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Director's Report to the National Advisory Council on Drug Abuse - February, 2006



Research Findings - Services Research

Office-Based Buprenorphine Treatment of Opioid Dependence

The authors compared patients entering a clinical trial of buprenorphine in a Primary Care Clinic (PCC) and those entering a local Opioid Treatment Program (OTP). They also compared the clinical characteristics and treatment outcomes of PCC patients with no history of methadone treatment to those with prior methadone treatment. PCC subjects (N=96) were enrolled in a 26-week randomized clinical trial of office-based buprenorphine/naloxone provided in a PCC. OTP subjects (N=94) were enrolled in methadone maintenance during the same time period. PCC subjects compared with OTP subjects were more likely to be male, full-time employed, have no history of methadone treatment, have fewer years of opioid dependence, and lower rates of injection drug use (IDU). The new-to-treatment PCC subjects were younger, more likely to be white, had fewer years of opioid dependence, were less likely to have a history of IDU, and had lower rates of hepatitis C than subjects with prior methadone treatment. Abstinence and treatment retention were comparable in both groups. The results suggest that office-based treatment of opioid dependence is associated with new types of patients entering into treatment. Treatment outcomes with buprenorphine in a PCC do not vary based on history of prior methadone treatment. Sullivan, L., Chawarski, M., O 'Connor, P., Schottenfeld, R. and Fiellin, D. The Practice of Office-Based Buprenorphine Treatment of Opioid Dependence: Is it Associated with New Patients Entering Into Treatment? Drug Alcohol Depend, 79(1), pp. 113-116, 2005.

Medical Exams At Entry To Treatment For Drug Abuse May Initiate Care For Hepatitis C

The researchers found in a national data base that all the methadone programs (n=95) and 50% of the drug-free programs (80 of 161) required a medical examination that included screening for signs and symptoms of liver disease and liver function testing. Nearly all the methadone programs (97%) provided referral to medical care or support for patients with test results positive for antibody to hepatitis C virus (HCV), compared with 75% of drug-free programs (P<.01). Drug-free programs requiring medical examinations provided education about HCV and testing for HCV to a larger proportion of their patients (P<.05) than those not providing the HCV education. These early screening medical visits are an important opportunity for monitoring and providing care for HCV infection, especially given the high dropout rates in the early stages of treatment for drug addiction. Hagan, H., Strauss, S., Astone, J. and Des Jarlais, D. Medical Examinations at Entry to Treatment for Drug Abuse as an Opportunity to Initiate Care for Hepatitis C Virus Infection. Clin Infect Dis, 40(5), pp. s297-s303, 2005.

Prison TC has a Positive Influence on Post-release Employment, Especially for Aftercare Participants

This study examined the effects of post-release transitional therapeutic community treatment on the drug use and employment rates of 1,319 male drug involved prisoners in the Delaware corrections system followed for up to 5 years after release. A comparison group received standard post-release supervision. Abstinence rates were 32.2% in the treatment group and 9.9% in the no-treatment group, and the treatment group had a higher overall proportion of time free of drug use. Time to relapse was a mean of 28.8 months in the treatment group versus 13.2 months in the no-treatment group. Relapse was defined as any use of any drug and was confirmed by urinalysis. Positive effects were seen even for those who did not complete treatment. The treatment group had a significantly higher rate of employment after leaving work release (54.6%) than did the no-treatment group (45.4%). Treatment during the transitional period between prison and community showed substantial and persistent benefits even for a cohort marked with extensive criminal history, low rates of marital bonds, and substantial unemployment. Butzin, C.A., Martin, S.S. and Inciardi, J.A. Treatment During Transition from Prison to Community and Subsequent Illicit Drug Use. J Subst Abuse Treat, 28(4), pp. 351-358, 2005.

Cost of HIV Medication Adherence Support Interventions

The objective of this study was to determine the direct cost of HIV adherence support programs participating in a cross-site evaluation in the US. Data on the frequency, type, and setting of adherence encounters; providers' professions; and adherence tools provided were collected for 1,122 patients enrolled in 13 interventions at 9 sites. The site staff estimated the average duration of each type of encounter and national wage rates were used for labour costs. The median (range) adherence encounters/year among interventions was 16.5 (4.3-104.6) per patient; encounters lasted 24.6 (8.9-40.9) minutes. Intervention direct cost was correlated with the average frequency of encounters (r = 0.57), but not with encounter duration or providers' professions. The median direct cost/month was 35 dollars (5 dollars-58 dollars) per patient, and included direct provider costs (66%); incentives (17%); reminders and other tools (8%); and direct administrative time, provider transportation, training, and home delivery (9%). The median direct cost/month from a societal perspective, which includes patient time and travel costs, was 47 dollars (24 dollars-114 dollars) per patient. Adherence interventions with moderate efficacy costing 100 dollars/month or less have been estimated to meet a cost-effectiveness threshold that is generally accepted in the US. Payers should consider enhanced reimbursement for adherence support services. Schackman, B.R., Finkelstein, R., Neukermans, C.P., Lewis, L. and Eldred, L. The Cost of HIV Medication Adherence Support Interventions: Results of a Cross-Site Evaluation. AIDS Care, 17(8), pp. 927-937, 2005.

Distress Tolerance and Early Smoking Relapse

A significant percentage of smokers attempting cessation relapse to smoking within a matter of days and very few of these individuals recover to achieve abstinence. Current models of relapse devote insufficient attention to this phenomenon of early smoking relapse. Furthermore, studies attempting to relate severity of nicotine withdrawal symptoms to short-term smoking cessation outcomes have yielded equivocal results. The authors argue that how one reacts to the discomfort of nicotine withdrawal is a more promising avenue of investigation than severity of withdrawal, and that inability to tolerate the distress of nicotine withdrawal and associated negative affect is a key factor in early smoking lapse and subsequent relapse. Early smoking lapsers are a particularly high-risk group of smokers, and no specialized treatment program exists to address the specific needs of these smokers. The authors propose a program that includes components of a standard smoking cessation program, both behavioral and pharmacological, as well as components derived from exposure-based procedures for anxiety related disorders. Development of such a program would aid this significant subpopulation of smokers at greatest risk for difficulties quitting smoking, with resulting important clinical and public health benefits. Brown, R., Lejuez, C., Kahler, C., Strong, D. and Zvolensky, M. Distress Tolerance and Early Smoking Lapse. Clin Psychol Rev, 25(6), pp. 713-733, 2005.

