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Director's Report to the National Advisory Council on Drug Abuse - May, 2007



Research Findings - Research on Medical Consequences of Drug Abuse and Co-Occurring Infections (HIV/AIDS, HCV)

Associations Between Methamphetamine Use and HIV among Men who have Sex with Men: A Model for Guiding Public Policy

Among men who have sex with men (MSM) in Los Angeles County, methamphetamine use is associated with high rates of HIV prevalence and sexual risk behaviors. In four separate samples of MSM who differed in the range of their intensity of methamphetamine use, from levels of recreational use to chronic use to those for MSM seeking drug abuse treatment, the association between methamphetamine use and HIV infection increased as the intensity of use increased. The lowest HIV prevalence rate (23%) was observed among MSM contacted through street outreach who mentioned recent methamphetamine use, followed by MSM who used at least once a month for six months (42%), followed by MSM seeking intensive outpatient treatment (61%). The highest rate (86%) was observed among MSM seeking residential treatment for methamphetamine dependence. The interleaving nature of these epidemics calls for comprehensive strategies that address methamphetamine use and concomitant sexual behaviors that increase risk of HIV transmission in this group already at high risk. These and other data suggest that MSM who infrequently use methamphetamine may respond to lower intensity/lower cost prevention and early intervention programs while those who use the drug at dependence levels may benefit from high intensity treatment to achieve goals of reduced drug use and HIV-risk sexual behaviors. Shoptaw, S., and Reback, C. Associations Between Methamphetamine Use and HIV among Men who have Sex with Men: A Model for Guiding Public Policy. J Urban Health, 83(6), pp. 1151-1157, 2006.

Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas

Community involvement and engagement can be important in shaping public health policies. For example, political pressure and direct action from the local community has been credited with having a central role in shaping attitudes and acceptance of syringe exchange programs (SEPs) in the United States. This study explored why SEPs are present in some localities but not others, hypothesizing that programs are unevenly distributed across geographic areas as a result of political, socioeconomic, and organizational characteristics of localities, including needs, resources, and local opposition. Researchers examined the effects of these factors on whether SEPs were present in different US metropolitan statistical areas in 2000. Significant predictors of the presence of an SEP included percentage of the population with a college education, the existence of local AIDS Coalition to Unleash Power (ACT UP) chapters, and the percentage of men who have sex with men in the population. By contrast, need was not found to be a predictor. Tempalski, B., Flom, P., Friedman, S., Des Jarlais, D., Friedman, J., McKnight, C., and Friedman, R. Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas. Am J Public Health, 97(3), pp. 437-447, 2007.

Needle Exchange Program Utilization and Entry into Drug User Treatment: Is There a Long-Term Connection in Baltimore, Maryland?

This study examined the relationship between Needle Exchange Program (NEP) utilization and treatment entry in Baltimore, Maryland. The sample was composed of 440 drug injectors with disadvantaged backgrounds. Face-to-face interviews, focusing on HIV risk behaviors, drug use, and health, were conducted between June 1997 and June 2002. Multivariate logistic analyses revealed that entering treatment was associated with NEP utilization, being female, and being HIV-positive. Cocaine sniffers/snorters were less likely to enter treatment. These findings highlight the importance of NEPs in linking injectors to treatment. They also suggest that treatment programs should be prepared and capable of addressing co-occurring problems, like HIV and mental illness. Study limitations are noted. Latkin, C., Davey, M., and Hua, W. Needle Exchange Program Utilization and Entry into Drug User Treatment: Is There a Long-Term Connection in Baltimore, Maryland? Subst Use Misuse, 41(14), pp. 1991-2001, 2006.

Delayed Diagnosis and Elevated Mortality in an Urban Population with HIV and Lung Cancer: Implications for Patient Care

