Substance Abuse Treatment, HIV/AIDS, and the Continuum of Response for People Who Inject Drugs

Diagnostic and Translational Utility of the Secondary Traumatic Stress Clinical Algorithm (STS-CA)

Current tools available to assess secondary traumatic stress (STS) do not account for whether the symptoms are functionally related to indirect trauma, determine functional impairment caused by the STS symptoms, and/or consider the duration of the disturbance. This prevents delineation of various expressions of traumatic stress related to indirect trauma that may constitute the phenomenon of STS. The STS Clinical Algorithm (STS-CA) was developed to make these distinctions, so that interventions can be tailored to need. This study investigates the following: (1) the diagnostic concordance between the STS-CA findings and scores on the Secondary Traumatic Stress Scale (STSS); (2) reasons for diagnostic discrepancies between the STS-CA and the STSS assessments. Three trained interviewers used the STS-CA to guide the determination of clinical outcome (N = 181) in a diverse group of helping professionals. There was 100% agreement between the CAPS and the STS-CA, and fair agreement (κ =.426, p = .000) between the STS-CA and the STSS. The STS-CA demonstrated more sensitivity in classifying positive cases, and specificity in delineating those with atypical cluster presentations or little to no functional impairment that prohibited a post-traumatic stress disorder diagnosis than the STSS. Effective treatment of STS requires proper identification and the delivery of protocols that are tailored to the unique ways that STS manifests. This study provides some insights into the utility of the STS-CA in guiding this process and creates STS categories to organize and classify intervention strategies.

Finding what works: identification of implementation strategies for the integration of methadone maintenance therapy and HIV services in Vietnam

Background

Integration of methadone maintenance therapy (MMT) and HIV services is an evidence-based intervention (EBI) that benefits HIV care and reduces costs. While MMT/HIV integration is recommended by the World Health Organization and the Centers for Disease Control and Prevention, it is not widely implemented, due to organizational and operational barriers. Our study applied an innovative process to identify implementation strategies to address these barriers.

Methods

Our process was adapted from the Expert Recommendations for Implementing Change (ERIC) protocol and consisted of two main phases. In Phase 1, we conducted 16 in-depth interviews with stakeholders and developed matrices to display barriers to integration. In Phase 2, we selected implementation strategies that addressed the barriers identified in Phase 1 and conducted a poll to vote on the most important and feasible strategies among a panel with expertise in cultural context and implementation science.

Results

Barriers fell into two broad categories: policy and programmatic. At the policy level, barriers included lack of a national mandate, different structures (MMT vs. HIV clinic) for cost reimbursement and staff salaries, and resistance on the part of staff to take on additional tasks without compensation. Programmatic barriers included the need for cross-training in MMT and HIV tasks, staff accountability, and commitment from local leaders. In Phase 2, we focused on programmatic challenges. Based on voting results and iterative dialogue with our expert panel, we selected several implementation strategies in the domains of technical assistance, staff accountability, and local commitment that targeted these barriers.

Conclusions

Key programmatic barriers to MMT/HIV integration in Vietnam may be addressed through implementation strategies that focus on technical assistance, staff accountability, and local commitment. Our process of identifying implementation strategies was simple, low cost, and potentially replicable to other settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0420-8) contains supplementary material, which is available to authorized users.

Factors responsible for incomplete linkage to care after HIV diagnosis: preliminary results from the Test and Keep in Care (TAK) project

OBJECTIVES

Linkage to care after HIV diagnosis remains underinvestigated in Europe, yet delays in linkage to care are an important obstacle to controlling the HIV epidemic. The Test and Keep in Care (TAK) project aims to determine the prevalence of HIV-positive persons who are lost or late to care and factors associated with this.

METHODS

Data from community-based voluntary counselling and testing that occurred in 2010-2011 were linked with data from HIV clinics using unique test numbers. Persons not registered in HIV clinics were considered lost to care (LTC). For statistical analysis, nonparametric tests were used for comparison, and a multivariable logistic regression model was developed that included all variables with P<0.1 from the univariable models.

RESULTS

A total of 110 persons were diagnosed as HIV-positive: 91% lived in central Poland, 5% were female and 71% were men who have sex with men (MSM). Forty-seven (42%) persons were LTC, seven of whom did not collect their enzyme-linked immunosorbent assay (ELISA) test result. Of those who registered, 75% registered within 1 month from HIV diagnosis, and 54% were late presenters. LTC individuals were more likely to have heterosexual or bisexual orientation, to have >20 sexual partners, to not be in a relationship with an HIV-positive partner, to not use condoms, and to be taking their first HIV test. In a logistic regression model, after adjusting for these factors, using condoms in a stable relationship decreased the odds of LTC by 72% (odds ratio 0.28; confidence interval 0.11-0.67).

CONCLUSIONS

Integration into care after HIV diagnosis requires improvement. Our results suggest that broadening awareness and counselling about sexual risks may have a positive impact.

Scaling up HIV prevention efforts targeting people who inject drugs in Central Asia: a review of key challenges and ways forward

BACKGROUND

In Central Asia, between 33% and 72% of cumulative HIV infections has been attributed to unsafe injection practices among people who inject drugs (PWID).

METHODS

We reviewed the current status and trends of national efforts in Central Asian countries to control HIV among PWID, and also reviewed the key structural and health-systems-related challenges that facilitate drug-use-related HIV risk in Central Asia.

RESULTS

The spectrum and scale of HIV prevention services targeting PWID vary considerably among Central Asian countries. In all countries, the potential impact of these interventions is hindered by several key features: a restrictive legal environment, poor performance of service providers, widespread opposition to harm reduction, deficient human resources and funding mechanisms, poor services integration, insufficient community involvement, and other structural factors.

CONCLUSIONS

Scaling up HIV prevention interventions in Central Asia will demand greater attention to the structural, health-care-related and social factors that facilitate HIV risk and impede service utilization among PWID. Multi-level combination prevention interventions should be developed with a focus on the sexual partners and risk networks of PWID, aiming at early detection of HIV, timely enrollment in HIV care, and retention in HIV care.

An expanded behavioral paradigm for prevention and treatment of HIV-1 infection

This article addresses behavioral and social research priorities for prevention and treatment of HIV-1 infection. The approach used to define these priorities is based on 3 premises: (1) Behavioral interventions for prevention and treatment are necessary but not sufficient for producing reductions in transmission or advances in treatment; the same is true of biomedical interventions, and by themselves, they cannot maximally impact the health of communities. (2) Combination prevention and treatment strategies should include optimal combinations of behavioral and biomedical strategies but also must include the varieties of the behaviors of individuals, communities, and systems needed to ensure effective treatment and prevention. (3) And it is no longer useful, given scientific advances in understanding how treatment contributes to prevention, to discuss prevention without incorporating treatment and vice versa. This redefinition of behavioral approaches in combination prevention and treatment provides a new paradigm for defining behavioral research in HIV-1 disease. No longer is it sufficient to focus on single behavior (eg, high-risk sexual behavior, adherence to antiretroviral medications) of individuals in a vertical way. Rather, the behavioral agenda not only need to expand to encompass traditional investigations of single behaviors but also need to include the behavior of many actors and systems that are essential in facilitating reductions in transmission and improvements in treatment outcomes. In addition, there is the need for expanded implementation research agenda to encompass the study of methods to achieve high coverage, acceptability, and effectiveness of available menu of interventions.