Hospital And Outpatient Health Services Utilization Among HIV-Infected Adults In Care: 2000-2002

Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization. The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multi-state sample of patients with HIV. Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002. The study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions. Chosen for inclusion, for each year, were HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002. Main outcome measures were the number of hospital admissions, total days in the hospital, and the number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits. Findings show that mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. The mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be 514 dollars in 2000, 472 dollars in 2001, and 424 dollars in 2002; outpatient costs PPPM were estimated at 108 dollars in 2000, 100 dollars in 2001, and 101 dollars in 2002. In conclusion, changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART. Fleishman, J., Gebo, K., Reilly, E., Conviser, R., Christopher Mathews, W., Todd Korthuis, P., Hellinger, J., Rutstein, R., Keiser, P., Rubin, H. and Moore, R. Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care 2000-2002. Med Care, 43(9), pp. 40-52, 2005.

HIV Intervention For Indigent Substance Abusing Women In The USVI

As the HIV/AIDS epidemic continues to expand and penetrate new communities around the globe, risk reduction intervention initiatives must continue to evolve and adapt to new challenges and populations. This is especially true in the Caribbean Basin, where the feminization of the HIV epidemic is tied to a cultural milieu characterized by pervasive gender inequality. HIV intervention programs in the Caribbean must treat women's risks as a function of the social context, standards, and meanings of sexual behaviors and practices in the local community. As such, this article describes an initiative to develop an HIV prevention-intervention protocol for the cultural context of substance abusing women in the US Virgin Islands. Through street-based survey research combined with focus groups and in-depth interviews with such "cultural insiders" as members of the substance-abusing target population, members of the local public health and social services system, and community leaders, a culturally sensitive HIV/AIDS protocol was developed which addresses the supports and barriers to risk reduction faced by substance abusing women in the Virgin Islands. Surratt, H.L. and Inciardi, J. A. Developing an HIV Intervention for Indigent Women Substance Abusers in the United States Virgin Islands. J Urban Health, 82(3-4), pp. iv74-iv83, 2005.

Condom Attitudes and Behaviors Among Injection Drug Users

This study examined condom attitudes, preferences, barriers, and use among a sample of 550-injection drug using clients of syringe exchange programs in California. In multivariate analyses, positive attitudes toward condoms were significantly associated with consistent condom use for vaginal, anal, and oral sex in the past six months, beyond the effects of confounding socio-demographic and HIV risk variables. Participants commonly cited partner-related barriers to condom use, such as reluctance to use condoms with steady partners (34%). Almost a quarter of the sample cited dislike of condoms (e.g., because of pleasure reduction). In addition, a third of respondents stated specific preferences regarding condom brands, sensitivity, sizes, and textures. Interventions that increase awareness about positive aspects of condom use and sexual risk from steady partners may be successful in increasing condom use among injection drug users. Bogart, L.M., Kral, A.H., Scott, A., Anderson, R., Flynn, N., Gilbert, M.L. and Bluthenthal, R.N. Condom Attitudes and Behaviors Among Injection Drug Users Participating in California Syringe Exchange Programs. AIDS Behav, pp. 1-10, 2005.

The Intersection of Violence with Culture and HIV Risk Among Sex Workers

The Republic of South Africa has become an epicentre of heterosexual HIV transmission among Black women, and the interface between violence against women, substance abuse, and HIV risk is becoming evident. This article describes the characteristics of Black South African women who engage in sex work in Pretoria and examines their intersecting experiences of high-risk sexual behaviour, substance abuse, and victimization. Ninety-three women were recruited into the study. Field staff collected biological measures of drug use and administered a structured, self-report interview. Findings indicate that young South African women who engage in sex work and use drugs rely on this activity as their main source of income and are supporting other family members. The majority of sample women reported experiencing some victimization at the hand of men, either clients or boyfriends, with many reporting childhood abuse histories; young women also report great fear of future victimization. Findings also suggest that as a result of their decreased likelihood of using protection, women who reported any sexual or physical victimization are at increased risk for HIV and other STIs. Results support the critical need for targeted, comprehensive interventions that address substance abuse, sexual risk, and violence as interrelated phenomena. Wechsberg, W.M., Luseno, W.M. and Lam, W.K. Violence Against Substance-Abusing South African Sex Workers: Intersection with Culture and HIV Risk. AIDS Care, 17, Supplement 1, pp. s55-s64, 2005.

The Incidence Of, Risk Factors For, and Sequelae Of Herpes Zoster Among HIV Patients In The Highly Active Antiretroviral Therapy Era

Whereas the incidence, risk factors, and clinical sequelae of herpes zoster have been studied in the general population and in HIV patients in the era before highly active antiretroviral therapy (HAART), they have yet to be fully understood in the current era of HAART. The investigators conducted a retrospective cohort study of patients enrolled in an urban HIV clinic between January 1, 1997 and December 31, 2001. Patients with an episode of herpes zoster during this period were identified, and their charts were reviewed. A nested case-control analysis was used to assess factors associated with an initial episode of herpes zoster. Multivariate conditional logistic regression analyses were used to assess risk factors for zoster. Logistic regression was performed to assess factors associated with complicated zoster. Two hundred eighty-two episodes of herpes zoster were identified in 239 patients. Of these episodes, 158 were new occurrences of zoster and 124 were recurrent zoster events. The incidence of zoster during the study period was 3.2 per 100 person-years of follow-up. The incident cases reflected the clinic population, with most patients being male (63%) and African American (77%) and having injection drug use as their HIV risk factor (49%). The mean age of the patients was 41 years. Sixty-seven percent of patients had single dermatomal involvement, and the thorax was involved in 41%. In multivariate regression, being on HAART (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.65 to 3.49) and a CD4 count of 50 to 200 cells/mm (OR = 2.69, 95% CI: 1.44 to 5.01) compared with a CD4 count less than 50 cells/mm were associated with an increased risk of zoster. Twenty-eight patients (18%) developed post-herpetic neuralgia (PHN), and 29 patients (18%) had other complications. Male-to-male sex as an HIV risk factor (P = 0.02) and being on HAART at a zoster episode (P = 0.03) were protective against complicated zoster. Results suggest that zoster infection rates have not changed in the current HAART era but that a significant percentage of patients develop complications, particularly PHN, which is quite remarkable considering the young age of the population. Gebo, K., Kalyani, R., Moore, R. and Polydefkis, M. The Incidence of, Risk Factors for, and Sequelae of Herpes Zoster Among HIV Patients in the Highly Active Antiretroviral Therapy Era. J Acquir Immune Defic Syndr, 40(2), pp. 169-174, 2005.

