Factors associated with suicidal ideation among people with HIV engaged in care

BACKGROUND

People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH.

METHOD

We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models.

RESULTS

Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI.

LIMITATIONS

SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor.

CONCLUSIONS

HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed.

AWARENESS: A cognitive behavioral intervention to reduce intersectional minority stress among sexual minority men living with HIV who use substances

Introduction:

The minority stress model is the primary explanatory model for disparities in substance use and other mental health problems among sexual minority men (SMM) compared to heterosexual men. This pilot randomized controlled trial tested the feasibility of AWARENESS, a novel 9-session cognitive-behavioral psychotherapeutic intervention that targets intersectional minority stress and stigma, among sexual minority men living with HIV who use substances.

Methods:

Feasibility was determined by the number of participants screened to obtain the target sample size, the percentage of eligible participants randomized, percentage of study intervention and assessment visits attended, time to complete study procedures, and percentage of data completeness of intervention assessments. Forty-two sexual minority men living with HIV with any illicit substance use or who reported at least one occasion of consuming five or more drinks in one setting in the last three months were randomized to AWARENESS (n = 22) or an attention control condition (n = 20).

Results:

Feasibility of the trial was supported, with adequate completion of study procedures and visits (73% completed all intervention sessions, 71% completed all study assessment sessions). This trial also demonstrated the feasibility of using AWARENESS skills and strategies in relation to multiple intersecting identities, with participants discussing an average of 5.7 identities (e.g., sexual orientation) or individual characteristics (e.g., socioeconomic status) in relation to intervention content.

Conclusion:

Our results support the feasibility of an AWARENESS trial to reduce intersectional minority stress related to multiple identities and characteristics among sexual minority men living with HIV who use substances

A Doctor is in the House: Stakeholder Focus Groups About Expanded Scope of Practice of Community Psychiatrists

We sought to understand stakeholder perspectives on barriers to metabolic screening for people with severe mental illness. We additionally assessed the feasibility of expanding psychiatrists' scope of practice to include treatment of cardiometabolic abnormalities. We conducted four focus groups among patients with severe mental illness, community psychiatrists, primary care providers, and public health administrators. Focus group transcripts were thematically analyzed. Three domains emerged: challenges with patient navigation of the complex health care system, problem list prioritization difficulties, and concern that treatment of cardiometabolic abnormalities were beyond the scope of practice of psychiatrists. Stakeholders agreed that navigating the health care system was challenging for this population and led to undertreatment of cardiometabolic risk factors. Expansion of psychiatrists' scope of practice within community mental health appears acceptable to patients and may be a mechanism to improve cardiometabolic care among people with severe mental illness.

Increasing HIV Testing in Inpatient Psychiatry

BACKGROUND

People with serious mental illness (SMI) are at elevated risk of HIV infection, but do not receive HIV tests regularly. Inpatient psychiatric admissions provide opportunities for HIV testing.

OBJECTIVE

This study retrospectively examined the impact of three sequential interventions designed to increase HIV testing on an acute inpatient psychiatry service: (1) advocacy by an administrative champion, (2) an on-site HIV counselor, and (3) a clinician championing HIV testing.

METHOD

Demographic and HIV testing data were extracted from hospital data systems for 11,360 admissions of HIV-negative patients to an inpatient psychiatry service between 2006 and 2012. Relationships among interventions, length of stay, patient demographics, and receipt of an HIV test were examined using general estimating equation methods.

RESULTS

In the year prior to the intervention, 7.2% of psychiatric inpatients received HIV tests. After 1 year of administrative advocacy, 11.2% received tests. Following the HIV counseling intervention, 25.1% of patients were tested. After the counseling intervention ended, continued administrative and clinical advocacy was associated with further increases in testing. In the final year studied, 30.3% of patients received HIV tests. Patients with shorter inpatient stays and those of Black or Asian race/ethnicity were less likely to be tested. Further, 1.6% of HIV tests were positive.

CONCLUSION

Three interventions of varying intensity were associated with a 5-fold increase in HIV testing on an acute inpatient psychiatry service. Nonetheless, 70% of inpatients were not tested. Continued efforts are needed to increase HIV testing in inpatient psychiatric settings.

Low Rates of HIV Testing Among Adults With Severe Mental Illness Receiving Care in Community Mental Health Settings

OBJECTIVE

This research aimed to characterize HIV testing rates among Medicaid recipients with severe mental illness who received public specialty mental health services.

METHODS

This retrospective cohort study examined California Medicaid records from October 1, 2010, to September 30, 2011 (N=56,895). Study participants were between age 18 and 67, utilized specialty mental health care services, were prescribed antipsychotic medications, and were not dually eligible for Medicare. Adjusted Poisson regression models were used to estimate the overall effects of predictor variables on HIV testing prevalence.

RESULTS

During the study period, 6.7% of people with severe mental illness received HIV testing. Men were 32% less likely to be tested for HIV than women (p<.001). Compared with whites, Asians/Pacific Islanders were 53% less likely and blacks were 82% more likely to be tested (p<.001). Those with comorbid drug or alcohol use disorders were more likely to be tested than those without such disorders (p<.001). Utilization of nonpsychiatric medical care was the strongest predictor of HIV testing (p<.001).

