) (P = .74). 92.2% of psychiatric patients with mental disorders secondary to multiple drug use (MDSDU) and 93.0% of psychiatric patients without MDSDU vs 96.2% of nonpsychiatric patients reached SVR12 (P = .05 and P = .20, respectively). The percentage of adherent patients to DAAs did not show differences between cohorts (P = .08). 30.2% of psychiatric patients and 27.6% of nonpsychiatric patients presented clinically relevant DDIs (P = .47). 1.7% vs 0.8% of psychiatric vs nonpsychiatric patients developed serious AEs (P = .39); no serious psychiatric AEs were present. DAAs have shown a slightly lower effectiveness in psychiatric patients with CHC, as a result of loss of follow up, which justifies the need for integrated and multidisciplinary health care teams. DAAs safety, adherence, and DDIs, however, are similar to that of nonpsychiatric patients.

Effectiveness of direct-acting antivirals for hepatitis C virus infection in hepatitis C/HIV coinfected individuals: A multicenter study

In a hepatitis C virus (HCV)/HIV-positive Brazilian cohort, evaluate the safety and efficacy of HCV DAAs, the frequency of resistance substitutions in the HCV NS5A and NS5B genes and identify predictors of treatment failure.Retrospective multicenter study of HCV/HIV patients treated with sofosbuvir (SOF)-based regimens at 10 reference centers in Brazil.Clinical and virological data were collected. Genetic diversity in the NS5A and NS5B genes was assessed by direct nucleotide sequencing. The primary outcome was sustained virological response (SVR) 12 weeks after DAA completion.Of 643 HCV/HIV patients analyzed, 74.7% were male, median CD4+ T cell count was 617 cells/mm, 90% had an undetectable HIV viral load. HCV genotype 1 was detected in 80.2%, and 60% were taking at least 1 medication other than antiretroviral drugs during their DAA therapy. Cirrhosis was present in 42%. An SOF/daclatasvir (DCV) regimen was used in most patients (98%). The frequency of NS5A polymorphisms associated with clinically relevant resistance to DCV was 2%; no relevant NS5B variants were identified. The SVR12 rate was 92.8% in an intention to treat (ITT) analysis and 96% in a modified ITT (m-ITT) analysis. AE occurred in 1.6% of patients. By multivariate analysis, therapeutic failure was associated, in the m-ITT analysis, with concomitant use of anticonvulsant drugs (P = .001), age (P = .04), and female gender (P = .04).SOF/DCV regimens were associated with a high SVR rate in an HCV/HIV population. The use of concurrent anticonvulsant drugs and DAAs decreases the chances of achieving an SVR.

The Aging Brain With HIV Infection: Effects of Alcoholism or Hepatitis C Comorbidity

As successfully treated individuals with Human Immunodeficiency Virus (HIV)-infected age, cognitive and health challenges of normal aging ensue, burdened by HIV, treatment side effects, and high prevalence comorbidities, notably, Alcohol Use Disorders (AUD) and Hepatitis C virus (HCV) infection. In 2013, people over 55 years old accounted for 26% of the estimated number of people living with HIV (~1.2 million). The aging brain is increasingly vulnerable to endogenous and exogenous insult which, coupled with HIV infection and comorbid risk factors, can lead to additive or synergistic effects on cognitive and motor function. This paper reviews the literature on neuropsychological and in vivo Magnetic Resonance Imaging (MRI) evaluation of the aging HIV brain, while also considering the effects of comorbidity for AUD and HCV.

Peripheral TNFα elevations in abstinent alcoholics are associated with hepatitis C infection

Substantial evidence supports the view that inflammatory processes contribute to brain alterations in HIV infection. Mechanisms recently proposed to underlie neuropathology in Alcohol Use Disorder (AUD) include elevations in peripheral cytokines that sensitize the brain to the damaging effects of alcohol. This study included 4 groups: healthy controls, individuals with AUD (abstinent from alcohol at examination), those infected with HIV, and those comorbid for HIV and AUD. The aim was to determine whether inflammatory cytokines are elevated in AUD as they are in HIV infection. Cytokines showing group differences included interferon gamma-induced protein 10 (IP-10) and tumor necrosis factor α (TNFα). Follow-up t-tests revealed that TNFα and IP-10 were higher in AUD than controls but only in AUD patients who were seropositive for Hepatitis C virus (HCV). Specificity of TNFα and IP-10 elevations to HCV infection status was provided by correlations between cytokine levels and HCV viral load and indices of liver integrity including albumin/globulin ratio, fibrosis scores, and AST/platelet count ratio. Because TNFα levels were mediated by HCV infection, this study provides no evidence for elevations in peripheral cytokines in "uncomplicated", abstinent alcoholics, independent of liver disease or HCV infection. Nonetheless, these results corroborate evidence for elevations in IP-10 and TNFα in HIV and for IP-10 levels in HIV+HCV co-infection.

