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Batchelder AW, Heo M, Foley JD, Sullivan MC, Lum P, Pericot Valverde I, Taylor LE, Mehta SH, Kim AY, Norton B, Tsui JI, Feinberg J, Page K, Litwin AH. Shame and stigma in association with the HCV cascade to cure among people who inject drugs. Drug Alcohol Depend 2023; 253:111013. [PMID: 37951006 DOI: 10.1016/j.drugalcdep.2023.111013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/26/2023] [Accepted: 10/22/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Psycho-social experiences including shame and experienced and internalized stigma have been associated with substance use, HCV infection, and reluctance to disclose HCV status and pursue treatment. These psycho-social barriers have been examined independently for many chronic diseases, including HCV, but to our knowledge have not been quantitatively explored in a large multi-site US-based sample of people who inject drugs (PWID) in HCV treatment. METHODS We examine baseline relationships with HCV-stigma and engagement across the HCV treatment cascade as well as baseline and longitudinal relationships between shame and engagement across the HCV treatment cascade including treatment initiation, adherence, completion, and sustained virologic response (SVR) among a multi-site sample of PWID with HCV, where N=755 were randomized to the pragmatic trial comparing HCV treatment outcomes in modified directly observed treatment (mDOT) or patient navigation, and N=623 initiated treatment. RESULTS While cross-sectional assessments of shame and HCV-stigma were not associated with engagement across the HCV treatment cascade, those whose shame scores decreased compared to those who reported consistently high and increasing levels of shame were significantly more likely to complete HCV treatment (aOR=5.29; 95%CI: 1.56,18.00) and achieve SVR (aOR=6.32; 95%CI: 1.61, 24.87). CONCLUSION Results underscore the relationships between lower levels of shame and health-related behavior and treatment outcomes among PWID and suggest SVR achievement may contribute to reductions in shame or that reductions in shame may contribute to continued treatment and thus SVR.
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Affiliation(s)
- Abigail W Batchelder
- Behavioral Medicine Program, Psychiatry Department, Massachusetts General Hospital, One Bowdoin Square, Suite 701, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, One Bowdoin Square, Suite 701, Boston, MA 02114, USA; The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, USA.
| | - Moonseong Heo
- Department of Public Health, College of Behavioral, Social, and Health Sciences, Clemson University, 116 Edwards Hall, Clemson, SC 29634, USA
| | - Jacklyn D Foley
- Behavioral Medicine Program, Psychiatry Department, Massachusetts General Hospital, One Bowdoin Square, Suite 701, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, One Bowdoin Square, Suite 701, Boston, MA 02114, USA
| | - Matthew C Sullivan
- Behavioral Medicine Program, Psychiatry Department, Massachusetts General Hospital, One Bowdoin Square, Suite 701, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, One Bowdoin Square, Suite 701, Boston, MA 02114, USA
| | - Paula Lum
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Lynn E Taylor
- College of Pharmacy, University of Rhode Island, Providence, RI, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Arthur Y Kim
- Department of Infectious Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Brianna Norton
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Judith Feinberg
- Department of Behavioral Medicine & Psychiatry and Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kim Page
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Alain H Litwin
- Department of Medicine, Clemson University, Clemson, SC, 29634 USA; Department of Medicine, University of South Carolina School of Medicine, Greenville, SC, USA; Department of Medicine, Prisma Health, Greenville, SC, USA.