Lung cancer is more common in HIV-infected patients than in the general population. In this study, researchers examined how effectively lung cancer was being diagnosed in HIV-infected patients. Retrospective review was undertaken to assess clinical diagnosis of lung cancer in HIV-infected patients at Johns Hopkins Hospital between 1986 and 2004. Ninety-two patients were identified. Compared to HIV-indeterminate patients (n=4973), HIV-infected individuals were younger, with more advanced cancer. CD4 counts and HIV-1 RNA levels indicated preserved immune function. Mortality was higher in HIV-infected patients, with 92% dying of lung cancer (hazard ratio, 1.57; 95% confidence interval, 1.25-1.96), compared to HIV-uninfected patients. Advanced stage and black race were associated with worse survival. After adjustment for these factors, HIV infection was not associated with increased mortality (hazard ratio, 1.04; 95% confidence interval, 0.83-1.32). Of 32 patients followed in the HIV clinic, 60% of chest radiographs had no evidence of neoplasm within 1 year of diagnosis compared to only 1 (4%) of 28 chest computed tomography scans. Nonspecific infiltrates were observed in 9 patients in the same area that cancer was subsequently diagnosed. The findings show that HIV-infected lung cancer patients have shortened survival mainly due to advanced stage. Low clinical suspicion and over reliance on chest radiographs hindered earlier detection. Aggressive follow-up of nonspecific pulmonary infiltrates in these patients is warranted. Brock, M., Hooker, C., Engels, E., Moore, R., Gillison, M., Alberg, A., Keruly, J., Yang, S., Heitmiller, R., Baylin, S., Herman, J., and Brahmer, J. Delayed Diagnosis and Elevated Mortality in an Urban Population with HIV and Lung Cancer: Implications for Patient Care. J Acquir Immune Defic Syndr, 43(1), pp. 47-55, 2006.

Risk of Non-AIDS-Related Mortality May Exceed Risk of AIDS-Related Mortality among Individuals Enrolling into Care with CD4+ Counts Greater than 200 cells/mm3

To quantify cause-specific mortality risk attributable to non-AIDS-related and AIDS-related causes before and after the advent of highly active antiretroviral therapy (HAART). Competing-risk methods were used to determine the cumulative AIDS-related and non-AIDS-related risk of mortality between 1990 and the end of 2003 in the Johns Hopkins HIV Clinical Cohort, a prospective cohort study. Beginning in 1997 with the introduction of HAART, all-cause mortality declined and has remained stable at approximately 39 deaths per 1000 person-years. AIDS-related mortality continued to decline in this period (P = 0.008), whereas non-AIDS-related mortality increased (P < 0.001). Using competing-risk methods, the risk of dying attributable to AIDS-related causes remains significantly higher than the risk of dying attributable to non-AIDS-related causes for patients with a CD4 count 200 cells/mm, however, non-AIDS-related mortality was greater than AIDS-related mortality, particularly among injection drug users. Other transmission categories had similar AIDS-related and non-AIDS-related cumulative mortalities. HAART has reduced mortality rates among HIV-infected individuals, but further efforts to reduce mortality in this population require increased attention to conditions that have not traditionally been considered to be HIV related. Lau, B., Gange, S., and Moore, R. Risk of Non-AIDS-Related Mortality May Exceed Risk of AIDS-Related Mortality among Individuals Enrolling into Care with CD4+ Counts Greater than 200 cells/mm3. J Acquir Immune Defic Syndr, 44(2), pp. 179-187, 2007.

Incidence of, Risk Factors for, Clinical Presentation, and 1-Year Outcomes of Infective Endocarditis in an Urban HIV Cohort

Previous studies described infective endocarditis (IE) in the era before highly active antiretroviral therapy (HAART); however, IE has not been well studied in the current HAART era. In this study, researchers evaluated the incidence of, risk factors for, clinical presentation, and 1-year outcomes of IE in HIV-infected patients. All cases of IE diagnosed between 1990 and 2002 in patients followed at the Johns Hopkins Hospital outpatient HIV clinic were evaluated. To identify factors associated with IE in the current era of HAART, a nested case-control analysis was employed for all initial episodes of IE occurring between 1996 and 2002. Logistic regression analyses were used to assess risk factors for IE and factors associated with 1-year mortality. IE incidence decreased from 20.5 to 6.6 per 1000 person-years (PY) between 1990 and 1995 and 1996 and 2002. The majority of IE cases were male (66%), African American (90%), and injection drug users (IDUs) (85%). In multivariate regression, an increased risk of IE occurred in IDUs (AOR, 8.71), those with CD4 counts <50 cells/mm, and those with HIV-1 RNA >100,000 copies/mL (AOR, 3.88). Common presenting symptoms included fever (62%), chills (31%), and shortness of breath (26%). The most common etiologic organism was Staphylococcus aureus (69%; of these 11 [28%] were methicillin resistant). Within 1 year, 16% had IE recurrence, and 52% died. Age over 40 years was associated with increased mortality. These findings show that IE rates have decreased in the current HAART era, but that IDUs and those with advanced immunosuppression are more likely to develop IE. In addition, there is significant morbidity and 1-year mortality in HIV-infected patients with IE, indicating the need for more aggressive follow-up, especially in those over 40 years of age. Future studies investigating the utility of IE prophylaxis in HIV patients with a history of IE may be warranted. Gebo, K., Burkey, M., Lucas, G., Moore, R., and Wilson, L. Incidence of, Risk Factors for, Clinical Presentation, and 1-Year Outcomes of Infective Endocarditis in an Urban HIV Cohort. J Acquir Immune Defic Syndr, 43(4), pp. 426-432, 2006.