Respiratory Symptom Relief Related To Reduction In Cigarette Use

Many smokers reduce their cigarette consumption during failed attempts to quit. This study reports the impact of changes in consumption on smoking-related respiratory symptom severity (SRRSS). Between February 2002 and May 2004, 383 smokers were recruited from 5 methadone maintenance programs for a randomized trial of nicotine replacement plus behavioral treatment, versus nicotine replacement alone for smoking cessation. Cigarette use in the 28 days prior to the interview, and severity of SRRSS using a 7-item respiratory index, were assessed at baseline and at 3-month follow-up. The outcome measured was the baseline, minus 3-month assessment difference in SRRSS score. Follow-up of 319 participants (83.3%), mean age 40.4 years, 51.4% male, who smoked 26.4 cigarettes per day, demonstrated a mean reduction of 16.7 cigarettes per day. A reduction in cigarette use was positively and significantly (b=0.29, t=5.16, P<.001) associated with a reduction in smoking-related symptom severity after adjusting for age, gender, race, years of regular smoking, baseline nicotine dependence, and history of treatment for asthma or emphysema. A 1.0 standard deviation reduction in average daily smoking (about 14.1 cigarettes) was associated with a 0.28 standard deviation decrease in smoking-related symptom severity. A reduction in symptom severity increases as absolute reduction in daily smoking increases. This is the first study to demonstrate an association between subjective short-term health changes and reduction in smoking. Stein, M., Weinstock, M., Herman, D. and Anderson, B. Respiratory Symptom Relief Related to Reduction in Cigarette Use. J Gen Intern Med, 20(10), pp. 89-94, 2005.

Persistence Of Antidepressant Treatment Effects In A Pharmacotherapy Plus Psychotherapy Trial For Active Injection Drug Users

The objective of this study was to determine if combined psychotherapy and pharmacotherapy reduces reported depressive symptoms compared to an assessment only condition for active drug injectors over nine months. Using a randomized controlled trial at an outpatient academic research office, the researchers applied psychotherapy (eight sessions of cognitive behavioral therapy) plus pharmacotherapy (citalopram) to active injection drug users with a DSM-IV diagnosis of major depression, dysthymia, substance-induced mood disorder with symptoms persisting for at least three months, or major depression plus dysthymia, and a Modified Hamilton Rating Scale for Depression (MHRSD) score greater than 13. The MHRSD scale scores were then assessed at the completion of three, six, and nine months. Participants (n = 109) were 64% male and 82% Caucasian, with a mean baseline MHRSD score of 20.7. Depression subtypes included major depression only (63%), substance-induced depression (17%), and double-depression (17%). Study retention at nine months was 89%. At the completion of three months of acute treatment, 26% of combined treatment patients (n = 53), compared to 12% of control patients (n = 56), were in remission (p = .047). At both six and nine months, the between-group differences in remission rates and mean MHRSD scores were insignificant, although the overall mean MHRSD score decreased from baseline (p < .01). At all follow-up assessments, depression remission was significantly associated with lower heroin use. Among active drug injectors diagnosed with depression, symptoms decline over time. Combined treatment is superior to an assessment-only condition in depression remission rates at the end-of-treatment, but this difference does not persist. Stein, M., Solomon, D., Anderson, B., Herman, D., Anthony, J., Brown, R., Ramsey, S. and Miller, I. Persistence of Antidepressant Treatment Effects in a Pharmacotherapy Plus Psychotherapy Trial for Active Injection Drug Users. Am J Addict, 14(4), pp. 346-357, 2005.

Screening For Depressive Symptoms Among Homeless Adults With Latent Tuberculosis

The purpose of this study was to examine predictors of screening results for depressive symptoms in a Los Angeles homeless population with latent tuberculosis (TB). Four hundred and fifteen homeless adults participating in a nurse case managed intervention were included in this analysis. Logistic regression results indicated that those who reported a physical health limitation, multiple sex partners, daily drug use, alcohol dependence, or not having completed high school were more likely to screen positive. Social support from non-drug users was protective. Given the importance of adherence to TB treatment regimens, the high prevalence of a positive screening for depressive symptoms in the homeless and the potential for depression to reduce adherence rates, routine screening and treatment for depression in high risk homeless adults being treated for TB may be warranted. Berg, J., Nyamathi, A., Christiani, A., Morisky, D. and Leake, B. Predictors of Screening Results for Depressive Symptoms Among Homeless Adults in Los Angeles with Latent Tuberculosis. Res Nurs Health, 28(3), pp. 220-229, 2005.

The Role of Judicial Status Hearings In Drug Court: Six and Twelve Month Outcomes

This article presents outcomes for a study seeking to isolate the effects of status hearings for drug abusers participating in drug court and builds on previously published work in this area. Subjects (n=200) were recruited from a misdemeanor drug court located in Wilmington, Delaware. Drug court participants were randomly assigned in equal proportions to attend either bi-weekly judicial status hearings, or hearings only as needed in response to poor performance in the program. Study results revealed no significant group effects, or group-by-time effects for drug use, alcohol intoxication, criminal activities, criminal charges, employment problems, psychiatric problems, or social/family functioning. Earlier analyses by investigators had revealed significantly better during-treatment outcomes for certain high-risk participants assigned to bi-weekly status hearings; however, this interaction effect did not extend beyond the active phase of drug court participation. This finding lead investigators to speculate that judges might be less able to influence high risk offenders as their discharge date from drug court approaches. Results from the study did reveal a significant pre-to-post improvement for drug court participants as a whole on self-reported substance use and criminal activity from intake to follow-up. Marlowe, D.B., Festinger, D.S., Dugosh, K.L. and Lee, P.A. Are Judicial Status Hearings a "Key Component" of Drug Court? Six and Twelve Month Outcomes. Drug Alcohol Depend, 79(2005), pp. 145-155, 2005.