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Perera R, Stephan L, Appa A, Giuliano R, Hoffman R, Lum P, Martin M. Meeting people where they are: implementing hospital-based substance use harm reduction. Harm Reduct J 2022; 19:14. [PMID: 35139877 PMCID: PMC8826677 DOI: 10.1186/s12954-022-00594-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospital-based addiction care focuses on assessing and diagnosing substance use disorders, managing withdrawal, and initiating medications for addiction treatment. Hospital harm reduction is generally limited to prescribing naloxone. Hospitals can better serve individuals with substance use disorders by incorporating harm reduction education and equipment provision as essential addiction care. We describe the implementation of a hospital intervention that provides harm reduction education and equipment (e.g., syringes, pipes, and fentanyl test strips) to patients via an addiction consult team in an urban, safety-net hospital. METHODS We performed a needs assessment to determine patient harm reduction needs. We partnered with a community-based organization who provided us harm reduction equipment and training. We engaged executive, regulatory, and nursing leadership to obtain support. After ensuring regulatory compliance, training our team, and developing a workflow, we implemented this harm reduction program that provides education and equipment to individuals whose substance use goals do not include abstinence. RESULTS During a 12-month period we provided 195 individuals harm reduction kits. CONCLUSIONS This intervention allowed us to advance hospital-based addiction care, better educate and engage patients, staff, and clinicians, and reduce stigma. By establishing a community harm reduction partner, obtaining support from hospital leadership, and incorporating feedback from staff, clinicians, and patients, we successfully implemented harm reduction education and equipment provision in a hospital setting as part of evidence-based addiction care. TRIAL REGISTRATION Commentary, none.
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Affiliation(s)
- Rachel Perera
- San Francisco General Hospital, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Louise Stephan
- Frank H Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
| | - Ayesha Appa
- San Francisco General Hospital, San Francisco, CA, USA.,Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ro Giuliano
- San Francisco AIDS Foundation, San Francisco, CA, USA
| | | | - Paula Lum
- San Francisco General Hospital, San Francisco, CA, USA.,Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Marlene Martin
- San Francisco General Hospital, San Francisco, CA, USA. .,Department of Medicine, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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Cox AL, Page K, Melia M, Veenhuis R, Massaccesi G, Osburn W, Wagner K, Giudice L, Stein E, Asher AK, Vassilev V, Lin L, Nicosia A, Capone S, Scarselli E, Folgori A, Gorman R, Chang S, Wolff P, Liang TJ, Ghany M, Wierzbicki M, Lum P. LB10. A Randomized, Double-Blind, Placebo-Controlled Efficacy Trial of a Vaccine to Prevent Chronic Hepatitis C Virus Infection in an at-Risk Population. Open Forum Infect Dis 2019. [PMCID: PMC6809985 DOI: 10.1093/ofid/ofz415.2493] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
The development of a safe and effective vaccine to prevent chronic hepatitis C virus (HCV) infection is a critical component of elimination efforts, providing the rationale for the first HCV vaccine efficacy trial.
Methods
In a randomized, multicenter, double-blind, placebo-controlled efficacy trial (NCT01436357), we evaluated a recombinant chimpanzee adenovirus 3 vector vaccine prime followed by a recombinant modified vaccinia Ankara boost, both encoding nonstructural proteins of HCV. HCV-uninfected adults 18–45 years old at-risk for HCV infection due to injection drug use were randomized to receive the prime-boost regimen or placebo at Days 0 and 56. Trial participants were monitored for vaccine reactogenicity, adverse events, and HCV viremia. Vaccine safety, immunogenicity, and efficacy against progression to chronic HCV infection were assessed.
Results
A total of 455 subjects received the prime-boost regimen or two doses of placebo, with 202 and 199 in the respective groups included in the according-to-protocol efficacy cohort. Overall incidence of infection was 14.1 infections per 100 person-years. There were no differences in development of chronic infection between vaccine and placebo arms, with 14 chronically infected subjects in each group. Specifically, the vaccine efficacy in preventing chronic infection was −0.53 (95% confidence interval [CI], −2.5 to 0.34). Of vaccinated subjects, 78% generated T-cell responses to ≥1 vaccine-encoded HCV antigens. The vaccine was generally safe and well tolerated with no serious vaccine-related adverse events. There were more solicited reports of adverse events after either injection in the vaccine group (81%) than in the placebo group (59%), with the difference mainly due to injection-site reactions. Serious adverse events and deaths occurred with similar frequencies in the two groups.
Conclusion
A randomized, placebo controlled, Phase I/II trial of a prime-boost vaccine to prevent chronic HCV infection was completed in an at-risk population, demonstrating the feasibility of conducting rigorous vaccine research in people who inject drugs. The regimen elicited robust immune responses without evident safety concerns, but did not provide protection against chronic HCV infection.