CD4+ Cell Count 6 Years after Commencement of Highly Active Antiretroviral Therapy in Persons with Sustained Virologic Suppression

Sustained suppression of the human immunodeficiency virus (HIV) type 1 RNA load with the use of highly active antiretroviral therapy (HAART) results in immunologic improvement, but it is not clear whether the CD4(+) cell count increases to normal levels or whether it reaches a less-than-normal plateau. In this study, researchers characterized the increase in the CD4(+) cell count in patients in clinical practice who maintained sustained viral suppression for up to 6 years. All patients were from the Johns Hopkins HIV Clinical Cohort, a longitudinal observational study of patients receiving primary HIV care in Baltimore, Maryland, who were observed for >1 year while receiving HAART and who had sustained suppression of the HIV RNA load at <400 copies/mL. Annual change in the CD4(+) cell count for up to 6 years after the start of HAART was analyzed, stratified by baseline CD4(+) cell counts of < or =200, 201-350, >350 cells/microL. The development of clinical events was assessed (death and new acquired immunodeficiency syndrome-defining illness) by Kaplan-Meier analysis. A total of 655 patients were observed for a median of 46 months (range, 13-72 months). The median change from baseline to most recent CD4(+) cell count was +274 cells/microL, with 92% of patients having an increase in CD4(+) cell count. By 6 years, the median CD4(+) cell count was 493 cells/microL among patients with baseline CD4(+) cell counts < or =200 cells/microL, 508 cells/microL among those with baseline CD4(+) cell counts of 201-350 cells/microL, and 829 cells/microL among those with baseline CD4(+) cell counts >350 cells/microL. In addition to baseline CD4(+) cell count, injection drug use and older age were associated with a lesser CD4(+) cell count response, and duration of therapy was associated with a greater CD4(+) cell count response. These findings show that only patients with baseline CD4(+) cell counts >350 cells/microL returned to nearly normal CD4(+) cell counts after 6 years of follow-up. Significant increases were observed in all CD4(+) cell count strata during the first year, but there was a lower plateau CD4(+) cell count at lower baseline CD4(+) cell strata. These data suggest that waiting to start HAART at lower CD4(+) cell counts will result in the CD4(+) cell count not returning to normal levels. Moore, R., and Keruly, J. CD4+ Cell Count 6 Years after Commencement of Highly Active Antiretroviral Therapy in Persons with Sustained Virologic Suppression. Clin Infect Dis, 44(3), pp. 441-446, 2007.

Hazardous Alcohol Use: A Risk Factor for Non-Adherence and Lack of Suppression in HIV Infection

Researchers examined the independent effect of alcohol and combined effects of drug and alcohol use on antiretroviral (ART) utilization, adherence, and viral suppression in an urban cohort of HIV-infected individuals. In an observational clinical cohort, alcohol use, active drug use, and adherence were prospectively assessed at 6-month intervals. Hazardous alcohol use was classified as >7 drinks/week or >3 drinks/occasion in women, and >14 drinks/week or >4 drinks/occasion in men and active drug use as any use in the previous 6 months. Study outcomes included ART utilization, 2-week adherence, and viral suppression. Generalized estimating equations were used to analyze the association between independent variables and outcomes. Analyses were adjusted for age, sex, race, years on ART, and clinic enrollment time. Between 1998 and 2003, 1711 participated in 5028 interviews, of whom 1433 received ART accounting for 3761 interviews. The prevalence of any alcohol use at the first interview was 45%, with 10% classified as hazardous drinkers. One-third of the sample used illicit drugs. In multivariate analyses adjusting for age, sex, race, active drug use, years on ART, and clinic enrollment time, hazardous alcohol use was independently associated with decreased ART utilization (AOR, 0.65; 95% CI: 0.51 to 0.82), 2-week adherence (AOR, 0.46; 95% CI: 0.34 to 0.63), and viral suppression (AOR, 0.76; 95% CI: 0.57 to 0.99) compared to no alcohol use. Concurrent injection drug use (IDU) exacerbated this negative effect on ART use, adherence, and suppression. These findings demonstrate that hazardous alcohol use alone and combined with IDU was associated with decreased ART uptake, adherence, and viral suppression. Interventions are needed to improve HIV outcomes in individuals with hazardous alcohol use. Chander, G., Lau, B., and Moore, R. Hazardous Alcohol Use: A Risk Factor for Non-Adherence and Lack of Suppression in HIV Infection. J Acquir Immune Defic Syndr, 43(4), pp. 411-417, 2006.