Common Processes May Account For Relapse Across Addictions

This study investigated the relationship between the duration of the most recent attempt to abstain from drug or alcohol use and psychological distress tolerance, as indexed by persistence on a mental arithmetic task. Participants were 89 individuals (63% male, 90% African American) in an inner-city residential substance abuse treatment facility; their mean age was 39 years. Results indicated that the duration of the most recent period of abstinence related positively to persistence on the psychological stress test, beyond the influence of demographics, substance use level, and negative affect. That is, the greater the capacity to tolerate psychological distress, the longer the period of abstinence. These findings extend previous work reporting significant positive relations between persistence on laboratory challenge procedures and the duration of abstinence following a quit attempt in smokers. This suggests that common processes may account for relapse across addictions. Daughters, S.B., Lejuez, C.W., Kahler, C.W., Strong, D.R. and Brown, R.A. Psychological Distress Tolerance and Duration of Most Recent Abstinence Attempt Among Residential Treatment-Seeking Substance Abusers. Psychol Addict Behav, 19(2), pp. 208-211, 2005.

Association of Childhood Physical Abuse To Poor Adult Outcomes

In asserting that men' s childhood physical abuse experiences are understudied, the investigators set out to obtain descriptions about men's personal childhood physical abuse histories and estimate their association with adult outcomes via a population-based telephone survey in urban areas with high frequency of domestic violence against girls and women. Two hundred ninety-eight (298) men were recruited through random-digit dialing. Interviewers asked six (6) items from the validated Conflict Tactics Scale and psychiatric, sexual, and legal history questions. One hundred of 197 (51%) participants had a history of childhood physical abuse. Most (73%) participants were abused by a parent. Childhood physical abuse history was associated with depression symptoms (P = 0.003), post-traumatic stress disorder symptoms (P < 0.001), number of lifetime sexual partners (P = 0.035), legal troubles (P = 0.002), and incarceration (P = 0.007) in unadjusted analyses and with depression symptoms (P = 0.015) and post-traumatic stress disorder symptoms (P = 0.003) in adjusted analyses. Potential limitations of the study pertain to whether there may have been inaccurate recall of past events. The lack of exposure time data disallowed direct comparison of abuse perpetration by mothers versus fathers, and other unmeasured variables related to childhood physical abuse might better explain poor adult outcomes. The high frequency of childhood physical abuse histories in this population-based male sample, coupled with the high proportion of parent perpetrators and the association between childhood physical abuse and adult outcomes that are often associated with perpetration of violence, argues for more study of, and clinical attentiveness to potential adult outcomes of men's own childhood physical abuse histories. Holmes, W. and Sammel, M. Brief Communication: Physical Abuse of Boys and Possible Associations with Poor Adult Outcomes. Ann Intern Med, 143(8), pp. 581-586, 2005.

Buprenorphine: Preventing HIV Transmission and Improving Care Of HIV+ Opioid Dependents

Buprenorphine is a new medication used to treat opioid dependence that shows promise for reducing the rate of HIV transmission and improving the care of opioid-dependent patients with HIV infection. Although buprenorphine faces fewer clinical and regulatory barriers than does methadone, the optimal strategy for integration of office-based treatment of opioid dependence and HIV disease is an area of on-going research. This review addresses the introduction of buprenorphine, in terms of public health, policy, and clinical implications for HIV-infected patients and for HIV care providers. Sullivan, L., Fiellin, D. and Lidz, V.M. Buprenorphine: Its Role in Preventing HIV Transmission and Improving the Care of HIV-Infected Patients with Opioid Dependence. Clin Infect Dis, 41(6), pp. 891-896, 2005.

Training Substance Abuse Treatment Staff to Care for Co-occurring Disorders

This article describes the design and implementation of an intervention to improve the quality of mental health care provided in outpatient substance abuse treatment programs without requiring new treatment staff. The intervention focuses on individuals with affective and anxiety disorders and consists of three components: training and supervising staff, educating and activating clients, and linking with community resources. The researchers evaluated three treatment programs (one intervention and two comparison) for the first component by having program staff complete both self-administered questionnaires and semi structured interviews. Staff knowledge and attitudes about co-occurring disorders, job satisfaction, and morale all indicated an improvement at the intervention relative to the comparison sites. Hunter, S., Watkins, K., Wenzel, S., Gilmore, J., Sheehe, J. and Griffin, B. Training Substance Abuse Treatment Staff to Care for Co-Occurring Disorders. J Subst Abuse Treat, 28(3), pp. 239-245, 2005.

Diversified Substance Abuse Service Options Enhances Organization Survival

Using a nationally representative sample of 450 substance abuse treatment centers, this research considers the extent to which specific types of service diversification reduce the likelihood of treatment center closure in the private sector. Based upon periodic interviews with senior management over a period ranging from 1995 to 2003, 26.4% of centers ceased to offer substance abuse treatment services. The number of treatment tracks tailored to specific demographic groups was negatively associated with the likelihood of closure. However, there was a positive association between closure and offering an inpatient psychiatric program. These findings suggest that there may be strategic benefits in expanding services to meet the needs of diverse clientele. Knudsen, H., Roman, P. and Ducharme, L. Does Service Diversification Enhance Organizational Survival?: Evidence from the Private Substance Abuse Treatment System. J Behav Health Serv Res, 32(3), pp. 241-252, 2005.

Culturally Specific Substance Use Prevention for Latino Youth

This study examined whether language preference, as an indicator of acculturation, moderated the effects of a culturally grounded substance use prevention intervention for Mexican and Mexican American middle school students (N = 2,146). The majority of the sample was male (52%). At baseline, participants were in 7th grade and post-tests were conducted when participants were in the 8th grade. The main hypothesis was that levels of program effectiveness would vary based on the language preference of the students and the specific culturally grounded version of the intervention they were assigned. Findings show that matching language preference to particular versions of the intervention did not influence substance use related program outcomes, but that overall program effects (intervention vs. control) did vary by language preference. English-language dominant participants, the most at risk sub-group, responded more positively to the intervention, while Spanish language dominant participants, did not demonstrate significant differences between the intervention and control groups. Implications for school social work prevention interventions and prevention science in general, are discussed. Marsiglia, F.F., Kulis, S., Wagstaff, D.A., Elek, E. and Dran, D. Acculturation Status and Substance Use Prevention in Mexican and Mexican-American Youth. Journal of Social Work Practice in the Addictions, 5(1-2), pp. 85-111, 2005.