Disclosures
Ventzislav Vassilev, PhD, GlaxoSmithKlein Vaccines (Employee), Lan Lin, MD, GlaxoSmithKlein Vaccines (Employee), Alfredo Nicosia, PhD, ReiThera (Employee, Shareholder), Antonella Folgori, PhD, ReiThera (Employee), ReiThera (Employee, Shareholder. Other Authors: No reported disclosures.
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Affiliation(s)
| | | | | | | | | | | | | | - Linda Giudice
- The University of California, San Francisco, San Francicso, California
| | - Ellen Stein
- The University of California, San Francisco, San Francicso, California
| | - Alice K Asher
- The University of California, San Francisco, San Francicso, California
| | | | - Lan Lin
- GlaxoSmithKline Vaccines, Wavre, Brussels Hoofdstedelijk Gewest, Belgium
| | | | | | | | | | - Richard Gorman
- The National Institute of Allergy and Infectious Diseases, Rockville, Maryland
| | - Soju Chang
- The National Institute of Allergy and Infectious Diseases, Rockville, Maryland
| | - Peter Wolff
- The National Institute of Allergy and Infectious Diseases, Rockville, Maryland
| | - T Jake Liang
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Marc Ghany
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | | | - Paula Lum
- The University of California, San Francisco, San Francicso, California
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Lambdin BH, Lorvick J, Mbwambo JK, Rwegasha J, Hassan S, Lum P, Kral AH. Prevalence and predictors of HCV among a cohort of opioid treatment patients in Dar es Salaam, Tanzania. Int J Drug Policy 2017; 45:64-69. [PMID: 28628854 PMCID: PMC6166640 DOI: 10.1016/j.drugpo.2017.05.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 05/09/2017] [Accepted: 05/15/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The government of Tanzania launched an opioid treatment program (OTP), using methadone, in Dar es Salaam in February of 2011. Hepatitis C virus (HCV) is a leading cause of morbidity and mortality globally, especially among people who inject drugs (PWID). We conducted a cross-sectional study among PWID engaged in OTP in Dar es Salaam to describe the prevalence and predictors of HCV antibody serostatus. METHODS Routine programmatic data on patients enrolled in Muhimbili National Hospital's OTP clinic from February 2011 to January 2013 were utilized. Multivariable Poisson regression was used to examine factors associated with HCV antibody serostatus. RESULTS A total of 630 PWID enrolled into the OTP clinic during the study period, seven percent of which were women. The overall seroprevalence of HCV antibody was 57% (95% Confidence interval: 53-61%). In adjusted analysis, methadone patients who used heroin for 5-10 years (adjusted prevalence ratio; aPR=1.41; 95% CI: 1.10-1.81) and >10years (aPR=1.48; 95% CI: 1.17-1.88) were more likely to be HCV antibody positive, compared to patients who used heroin for <5years. Patients who reported sharing needles or other equipment at their last injection (aPR=1.20; 95% CI: 1.01-1.41; p=0.022), being arrested (aPR=1.20; 95% CI: 1.04-1.40; p=0.012) and who were HIV-positive (aPR=1.84; 95% CI: 1.56-2.16; p<0.001) were also more likely to be HCV antibody positive than their counterparts. CONCLUSION Our observed HCV antibody prevalence among PWID engaged in OTP is higher than previously reported estimates in Dar es Salaam. Predictors of HCV antibody serostatus in this sample were similar to those found among PWID in many other settings. Integrating HCV care and treatment into OTP clinics should be considered, leveraging lessons learned from the integration of HIV services into OTP. Global efforts to develop HCV care and treatment programs in low and middle-income countries are critical, especially among PWID who have a high burden of HCV.
