Pilot RCT comparing low-dose naltrexone, gabapentin and placebo to reduce pain among people with HIV with alcohol problems

BACKGROUND

To estimate the effects on pain of two medications (low-dose naltrexone and gabapentin) compared to placebo among people with HIV (PWH) with heavy alcohol use and chronic pain.

METHODS

We conducted a pilot, randomized, double-blinded, 3-arm study of PWH with chronic pain and past-year heavy alcohol use in 2021. Participants were recruited in St. Petersburg, Russia, and randomized to receive daily low-dose naltrexone (4.5mg), gabapentin (up to 1800mg), or placebo. The two primary outcomes were change in self-reported pain severity and pain interference measured with the Brief Pain Inventory from baseline to 8 weeks.

RESULTS

Participants (N = 45, 15 in each arm) had the following baseline characteristics: 64% male; age 41 years (SD±7); mean 2 (SD±4) heavy drinking days in the past month and mean pain severity and interference were 3.2 (SD±1) and 3.0 (SD±2), respectively. Pain severity decreased for all three arms. Mean differences in change in pain severity for gabapentin vs. placebo, and naltrexone vs. placebo were -0.27 (95% confidence interval [CI] -1.76, 1.23; p = 0.73) and 0.88 (95% CI -0.7, 2.46; p = 0.55), respectively. Pain interference decreased for all three arms. Mean differences in change in pain interference for gabapentin vs. placebo, and naltrexone vs. placebo was 0.16 (95% CI -1.38, 1.71; p = 0.83) and 0.40 (95% CI -1.18, 1.99; p = 0.83), respectively.

CONCLUSION

Neither gabapentin nor low-dose naltrexone appeared to improve pain more than placebo among PWH with chronic pain and past-year heavy alcohol use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT4052139).

Stigma and other correlates of sharing injection equipment among people with HIV in St. Petersburg, Russia

Stigma that people with HIV who inject drugs experience negatively impacts HIV and substance use care, but stigma's association with sharing injection equipment is not known. This is a cross-sectional analysis of data from two studies of people with HIV reporting drug injection (N = 319) in St. Petersburg, Russia (September 2018-December 2020). We used logistic regression to examine associations between HIV stigma and substance use stigma scores (categorised into quartiles) and past 30-day equipment sharing, adjusting for demographic and clinical characteristics. Secondary analyses examined associations of arrest history and social support with sharing equipment. Almost half (48.6%) of participants reported sharing injection equipment. Among groups who did and did not share, mean HIV stigma (2.3 vs 2.2) and substance use stigma (32 vs 31) scores were similar. Adjusted analyses detected no significant associations between HIV stigma quartiles (global p-value = 0.85) or substance use stigma quartiles (global p-value = 0.51) and sharing equipment. Neither arrest history nor social support were significantly associated with sharing equipment. In this cohort, sharing injection equipment was common and did not vary based on stigma, arrest history, or social support. To reduce equipment sharing, investments in sterile injection equipment access in Russia should be prioritised over interventions to address stigma.

HPV vaccine recommendations by age: A survey of providers in federally qualified health centers

Clinician recommendation remains a critical factor in improving HPV vaccine uptake. Clinicians practicing in federally qualified health centers were surveyed between October 2021 and July 2022. Clinicians were asked how they recommended HPV vaccination for patients aged 9-10, 11-12, 13-18, 19-26, and 27-45 y (strongly recommend, offer but do not recommend strongly, discuss only if the patient initiates the conversation, or recommend against). Descriptive statistics were assessed, and exact binomial logistic regression analyses were utilized to examine factors associated with HPV vaccination recommendation in 9-10-y-old patients. Respondents (n = 148) were primarily female (85%), between the ages of 30-39 (38%), white, non-Hispanic (62%), advanced practice providers (55%), family medicine specialty (70%), and practicing in the Northeast (63%). Strong recommendations for HPV vaccination varied by age: 65% strongly recommended for ages 9-10, 94% for ages 11-12, 96% for ages 13-18, 82% for age 19-26, and 26% for ages 27-45 y. Compared to Women's Health/OBGYN specialty, family medicine clinicians were less likely to recommend HPV vaccination at ages 9-10 (p = .03). Approximately two-thirds of clinicians practicing in federally qualified health centers or safety net settings strongly recommend HPV vaccine series initiation at ages 9-10. Additional research is needed to improve recommendations in younger age groups.

