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Heiman E, Alexander M, Zhang R, Zheng Z, Miller LS. High Hepatitis C Cure Rates Among Patients With Alcohol Use at a Safety-Net Hepatitis C Clinic. J Addict Med 2024; 18:463-465. [PMID: 38534007 DOI: 10.1097/adm.0000000000001307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
OBJECTIVES We set out to examine several aspects of the relationship between alcohol use and hepatitis C virus (HCV) among a cohort of patients treated at an HCV clinic within a safety net hospital. We examined (1) the prevalence of alcohol use among patients treated for HCV, (2) the likelihood of being started on treatment among patients who reported drinking alcohol compared with those who did not, and (3) the associations between alcohol use and HCV cure. METHODS We performed a retrospective chart abstraction study using data from the Grady Liver Clinic, a specialty HCV clinic colocated in Grady Memorial Hospital's primary care clinic and run by general internists. RESULTS Nine hundred fifty-four patients were included. The sustained virologic response rate among those with 12-week posttreatment measurement was 99.2%, with only 5 patients experiencing virologic failure. None of the alcohol use indicators significantly impacted sustained virologic response or loss to follow-up. Estimates of alcohol use ranged from 28.9% (by International Classification of Diseases, Tenth Revision , code) to 48.9% (clinician documentation). Treatment initiation rates were the same among those who did and did not report alcohol use. CONCLUSIONS Alcohol use was not associated with decreased HCV cure rates. Our findings validate the inclusion of patients with alcohol use in HCV treatment programs.
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Affiliation(s)
- Erica Heiman
- From the Department of Internal Medicine, Yale School of Medicine, New Haven, CT (EH); Georgia State University, Atlanta, GA (MA); Rollins School of Public Health, Emory University, Atlanta, GA (RZ, ZZ); and Department of Medicine, Emory University, Atlanta, GA (LSM)
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2
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Verheij C, Haagsma JA, Koch BCP, Segers AEM, Schuit SCE, Rood PPM. Screening for hazardous alcohol use in the Emergency Department: Comparison of phosphatidylethanol with the Alcohol Use Disorders Identification Test and the Timeline Follow-back. Alcohol Clin Exp Res 2022; 46:2225-2235. [PMID: 36520053 PMCID: PMC10107187 DOI: 10.1111/acer.14958] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/10/2022] [Accepted: 10/07/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Up to 15% of all visits to the Emergency Department (ED) are alcohol related. Identification of problematic alcohol use is important in this setting because it allows for intervention and prevention efforts. This study investigated the correlation between the objective phosphatidylethanol (PEth) marker and the subjective Alcohol Use Disorders Identification Test (AUDIT) and Timeline Followback Questionnaire (TLFB) as screening methods for hazardous alcohol use in the general ED population. METHODS This prospective cohort study included 301 ED patients (57% male) who were seen in the ED and required to give a blood sample. The correlation between the values of PEth (PEth 16:0/18:1 and PEth 16:0/18:2) and the scores on the AUDIT and TLFB were analyzed using Spearman's rank correlation coefficient. Differences between risk categories of PEth and AUDIT were also examined. RESULTS The Spearman correlation coefficients between PEth 16:0/18:1|PEth 16:0/18:2 values and the AUDIT scores were moderate (PEth 16:0/18:1: 0.67, p < 0.001; PEth 16:0/18:2: 0.67, p < 0.001). Of the patients who scored 'low risk drinking/abstinence' according to the AUDIT questionnaire, respectively 1% and 4% had PEth 16:0/18:1|PEth 16:0/18:2 values indicating excessive alcohol use, and another 10% and 12% had PEth 16:0/18:1|PEth 16:0/18:2 values indicating moderate alcohol consumption. Of the 12 (PEth 16:0/18:1) and 25 (PEth 16:0/18:2) patients with high-risk values, respectively 25% and 40% scored in the lowest risk category on the AUDIT questionnaire. Spearman correlation coefficients between PEth 16:0/18:1|PEth 16:0/18:2 values and TLFB two-week scores were high (PEth 16:0/18:1: 0.74, p < 0.001; PEth 16:0/18:2: 0.82, p < 0.001). CONCLUSIONS AUDIT scores were moderately correlated with PEth values in the general ED population. In almost all cases where there was not a good correlation, patients had high PEth values with low AUDIT scores. We conclude that PEth identifies patients with problematic alcohol use who are missed by the AUDIT questionnaire and therefore PEth could be used as an additional screening method for hazardous alcohol use in this population.