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Affiliation(s)
- Barrot H Lambdin
- RTI-International, San Francisco, CA , United States; University of California San Francisco, San Francisco, CA, United States; University of Washington, Seattle, WA, United States.
| | | | - Jessie K Mbwambo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - John Rwegasha
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Paula Lum
- University of California San Francisco, San Francisco, CA, United States
| | - Alex H Kral
- RTI-International, San Francisco, CA , United States
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Vijayaraghavan M, Yuan P, Gregorich S, Lum P, Appelle N, Napoles AM, Kalkhoran S, Satterfield J. Disparities in receipt of 5As for smoking cessation in diverse primary care and HIV clinics. Prev Med Rep 2017; 6:80-87. [PMID: 28271025 PMCID: PMC5334546 DOI: 10.1016/j.pmedr.2017.02.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/23/2017] [Accepted: 02/17/2017] [Indexed: 12/02/2022] Open
Abstract
Clinical practice guidelines recommend that clinicians implement the 5As (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation at every clinical encounter. We sought to examine the prevalence of patient- and clinician-reported 5As in two primary care and one HIV care clinics in San Francisco, California between August 2013 and March 2014 (n = 462 patients and n = 61 clinicians). We used multivariable logistic regression analysis to identify factors associated with receipt of the 5As, adjusting for patient demographics, patient insurance, clinic site, patient tobacco use, and patient comorbidities. The patient-reported prevalence of 5As receipt was as follows: Ask, 49.9%; Advise, 47.2%; Assess, 40.6%; any Assist, 44.9%; and Arrange, 22.4%. In multivariable analysis, receipt of Advise, Assess, and Assist were associated with older patient age. Whereas patients with HIV had a lower odds of reporting being advised (AOR 0.5, 95% CI 0.3–0.8) or assessed for readiness to quit (AOR 0.6, 95% CI 0.4–0.9), patients with pulmonary diseases had higher odds of reporting being assisted (AOR 1.6, 95% 1.0–2.6) than patients without these diagnoses. Although the majority of clinicians reported asking (91.8%), advising (91.8%), and assessing (93.4%) tobacco use ‘most of the time’ or ‘always’ during a clinical encounter, fewer reported assisting (65.7%) or arranging (19.7%) follow-up. Only half of patients reported being screened for tobacco use and fewer reported receipt of the other 5As, with significant disparities in receipt of the 5As among patients with HIV. Our findings confirm the need for interventions to increase clinician-delivered cessation treatment in primary and HIV care. Clinical practice guidelines recommend the use of 5As for smoking cessation. Patient reports of Assist and Arrange were low in primary care and HIV care. There were significant disparities in the receipt of 5As among patients with HIV. Digital interventions could facilitate clinician-delivered 5As for patients.
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Affiliation(s)
- Maya Vijayaraghavan
- Division of General Internal Medicine/Zuckerberg San Francisco General Hospital, University of California, San Francisco, United States
- Corresponding author at: University of California, San Francisco, Division of General Internal Medicine/San Francisco General Hospital, UCSF Box 1364, 1001 Potrero Avenue, United States.University of California, San FranciscoDivision of General Internal Medicine/San Francisco General HospitalUCSF Box 13641001 Potrero AvenueUnited States
| | - Patrick Yuan
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, United States
| | - Steven Gregorich
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, United States
| | - Paula Lum
- Division of HIV/AIDS, Department of Medicine, University of California, San Francisco, United States
| | - Nicole Appelle
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, United States
| | - Anna Maria Napoles
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, United States
| | - Sara Kalkhoran
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, United States
| | - Jason Satterfield
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, United States
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Dawson Rose C, Cuca YP, Kamitani E, Eng S, Zepf R, Draughon J, Lum P. Using Interactive Web-Based Screening, Brief Intervention and Referral to Treatment in an Urban, Safety-Net HIV Clinic. AIDS Behav 2015; 19 Suppl 2:186-93. [PMID: 25963770 DOI: 10.1007/s10461-015-1078-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Substance use among people living with HIV is high, and screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based approach to addressing the issue. We examined whether patients would participate in a technology-based SBIRT program in an urban HIV clinic. An SBIRT intervention was programmed into the clinic's web-based patient portal linked to their personal health record. We examined: demographic, health, HIV, and substance use characteristics of participants who completed the web-based intervention compared to those who did not. Fewer than half of the 96 participants assigned to the web-based SBIRT completed it (n = 39; 41 %). Participants who completed the web-based intervention had significantly higher amphetamine SSIS scores than those who did not complete the intervention. Participants whose substance use is more harmful may be more motivated to seek help from a variety of sources. In addition, it is important that technology-based approaches to behavioral interventions in clinics take into consideration feasibility, client knowledge, and comfort using technology.