Examining the perceived impact of the COVID-19 pandemic on cervical cancer screening practices among clinicians practicing in Federally Qualified Health Centers: A mixed methods study

Background

The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed methods study we explored perceived pandemic-related practice changes to cervical cancer screenings in federally qualified health centers (FQHCs).

Methods

Between October 2021 and June 2022, we conducted a national web survey of clinicians (physicians and advanced practice providers) who performed cervical cancer screening in FQHCs in the United States during the post-acute phase of the COVID-19 pandemic, along with a sub-set of qualitative interviews via video conference, to examine perceived changes in cervical cancer screening practices during the pandemic.

Results

A total of 148 clinicians completed surveys; a subset (n=13) completed qualitative interviews. Most (86%) reported reduced cervical cancer screening early in the pandemic, and 28% reported continued reduction in services at the time of survey completion (October 2021- July 2022). Nearly half (45%) reported staff shortages impacting their ability to screen or track patients. Compared to clinicians in Obstetrics/Gynecology/Women's health, those in family medicine and other specialties more often reported reduced screening compared to pre-pandemic. Most (92%) felt that screening using HPV self-sampling would be very or somewhat helpful to address screening backlogs. Qualitative interviews highlighted the impacts of staff shortages and strategies for improvement.

Conclusions

Findings highlight that in late 2021 and early 2022, many clinicians in FQHCs reported reduced cervical cancer screening and of pandemic-related staffing shortages impacting screening and follow-up. If not addressed, reduced screenings among underserved populations could worsen cervical cancer disparities in the future.

Funding

This study was funded by the American Cancer Society, who had no role in the study's design, conduct, or reporting.

Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment

Background

The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed method study we explored perceived pandemic-related practice changes to cervical cancer screenings and colposcopies.

Methods

In 2021, a national sample of 1251 clinicians completed surveys, including 675 clinicians who performed colposcopy; a subset (n=55) of clinicians completed qualitative interviews.

Results

Nearly half of all clinicians reported they were currently performing fewer cervical cancer screenings (47%) and colposcopies (44% of those who perform the procedure) than before the pandemic. About one-fifth (18.6%) of colposcopists reported performing fewer LEEPs than prior to the pandemic. Binomial regression analyses indicated that older, as well as internal medicine and family medicine clinicians (compared to OB-GYNs), and those practicing in community health centers (compared to private practice) had higher odds of reporting reduced screening. Among colposcopists, internal medicine physicians and those practicing in community health centers had higher odds of reporting reduced colposcopies. Qualitative interviews highlighted pandemic-related care disruptions and lack of tracking systems to identify overdue screenings.

Conclusions

Reductions in cervical cancer screening and colposcopy among nearly half of clinicians more than 1 year into the pandemic raise concerns that inadequate screening and follow-up will lead to future increases in preventable cancers.

Funding

This study was funded by the American Cancer Society, who had no role in the study's design, conduct, or reporting.

Food Insecurity and Transmission Risks Among People with HIV Who Use Substances

Food insecurity (FI) impacts people with HIV (PWH) and those who use substances (i.e. drugs and alcohol). We evaluated the longitudinal association between FI and HIV transmission risks (unprotected sexual contacts and shared needles/syringes). Among 351 PWH who use substances in Russia, 51.6% reported FI and 37.0% past month injection drug use. The mean number of unprotected sexual contacts in the past 90 days was 13.4 (SD 30.1); 9.7% reported sharing needles/syringes in the past month. We did not find a significant association between mild/moderate FI (adjusted IRR = 0.87, 95% CI 0.47, 1.61) or severe FI (aIRR = 0.84, 95% CI 0.46, 1.54; global p = 0.85) and unprotected sexual contacts. We observed a significant association between severe FI and sharing needles/syringes in the past month (adjusted OR = 3.27, 95% CI 1.45, 7.39; p = 0.004), but not between mild/moderate FI and sharing needles/syringes in the past month (aOR = 1.40,95% CI 0.58, 3.38; p = 0.45). These findings suggest that severe FI could be a potential target for interventions to lower HIV transmission.