CONCLUSIONS

Most adults with severe mental illness receiving public specialty mental health services were not tested for HIV during a one-year period. Public health administrators must prioritize HIV testing for early identification of HIV infection and prevention of HIV transmission.

Sexual orientation and treatment-seeking for depression in a multilingual worldwide sample

BACKGROUND

Prior research has found higher rates of mental health problems among sexual minority individuals. We examine treatment-seeking for depression, as well as its relationship with sexual orientation, in a large, multilingual, international sample.

METHOD

Participants in an automated, quintilingual internet-based depression screening tool were screened for depression, and completed several background measures, including sexual orientation (with an option to decline to state) and past and current depression treatment seeking.

RESULTS

3695 participants screened positive for current or past depression and responded to the sexual orientation question. Those who declined to state their sexual orientation were far less likely to seek any treatment than individuals endorsing any orientation; they were especially unlikely to seek psychotherapy. Individuals identifying as bisexual sought both psychotherapy and alternative treatments at a higher rate than other groups. An interaction was observed between sexual orientation and gender, such that lesbian women were especially likely to have used psychotherapy. Other variables that emerged as significant predictors of treatment-seeking for depression included age and participant's language.

LIMITATIONS

Limitations include possible misinterpretation of translated terms due to regional differences, and possible limits to generalizability due to this study being conducted on the internet.

CONCLUSIONS

Our results suggest that individuals who decline to state their sexual orientation may be more likely to forgo effective treatments for depression. Further studies of depression service utilization should focus on developing treatment modalities that could better engage sexual minority individuals, especially those who are reluctant to disclose their orientation.

Does substance use compromise depression treatment in persons with HIV? Findings from a randomized controlled trial

Depression and substance use are significant obstacles to effective HIV care. Using data derived from a randomized controlled trial of persons with HIV who are homeless or marginally housed, this study assesses the utility of antidepressant treatment among persons with HIV, depression, and active substance use. Participants were diagnosed with depressive disorders and randomly assigned to receive directly observed therapy with fluoxetine or a referral to community mental health treatment. Assessments, conducted at baseline and every 3 months over a 9-month period, included the Hamilton Rating Scale for Depression, the Beck Depression Inventory II, and self-report of alcohol, crack, cocaine, heroin, or methamphetamine use in the past 90 days. To investigate the effect of antidepressant treatment in the setting of active substance use, the authors fit mixed-effects linear regression models to estimate the effect of directly observed fluoxetine on depressive symptom severity after stratifying by any alcohol use or any illicit drug use. To investigate whether alcohol use or illicit drug use moderated the antidepressant treatment response, the authors examined the interaction terms. The effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant irrespective of alcohol use status. When stratified by illicit drug use status, the effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant only among persons who did not use illicit drugs. The interaction terms were not statistically significant. This study found a benefit of antidepressant treatment in persons with HIV, depression, and alcohol use. In addition, this study found no evidence that either alcohol use or illicit drug use moderates the antidepressant treatment response. Altogether, these findings support the use of antidepressant medication in this population. The public health impact of research in this area is significant given the known adverse effects of depression on HIV-related health outcomes. ClinicalTrials.gov Identifier: NCT00338767.

Substance use and drinking outcomes in Personalized Cognitive Counseling randomized trial for episodic substance-using men who have sex with men

BACKGROUND

Non-dependent alcohol and substance use patterns are prevalent among men who have sex with men (MSM), yet few effective interventions to reduce their substance use are available for these men. We evaluated whether an adapted brief counseling intervention aimed at reducing HIV risk behavior was associated with secondary benefits of reducing substance use among episodic substance-using MSM (SUMSM).

METHODS

326 episodic SUMSM were randomized to brief Personalized Cognitive Counseling (PCC) intervention with rapid HIV testing or to rapid HIV testing only control. Both arms followed over 6 months. Trends in substance use were examined using GEE Poisson models with robust standard errors by arm. Reductions in frequency of use were examined using ordered logistic regression.

RESULTS

In intent-to-treat analyses, compared to men who received rapid HIV testing only, we found men randomized to PCC with rapid HIV testing were more likely to report abstaining from alcohol consumption (RR=0.93; 95% CI=0.89-0.97), marijuana use (RR=0.84; 95% CI=0.73-0.98), and erectile dysfunction drug use (EDD; RR=0.51; 95% CI=0.33-0.79) over the 6-month follow-up. PCC was also significantly associated with reductions in frequency of alcohol intoxication (OR=0.58; 95% CI=0.36-0.90) over follow-up. Furthermore, we found PCC was associated with significant reductions in number of unprotected anal intercourse events while under the influence of methamphetamine (RR=0.26; 95% CI=0.08-0.84).

CONCLUSION

The addition of adapted PCC to rapid HIV testing may have benefits in increasing abstinence from certain classes of substances previously associated with HIV risk, including alcohol and EDD; and reducing alcohol intoxication frequency and high-risk sexual behaviors concurrent with methamphetamine use.

Descriptive analysis of a novel health care approach: reverse colocation-primary care in a community mental health "home"

OBJECTIVE

Persons with serious mental illness have increased rates of chronic medical conditions, have limited access to primary care, and incur significant health care expenditures. Few studies have explored providing medical care for these patients in the ambulatory mental health setting. This study describes a real-world population of mental health patients receiving primary care services in a community mental health clinic to better understand how limited primary care resources are being utilized.