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Hinks TSC, Zhou XY, Lum P, Staples KJ, Dimitrov B, Smith C, Ward J, Howarth PH, Walls AF, Gadola SD, Djukanovic R. S23 Multidimensional phenotypes of asthma. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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McCance-Katz EF, Gruber VA, Beatty G, Lum P, Ma Q, DiFrancesco R, Hochreiter J, Wallace PK, Faiman MD, Morse GD. Interaction of disulfiram with antiretroviral medications: efavirenz increases while atazanavir decreases disulfiram effect on enzymes of alcohol metabolism. Am J Addict 2013; 23:137-44. [PMID: 24118434 DOI: 10.1111/j.1521-0391.2013.12081.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/06/2013] [Accepted: 03/23/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Alcohol abuse complicates treatment of HIV disease and is linked to poor outcomes. Alcohol pharmacotherapies, including disulfiram (DIS), are infrequently utilized in co-occurring HIV and alcohol use disorders possibly related to concerns about drug interactions between antiretroviral (ARV) medications and DIS. METHOD This pharmacokinetics study (n=40) examined the effect of DIS on efavirenz (EFV), ritonavir (RTV), or atazanavir (ATV) and the effect of these ARV medications on DIS metabolism and aldehyde dehydrogenase (ALDH) activity which mediates the DIS-alcohol reaction. RESULTS EFV administration was associated with decreased S-Methyl-N-N-diethylthiocarbamate (DIS carbamate), a metabolite of DIS (p=.001) and a precursor to the metabolite responsible for ALDH inhibition, S-methyl-N,N-diethylthiolcarbamate sulfoxide (DETC-MeSO). EFV was associated with increased DIS inhibition of ALDH activity relative to DIS alone administration possibly as a result of EFV-associated induction of CYP 3A4 which metabolizes the carbamate to DETC-MeSO (which inhibits ALDH). Conversely, ATV co-administration reduced the effect of DIS on ALDH activity possibly as a result of ATV inhibition of CYP 3A4. DIS administration had no significant effect on any ARV studied. DISCUSSION/CONCLUSIONS ATV may render DIS ineffective in treatment of alcoholism. FUTURE DIRECTIONS DIS is infrequently utilized in HIV-infected individuals due to concerns about adverse interactions and side effects. Findings from this study indicate that, with ongoing clinical monitoring, DIS should be reconsidered given its potential efficacy for alcohol and potentially, cocaine use disorders, that may occur in this population.
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Page K, Osburn W, Evans J, Hahn JA, Lum P, Asher A, Delwart E, Tobler L, Cox AL, Busch MP. Frequent longitudinal sampling of hepatitis C virus infection in injection drug users reveals intermittently detectable viremia and reinfection. Clin Infect Dis 2012; 56:405-13. [PMID: 23090930 DOI: 10.1093/cid/cis921] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Detection of hepatitis C virus (HCV) reinfection and intercalation (ie, intermittent recurrent bouts of viremia with homologous virus interspersed with aviremic periods) requires extensive and frequent evaluation and viral sequencing. METHODS HCV infection outcomes were studied prospectively in active injection drug users with recurrent HCV RNA-positive tests after serial negative results. HCV viremia and viral sequences (Core/E1) were assessed from monthly blood samples. RESULTS Viral clearance, reinfection, and intercalating infection were all detected. Among 44 participants with apparently resolved HCV (26 incident HCV clearers and 18 enrolled with already resolved infection), 36 (82%) remained persistently HCV RNA negative, but 8 demonstrated intermittent recurrent viremia. Four of these (50%) had confirmed reinfection with a heterologous virus; 3 demonstrated viral intercalation, and 1 was not classifiable as either. Estimated incidence of first reinfection was 5.4 per 100 person-years (95% confidence interval, 2.0-14.5). Six (75%) participants, including 3 of 4 with reinfection, demonstrated sustained viral clearance for a median of 26 months since last HCV RNA test. CONCLUSIONS These results show that frequent monitoring and viral sequencing are required to correctly assess HCV outcomes and estimate incidence of reinfection (which was previously overestimated). Sustained clearance may take many months and occur after episodes of reinfection and viral intercalation. Three of 4 subjects who had confirmed reinfection showed evidence of long-term clearance. Viral intercalation occurs with significant frequency. Further studies of these events, especially immunological, are needed to inform HCV clinical care and vaccine development.