The impacts of COVID-19 on structural inequities faced by people living with HIV who inject drugs: A qualitative study in St. Petersburg, Russia

BACKGROUND

People who inject drugs (PWID) living with HIV may be disproportionately impacted by pandemic restrictions. This study qualitatively explored the impacts of the SARS-CoV-2 pandemic on PWID with HIV in St. Petersburg, Russia.

METHODS

In March and April 2021, we conducted remote, semi-structured interviews with PWID with HIV, health care providers, and harm reductionists.

RESULTS

We interviewed 25 PWID with HIV (aged 28-56 years, 46% female) and 11 providers. The pandemic exacerbated economic and psychological challenges experienced by PWID with HIV. Simultaneously, barriers to HIV care access, ART prescription refill and dispensing and police violence, which hindered the health and safety of PWID with HIV, were themselves hindered from normal operations by the pandemic, significantly reducing these burdens.

CONCLUSION

Pandemic responses should account for the unique vulnerabilities of PWID with HIV to avoid worsening the structural violence they already experience. Wherever the pandemic decreased structural barriers, such as institutional, administrative, and bureaucratic challenges and state violence enacted by police and other elements of the criminal justice system, such changes should be protected.

An acceptance-based, intersectional stigma coping intervention for people with HIV who inject drugs-a randomized clinical trial

Background

People with HIV who inject drugs experience intersecting forms of stigma that adversely impact care access. This RCT aimed to evaluate effects of a behavioral intersectional stigma coping intervention on stigma and care utilization.

Methods

We recruited 100 participants with HIV and past-30-day injection drug use at a non-governmental harm reduction organization in St. Petersburg, Russia, and randomized them 1:2 to receive usual services only or an additional intervention of three weekly 2-h group sessions. Primary outcomes were change in HIV and substance use stigma scores at one month after randomization. Secondary outcomes were initiation of antiretroviral treatment (ART), substance use care utilization, and changes in frequency of past-30-days drug injection at six months. The trial was registered as NCT03695393 at clinicaltrials.gov.

Findings

Participant median age was 38.1 years, 49% were female. Comparing 67 intervention and 33 control group participants recruited October 2019-September 2020, the adjusted mean difference (AMD) in change in HIV and substance use stigma scores one month after baseline were 0.40, (95% CI: -0.14 to 0.93, p = 0.14) and -2.18 (95% CI: -4.87 to 0.52, p = 0.11), respectively. More intervention participants than control participants initiated ART (n = 13, 20% vs n = 1, 3%, proportion difference 0.17, 95% CI: 0.05-0.29, p = 0.01) and utilized substance use care (n = 15, 23% vs n = 2, 6%, proportion difference 0.17, 95% CI: 0.03-0.31, p = 0.02). The adjusted median difference in change in injecting drug use frequency 6 months after baseline was -3.33, 95% CI: -8.51 to 1.84, p = 0.21). Five not intervention-related serious adverse events (7.5%) occurred in the intervention group, one (3.0%) serious adverse event in the control group.

Interpretation

This brief stigma-coping intervention did not change stigma manifestations or drug use behaviors in people with HIV and injection drug use. However, it seemed to reduce stigma's impact as an HIV and substance use care barrier.

Funding

R00DA041245, K99DA041245, P30AI042853.

Correlates of Intersectional HIV and Substance Use Stigma Affecting People with HIV and Substance Use in St. Petersburg, Russia

People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.

Addressing intersectional stigma as a care barrier for HIV-positive people who inject drugs: Design of an RCT in St. Petersburg, Russia

Background

HIV-positive people who inject drugs (PWID) experience stigma related to their substance use and HIV, with adverse consequences to their health care utilization and mental health. To help affected individuals cope with their intersectional stigma and reduce its negative impact on health and health care, we adapted a behavioral stigma coping intervention for this HIV key population.