Multiperson Use of Syringes among Injection Drug Users in a Needle Exchange Program: A Gene-Based Molecular Epidemiologic Analysis

Syringe-sharing behaviors among injection drug users (IDUs) are typically based on self-reports and subject to socially desirable responding. In this study, researchers used 3 short tandem repeat (STR) genetic biomarkers to detect sharing in 2,512 syringes exchanged by 315 IDUs in the Baltimore needle exchange program (NEP; 738 person-visits). Demographic characteristics as well as direct and indirect needle-sharing behaviors corresponding to the closest AIDS Link to Intravenous Experience (ALIVE) study visits were examined for association with multiperson use (MPU) of syringes. Overall, 56% of the syringes exchanged at the Baltimore NEP had evidence of MPU. Less MPU of syringes (48% vs. 71%; P < 0.0001) was seen with more rapid syringe turnaround (<3 days). IDUs always exchanging their own syringes ("primary" syringes) were less likely to return syringes with evidence of MPU (52%) than those who exchanged syringes for others ("secondary" syringes; 64%; P = 0.0001) and those exchanging primary and secondary syringes (58%; P = 0.004). In a multivariate analysis restricted to primary exchangers, MPU of syringes was associated with sharing cotton (adjusted odds ratio [AOR] = 2.06, 95% confidence interval [CI]: 1.30 to 3.28), lending syringes (AOR = 1.70, 95% CI: 1.24 to 2.34), and injecting less than daily (AOR = 0.64, 95% CI: 0.43 to 0.95). These findings support additional public health interventions such as expanded syringe access to prevent HIV and other blood-borne infections. Testing of STRs represents a promising and innovative approach to examining and accessing complex behavioral data, including syringe sharing. Shrestha, S., Smith, M., Broman, K., Farzadegan, H., Vlahov, D., and Strathdee, S. Multiperson Use of Syringes among Injection Drug Users in a Needle Exchange Program: A Gene-Based Molecular Epidemiologic Analysis. J Acquir Immune Defic Syndr, 43(3), pp. 335-343, 2006.

Design and Feasibility of a Randomized Behavioral Intervention to Reduce Distributive Injection Risk and Improve Health-Care Access Among Hepatitis C Virus Positive Injection Drug Users: The Study to Reduce Intravenous Exposures (STRIVE)

Hepatitis C virus (HCV) is hyperendemic among injection drug users (IDUs). However, few scientifically proven interventions to prevent secondary transmission of HCV from infected IDUs to others exist. This report describes the design, feasibility, and baseline characteristics of participants enrolled in the Study to Reduce Intravenous Exposure (STRIVE). STRIVE was a multisite, randomized-control trial to test a behavioral intervention developed to reduce distribution of used injection equipment (needles, cookers, cottons, and rinse water) and increase health-care utilization among antibody HCV (anti-HCV) positive IDUs. STRIVE enrolled anti-HCV positive IDU in Baltimore, New York City, and Seattle; participants completed behavioral assessments and venipuncture for HIV, HCV-RNA, and liver function tests (LFTs) and were randomized to attend either a six-session, small-group, peer-mentoring intervention workshop or a time-matched, attention-control condition. Follow-up visits were conducted at 3 and 6 months. At baseline, of the 630 HCV-positive IDUs enrolled (mean age of 26 years, 60% white, 76% male), 55% reported distributive needle sharing, whereas 74, 69, and 69% reported sharing cookers, cottons, and rinse water, respectively. Health-care access was low, with 41% reporting an emergency room as their main source of medical care. Among those enrolled, 66% (418/630) were randomized: 53% (222/418) and 47% (196/418) to the intervention and control conditions, respectively. Follow-up rates were 70 and 73% for the 3- and 6-month visits, respectively. Distributive sharing of used injection equipment was common but care for HCV remained low, indicating the importance of developing effective HCV-related interventions with IDUs to avert their potential new spread of the infection and improve their health care access and use. Kapadia, F., Latka, M., Hagan, H., Golub, E., Campbell, J., Coady, M., Garfein, R., Thomas, D., Bonner, S., Thiel, T., and Strathdee, S. Design and Feasibility of a Randomized Behavioral Intervention to Reduce Distributive Injection Risk and Improve Health-Care Access Among Hepatitis C Virus Positive Injection Drug Users: The Study to Reduce Intravenous Exposures (STRIVE). J Urban Health, 84(1), pp. 99-115, 2007.