METHOD

Chart review was performed on patients receiving colocated primary care (colocation group, N = 143) and randomly chosen patients receiving mental health care only (mental-health group, N = 156) from January 2006 through June 2011. Demographic and mental and physical health variables were assessed.

RESULTS

Compared to the mental-health group, the colocation patients had more psychiatric hospitalizations (mean = 1.07 vs 0.23, P < .01), were more likely to be homeless (P < .01), and were more likely to require intensive case management (P < .01). Interestingly, the colocation group was not more medically ill than the mental-health group on key metabolic measures, including mean body mass index (colocation = 27.8 vs mental-health = 28.7, P = .392), low-density liprotein (colocation = 110.0 vs mental-health = 104.4, P = .480), and glucose (colocation = 94.1 vs mental-health = 109.2, P = .059). The most common medical disorders in the colocation group were related to metabolic syndrome.

CONCLUSIONS

Colocated primary care services were allocated on the basis of severity of psychiatric impairment rather than severity of medical illness. This program serves as a model for other systems to employ for integrated primary and behavioral health services for patients with serious mental illness.

Dose-response associations between number and frequency of substance use and high-risk sexual behaviors among HIV-negative substance-using men who have sex with men (SUMSM) in San Francisco

We evaluated the relationship between frequency and number of substances used and HIV risk [ie, serodiscordant unprotected anal intercourse (SDUAI)] among 3173 HIV-negative substance-using MSM. Compared with nonusers, the adjusted odds ratio (AOR) for SDUAI among episodic and at least weekly users, respectively, was 3.31 [95% confidence interval (CI), 2.55 to 4.28] and 5.46 (95% CI, 3.80 to 7.84) for methamphetamine, 1.86 (95% CI, 1.51 to 2.29) and 3.13 (95% CI, 2.12 to 4.63) for cocaine, and 2.08 (95% CI, 1.68 to 2.56) and 2.54 (95% CI, 1.85 to 3.48) for poppers. Heavy alcohol drinkers reported more SDUAI than moderate drinkers [AOR, 1.90 (95% CI, 1.43 to 2.51)]. Compared with nonusers, AORs for using 1, 2, and ≥3 substances were 16.81 (95% CI, 12.25 to 23.08), 27.31 (95% CI, 18.93 to 39.39), and 46.38 (95% CI, 30.65 to 70.19), respectively. High-risk sexual behaviors were strongly associated with frequency and number of substances used.

Primary care providers' views on metabolic monitoring of outpatients taking antipsychotic medication

OBJECTIVE

The purpose of this study was to evaluate attitudes of primary care providers toward barriers to metabolic monitoring and to characterize their beliefs about providers' responsibility for monitoring and reducing cardiovascular risk for people with severe mental illness.

METHODS

An anonymous survey was administered to 214 primary care providers working in 23 public community health clinics in San Francisco.

RESULTS

The response rate was 77% (164 of 214). Nearly 40% of primary care providers were unaware of consensus guidelines for metabolic monitoring of people who take second-generation antipsychotic medications. Responses showed variation in providers' beliefs about who should monitor patients' metabolic risk. The major barriers to metabolic monitoring were severity of psychiatric illness, difficulty collaborating with psychiatrists, and difficulty arranging psychiatric follow-up.

CONCLUSIONS

Primary care providers believed that better communication between primary care providers and psychiatrists would facilitate metabolic monitoring and promote better treatment for patients with severe mental illness who are taking antipsychotic medications.

A randomized clinical trial of smoking cessation treatments provided in HIV clinical care settings

INTRODUCTION

Identifying successful smoking treatment interventions and methods of delivery is critical given the smoking rates among HIV-positive populations and the medical implications of smoking in this population. This study compared the efficacy of 3 smoking cessation interventions provided in HIV clinical treatment settings.

METHODS

Following a baseline assessment, 209 HIV-positive smokers were randomly assigned to 1 of 3 conditions in a parallel group design. Treatment conditions were individual counseling plus nicotine replacement treatment (NRT), a computer-based Internet smoking treatment plus NRT, and self-help plus NRT. Smoking status was determined at follow-up assessments completed at 12, 24, 36, and 52 weeks following treatment initiation.

RESULTS

Cessation rates ranged from 15% to 29%; however, no statistically significant differences in abstinence were found among the treatment conditions over time. Those employed, those who reported a greater desire to quit, or those with lower mood disturbance scores were more likely to achieve abstinence (p < .01). The number of cigarettes participants reported smoking in the 24hr prior to each assessment significantly declined over time (p < .001).

CONCLUSIONS

Although we found no differences in abstinence rates across groups, the results indicate that integration of smoking cessation interventions is feasible in HIV clinical treatment settings, and cessation results are promising. The overall abstinence rates we report are comparable to those found in similar treatment studies across multiple populations. Further research is warranted.

Directly observed antidepressant medication treatment and HIV outcomes among homeless and marginally housed HIV-positive adults: a randomized controlled trial

OBJECTIVES

We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008.

METHODS

We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL).