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Affiliation(s)
- Carolien Verheij
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Juanita A Haagsma
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anne E M Segers
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Stephanie C E Schuit
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Board of Directors, University Medical Center Groningen, Groningen, The Netherlands
| | - Pleunie P M Rood
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Isfordink CJ, Smit C, Boyd A, de Regt MJA, Rijnders BJA, van Crevel R, Ackens RP, Reiss P, Arends JE, van der Valk M. Low hepatitis C virus-viremia prevalence yet continued barriers to direct-acting antiviral treatment in people living with HIV in the Netherlands. AIDS 2022; 36:773-783. [PMID: 34999607 DOI: 10.1097/qad.0000000000003159] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To describe hepatitis C virus (HCV)-viremia prevalence and barriers to direct-acting antiviral (DAA) treatment during unrestricted access to DAA in a nationwide cohort of people with HIV (PWH). DESIGN Retrospective analysis of prospectively collected data. METHODS We calculated yearly HCV-viremia prevalence as proportion of HCV RNA-positive individuals ever HCV-tested. We then included HCV-viremic individuals with ≥1 visit during the era of universal DAA-access (database lock = December 31, 2018). Based on their last visit, individuals were grouped as DAA-treated or -untreated. Variables associated with lack of DAA-treatment were assessed using targeted maximum likelihood estimation. In November 2020, physicians of DAA-untreated individuals completed a questionnaire on barriers to DAA-uptake and onward HCV-transmission risk. RESULTS Among 25 196 PWH, HCV-viremia decreased from 4% to 5% between 2000 and 2014 to 0.6% in 2019. Being DAA-untreated was associated with HIV-transmission route other than men who have sex with men, older age, infrequent follow-up, severe alcohol use, detectable HIV-RNA, HCV-genotype 3, and larger hospital size. With universal DAA-access, 72 of 979 HCV-viremic individuals remained DAA-untreated at their last visit. Of these, 39 were no longer in care, 27 remained DAA-untreated in care, and six initiated DAA since database lock. Most common physician-reported barriers to DAA-uptake were patient refusal (20/72, 28%) and infrequent visit attendance (19/72, 26%). Only one DAA-untreated individual in care was engaging in activities associated with onward HCV-transmission. CONCLUSIONS Prevalence of HCV-viremic PWH is low in the Netherlands, coinciding with widespread DAA-uptake. Barriers to DAA-uptake appear mostly patient-related, while HCV-transmission seems unlikely from the few DAA-untreated in care.
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Affiliation(s)
- Cas J Isfordink
- Department of Internal Medicine and Infectious Diseases, UMC Utrecht, Utrecht
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Centers, University of Amsterdam
| | | | - Anders Boyd
- Stichting HIV Monitoring, Amsterdam
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam
| | - Marieke J A de Regt
- Department of Internal Medicine and Infectious Diseases, Onze Lieve Vrouwe Gasthuis, Amsterdam
| | - Bart J A Rijnders
- Department of Internal Medicine, Section Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen
| | - Robin P Ackens
- Department of Internal Medicine, Division of Infectious Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter Reiss
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Centers, University of Amsterdam
- Stichting HIV Monitoring, Amsterdam
| | - Joop E Arends
- Department of Internal Medicine and Infectious Diseases, UMC Utrecht, Utrecht
| | - Marc van der Valk
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Centers, University of Amsterdam
- Stichting HIV Monitoring, Amsterdam
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Ward KM, Falade-Nwulia O, Moon J, Sutcliffe CG, Brinkley S, Haselhuhn T, Katz S, Herne K, Arteaga L, Mehta SH, Latkin C, Brooner RK, Sulkowski MS. Nonadherence to Ledipasvir/Sofosbuvir Did Not Predict Sustained Virologic Response in a Randomized Controlled Trial of Human Immunodeficiency Virus/Hepatitis C Virus Coinfected Persons Who Use Drugs. J Infect Dis 2022; 225:903-911. [PMID: 34543417 PMCID: PMC8889293 DOI: 10.1093/infdis/jiab477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/17/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Eliminating hepatitis C virus (HCV) will require effective treatment delivery to persons with substance use disorders (SUDs). We evaluated the relationship between ledipasvir/sofosbuvir treatment persistence (receiving 84 tablets), adherence, and sustained virologic response (SVR) in persons with human immunodeficiency virus (HIV)/HCV coinfection. METHODS Of the 144 participants with HIV/HCV and SUDs, 110 initiated a 12-week treatment course under 1 of 3 conditions (usual care, peer mentors, and cash incentives). We used self-report, pharmacy pill counts, and expected date of refill to examine adherence. Persistent participants were categorized as high adherence (taking ≥90% of doses) or low adherence (taking <90% of doses). RESULTS Most participants persisted on treatment after initiation (n = 105), with 95% (n = 100) achieving SVR. One third (34%) of participants had moderate/heavy alcohol use by the biomarker phosphatidylethanol ([Peth] ≥50 ng/mL), and 44% had urine toxicology positive for cocaine or heroin at enrollment. The proportion of persons with high adherence was 72% (n = 76), and the proportion of persons with low adherence was 28%. Although low adherence was associated with moderate/heavy alcohol use by PEth (relative risk = 2.77; 95% confidence interval, 1.50-5.12), SVR did not vary according to adherence (P = .702), and most participants (97%) with low adherence achieved SVR. CONCLUSIONS Treatment persistence led to high SVR rates among persons with HIV/HCV, despite imperfect adherence and SUDs.