Impact of HIV Testing on Uptake of HIV Therapy among Antiretroviral Naive HIV-infected Injection Drug Users

Improving access to antiretroviral therapy among injection drug users remains an urgent public health concern. This study examined the time to antiretroviral therapy (ART) use among antiretroviral naive HIV-infected IDUs who were unaware of their HIV status to examine the impact of receipt of HIV test results on uptake of ART. Time to ART use was examined using Kaplan-Meier methods, and factors associated with the time to ART were evaluated using Cox proportional hazards regression. Between May 1996 and May 2003, 312 HIV-infected individuals were enrolled into the Barriers to Antiretroviral Therapy (BART) cohort, among whom 105 (33.7%) reported not knowing their HIV status at baseline. At 24 months post-baseline, those participants who returned for test results within 8 months initiated ART at a significantly elevated rate [adjusted relative hazard = 1.87 (95% CI: 1.05 - 3.33)]. These findings demonstrate the potential to improve uptake of ART among IDUs through targeted HIV testing and counseling initiatives that encourage the receipt of HIV test results, and suggest that strategies to improve awareness of HIV infection may improve access to antiretroviral therapy. Wood, E., Kerr, T., Hogg, R., Palepu, A., Zhang, R., Strathdee, S., and Montaner, J. Impact of HIV Testing on Uptake of HIV Therapy among Antiretroviral Naive HIV-infected Injection Drug Users. Drug Alcohol Rev, 25(5), pp. 451-454, 2006.

Frequent Needle Exchange Use and HIV Incidence in Vancouver, Canada

Researchers evaluated possible explanations for the observed association between elevated HIV rates and frequent needle exchange attendance that had been reported from a prior study in Vancouver. They used a prospective observational cohort study of injection drug users in Vancouver, BC, and examined HIV incidence rates with stratified Kaplan-Meier methods and Cox proportional hazards regression. Between May 1996 and December 2004, 1035 individuals were recruited. At 48 months after recruitment, the cumulative HIV incidence rate was 18.1% among those reporting daily needle exchange use at baseline compared with 10.7% among those who did not report this behavior (P<.001). However, comparing HIV incidence among daily vs. non-daily exchange users, while stratifying the cohort into those who did (23.2% vs. 16.8%; P=.157) and did not (11.4% vs. 9.0%; P=.232) report daily cocaine injection at baseline, the association between daily exchange use and HIV incidence was no longer significant. In an adjusted Cox model, daily exchange use was not associated with the time to HIV seroconversion (relative hazard=1.41 [95% confidence interval, 0.95-2.09]). These findings indicate that differential HIV incidence rates between frequent and nonfrequent needle exchange attendees can be explained by the higher risk profile of daily attendees. Causal factors, including the high rates of cocaine injection and other local injection drug user characteristics, explain the Vancouver HIV outbreak. Wood, E., Lloyd-Smith, E., Li, K., Strathdee, S., Small, W., Tyndall, M., Montaner, J., and Kerr, T. Frequent Needle Exchange Use and HIV Incidence in Vancouver, Canada. Am J Med, 120(2), pp. 172-179, 2007.

Frequent Methamphetamine Use is Associated with Primary Non-nucleoside Reverse Transcriptase Inhibitor Resistance

Researchers determined whether methamphetamine use is associated with the increased prevalence of primary HIV drug resistance among a cohort of 300 men who have sex with men recently infected with HIV. Of the 300, 83 (28%) reported recent meth use; 12% reported weekly use; and 77 (26%) had resistance to at least one antiretroviral drug. Among frequent meth users, 34% were resistant to at least one class of antiretroviral drug compared to 21% of infrequent users and 25% of non-users. In a multivariate model, controlling for multiple sex partners, race/ethnicity, other illicit drug use, and previous use of antiretrovirals, researchers 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. These findings are a concern, particularly because research has shown that resistance to NNRTIs is associated with a significantly greater mortality risk compared to resistance to PIs. The authors postulate that their findings may be caused by methamphetamine-associated treatment interruptions among source partners. Colfax, G., Vittinghoff, E., Grant, R., Lum, P., Spotts, G., and Hecht, F. Frequent Methamphetamine Use is Associated with Primary Non-nucleoside Reverse Transcriptase Inhibitor Resistance. AIDS, 21(2), pp. 239-241, 2007.