RESULTS

The intervention reduced depression symptom severity (b = -1.97; 95% confidence interval [CI] = -0.85, -3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes.

CONCLUSIONS

Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.

Impact of capacity reductions in acute public-sector inpatient psychiatric services

OBJECTIVE

This study tested the hypothesis that reductions in acute public-sector psychiatric inpatient capacity in a major urban area would be associated with negative impacts on patients and the community.

METHODS

The impact of two discrete service changes that reduced acute inpatient capacity by 50% in a single public-sector general hospital setting was examined. Indicators of impact were obtained from existing administrative databases for a 33-month period. Indicators included measures of utilization and case mix on the acute inpatient and psychiatric emergency services, suicides among community mental health clients, and psychiatric evaluations conducted in county jails.

RESULTS

Reductions in inpatient capacity were not associated with hypothesized negative impacts, such as increased demand for psychiatric emergency services, decreased access to emergency or inpatient services, or increased recidivism to inpatient care. Similarly, neither the number of suicides among community mental health clients nor the number of jail psychiatric evaluations increased after capacity reduction.

CONCLUSIONS

Data from a single urban public-sector setting suggest that acute inpatient psychiatric capacity may be reduced without negative impacts on patients or the community. In this setting, collaboration between inpatient and outpatient providers to speed discharge facilitated reductions in inpatient length of stay that made it possible to serve the same number of patients with fewer resources. Other service system adjustments may be more appropriate in other settings, and alternative approaches to reducing utilization of high-cost inpatient care warrant examination.

Thoughts, attitudes, and feelings of HIV-positive MSM associated with high transmission-risk sex

This study presents survey data collected from a sample of HIV-positive men (N = 182) who had high transmission-risk sex, defined as unprotected anal intercourse with a man whose HIV-status was negative or unknown, in the previous 6 months. Despite the tremendous changes in HIV treatment and their impact on people living with HIV, little recent research has examined current trends in their thoughts toward unprotected anal intercourse. Here, the authors describe the self-justifications reported by HIV-positive men who have sex with men (MSM) in their current study conducted between 2006 and 2009 and explore key differences between the those of the HIV-positive MSM and those collected from a previous cohort of HIV-negative men (n = 124), who previously reported engaging in high transmission-risk sex. Whereas HIV-negative men focused on themes related to the impulsivity of and gratification from unprotected intercourse, HIV-positive men focused on themes regarding the deferral of responsibility/assumption the partner is positive (i.e., "If he's doing X, he must be positive . . ."), or the role of condomless sex fulfilling emotional needs. The findings highlight unique aspects of how HIV-positive men approach decision making regarding the use of condoms, as well as how they perceive issues of responsibility for initiating safer sex practices.

Factors affecting psychiatric inpatient hospitalization from a psychiatric emergency service

OBJECTIVE

As a gateway to the mental health system, psychiatric emergency services (PES) are charged with assessing a heterogeneous array of short-term and long-term psychiatric crises. However, few studies have examined factors associated with inpatient psychiatric hospitalization following PES in a racially diverse sample. We examine the demographic, service use and clinical factors associated with inpatient hospitalization and differences in predisposing factors by race and ethnicity.

METHOD

Three months of consecutive admissions to San Francisco's only 24-h PES (N = 1,305) were reviewed. Logistic regression was used to estimate the associations between demographic, service use, and clinical factors and inpatient psychiatric hospitalization. We then estimated separate models for Asians, Blacks, Latinos and Whites.

RESULTS

Clinical severity was a consistent predictor of hospitalization. However, age, gender, race/ethnicity, homelessness and employment status were all significant related to hospitalization. Alcohol and drug use were associated with lower probability of inpatient admission, however specific substances appear particularly salient for different racial/ethnic groups.

DISCUSSION

While clinical characteristics played an essential role in disposition decisions, these results point to the importance of factors external to PES. Individual and community factors that affect use of psychiatric emergency services merit additional focused attention.

HIV is hyperendemic among men who have sex with men in San Francisco: 10-year trends in HIV incidence, HIV prevalence, sexually transmitted infections and sexual risk behaviour

OBJECTIVES

To evaluate trends in the HIV epidemic among men who have sex with men (MSM) in San Francisco and the implications for HIV prevention.

METHODS

An ecological approach assessed temporal trends in sexual risk behaviour, sexually transmitted infections (STI), HIV incidence and prevalence from multiple data sources between 1998 and 2007.

RESULTS

By 2007, there were over 13 000 HIV-infected MSM living in San Francisco. No consistent upward or downward temporal trends were found in HIV incidence, newly reported HIV cases, AIDS deaths, proportion of AIDS cases using antiretroviral therapy, rectal gonorrhoea or primary and secondary syphilis cases among MSM during the study period. Trends in indicators of sexual risk behaviour among MSM were mixed. Overall, unprotected anal intercourse (UAI) increased in community-based surveys. Among HIV-positive MSM, no significant trends were noted for UAI. Among HIV-negative MSM, UAI with unknown serostatus partners decreased but increased with potentially discordant serostatus partners. Among MSM seeking HIV testing, increases were noted in insertive UAI at anonymous testing sites and at the STI clinic, in receptive UAI at anonymous test sites and in receptive UAI with a known HIV-positive partner at the STI clinic.