Objective

To conduct a randomized controlled trial (RCT) testing the ‘Stigma Coping to Reduce HIV risks and Improve substance use Prevention and Treatment’ (SCRIPT) intervention, a community-based, adapted form of Acceptance and Commitment Therapy (ACT), for PWID living with HIV in St. Petersburg, Russia.

Methods

We recruited 100 PWID living with HIV from civil society organizations (CSO) delivering harm reduction and HIV prevention services in St. Petersburg, Russia. We randomized participants 2:1 to receive either the intervention (three adapted ACT sessions in a group format over one month and usual CSO care) or usual CSO care alone. ACT aims to help affected individuals cope with stigma by increasing their psychological flexibility to handle stigma-related negative expectations, emotions and experiences. The primary outcomes were satisfaction with the intervention, and changes in HIV and substance use stigma scores.

Conclusions

Stigma coping interventions targeting HIV-positive PWID outside of formal health care settings may help them confront negativities in their lives originating from intersectional stigma and reduce stigma's impact as a health care barrier.

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HIV-positive people who inject drugs face stigma due to both substance use and HIV.

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Interventions are scarce to help this population reduce stigma as care barrier.

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We recruited participants outside of the formal health care setting in Russia.

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We partnered with multiple organizations to recruit and retain stigmatized people.

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We evaluated the intervention's effects on stigma, health care, & health outcomes.

Biodegradability of Chlorophenols in Surface Waters from the Urban Area of Buenos Aires

Biodegradability of 2-Chlorophenol (2-CP), 3-Chlorophenol (3-CP), 4-Chlorophenol (4-CP), 2,4-Dichlorophenol (2,4-DCP) and 2,4,6 Trichlorophenol (2,4,6-TCP) has been tested in surface waters in the urban area of Buenos Aires. Samples were taken from the La Plata River and from the Reconquista and Matanza-Riachuelo basins, with a total amount of 18 sampling points. Water quality was established measuring chemical oxygen demand (COD), biochemical oxygen demand (BOD₅), and both Escherichia coli and Enterococcus counts. Biodegradability was carried out by a respirometric method, using a concentration of 20 mg L^-1 of chlorophenol, and the surface water as inoculum. Chlorophenols concentration in the same water samples were simultaneously measured by a solid phase microextraction (SPME) procedure followed by gas chromatography-mass spectrometry (GC-MS). 2,4-DCP was the most degradable compound followed by 2,4,6-TCP, 4-CP, 3-CP and 2-CP. Biodegradability showed no correlation with compound concentration. At most sampling points the concentration was below the detection limit for all congeners. Biodegradability does not correlate even with COD, BOD₅, or fecal contamination. Biodegradability assays highlighted information about bacterial exposure to contaminants that parameters routinely used for watercourse characterization do not reveal. For this reason, they might be a helpful tool to complete the characterization of a site.

Genetic and phenotypic characterization of sylvatic dengue virus type 4 strains

Four serotypes of dengue virus (DENV 1-4) currently circulate between humans and domestic/peridomestic Aedes mosquitoes, resulting in 100 million infections per year. All four serotypes emerged, independently, from sylvatic progenitors transmitted among non-human primates by arboreal Aedes mosquitoes. This study investigated the genetic and phenotypic changes associated with emergence of human DENV-4 from its sylvatic ancestors. Analysis of complete genomes of 3 sylvatic and 4 human strains revealed high conservation of both the 5'- and 3'-untranslated regions but considerable divergence within the open reading frame. Additionally, the two ecotypes did not differ significantly in replication dynamics in cultured human liver (Huh-7), monkey kidney (Vero) or mosquito (C6/36) cells, although significant inter-strain variation within ecotypes was detected. These findings are in partial agreement with previous studies of DENV-2, where human strains produced a larger number of progeny than sylvatic strains in human liver cells but not in monkey or mosquito cells.