Personality disorders among Spanish prisoners starting hepatitis C treatment: Prevalence and associated factors

The purpose of this study was to assess the prevalence of personality disorders (PDs) and their associated factors in prisoners who initiate chronic hepatitis C (CHC) treatment in 25 Spanish prisons. The Personality Diagnostic Questionnaire-4 was used to diagnose PDs according to DSM-IV criteria. Factors potentially associated with a PD diagnosis were evaluated by logistic regression analysis. Two hundred and fifty-five patients were initially assessed and 62 (24.3%) were excluded due to an incomplete or invalid self-report screening questionnaire. PD prevalence was 70.5%, with antisocial PD being the most prevalent (46.1%). In terms of PD clusters, the most prevalent was cluster-B (55.4%). PD diagnosis was associated with HCV genotypes 1, 2, or 3 (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.02-4.49). Patients with a cluster-B PD were more likely to be infected with HCV genotypes 1, 2, or 3 (OR 2.37, 95% CI 1.08-5.23) and be HIV-infected (OR 2.20, 95% CI 1.10-4.39), to report past-year injection drug use (OR 7.17, 95% CI 1.49-34.58), and to have stage 3 or 4 fibrosis (OR 2.16, 95% CI 1.06-4.49). The prevalence of PDs in Spanish prisoners who initiate CHC treatment is very high. PD management issues should be considered in treating CHC patients in prisons.

Neuroimmune basis of methamphetamine toxicity

Although it is not known which antigen-specific immune responses (or if antigen-specific immune responses) are relevant or required for methamphetamine's neurotoxic effects, it is apparent that methamphetamine exposure is associated with significant effects on adaptive and innate immunity. Alterations in lymphocyte activity and number, changes in cytokine signaling, impairments in phagocytic functions, and glial activation and gliosis have all been reported. These drug-induced changes in immune response, particularly within the CNS, are now thought to play a critical role in the addiction process for methamphetamine dependence as well as for other substance use disorders. In Section 2, methamphetamine's effects on glial cell (e.g., microglia and astrocytes) activity and inflammatory signaling cascades are summarized, including how alterations in immune cell function can induce the neurotoxic and addictive effects of methamphetamine. Section 2 also describes neurotransmitter involvement in the modulation of methamphetamine's inflammatory effects. Section 3 discusses the very recent use of pharmacological and genetic animal models which have helped elucidate the behavioral effects of methamphetamine's neurotoxic effects and the role of the immune system. Section 4 is focused on the effects of methamphetamine on blood-brain barrier integrity and associated immune consequences. Clinical considerations such as the combined effects of methamphetamine and HIV and/or HCV on brain structure and function are included in Section 4. Finally, in Section 5, immune-based treatment strategies are reviewed, with a focus on vaccine development, neuroimmune therapies, and other anti-inflammatory approaches.

Combination prevention: new hope for stopping the epidemic

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

Progress realized: trends in HIV-1 viral load and CD4 cell count in a tertiary-care center from 1999 through 2011

BACKGROUND

HIV-1 RNA and CD4 cell counts are important parameters for HIV care. The objective of this study was to assess the overall trends in HIV-1 viral load and CD4 cell counts within our clinic.

METHODS

Patients with at least one of each test performed by the Infectious Diseases Laboratory from 1999 through 2011 were included in this analysis. By adapting a novel statistical model, log(10) HIV-1 RNA means were estimated by month, and log(10)-transformed HIV-1 RNA means were estimated by calendar year. Geometric means were calculated for CD4 cell counts by month and calendar year. Log(10) HIV-1 RNA and CD4 cell count monthly means were also examined with polynomial regression.

RESULTS

There were 1,814 individuals with approximately 25,000 paired tests over the 13-year observation period. Based on each patient's final value of the year, the percentage of patients with viral loads below the lower limit of quantitation rose from 29% in 1999 to 72% in 2011, while the percentage with CD4 counts <200 cells/µL fell from 31% to 11%. On average annually, the mean HIV-1 RNA decreased by 86 copies/mL and the mean CD4 counts increased by 16 cells/µL. For the monthly means, the correlations (R(2)) from second-order polynomial regressions were 0.944 for log(10) HIV-1 RNA and 0.840 for CD4 cell counts.