CONCLUSIONS

Temporal trends in multiple biological and behavioural indicators over the past decade describe a hyperendemic state of HIV infection among MSM in San Francisco, whereby prevalence has stabilised at a very high level. In the absence of new, effective prevention strategies this state will persist.

Effects of time-limited dynamic psychotherapy on distress among HIV-seropositive men who have sex with men

The current study seeks to examine changes in distress associated with receiving time-limited dynamic psychotherapy (TLDP) among men who have sex with men (MSM) who are also living with HIV and AIDS. Participants included 79 HIV-seropositive MSM who were seeking psychotherapy at a community mental health clinic between January 2000 and June 2005. Participants' had a mean age of 42 and were predominantly European American (77%), although Latinos (13%), African Americans (5%), and Asian Americans (4%) were also included. Each participant completed a pretest on a self-report measure of subjective distress, the Outcome Questionnaire 45.2 (OQ-45.2), received 20 sessions of TLDP over the course of 20 weeks, and then completed a posttest on the OQ-45.2 to examine changes associated with TLDP. Participants' self-reported distress showed statistically significant decreases after 20 sessions of TLDP. Furthermore, the overall effects were strong, suggesting that decreases in distress were clinically meaningful as well as statistically significant. These results are particularly significant in light of the AIDS Health Project's (AHP's) policy of assigning higher functioning clients to TLDP therapists at intake, indicating that the participants in this study began treatment with lower pretest scores than mental health clients in the general population. These results suggest that HIV-seropositive MSM who receive TLDP may experience significantly decreased distress. Future research using a randomized study design is needed to compare such benefits to those of more standard psychological interventions for this population. Strengths and limitations of the study are discussed in detail.

Brief Cognitive Counseling With HIV Testing To Reduce Sexual Risk Among Men Who Have Sex With Men

OBJECTIVES

To test the efficacy and acceptability of a single-session personalized cognitive counseling (PCC) intervention delivered by paraprofessionals during HIV voluntary counseling and testing.

METHODS

HIV-negative men who have sex with men (MSM; n = 336) were randomly allocated to PCC or usual counseling (UC) between October 2002 and September 2004. The primary outcome was the number of episodes of unprotected anal intercourse (UAI) with any nonprimary partner of nonconcordant HIV serostatus in the preceding 90 days, measured at baseline, 6 months, and 12 months. Impact was assessed as "intent to treat" by random-intercept Poisson regression analysis. Acceptability was assessed by a standardized client satisfaction survey.

RESULTS

Men receiving PCC and UC reported comparable levels of HIV nonconcordant UAI at baseline (mean episodes: 4.2 vs. 4.8, respectively; P = 0.151). UAI decreased by more than 60% to 1.9 episodes at 6 months in the PCC arm (P < 0.001 vs. baseline) but was unchanged at 4.3 episodes for the UC arm (P = 0.069 vs. baseline). At 6 months, men receiving PCC reported significantly less risk than those receiving UC (P = 0.029 for difference to PCC). Risk reduction in the PCC arm was sustained from 6 to 12 months at 1.9 (P = 0.181), whereas risk significantly decreased in the UC arm to 2.2 during this interval (P < 0.001 vs. 6 months; P = 0.756 vs. PCC at 12 months). Significantly more PCC participants were "very satisfied" with the counseling experience (78.2%) versus UC participants (59.2%) (P = 0.002).

CONCLUSIONS

Both interventions were effective in reducing high-risk sexual behavior among MSM repeat testers. PCC participants demonstrated significant behavioral change more swiftly and reported a more satisfying counseling experience than UC participants.

Late Diagnosis of HIV Infection

BACKGROUND

Persons diagnosed late in the course of HIV infection may be unknowingly transmitting infection and once diagnosed may have worse outcomes and greater medical expenses.

METHODS

Persons diagnosed with AIDS in San Francisco between 2001 and 2005 were included. Late testers were persons diagnosed with HIV 12 months or less before their AIDS diagnosis. Prevalence trends, demographic and risk correlates, and predictors of late testing were measured.

RESULTS

Among 2139 persons included, 830 (38.8%) were late testers. The prevalence of late testing was stable between 2001 and 2005. Late testing was more likely among persons <30 years old (Odds ratio [OR]: 1.99, 95% confidence interval [CI]: 1.4, 2.8), heterosexuals (OR: 1.88, 95% CI: 1.1, 3.1), persons without a reported risk (OR: 2.88, 95% CI: 1.7, 5.0), persons with private insurance (OR: 1.82, 95% CI: 1.4, 2.4), no insurance (OR: 1.83, 95% CI: 1.4, 2.4), born outside of the United States (OR: 1.64, 95% CI: 1.2, 2.2), and whose initial AIDS diagnosis was an opportunistic infection (OR: 2.24, 95% CI: 1.8, 2.8).

CONCLUSIONS

A large proportion of persons with AIDS have tested late in the course of HIV infection and this proportion has not declined in recent years. Routine testing in medical settings, and use of rapid oral-fluid testing in traditional and nontraditional settings may increase early HIV diagnosis.