Homeless Chronicity Links to Quality of Life Among Adult Addicts

Using data from a 2-year cohort of addicted persons, Dr. Kertesz and colleagues tested whether changes in mental and physical health-related quality of life (HRQOL) differed according to homeless chronicity. Using self-reported homelessness, subjects were classified as chronically homeless (CH; n = 60), transitionally homeless (TRANS; n = 108), or as housed comparison subjects (HSD; n = 106). The Short Form-36 Health Survey, administered at baseline and 2 follow-ups over a period of 2 years, provided a Mental Component Summary (MCS) and a Physical Component Summary (PCS) for HRQOL. Mixed model linear regression was used to test the association between housing status, MCS, and PCS. Additional models assessed whether medical, psychiatric, addiction, and social support measures could account for HRQOL differences. All subjects had low MCS scores at study entry. Nevertheless, there was a significant housing status-by-time interaction (P = 0.01). At final follow-up, CH and TRANS subjects had lower adjusted MCS scores than HSD subjects for the 3 groups, respectively; all P < or = 0.01). By contrast, housing status and PCS were not significantly associated (P = 0.19). Medical, psychiatric, addiction, and social support variables had significant associations with MCS, and their inclusion in the regression reduced the apparent effect of housing status on MCS. Chronic homelessness was associated with especially poor mental but not physical HRQOL over time. These findings reinforce a new typology of homelessness and mitigate against the notion that substance abuse alone accounts for the mental health status of the chronically homeless. Kertesz, S., Larson, M., Horton, N., Winter, M., Saitz, R. and Samet, J. Homeless Chronicity and Health-Related Quality of Life Trajectories Among Adults with Addictions. Med Care, 43(6), pp. 574-585, 2005.

Reductions In HIV Risk Behaviors Among Depressed Drug Injectors

This study examines if, by reducing depressive symptoms by combined psychotherapy and pharmacotherapy, whether a reduction of HIV drug risk behavior occurs compared to an assessment-only condition for active drug injectors over 9 months. Active injection drug users with a DSM-IV diagnosis of major depression, dysthymia, substance-induced mood disorder with depressive features persisting for at least 3 months, or major depression plus dysthymia. In addition, participants had a Hamilton Rating Scale for Depression (MHRSD) score greater than 13. The study was conducted as a randomized controlled trial, and performed in an outpatient academic research office. The treatment group received psychotherapy (8 sessions of cognitive behavioral therapy) plus antidepressant pharmacotherapy over 3 months. The control group received assessment only. The primary outcome measurement instrument is the HIV Risk Assessment Battery (RAB) drug scale scores, measured at three, six and nine months, and depression remission (MHRSD score less than or equal to 8). There were 109 participants, of which 64% were male, 82% Caucasian, with a mean baseline MHRSD score of 20.7. Depression subtypes included major depression only (63%), substance-induced depression (17%), and double-depression (17%). Overall, study retention at nine months was 89%. Reported HIV drug risk scores decreased sharply over the first 3 months and continued to decline throughout the follow-up period. The differences between group differences were not significant (in the intention-to-treat analysis). However, highly adherent participants did show significantly lower HIV drug risk scores at 3 months (p less than .05), but not at 6 and 9 months. Depression remission was significantly associated with lower HIV drug risk scores at follow-ups. This study did not show that combined psychotherapy and pharmacotherapy could produce a significant reduction in HIV drug risk beyond that seen in an assessment-only control group; although both groups did show declines in HIV risk behavior. However, declines in HIV drug risk were found in participants with high protocol adherence, and those with depression remission. Stein, M., Anderson, B., Solomon, D., Herman, D., Ramsey, S., Brown, R. and Miller, I. Reductions in HIV Risk Behaviors Among Depressed Drug Injectors. Am J Drug Alcohol Abuse, 31(3), pp. 17-32, 2005.

Integrating Hepatitis C Services into Existing HIV Services

Using data collected in a telephone survey with 89 drug treatment units throughout the United States, this paper examines the extent to which drug treatment units have expanded their HIV services to include those for HCV, and the extent to which this expansion was facilitated by having HIV services in place. Overall, a greater proportion of methadone maintenance than drug-free treatment units provided services for HIV and HCV. The majority of units in both modalities that provided HIV- and HCV-related services expanded their HIV service delivery to include similar HCV services, and one third expanded all of their HIV services. A large number of these units, however, indicated that having an HIV service infrastructure did not facilitate this expansion, often because the units wanted to emphasize differences in the two viral infections. Strauss, S., Astone, J., Des Jarlais, D.,and Hagan, H. Integrating Hepatitis C Services into Existing HIV Services: The Experiences of a Sample of U.S. Drug Treatment Units. AIDS Patient Care STDS, 19(2), pp. 78-88, 2005.

Provision Of Mental Health and Substance Abuse Services Challenges The Dually Diagnosed

This paper reports on a survey of administrators (n = 26) and staff (n = 248) in 10 mental health and 16 substance abuse programs in Los Angeles County providing services to individuals with co-occurring disorders. Although half or more of the administrators and staff reported that their programs had some degree of on-site service integration, there was a lack of agreement within most programs as to the extent of integration. A substantial number of dually diagnosed clients in these programs were concurrently receiving either mental health or substance abuse services from other treatment providers, indicating that many of their clients needed to negotiate two distinct service systems. There may be a lack of cohesion regarding treatment approach even within the same program. Future research is needed regarding the divergent perceptions of administrators and staff and their relationship to treatment outcomes. Gil-Rivas, V. and Grella, C. Treatment Services and Service Delivery Models for Dually Diagnosed Clients: Variations Across Mental Health and Substance Abuse Providers. Community Ment Health J, 41(3), pp. 251-266, 2005.