Limited Effectiveness of Antiviral Treatment for Hepatitis C in an Urban HIV Clinic

Researchers sought to evaluate predictors and trends of referral for hepatitis C virus (HCV) care, clinic attendance and treatment in an urban HIV clinic. They conducted a retrospective cohort analysis in which 845 of 1318 co-infected adults who attended the Johns Hopkins HIV clinic between 1998 and 2003 after an on-site viral hepatitis clinic was opened, attended regularly (>/= 1 visit/year for >/= 2 years). Logistic regression was used to examine predictors of referral. A total of 277 (33%) of 845 were referred for HCV care. Independent predictors of referral included percentage elevated alanine aminotransferase levels [adjusted odds ratio (AOR) for 10% increase, 1.16; 95% confidence interval (CI), 1.10-1.22] and CD4 cell count > 350 cells/microl (AOR, 3.20; 95% CI, 2.10-4.90), while injection drug use was a barrier to referral (AOR, 0.26; 95% CI, 0.11-0.64). Overall referral rate increased from < 1% in 1998 to 28% in 2003; however, even in 2003, 65% of those with CD4 cell count > 200 cells/microl were not referred. One hundred and eighty-five (67%) of 277 referred kept their appointment, of whom 32% failed to complete a pre-treatment evaluation. Of the remaining 125, only 69 (55%) were medically eligible for treatment, and 29 (42%) underwent HCV treatment. Ninety percent of 29 were infected with genotype 1 and 70% were African American; six (21%) achieved sustained virologic response (SVR). Only 0.7% of the full cohort achieved SVR. These findings indicate that, although the potential for SVR and the recent marked increase in access to HCV care are encouraging, overall effectiveness of anti-HCV treatment in this urban, chiefly African American, HCV genotype 1 HIV clinic is extremely low. The findings highlight the urgent need for new therapies and treatment strategies for HCV. Mehta, S., Lucas, G., Mirel, L., Torbenson, M., Higgins, Y., Moore, R., Thomas, D., and Sulkowski, M. Limited Effectiveness of Antiviral Treatment for Hepatitis C in an Urban HIV Clinic. AIDS, 20(18), pp. 2361-2369, 2006.

Effects of Pegylated Interferon alfa-2b on the Pharmacokinetic and Pharmacodynamic Properties of Methadone: A Prospective, Nonrandomized, Crossover Study in Patients Coinfected with Hepatitis C and HIV Receiving Methadone Maintenance Treatment

Hepatitis C (HCV) is common among methadone-maintained HIV-positive individuals. Pegylated interferon (pegIFN) used in combination with ribavirin is conventional treatment for HCV. However, pegIFN has been associated with adverse effects (AEs) that may simulate opioid withdrawal and be confused with insufficient methadone dosage. The aim of this study was to determine, using methadone pharmacokinetic properties, whether methadone dosage adjustments are needed on initiation of treatment with pegIFN alfa-2b for HCV in methadone-maintained HIV-positive patients. Patients over age 18, coinfected with chronic HCV and HIV, who had been receiving methadone maintenance treatment (dosage, 40-200 mg/d PO) for at least 8 weeks prior to enrollment were eligible. Nine patients were included in the study (7 men, 2 women; 7 Hispanic, 2 black; mean [SD] age, 41 [8.3] years; mean [SD] weight, 75.0 [12.3] kg). No significant changes were observed from baseline in mean C(max), T(max), C(min), AUC, and CL/F values despite 80% power to detect a 30% change in either direction. Changes from baseline in SOWS and OOWS scores were not statistically significant. The only AEs reported were mild and consistent with those expected after pegIFN alfa-2b administration, such as inflammation at the injection site and mild, brief, flulike symptoms. Based on the results of this small, prospective, nonrandomized study, pegIFN alfa-2b did not appear to precipitate opioid withdrawal in this sample of methadone-maintained persons with HIV and chronic HCV coinfection; methadone dosage adjustments were unlikely to be needed. Berk, S.I., Litwin, A.H., Arnsten, J.H., Du, E., Soloway, I., Gourevitch, M.N. Clin Ther. 29(1), pp. 131-138, January 2007.