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Affiliation(s)
- Kimberly Page
- University of California, San Francisco, San Francisco, CA 94105, USA.
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Dias PT, Hahn JA, Delwart E, Edlin B, Martin J, Lum P, Evans J, Kral A, Deeks S, Busch MP, Page K. Temporal changes in HCV genotype distribution in three different high risk populations in San Francisco, California. BMC Infect Dis 2011; 11:208. [PMID: 21810243 PMCID: PMC3199778 DOI: 10.1186/1471-2334-11-208] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 08/02/2011] [Indexed: 12/19/2022] Open
Abstract
Background Hepatitis C virus (HCV) genotype (GT) has become an important measure in the diagnosis and monitoring of HCV infection treatment. In the United States (U.S.) HCV GT 1 is reported as the most common infecting GT among chronically infected patients. In Europe, however, recent studies have suggested that the epidemiology of HCV GTs is changing. Methods We assessed HCV GT distribution in 460 patients from three HCV-infected high risk populations in San Francisco, and examined patterns by birth cohort to assess temporal trends. Multiple logistic regression was used to assess factors independently associated with GT 1 infection compared to other GTs (2, 3, and 4). Results Overall, GT 1 was predominant (72.4%), however younger injection drug users (IDU) had a lower proportion of GT 1 infections (54.7%) compared to older IDU and HIV-infected patients (80.5% and 76.6%, respectively). Analysis by birth cohort showed increasing proportions of non-GT 1 infections associated with year of birth: birth before 1970 was independently associated with higher adjusted odds of GT 1: AOR 2.03 (95% CI: 1.23, 3.34). African-Americans as compared to whites also had higher adjusted odds of GT 1 infection (AOR: 3.37; 95% CI: 1.89, 5.99). Conclusions Although, HCV GT 1 remains the most prevalent GT, especially among older groups, changes in GT distribution could have significant implications for how HCV might be controlled on a population level and treated on an individual level.
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Affiliation(s)
- Paulo Telles Dias
- Núcleo de Estudos e Pesquisas em Atenção ao Uso de Drogas (NEPAD)-Universidade do Estado do Rio de Janeiro (State University of Rio de Janeiro), 20940-200 Rio de Janeiro, RJ, Brasil
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Page K, Hahn JA, Evans J, Shiboski S, Lum P, Delwart E, Tobler L, Andrews W, Avanesyan L, Cooper S, Busch MP. Acute hepatitis C virus infection in young adult injection drug users: a prospective study of incident infection, resolution, and reinfection. J Infect Dis 2009; 200:1216-26. [PMID: 19764883 DOI: 10.1086/605947] [Citation(s) in RCA: 234] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection, clearance, and reinfection are best studied in injection drug users (IDUs), who have the highest incidence of HCV and are likely to represent most infections. METHODS A prospective cohort of HCV-negative young IDUs was followed up from January 2000 to September 2007, to identify acute and incident HCV and prospectively study infection outcomes. RESULTS Among 1,191 young IDUs screened, 731 (61.4%) were HCV negative, and 520 (71.1%) of the 731 were enrolled into follow-up. Cumulative HCV incidence was 26.7/100 person-years of observation (95% confidence interval [CI], 21.5-31.6). Of 135 acute/incident HCV infections, 95 (70.4%) were followed; 20 (21.1%) of the 95 infections cleared. Women had a significantly higher incidence of viral clearance than did men (age-adjusted hazard ratio, 2.91 [95% CI, 1.68-5.03]) and also showed a faster rate of early HCV viremia decline (P < .01). The estimated reinfection rate was 24.6/100 person-years of observation (95% CI, 11.7-51.6). Among 7 individuals, multiple episodes of HCV reinfection and reclearance were observed. CONCLUSIONS In this large sample of young IDUs, females show demonstrative differences in their rates of viral clearance and kinetics of early viral decline. Recurring reinfection and reclearance suggest possible protection against persistent infection. These results should inform HCV clinical care and vaccine development.