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Affiliation(s)
- Kathleen M Ward
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Juhi Moon
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Catherine G Sutcliffe
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sherilyn Brinkley
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Taryn Haselhuhn
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Stephanie Katz
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kayla Herne
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Lilian Arteaga
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert K Brooner
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mark S Sulkowski
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Irvin R, Gamble T, Malone J, Wang Z, Wilson E, Hughes JP, Farley J, Mayer KH, Del Rio C, Batey DS, Cummings V, Remien RH, Beyrer C, Thio CL. HIV Prevention Trials Network 078: High Prevalence of Hepatitis C Virus Antibodies Among Urban US Men Who Have Sex With Men, Independent of Human Immunodeficiency Virus Status. Clin Infect Dis 2021; 73:e2205-e2210. [PMID: 33346798 PMCID: PMC8492204 DOI: 10.1093/cid/ciaa1869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sexual transmission of hepatitis C virus (HCV) is uncommon, yet documented among men who have sex with men (MSM), primarily among those with human immunodeficiency virus (HIV). METHODS In the HIV Prevention Trials Network 078 study (HPTN 078), which assessed an integrated strategy to achieve HIV viral suppression, 1305 MSM were screened across 4 geographically diverse US cities. At screening, demographic/behavioral/psychosocial questionnaires were completed, along with HIV and HCV testing. Multivariable logistic regression was used to evaluate associations with HCV antibody positivity. RESULTS Among the 1287 (99%) of the MSM with HCV antibody results, the median age was 41, 69% were black, 85% had a high school education or more, 35% were employed, 70% had HIV, and 21% had undergone substance use counseling. The median lifetime number of male sexual partners was 17 (interquartile range, 6-50), and 246 (19%) were HCV antibody positive. HCV antibody positivity was high in MSM with HIV (20%) and MSM without HIV (17%) (P = .12) and was higher in those receiving substance use counseling (36%) than in those who had not (15%) (P ≤ .01). Substance use counseling (odds ratio, 2.51; 95% confidence interval, 1.80-3.51) and unstable housing (2.16; 1.40-3.33) were associated with HCV antibody positivity. CONCLUSIONS Nearly 1 in 5 MSM screened for HPTN 078 have been infected with HCV. The prevalence is high regardless of HIV status and is high even in those who did not undergo substance use counseling. In HIV burden networks, high HCV infection prevalence may occur in MSM without HIV. As implementation of preexposure prophylaxis expands and condom use declines, routine HCV counseling and screening among MSM are important.