CONCLUSIONS

Marked improvements in HIV-1 RNA suppression and CD4 cell counts were achieved in a large inner-city population from 1999 through 2011. This success demonstrates that sustained viral control with improved immunologic status can be a realistic goal for most individuals in clinical care.

Mental health disorders and the risk of AIDS-defining illness and death in HIV-infected veterans

OBJECTIVE

Mental health comorbidities are common in HIV-infected veterans and can impact clinical outcomes for HIV. We examined the impact of mental health diagnoses on progression to AIDS-defining illness (ADI) and death in a large cohort of HIV-infected veterans who accessed care between 2001 and 2006.

DESIGN

Retrospective cohort study using the national Veterans Health Administration (VHA) HIV Clinical Case Registry.

METHODS

We identified HIV-infected veterans initiating combination antiretroviral therapy (cART) within the VHA between 2000 and 2006. The prevalences of the following mental health diagnoses were examined: schizophrenia, bipolar disorder, depression, anxiety, and substance use disorder. Cox proportional hazards models were constructed to examine the relationship between mental health conditions and two outcomes, all-cause mortality and ADI. Models were computed before and after adjusting for confounding factors including age, race, baseline CD4 cell count, comorbidities and cART adherence.

RESULTS

Among 9003 veterans receiving cART, 31% had no mental health diagnosis. Age, race, baseline comorbidity score, CD4, and cART adherence were associated with shorter time to ADI or death. All-cause mortality was more likely among veterans with schizophrenia, bipolar disorder and substance use, and ADI was more likely to occur among veterans with substance use disorder.

CONCLUSIONS

Our results demonstrate the high prevalence of mental health diagnoses among HIV-infected veterans. In the era of highly active antiretroviral therapy, presence of psychiatric diagnoses impacted survival and development of ADI. More aggressive measures addressing substance abuse and severe mental illness in HIV-infected veterans are necessary.

Challenges facing providers caring for HIV/HCV-coinfected patients

Despite the high prevalence of hepatitis C virus (HCV) infection among injection drug users also infected with human immunodeficiency virus (HIV), and the synergistic adverse effect of the two diseases on patients' health and survival, research on the clinical management of these patients and particularly the low uptake of HCV therapy is limited. We conducted qualitative interviews with 17 HIV providers from two urban public hospitals. We discovered that the limitations of the current state of medical knowledge, the severe side effects of HIV and HCV therapies, and the psychosocial vulnerability of HIV/HCV-coinfected patients combined with their resistance to becoming informed about HCV posed significant challenges for providers. To contend with these challenges, providers incorporated key dimensions of patient-centered medicine in their practice, such as considering their patients' psychosocial profiles and the meaning patients assign to being coinfected, and finding ways to engage their patients in a therapeutic alliance.

Disruption of emotion and conflict processing in HIV infection with and without alcoholism comorbidity

Alcoholism and HIV-1 infection each affect components of selective attention and cognitive control that may contribute to deficits in emotion processing based on closely interacting fronto-parietal attention and frontal-subcortical emotion systems. Here, we investigated whether patients with alcoholism, HIV-1 infection, or both diseases have greater difficulty than healthy controls in resolving conflict from emotional words with different valences. Accordingly, patients with alcoholism (ALC, n = 20), HIV-1 infection (HIV, n = 20), ALC + HIV comorbidity (n = 22), and controls (CTL, n = 16) performed an emotional Stroop Match-to-Sample task, which assessed the contribution of emotion (happy, angry) to cognitive control (Stroop conflict processing). ALC + HIV showed greater Stroop effects than HIV, ALC, or CTL for negative (ANGRY) but not for positive (HAPPY) words, and also when the cue color did not match the Stroop stimulus color; the comorbid group performed similarly to the others when cue and word colors matched. Furthermore, emotionally salient face cues prolonged color-matching responses in all groups. HIV alone, compared with the other three groups, showed disproportionately slowed color-matching time when trials featured angry faces. The enhanced Stroop effects prominent in ALC + HIV suggest difficulty in exercising attentional top-down control on processes that consume attentional capacity, especially when cognitive effort is required to ignore negative emotions.