Priapism and quetiapine: a case report

Priapism is a "persistent erection not accompanied by sexual desire or stimulation, usually lasting more than six hours and typically involving only the corpora cavernosa." Here we report on a gay male patient from our HIV/AIDS mental health clinic who developed serious priapism on quetiapine and recreational amphetamine. Gay men are at high risk for amphetamine use, and as such, this potential association between priapism, quetiapine, and amphetamine use should be considered in making prescription decisions with these patients.

Availability of combination therapy for HIV: effects on sexual risk taking in a sample of high-risk gay and bisexual men

The objective of this study was to assess the impact of successes in the medical treatment of HIV disease on the perceptions of high-risk gay and bisexual men attending an anonymous testing site towards becoming infected with HIV and on their decisions to have unsafe sex. A cross-sectional survey with a face-to-face interview and self-recorded information was used. A convenience sample of high-risk men seeking anonymous HIV antibody counselling was recruited for an intervention study. To be eligible, men had to have a history of at least one previous negative antibody test and unprotected anal intercourse within the last year. Upon enrollment, subjects were asked about the impact of new treatment developments on their decisions to engage in high-risk sex both in the recent past and in the future. In general, neither the recent successes in treating HIV nor the availability of combination therapy had any impact on the men's decisions about safe sex, although a minority of men reported less concern about becoming HIV-positive. Also, some men reported already having taken more risk. In conclusion, a small number of men in this high-risk population have increased risk behaviour as a result of recent treatment advances. These results merit continued monitoring.

Changing sexual behavior among gay male repeat testers for HIV: a randomized, controlled trial of a single-session intervention

CONTEXT

High-risk sexual behavior is increasingly prevalent among men who have sex with men (MSM) and among men with a history of repeat testing for HIV.

OBJECTIVES

The study assessed whether one counseling intervention session focusing on self-justifications (thoughts, attitudes, or beliefs that allow the participant to engage in high-risk sexual behaviors) at most recent unprotected anal intercourse (UAI) is effective in reducing future high-risk behaviors among HIV-negative men.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, controlled, counseling intervention trial was conducted at an anonymous testing site in San Francisco, California, between May 1997 and January 2000. Participants were 248 MSM with a history of at least one previous negative HIV test result and self-reported UAI (receptive or insertive) in the previous 12 months with partners of unknown or discordant HIV status. Two intervention groups received standard HIV test counseling plus a cognitive-behavioral intervention, and two control groups received only standard HIV test counseling. Follow-up evaluation was at 6 and 12 months.

MAIN OUTCOME MEASURE

Number of episodes of UAI with nonprimary partners (of unknown or discordant HIV status) in the 90 days preceding the interview was measured via self-report during face-to-face interview.

RESULTS

A novel counseling intervention focusing on self-justifications significantly decreased the proportion of participants reporting UAI with nonprimary partners of unknown or discordant HIV status at 6 and 12 months (from 66% to 21% at 6 months and to 26% at 12 months, p =.002; p <.001) as compared with a control group when added to standard client-centered HIV counseling and testing.

CONCLUSIONS

A specific, single-session counseling intervention focusing on a reevaluation of a person's self-justifications operant during a recent occasion of high-risk behavior may prove useful in decreasing individual risk behavior and thus limiting community-level HIV transmission.

Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: San Francisco

OBJECTIVES

This study assessed the countervailing effects on HIV incidence of highly active antiretroviral treatment (HAART) among San Francisco men who have sex with men (MSM).

METHODS

Behavioral risk was determined on the basis of responses to cross-sectional community interviews. HIV incidence was assessed through application of an enzyme-linked immunoassay testing strategy.

RESULTS

Use of HAART among MSM living with AIDS increased from 4% in 1995 to 54% in 1999. The percentage of MSM who reported both unprotected anal intercourse and multiple sexual partners increased from 24% in 1994 to 45% in 1999. The annual HIV incidence rate increased from 2.1% in 1996 to 4.2% in 1999 among MSM who sought anonymous HIV testing, and the rate was high (5.3%) but stable in a blinded survey of MSM seeking sexually transmitted disease services.

CONCLUSIONS

Any decrease in per contact risk of HIV transmission due to HAART use appears to have been counterbalanced or overwhelmed by increases in the number of unsafe sexual episodes.

Deciding where and how to be tested for HIV: what matters most?

This study examined preferences for specific types of HIV tests as well as for test attributes such as cost, counseling, and privacy. A survey was administered to 354 clients of public testing services. Nonparametric tests and logistic regression were used to compare test preferences and attribute ratings, and to assess differences by demographic and risk groups. Nearly two thirds of respondents chose a public clinic test as their first choice, whereas 24% chose a home self-test, 12% chose a test at a doctor's office, and 1% chose a home specimen-collection test. Three attributes (accuracy/timeliness, privacy of test disclosure, and linking of test results) were rated equally-and most-important. In-person counseling was endorsed as the fourth most important attribute. Availability of in-person counseling was the strongest predictor of "loyalty" to public clinic tests-a consistent preference for that type of test even when the other tests were offered as additional no-cost options. There was also substantial interest in home self-tests. The results suggest specific attributes of testing that may be particularly important to individuals from diverse demographic and risk backgrounds.