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Affiliation(s)
- Kimberly Page
- Department of Epidemiology and Biostatistics, University of California, San Francisco, 50 Beale St, Ste 1200, San Francisco, CA 94105, USA.
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Colfax GN, Vittinghoff E, Grant R, Lum P, Spotts G, Hecht FM. Frequent methamphetamine use is associated with primary non-nucleoside reverse transcriptase inhibitor resistance. AIDS 2007; 21:239-41. [PMID: 17197817 DOI: 10.1097/qad.0b013e3280114a29] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We determined whether methamphetamine use is associated with the increased prevalence of primary HIV drug resistance among a cohort of men who have sex with men recently infected with HIV. In multivariate analysis, we found that frequent methamphetamine use was strongly associated with primary non-nucleoside reverse transcriptase inhibitor resistance, but not with protease inhibitor or nucleoside reverse transcriptase inhibitor resistance. We postulate that this association may be caused by methamphetamine-associated treatment interruptions among source partners.
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Affiliation(s)
- Grant Nash Colfax
- AIDS Office, San Francisco Department of Public Health, San Francisco, California, USA
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Abstract
The crystal structure of a putative metal-chelate-type adenosine triphosphate (ATP)-binding cassette (ABC) transporter encoded by genes HI1470 and HI1471 of Haemophilus influenzae has been solved at 2.4 angstrom resolution. The permeation pathway exhibits an inward-facing conformation, in contrast to the outward-facing state previously observed for the homologous vitamin B12 importer BtuCD. Although the structures of both HI1470/1 and BtuCD have been solved in nucleotide-free states, the pairs of ABC subunits in these two structures differ by a translational shift in the plane of the membrane that coincides with a repositioning of the membrane-spanning subunits. The differences observed between these ABC transporters involve relatively modest rearrangements and may serve as structural models for inward- and outward-facing conformations relevant to the alternating access mechanism of substrate translocation.
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Affiliation(s)
- H W Pinkett
- Division of Chemistry and Chemical Engineering, Howard Hughes Medical Institute, MC 114-96, California Institute of Technology (Caltech), Pasadena, CA 91125, USA
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Bacon O, Lum P, Hahn J, Evans J, Davidson P, Moss A, Page-Shafer K. Commercial Sex Work and Risk of HIV Infection Among Young Drug-Injecting Men Who Have Sex With Men in San Francisco. Sex Transm Dis 2006; 33:228-34. [PMID: 16565643 DOI: 10.1097/01.olq.0000204914.91923.ad] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the relationship between sex work and HIV infection among young injection drug-using men who have sex with men (MSM-IDU). STUDY DESIGN This study was a cross-sectional analysis of behavioral and serologic data collected from 227 street-recruited MSM-IDU in San Francisco, California, between January 2000 and November 2001. RESULTS Sixty-eight percent of participants reported being paid by another man for sex. HIV prevalence was 12% (95% confidence interval, 8-16%); 42% of seropositive participants were unaware of their infection. HIV was independently associated with higher number of paying male partners and history of gonorrhea and inversely associated with number of female partners, education, and syringe-sharing. Consistent condom use overall was 41%, but varied significantly by type of partner. CONCLUSIONS Among MSM-IDU in San Francisco, sex work with men is strongly associated with HIV infection and the prevalence of condom use is low. HIV prevention among MSM-IDU must be tailored to address the excess risk associated with sex work.