Employment Behaviors Among Drug Using Welfare Recipients

This study examines how drug using welfare recipient's employment behaviors (i.e., expectations, employment commitment, job search self-efficacy, job-seeking support from friends, economic hardship and anxiety) affected employment-seeking behavior and impacted the welfare-to-work mandate. Regression analyses estimate the effect of the seven psychosocial domains on employment seeking behaviors and job search intensity on a sample of 222 welfare-to-work recipients in Houston. The results show that psychological domains affected drug users and non-drug users differently as they searched for employment. Specifically, self-efficacy and anxiety are negatively related to job seeking behavior. In addition, job expectations and economic hardship were both positively related to job-search intensity. Psychosocial domains such as motivation and job search efficacy are good predictors of employment seeking behaviors, but these factors are not as powerful among the drug using population. Thus, specific interventions must be developed for drug using welfare recipients if they are expected to exit welfare and integrate into the labor force successfully. Montoya, I. D. Employment Behaviors Among Drug Using Welfare Recipients. Journal of Addictions Nursing, 16 pp. 187-193, 2005.

People Who Feel Shame are More Likely to Have Substance Abuse Problems Whether or Not They Have Criminal Histories

Previous research has demonstrated that shame-proneness (the tendency to feel bad about the self) relates to a variety of life problems, whereas guilt-proneness (the tendency to feel bad about a specific behavior) is more likely to be adaptive. The current analyses sought to clarify the relations of shame-proneness and guilt-proneness to substance use problems in three samples with differing levels of alcohol and drug problem severity: college undergraduates (Study 1 N=235, Study 2 N=249) and jail inmates (Study 3 N=332). Across samples, shame-proneness was generally positively correlated with substance use problems, whereas guilt-proneness was inversely related (or unrelated) to substance use problems. Results suggest that shame and guilt should be considered separately in the prevention and treatment of substance misuse. Dearing, R.L., Stuewig, J. and Tangney, J.P. On the Importance of Distinguishing Shame from Guilt: Relations to Problematic Alcohol and Drug Use. Addict Behav, 30(7), pp. 1392-1404, 2005.

Women in Outpatient Treatment for Methamphetamine Improved Family Relationships and Their Medical Condition Relative to Men

This prospective longitudinal study examined treatment outcomes among 1,073 methamphetamine-abusing patients (567 women, 506 men) from 32 community-based outpatient and residential programs in 13 California counties. Data were collected at intake and at 3 months and 9 months after admission. With one exception, improvements from baseline to follow-up were observed in all areas measured by the Addiction Severity Index for both women and men in either modality. Compared to men, women demonstrated greater improvement in family relationships and medical problems, and similar improvement in all other areas, despite the fact that more women were unemployed, had childcare responsibilities, were living with someone who also used alcohol or drugs, had been physically or sexually abused, and reported more psychiatric symptoms. Implications for service improvement are discussed. Hser, Y., Evans, E. and Huang, Y. Treatment Outcomes Among Women and Men Methamphetamine Abusers in California. J Subst Abuse Treat, 28(1), pp. 775-785, 2005.

An Improvement in Virologic Response to Highly Active Antiretroviral Therapy in Clinical Practice From 1996 Through 2002

Early studies of highly active antiretroviral therapy (HAART) use in clinical practice suggested sub optimal rates of viral suppression. HAART regimens and expertise in the use of HAART have since evolved, and the investigators sought to determine how virologic response to HAART has changed in clinical practice. They compared all patients (1,255) who started a first HAART regimen from 1996 through 2002 in a longitudinal cohort of HIV-infected patients in care in Baltimore. There were significant improvements in suppressing HIV RNA to < 400 copies/mL, ranging from 43.8% (1996) to 72.4% (2001-2002) by 6 months and from 60.1% (1996) to 79.9% (2001-2002) by 12 months (both P < 0.01 for trend). There were also significant improvements in CD4 cell response. Over time, there was a significant increase in the use of a nonnucleoside reverse transcriptase inhibitor (NNRTI) or boosted protease inhibitor (PI) regimen compared with a single PI as well as an increase in the number of patients who were antiretroviral (ARV) naive. There was also a significant temporal trend from 1996 through 2002 in achieving a suppressed HIV RNA level, adjusting for being ARV naive, specific HAART regimen, CD4 cell count, HIV-1 RNA level, and demographic factors. These observations suggests that improved virologic response may also be attributable to other factors such as a greater focus on medication adherence, improved ARV tolerability, and ease of dosing. Moore, R., Keruly, J., Gebo, K. and Lucas, G. An Improvement in Virologic Response to Highly Active Antiretroviral Therapy in Clinical Practice from 1996 through 2002. J Acquir Immune Defic Syndr, 39(2), pp. 195-198, 2005.

Length of Stay in Drug Abuse Treatment Impacted by Program Size

Admissions to 20 publicly funded alcohol and drug detoxification centers in Massachusetts were examined to identify program and patient variables that influenced length of stay. The last admission during fiscal year 1996 was abstracted for patients 18 years of age and older seeking alcohol, cocaine, or heroin detoxification (n=21,311; 29% women). A hierarchical generalized linear model examined the effects of patient and program characteristics on variation in length of stay and tested case-mix adjustments. Program size had the most influence on mean adjusted length of stay; stays were more than 40% longer in detoxification centers with 35 or more beds (7.69 days) than in centers with less than 35 beds (5.42 days). The study highlights the contribution of program size to treatment processes and suggests the need for more attention to program attributes in studies of patient outcomes and treatment processes. Jonkman, J., McCarty, D., Harwood, H., Normand, S. and Caspi, Y. Practice Variation and Length of Stay in Alcohol and Drug Detoxification Centers. J Subst Abuse Treat, 28(1), pp. 11-18, 2005.

Patterns Of Diagnoses In Hospital Admissions In A Multi-State Cohort of HIV-Positive Adults In 2001