HIV testing in gay sex clubs

The purpose of this study was to evaluate a programme of human immunodeficiency virus (HIV) antibody testing at gay sex clubs. Conducting secondary analyses with 2 datasets, we evaluated HIV-testing preferences of patrons at 2 sex clubs and compared their risks to testers at a standard testing clinic. Sex club testers had significantly more partners and were significantly older than their clinic peers. Sixteen per cent of sex club testers reported that they would not test if testing were not available at the sex club. Gay sex clubs offer an opportunity to reach men at high risk for HIV, some who otherwise may not test.

Name-based reporting of HIV-positive test results as a deterrent to testing

OBJECTIVES

This study evaluated attitudes toward name-based reporting of HIV.

METHODS

One hundred thirty high-risk, male repeat testers received information on the public health benefits of name-based reporting and reported their intentions to test.

RESULTS

Of the 67 men who were randomly selected and asked their intentions before hearing the benefits, 63% said they would not test if reporting were required. After hearing the benefits, 19% changed their minds (P < .014). Of the 63 men who were asked only after hearing the benefits, 44% would not test.

CONCLUSIONS

Implementing name-based reporting without working before-hand to change attitudes could undermine the benefits of both testing and HIV surveillance.

Psychosocial correlates of unprotected anal sex in a cohort of gay men attending an HIV-negative support group

The objective of this report is to identify psychosocial correlates of unprotected anal sex among attendants at a support group for HIV-negative gay and bisexual men. Presupport group measures were given to 55 self-identified urban HIV-negative gay and bisexual men in a high-incidence HIV location (San Francisco) attending a 10-week, weekly, 2-hour support group at the University of California at San Francisco (UCSF) AIDS Health Project. Participants completed self-administered questionnaires that included measures of perceived risk, condom self-efficacy, social support, HIV knowledge, and depression. At baseline, 25% of the participants reported unprotected anal sex (receptive or insertive) in the two months preceding enrollment. This finding was independent of whether the participant was single or involved in a relationship, and whether or not the participant's partner was infected with HIV. Participants were found to generally have very high AIDS knowledge and low depression scores. In bivariate analysis, unprotected anal sex was associated with low condom self-efficacy, low AIDS knowledge, dissatisfaction with social support, and lower commitment to safer sex. In multivariate analysis, unprotected anal sex was independently associated with low condom self-efficacy (p = .006), and low AIDS knowledge (p = .007). Additionally, a borderline significant result was found when measuring satisfaction with social support (p =.085). No association was found between depression scores and unprotected sexual activity.

Relationship of beta 2 microglobulin and CD4 counts to neuropsychological performance in HIV-1-infected intravenous drug users

This study explores the relationship of immune dysfunction to the neuropsychological performance of i.v. drug users (IVDUs) infected with HIV-1. Ninety-seven HIV-positive and 45 HIV-negative former IVDUs on methadone maintenance were evaluated using neuropsychological measures, physical examinations, and measures of immune function, including absolute CD4 counts and beta 2 microglobulin (beta 2-M). There were no significant differences between the HIV-positive and HIV-negative subjects on any single neuropsychological domain. There was, however, a significant group difference on a composite indicator of neuropsychological impairment, with 32% of HIV-positive subjects demonstrating some degree of overall impairment compared with only 13% of HIV-negative subjects. HIV-positive subjects were then stratified according to the Centers for Disease Control (CDC) symptom groupings: group II, asymptomatic, n = 29; group III, lymphadenopathy, n = 30; and group IV A or C-2, symptomatic, non-AIDS, n = 38. There were no significant neuropsychological differences among the three CDC groups. The HIV-positive subjects were also stratified on absolute CD4 counts (< or = 200, 201-400, and > 400) and beta 2-M (> or = 5, 3-5, and < 3). Individuals with greater immune compromise (CD4, < 200, beta 2-M, > or = 5) were more impaired on measures of motor functioning. beta 2-M was found to be a better predictor than CD4 count of impaired neuropsychological performance. Furthermore, individuals with beta 2-M values > or = 5 have more than a threefold increase in the incidence of neuropsychological impairment than those with beta 2-M values < 3.0. These results suggest that beta 2-M may serve as a useful clinical marker for the development of neuropsychological impairment and that the risk of such impairment increases as the immune system weakens.

The University of California at San Francisco AIDS Health Project. A community psychiatry approach to the AIDS epidemic

Each program within the AIDS Health Project is designed to work with individuals at different points along the continuum between a state of health at one end of the spectrum and the clinical disorder of AIDS at the other. Thus, individual programs reflect different levels of prevention. For example, the Prevention and Support Services (formerly the Worried Well) Program is an example of primary prevention; i.e., services are provided to healthy individuals who are at risk in an attempt to keep them from contracting the disease. The HIV Positives Being Positive Program is an example of secondary prevention in which services are provided to those who have premonitory symptoms of disease but have not yet developed the full-blown illness. The AIDS antibody counseling and testing program has elements of both primary and secondary prevention, as individuals who are counseled may prove to have either a positive or a negative test. Finally, the Mental Health Program at San Francisco General Hospital and the AIDS and Substance Abuse Program (ASAP) are examples of tertiary prevention. (Note: The ASAP actually incorporates all three levels of prevention through its various activities. As the original impetus for its development was to provide services to people with AIDS, however, we have listed it as a tertiary program.) In these programs, services are provided to individuals with the illness in an attempt to prevent psychological decompensation, to provide relief of current distress, and, perhaps, to delay disease progression.