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Affiliation(s)
- Risha Irvin
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Theresa Gamble
- HPTN Leadership and Operations Center, FHI 360, Durham, North Carolina, USA
| | | | - Zhe Wang
- Statistical Center for HIV/AIDS Research and Prevention, Seattle, Washington , USA
| | - Ethan Wilson
- Statistical Center for HIV/AIDS Research and Prevention, Seattle, Washington , USA
| | | | - Jason Farley
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Kenneth H Mayer
- The Fenway Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Del Rio
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - D Scott Batey
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, New York, USA
| | - Chris Beyrer
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Chloe L Thio
- Johns Hopkins University, Baltimore, Maryland, USA
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Hahn JA, Murnane PM, Vittinghoff E, Muyindike WR, Emenyonu NI, Fatch R, Chamie G, Haberer JE, Francis JM, Kapiga S, Jacobson K, Myers B, Couture MC, DiClemente RJ, Brown JL, So-Armah K, Sulkowski M, Marcus GM, Woolf-King S, Cook RL, Richards VL, Molina P, Ferguson T, Welsh D, Piano MR, Phillips SA, Stewart S, Afshar M, Page K, McGinnis K, Fiellin DA, Justice AC, Bryant K, Saitz R. Factors associated with phosphatidylethanol (PEth) sensitivity for detecting unhealthy alcohol use: An individual patient data meta-analysis. Alcohol Clin Exp Res 2021; 45:1166-1187. [PMID: 33837975 PMCID: PMC8254773 DOI: 10.1111/acer.14611] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Objective measurement of alcohol consumption is important for clinical care and research. Adjusting for self-reported alcohol use, we conducted an individual participant data (IPD) meta-analysis to examine factors associated with the sensitivity of phosphatidylethanol (PEth), an alcohol metabolite, among persons self-reporting unhealthy alcohol consumption. METHODS We identified 21 eligible studies and obtained 4073 observations from 3085 participants with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) positive scores (≥3 for women and ≥4 for men) and PEth measurements. We conducted 1-step IPD meta-analysis using mixed effects models with random intercepts for study site. We examined the associations between demographic (sex, race/ethnicity, and age) and biologic (body mass index-BMI, hemoglobin, HIV status, liver fibrosis, and venous versus finger-prick blood collection) variables with PEth sensitivity (PEth≥8 ng/ml), adjusting for the level of self-reported alcohol use using the AUDIT-C score. RESULTS One third (31%) of participants were women, 32% were African, 28% African American, 28% White, and 12% other race/ethnicity. PEth sensitivity (i.e., ≥8 ng/ml) was 81.8%. After adjusting for AUDIT-C, we found no associations of sex, age, race/ethnicity, or method of blood collection with PEth sensitivity. In models that additionally included biologic variables, those with higher hemoglobin and indeterminate and advanced liver fibrosis had significantly higher odds of PEth sensitivity; those with higher BMI and those living with HIV had significantly lower odds of PEth sensitivity. African Americans and Africans had higher odds of PEth sensitivity than whites in models that included biologic variables. CONCLUSIONS Among people reporting unhealthy alcohol use, several biological factors (hemoglobin, BMI, liver fibrosis, and HIV status) were associated with PEth sensitivity. Race/ethnicity was associated with PEth sensitivity in some models but age, sex, and method of blood collection were not. Clinicians should be aware of these factors, and researchers should consider adjusting analyses for these characteristics where possible.
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Affiliation(s)
- Judith A Hahn
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Pamela M Murnane
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Winnie R Muyindike
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nneka I Emenyonu
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Robin Fatch
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Gabriel Chamie
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Joel M Francis
- National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Department of Family Medicine and Primary Care, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Saidi Kapiga
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Karen Jacobson
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Tygerberg, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Ralph J DiClemente
- Department of Social and Behavioral Sciences, NYU School of Global Public Health, New York, NY, USA
| | - Jennifer L Brown
- Department of Psychology and Psychiatry and Behavioral Neuroscience, Center for Addiction Research, University of Cincinnati, Cincinnati, OH, USA
| | - Kaku So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mark Sulkowski
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gregory M Marcus
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sarah Woolf-King
- Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Robert L Cook
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
| | | | - Patricia Molina
- Comprehensive Alcohol-HIV/AIDS Research Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
- Department of Physiology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Tekeda Ferguson
- Comprehensive Alcohol-HIV/AIDS Research Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
- Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - David Welsh
- Comprehensive Alcohol-HIV/AIDS Research Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
- Department of Internal Medicine, Department of Microbiology, Immunology, & Parasitology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Mariann R Piano
- Center for Research Development and Scholarship, Vanderbilt University, Nashville, TN, USA
| | | | - Scott Stewart
- Department of Family Medicine, Division of Addiction Medicine, University at Buffalo, Buffalo, NY, USA
| | - Majid Afshar
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin - Madison, Madison, WI, USA
| | - Kimberly Page
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Kathleen McGinnis
- West Haven VA Healthcare System, United States Department of Veterans Affairs, West Haven, CT, USA
| | - David A Fiellin
- Yale School of Medicine, New Haven, CT, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Amy C Justice
- West Haven VA Healthcare System, United States Department of Veterans Affairs, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Kendall Bryant
- National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Richard Saitz
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Grayken Center on Addiction, Boston Medical Center, Boston, MA, USA
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