Admissions for AIDS-related illnesses decreased soon after the introduction of highly active antiretroviral therapy (HAART), but it is unclear if the trends have continued in the current HAART era. The investigators examined the diagnoses for hospitalizations of patients with HIV in 2001. Demographic and healthcare data were collected for 8,376 patients from 6 U.S. HIV care sites. Diagnoses were categorized into 18 disease groups and Poisson regression was used to analyze the number of admissions for each of the 4 most common groups. Investigators also compared patients with admissions for AIDS-defining illnesses (ADI) with patients admitted for other diagnoses. Findings revealed that twenty-one percent of patients had at least 1 hospitalization. Among patients hospitalized at least once, 28% were hospitalized for an ADI. Comparing diagnosis categories, the most common hospitalizations were AIDS-defining illnesses (21.6%), gastrointestinal (GI) diseases (9.5%), mental illnesses (9.0%), and circulatory diseases (7.4%). In multivariate analysis, women had higher hospitalization rates than men for ADI (incidence rate ratio [IRR], 1.50; 95% confidence interval [CI], 1.25-1.79) and GI diseases (IRR, 1.52; 95% CI, 1.15-2.00). Compared with whites, blacks had higher admission rates for mental illnesses (IRR, 1.70; 95% CI, 1.22-2.36), but not for ADI. As expected, CD4 count and viral load were associated with ADI admission rates; CD4 counts were also related to hospitalizations for GI and circulatory conditions. Thus, five years after the introduction of HAART, AIDS-defining illnesses continue to have the highest hospitalization rate among the diagnosis categories examined. This result emphasizes the importance of vaccination for pneumonia and influenza, as well as prophylaxis for Pneumocystis jiroveci pneumonia. The relatively large number of mental illness admissions highlights the need for co-management of psychiatric disease, substance abuse, and HIV. Overall, the majority of patients were hospitalized for reasons other than ADI, illustrating the importance of managing comorbid conditions in this population. Data from this cohort of patients with HIV may help guide the allocation of healthcare resources by enhancing our understanding of factors associated with variation in inpatient utilization rates. An understanding of healthcare utilization patterns is important for optimization of care and resource allocation. Betz, M., Gebo, K., Barber, E., Sklar, P., Fleishman, J., Reilly, E. and Christopher Mathews, W. Patterns of Diagnoses in Hospital Admissions in a Multistate Cohort of HIV-Positive Adults in 2001. Med Care, 43(9), pp. 3-14, 2005.

High Rates Of Primary Mycobacterium Avium Complex And Pneumocystis Jiroveci Prophylaxis In The U.S.

National data from the mid-1990s demonstrated that many eligible patients with HIV infection do not receive prophylaxis for opportunistic infections (OIs) and that racial and gender disparities existed in OI prophylaxis receipt. The investigative team examined whether demographic disparities in the use of OI prophylaxis persisted in 2001 and whether outpatient care was associated with OI prophylaxis utilization. Demographic, clinical, and pharmacy utilization data were collected from 10 U.S. HIV primary care sites in the HIV Research Network (HIVRN). This study consisted of adult patients (>or=18 years old) in longitudinal HIV primary care. Indications for Pneumocystis jiroveci pneumonia (PCP) or Mycobacterium avium complex (MAC) prophylaxis were 2 or more CD4 counts less than 200 or 50 cells/mm(3) during calendar year (CY) 2001, respectively. Using multivariate logistic regression, they examined demographic and clinical characteristics associated with receipt of PCP or MAC prophylaxis and the association of outpatient utilization with appropriate OI prophylaxis. As for findings, among eligible patients, 88.1% received PCP prophylaxis and 87.6% received MAC prophylaxis. Approximately 80% had 4 or more outpatient visits during CY 2001. Adjusting for care site, male gender (odds ratio [OR], 1.47), Medicare coverage (OR, 1.60), and having 4 or more outpatient visits in a year (OR, 2.34) were significantly associated with increased likelihood of PCP prophylaxis. Adjusting for care site, having 4 or more outpatient visits in a year (OR, 1.85) was associated with increased likelihood of receipt of MAC prophylaxis. There were no demographic or insurance characteristics associated with receipt of MAC prophylaxis. In conclusion, the overall prevalence of OI prophylaxis has increased since the mid-1990s, and previous racial and HIV risk factor disparities in receipt of OI prophylaxis were found to have waned. Integration into the healthcare system is considered an important correlate to receiving OI prophylaxis. Gebo, K., Fleishman, J., Reilly, E., Moore, R. and Moore, R. High Rates of Primary Mycobacterium Avium Complex and Pneumocystis Jiroveci Prophylaxis in the United States. Med Care, 43(9), pp. 23-30, 2005.

Motivational Group Counseling For Substance Users In A Soup Kitchen

Soup kitchens tend to serve substance abusing homeless adults. 289 soup kitchen guests who reported drug or alcohol problems were randomly assigned to information and referral (I and R) plus peer advocacy (N=139) or to an experimental 12-session motivational group followed by a 36-session cognitive-behavioral group, plus I and R and peer advocacy. Experimental subjects were significantly more likely to have increased their participation in some type of substance abuse intervention during the follow-up period; and they were significantly more likely to have reduced both drinking and heavy drinking at follow-up than the comparison group. Experimental intervention was more effective for participants with higher rather than lower substance abuse severity at baseline. These results support the concept that motivationally enhanced group counseling, provided as a low-threshold outreach intervention, can help to increase participation in formal treatment and 12-step groups and to reduce substance abuse, particularly for those starting with high severity of use. Rosenblum, A., Magura, S., Kayman, D. and Fong, C. Motivationally Enhanced Group Counseling for Substance Users in a Soup Kitchen: A Randomized Clinical Trial. Drug Alcohol Depend, 80(1), pp. 91-103, 2005.

Physician Attitudes Regarding the Prescription of Medical Marijuana

Surveys of physicians' attitudes regarding the therapeutic value of marijuana are rare. Drawing on a national sample of 960 (adjusted response rate 66%) family physicians, general internists, obstetrician-gynecologists, psychiatrists, and addiction specialists, who offered opinions about the legal prescription of marijuana as medical therapy. Thirty-six percent believed prescribed marijuana should be legal and 26% were neutral to the proposition. Non-moralistic attitudes toward substance use were significantly associated with support for physician prescription, as was internal medicine and obstetrics-gynecology specialization. Physicians are, in general, less supportive than the general American public regarding the use of medical marijuana. Charuvastra, A., Friedmann, P. and Stein, M. Physician Attitudes Regarding The Prescription Of Medical Marijuana. J Addict Dis, 24(3), pp. 87-93, 2005.

Financial Transfers Reduce Help-Seeking Behavior

This article examines the factors affecting the help-seeking behavior for HIV-related social services among a sample of HIV+ urban poor individuals. The author examines how financial transfers from friends and family affect the decision to seek HIV social services from public and community organizations. The effect of transfers on the help-seeking behavior is examined while controlling for sociodemographic factors, Acquired Immunodeficiency Syndrome (AIDS) status, and HIV+ status. The results showed that financial transfers from friends and family had a negative effect on individual's help-seeking behavior for social HIV-services, especially for supportive services. The results also showed that sociodemographic factors and HIV-transmission mode were significant determinants in the help-seeking behavior for HIV-services. The significance of such findings imply an informed public health policy should include the balanced combination of transfers as well as appropriately targeted public funds. Montoya, I. D. Help-Seeking Behavior for HIV-Related Social Services Among the Urban Poor. Int'L J. Self Help & Self Care, 2(4), pp. 271-283, 2004.