Immune function and neuropsychological performance in HIV-1-infected homosexual men

This study explores the relationship of immune dysfunction to the neuropsychological performance of individuals infected with HIV-1. Fifty-five HIV-positive homosexual men and 37 negative homosexual controls were evaluated using neuropsychological measures, physical exams, and measures of immune functioning. There were no significant differences favoring HIV-negative subjects over HIV-positive subjects. HIV-positive subjects, in fact, performed slightly better on attention and memory procedures. The HIV-positive subjects were then stratified according to the Centers for Disease Control symptom groupings (Group II, asymptomatic, n = 19; Group III, lymphadenopathy, n = 17; and Group IVA or C-2, symptomatic, non-AIDS, (n = 19). There were no significant neuropsychological differences among the three CDC groups. The HIV-positive subjects were also stratified on two measures of immune functioning: absolute CD4 counts (< 200, 201-400, > 400) and beta 2-microglobulin (beta 2M) (> or = 5.0, 3.0-5.0, < 3.0). Individuals with greater immune compromise, as measured by beta 2M, were more impaired on measures of attention and memory and had greater overall neuropsychological impairment (p < 0.05). Furthermore, 57% of the subjects who were abnormal on beta 2M were also impaired on measures of attention and memory, whereas only 14% of those with normal beta 2M were impaired on these same measures (p < 0.05). These results suggest that HIV-positive asymptomatics without evidence of immune compromise do not appear to be at greater risk of cognitive impairment than HIV-negative controls. However, for those HIV-positive individuals who are immune-compromised (even while asymptomatic), there is increased risk of neuropsychological impairment. These results also suggest that knowledge of serostatus and the use of the CDC classification system alone are insufficient in exploring the development of neuropsychiatric changes in HIV-1 infection.

Relationship of CD4 counts to neurophysiological function in HIV-1--infected homosexual men

OBJECTIVE

To explore the relationship of immune dysfunction to neurophysiological measures of brain-stem conduction time.

DESIGN

Three-year longitudinal prospective cohort study; results of time 1 analyses reported.

SETTING

San Francisco (California) General Hospital, Departments of Psychiatry and Epidemiology.

PATIENTS

Volunteer sample of 55 human immunodeficiency virus (HIV)-positive and 37 HIV-negative homosexual men recruited from a larger cohort of homosexual men followed up since 1983 at San Francisco General Hospital as part of an ongoing study of the natural history and course of HIV type 1 infection.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Auditory brain-stem responses and somatosensory evoked potentials for subjects stratified separately on HIV serostatus, Centers for Disease Control and Prevention symptom groupings, and absolute CD4 counts.

RESULTS

The HIV-positive subjects had an increased wave III-V interpeak latency of the right ear auditory brain-stem response compared with the HIV-negative subjects (t test, P < .05). There were no significant differences among the three Centers for Disease Control and Prevention groupings on any evoked potential measure. When HIV-positive subjects were stratified on a measure of immune functioning, ie, CD4 counts, individuals with greater immune suppression were more impaired on speed of auditory brain-stem conduction time (Mann-Whitney U test, P < .05). Furthermore, 85% of subjects impaired on this evoked potential measure had CD4 counts of less than 0.40 x 10(9)/L (400/microL), whereas only 15% of those impaired on this measure had CD4 counts of greater than 0.40 x 10(9)/L.

CONCLUSIONS

Asymptomatic HIV-positive subjects who do not have evidence of immune suppression do not appear to be at greater risk for neurophysiological impairment than HIV-negative subjects. The HIV-positive individuals who are immune suppressed (even while asymptomatic) appear to have an increased likelihood of central conduction time slowing as measured by evoked potential procedures.

A roundtable discussion: hospital leaders discuss QI implementation issues

To address critical questions regarding the practical application of quality improvement (QI) concepts within health care, the Joint Commission visited six hospitals that have been implementing QI for several years. After the site visits, the leaders of these hospitals participated in a roundtable discussion of QI issues. The discussion centered around nuts-and-bolts topics, such as leadership, implementing QI, barriers/resistances, medical staff involvement, cultural change, institutionalizing QI, and external environment. The roundtable discussion is excerpted in full from a new book, Striving Toward Improvement: Six Hospitals in Search of Quality, which tells the stories of the six hospitals and their transitions to QI.

Management and residential placement problems of patients with HIV-related cognitive impairment

The Neuropsychiatric AIDS Rating Scale, which classifies HIV-related cognitive impairment along a six-stage continuum, was used to explore the relationship between the severity of impairment and management and residential problems among 318 persons in San Francisco with suspected HIV-related cognitive impairment. Nearly half of the sample were in the moderate, severe, or end stage of impairment. One-third of the 318 persons, most of whom were in the moderate and severe stages, were reported to present residential placement problems. The management problems most associated with placement difficulties were home safety, wandering, confusion, and memory difficulties. More than a fourth of the moderately to severely impaired patients were living alone with no outside help or were homeless and living on the streets. Results of this study support the development of specialized residential programs for patients with HIV-related cognitive impairment.