Feasibility and Acceptability of Rapid HIV Testing

For correctional HIV testing programs, delivery of HIV test results can be difficult because of short incarceration times for many inmates. Rapid HIV testing enables immediate delivery of test results and can be performed in conjunction with risk reduction counseling. The objective of this study was to determine the feasibility and acceptability of rapid HIV testing within the Rhode Island Department of Corrections jail. Jail detainees were randomly asked to participate in the study. The study included: (1) completing a questionnaire that investigated HIV risk behavior, incarceration history, HIV testing history, and attitudes toward routine HIV testing in jail and toward partner notification services; (2) individualized HIV risk reduction counseling; and (3) the option of rapid HIV testing with delivery of test results. One hundred thirteen inmates were asked to participate and 100 (88%) participated. Among the subjects, there was a high frequency of incarceration and subjects were at significant risk of HIV infection, yet there was low perceived risk. Ninety-five percent of participants underwent rapid HIV testing. Of those, 99% had negative test results and one subject had a preliminary positive result. All subjects received rapid test results and individualized risk reduction counseling. The majority of subjects supported routine HIV testing in jail and the concept of partner notification services. In this population of jail detainees, rapid HIV testing was feasible and highly acceptable. Further studies are needed to successfully incorporate rapid HIV testing into jail HIV screening programs. Beckwith, C.G., Atunah-Jay, S., Cohen, J., Macalino, G., Poshkus, M., Rich, J.D., Flanigan, T.P., and Lally, M.A. AIDS Patient Care STDS. 21(1), pp. 41-47, January 2007.

Specific Targeted Antiviral Therapy for Hepatitis C - Review

Since the discovery of the hepatitis C virus (HCV) as the major cause of non-A, non-B hepatitis in 1989, the search for specific targeted antiviral therapy for HCV (STAT-C) has been underway. Recently, major advances in the understanding of HCV biology and the development of an in vitro system of HCV replication have contributed to the selection of multiple candidate drugs for the treatment of hepatitis C. In 2006, five such candidate drugs have entered phase II clinical trials in patients chronically infected with hepatitis C, including small molecule inhibitors of the HCV NS3 serine protease and NS5B RNA-dependent RNA polymerase. This review focuses on hepatitis C protease and polymerase inhibitors that have progressed to phase II clinical development, foreshadowing the era of STAT-Cs. Sulkowski, M.S. Curr Gastroenterol Rep. 9(1), pp. 5-13, February 2007.

Hepatitis C Management by Addiction Medicine Physicians: Results from a National Survey

Drug users are disproportionately affected by hepatitis C virus (HCV), yet they face barriers to health care that place them at risk for levels of HCV-related care that are lower than those of nondrug users. Substance abuse treatment physicians may treat more HCV-infected persons than other generalist physicians, yet little is known about how such physicians facilitate HCV-related care. A nationwide survey of American Society of Addiction Medicine physicians (n =320) was conducted to determine substance abuse physicians' HCV-related management practices and to describe factors associated with these practices. Findings showed that substance abuse treatment physicians promoted several elements of HCV-related care, including screening for HCV antibodies, recommending vaccinations against hepatitis A and B, and referring patients to subspecialists for HCV treatment. Substance abuse physicians who also provide primary medical or HIV-related care were most likely to facilitate HCV-related care. A significant minority of physicians were either providing HCV antiviral treatment or willing to provide HCV antiviral treatment. Litwin, A.H., Kunins, H.V., Berg, K.M., Federman, A.D., Heavner, K.K., Gourevitch, M.N., and Arnsten, J.H. J Subst Abuse Treat., March 20, 2007.