Research Agenda For Economic Evaluation of Substance Abuse Services

Economic analyses of substance abuse interventions play a critical role in informing the decision makers involved in funding these programs. In May 2003, a blue ribbon task force (BRTF) was formed to assess the status of addiction health services research at the National Institute on Drug Abuse and to develop recommendations to strengthen their research portfolio. The recommendations presented in this article develop and expand the economic perspective. With the emergence of new and more effective interventions, the adoption of costlier services still demands justification based on economic evidence. Updated and more rigorous economic information allows patients, health care professionals, insurance companies, policymakers, and others to allocate scarce resources more efficiently. To prepare for the next wave of addiction health services research, this article presents background information on the economics of addiction health services, reviews recent empirical and methodological contributions, and provides 15 research recommendations. French, M.T. and Drummond, M.F. A Research Agenda for Economic Evaluation of Substance Abuse Services. J Subst Abuse Treat, 29(2), pp. 125-137, 2005.

Economic Methods For Adolescent Substance Abuse Treatment

Only a few economic evaluations have been conducted for adolescent-specific treatments. This is the first article to present rigorous methodological guidelines for estimating the economic costs and benefits of adolescent substance abuse treatments, while also addressing the potential challenges associated with such research activities. A representative case study of two adolescent substance abuse treatment programs (one residential and one outpatient) is presented to show some of the initial steps of a comprehensive economic evaluation (e.g., cost analyses, selection of treatment outcome measures, and valuation of outcome measures via monetary conversion factors). Cost data were collected and analyzed using the Drug Abuse Treatment Cost Analysis Program. Monetary conversion factors were obtained and presented for a variety of treatment outcomes. The methodological guidelines, discussion of analytic challenges, and recommendations set forth in this article provide a foundation for future economic studies on adolescent substance abuse treatments. Zavala, S., French, M., Henderson, C., Alberga, L., Rowe, C. and Liddle, H. Guidelines and Challenges for Estimating the Economic Costs and Benefits of Adolescent Substance Abuse Treatments. J Subst Abuse Treat, 29(3), pp. 191-205, 2005.

Challenges In Conducting International Health Research

The Comprehensive Drug Research Center (CDRC) at the University of Miami was established in the early 1970s. Through the decades, investigators from the CDRC have worked with investigators from several countries to establish joint research efforts. Countries often do not have the infrastructure or monetary resources to carry out research on their own. Collaborating with institutions in these countries to build a sustainable capacity for research is a worthwhile and satisfying endeavor, and it presents a method for initiating research and building the necessary research structures. However, working with other countries presents a unique set of challenges and ethical dilemmas. This article presents some of the specific challenges encountered in these research efforts and describes what has done to resolve the problems and work more effectively and efficiently with foreign investigators. McCoy, C., Achi, R., Wolfe, H. and Crandall, L. The CDRC Principles of International Health Research. J Urban Health, 82(3-4), pp. iv5-iv8, 2005.

Immunologic Function And Virologic Suppression Among Children With Perinatally Acquired HIV Infection On HAART

The goal of highly active antiretroviral therapy (HAART) has been to stabilize and reconstitute immune function and suppress viral replication to the greatest degree possible. Suppression of HIV viral replication has been associated with improved long-term and short-term prognosis. Limited data are available on the level of virologic suppression and immune function of pediatric patients followed in clinical settings in the HAART era. The objective of this study was to assess the level of virologic suppression and immune function in a cohort of children with perinatally acquired HIV infection followed at dedicated HIV specialty care sites. This study comprised a cohort study of HIV-infected children and adolescents. Study subjects consisted of 263 HIV-positive children (< or=17 years old), on HAART, with at least one outpatient visit and CD4 test recorded in 2001 seen at 4 U.S. HIV primary pediatrics and specialty care sites (2 eastern, 1 southern, and 1 western). Measures consisted of all plasma HIV-1 RNA levels < or=400 during calendar year 2001. Two hundred sixty-three patients received HIV-related treatment during 2001, with a mean age of 8.5 years. Sixty-eight percent were black, 54% were females, and the majority (85%) was insured by Medicaid. A total of 28.6% had a class C AIDS diagnosis. A total of 23.5% and 34% of patients maintained viral suppression at <50 copies per milliliter (cpm), or <400 cpm, respectively, for the calendar year; 32.5% and 38.8%, respectively, fulfilled the criteria if one "blip" to <5000 cpm was allowed. Forty-eight percent maintained all viral loads <5000 cpm, and 74.9% overall had HIV-1 RNAs < or=15,000 cpm. Eighty-seven percent of patients had CD4% >25; only 4.2% had CD4 <15%. Overall, 12.5% of patients had either CD4% <15 or severely decreased absolute CD4 counts (adjusted for age). A total of 4.6% of patients had HIV-1 RNAs >100,000 cpm and severe immunosuppression. Patients who were less likely to achieve virologic suppression to <400 cpm included those with CD4 count <200 cells/mm(3) (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.007-0.46), those with AIDS (OR, 0.5; 95% CI, 0.28-0.94), and those with moderate (OR, 0.42; 95% CI, 0.22-0.79), or severe immunologic suppression (OR, 0.14; 95% CI, 0.046-0.43) based on CD4%. CONCLUSION: In this multisite, pediatric cohort, the rate of near-complete virologic suppression (<50 or <400 cpm) was low. However, the majority of patients have near-normal CD4 counts and viral loads <15,000 cpm. Follow up will be critical to assess the implications of ongoing low-level viral replication with near-normal CD4 values. Rutstein, R., Gebo, K., Flynn, P., Fleishman, J., Sharp, V., Siberry, G., and Spector, S. Immunologic Function and Virologic Suppression Among Children with Perinatally Acquired HIV Infection on Highly Active Antiretroviral Therapy. Med Care, 43(9), pp. 15-22, 2005.


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