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Affiliation(s)
- Oliver Bacon
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco,and the Positive Health Program, Department of Medicine, San Francisco General Hospital, California 94105, USA
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Bacon O, Lum P, Hahn J, Evans J, Davidson P, Moss A, Page-Shafer K. Commercial sex work and risk of HIV infection among young drug-injecting men who have sex with men in San Francisco. Sex Transm Dis 2006. [PMID: 16565643 DOI: 10.1097/ol.olq.0000204914.91923.ad] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the relationship between sex work and HIV infection among young injection drug-using men who have sex with men (MSM-IDU). STUDY DESIGN This study was a cross-sectional analysis of behavioral and serologic data collected from 227 street-recruited MSM-IDU in San Francisco, California, between January 2000 and November 2001. RESULTS Sixty-eight percent of participants reported being paid by another man for sex. HIV prevalence was 12% (95% confidence interval, 8-16%); 42% of seropositive participants were unaware of their infection. HIV was independently associated with higher number of paying male partners and history of gonorrhea and inversely associated with number of female partners, education, and syringe-sharing. Consistent condom use overall was 41%, but varied significantly by type of partner. CONCLUSIONS Among MSM-IDU in San Francisco, sex work with men is strongly associated with HIV infection and the prevalence of condom use is low. HIV prevention among MSM-IDU must be tailored to address the excess risk associated with sex work.
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Affiliation(s)
- Oliver Bacon
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco,and the Positive Health Program, Department of Medicine, San Francisco General Hospital, California 94105, USA
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Luetkemeyer A, Hare CB, Stansell J, Tien PC, Charlesbois E, Lum P, Havlir D, Peters M. Clinical presentation and course of acute hepatitis C infection in HIV-infected patients. J Acquir Immune Defic Syndr 2006; 41:31-6. [PMID: 16340470 PMCID: PMC4050666 DOI: 10.1097/01.qai.0000191281.77954.27] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hepatitis C virus (HCV) has become a significant source of morbidity and mortality in HIV-infected patients. However, little is known about the clinical presentation and course of acute HCV infection in this population. This study reports the outcomes of acute HCV infection in 9 HIV-infected men. Sex with men was the only reported risk factor for HCV infection in 6 of the subjects. Clinical presentation of acute HCV ranged from incidentally discovered elevated transaminases to severe liver dysfunction requiring hospitalization. At the time of HCV diagnosis, 8 of 9 patients had CD4+ counts >250 cells/mm(3), and 6 had HIV viral loads of < or =5000 copies/mL. Eight patients were receiving antiretroviral therapy. Outcome of these acute HCV infections varied. Five patients experienced virologic clearance, 2 in whom virus cleared spontaneously and 3 who were treated with pegylated interferon and ribavirin. Four patients developed chronic infection, one of whom had a relapse during HCV treatment and 3 of whom were untreated. All 4 patients to whom HCV therapy was administered experienced significant anemia or neutropenia, necessitating dose reduction or support with growth factors. Prompt recognition of acute HCV infection may minimize antiretroviral treatment interruption and will allow early treatment, which may improve virologic clearance. Unexplained transaminase elevations in HIV-infected patients, including men who have sex with men, should trigger an evaluation for acute HCV infection.
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Affiliation(s)
- Annie Luetkemeyer
- HIV/AIDS Division, San Francisco General Hospital, University of California at San Francisco, CA 94110, USA.
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Hong CZ, Lee S, Lum P. Cervical radiculopathy. Clinical, radiographic and EMG findings. Orthop Rev 1986; 15:433-9. [PMID: 3453464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This retrospective study reviewed clinical, radiographic, and electromyographic (EMG) findings in 108 patients with cervical radiculopathy. Radiographic evaluation included measurements of the size of the intervertebral foramina and the space for the intervertebral disk. The results showed that the clinical findings correlated well with the EMG abnormalities but not with the radiographic findings. The extent of the intervertebral foramen and the disk space narrowing correlated poorly with the severity of EMG abnormalities. It is suggested that radiographic findings alone may be an inadequate basis for a diagnosis of cervical radiculopathy. EMG examination may be very helpful in such a diagnosis and may be more accurate in assessing radiculopathy than the plain films in certain cases.
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Affiliation(s)
- C Z Hong
- Department of Physical Medicine and Rehabilitation, University of California, Irvine
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