HIV Testing in Correctional Agencies and Community Treatment Programs: The Impact of Internal Organizational Structure

This study compares the provision of HIV testing in a nationally representative sample of correctional agencies and community-based substance abuse treatment programs and identifies the internal organizational-level correlates of HIV testing in both organizations. Using an organizational diffusion theoretical framework, Diffusion of innovations, the impact of Centralization of Power, Complexity, Formalization, Interconnectedness, Organizational Resources, and Organizational Size on HIV testing was examined in correctional agencies and treatment programs. Although there were no significant differences in the provision of HIV testing among correctional agencies (49%) and treatment programs (50%), the internal organizational-level correlates were more predictive of HIV testing in correctional agencies. Specifically, all dimensions, with the exception of Formalization, were related to the provision of HIV testing in correctional agencies. Implications for correctional agencies and community treatment to adopt HIV testing are discussed. Oser, C.B., Tindall, M.S., and Leukefeld, C.G. J Subst Abuse Treat. 32(3), pp. 301-310, April 2007.

Prevalence of Opioid Analgesic Injection Among Rural Nonmedical Opioid Analgesic Users

The purpose of this study was to examine the prevalence and correlates of opioid analgesic injection (OAI) in a cohort of opioid analgesic users through a cross-sectional study of 184 participants from rural Appalachian Kentucky. The majority of participants were male (54.9%), white (98.4%) and the median age was 30 years. The self-reported lifetime prevalence of injection drug use (IDU) was 44.3%, with 35.3% of respondents reporting injection of oral opioid analgesic formulations. The prevalence of self-reported hepatitis C (HCV) was 14.8%, significantly greater than those not injecting opioid analgesics. Receptive needle sharing, distributive needle sharing and sharing of other injection paraphernalia was reported by 10.5%, 26.3%, and 42.1% of those currently injecting, respectively. Opioid analgesic injection was more prevalent in this rural population than has been found in previous reports. This study suggests a rising problem with injecting among rural opioid users, a problem more typically associated with urban drug users. Educating injectors of opioid analgesics on safe needle practices is necessary in order to curb the transmission of HIV, HCV, and other infectious diseases. Further study on the longitudinal course of opioid analgesic injection in this population appears warranted. Havens, J.R., Walker, R., and Leukefeld, C.G. Drug Alcohol Depend. 87(1), pp. 98-102, February 23, 2007.

Multi-sample Standardization and Decomposition Analysis: An Application to Comparisons of Methamphetamine Use Among Rural Drug Users in Three American States

This study demonstrates the use of standardization and decomposition analysis (SDA) techniques to compare outcome measures simultaneously among multiple populations. Methamphetamine use among rural stimulant drug users in three geographically distinct areas of the US (Arkansas, Kentucky, and Ohio) is presented as an example of applying SDA. Findings show that the observed crude rate of 'ever used' methamphetamine in the past 30 days and the frequency of methamphetamine use in the past 30 days were much higher in Kentucky than in the other two states. However, after the compositions of socio-demographic confounding factors were standardized across the samples, the two measures of methamphetamine use ranked highest in Arkansas, followed by Kentucky, and then Ohio. Confounding factors contributed in various dimensions to the differences in the observed outcome measures among the distinct samples. The study shows that SDA is a useful technique for multi-population comparisons, providing an opportunity to look at data from a different perspective in medical studies. Wang, J., Carlson, R.G., Falck, R.S., Leukefeld, C., and Booth, B.M. Stat Med. January 23, 2007.

Survivors of Violence-related Facial Injury: Psychiatric Needs and Barriers to Mental Health Care

This study examined mental health needs, receptivity to psychosocial aftercare, and barriers to care among survivors of violence-related facial injuries. Face-to-face interviews were conducted with 25 consecutively treated individuals at a hospital-based specialty outpatient clinic one month after a violence-related facial injury. To participate in the study, patients had to screen positive for a substance use disorder, major depression or posttraumatic stress disorder (PTSD). Participants were questioned about receptivity to an aftercare program and perceived barriers to care. Of those screened for study eligibility (n=62), a substantial proportion met probable criteria for AUD (31%), PTSD (34%) and major depression (35%). Among those completing the core interview (n=25), 80% met probable criteria for two or more psychiatric disorders. The majority (84%) expressed interest in psychosocial aftercare. However, barriers such as cost, insufficient information about counseling and obtaining services, transportation and preferences for self-reliance were commonly endorsed. Survivors of violence-related facial injuries have substantial mental health needs and appear receptive to psychosocial aftercare. However, significant treatment barriers must be addressed. Findings underscore the value of a collaborative care model for treating violence-related facial trauma patients seeking care in specialty outpatient oral and maxillofacial clinics. Wong, E.C., Marshall, G.N., Shetty, V., Zhou, A., Belzberg, H., and Yamashita, D.D. Gen Hosp Psychiatry. 29(2), pp. 117-122, March-April 2007.


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