David S. Metzger

Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: role of treatment services.

This study examined the patient and treatment factors associated with 6-month outcome in 649 opiate-, alcohol-, and cocaine-dependent (male and female) adults, treated in inpatient and outpatient settings, in 22 publicly and privately funded programs. Outcomes were predicted by similar factors, regardless of the drug problem of the patient or the type of treatment setting or funding. Greater substance use at follow-up was predicted only by greater severity of alcohol and drug use at treatment admission, not by the number of services received during treatment. Better social adjustment at follow-up was negatively predicted by more severe psychiatric, employment, and family problems at admission and positively predicted by more psychiatric, family, employment, and medical services provided during treatment.

Evaluating the Effectiveness of Addiction Treatments: Reasonable Expectations, Appropriate Comparisons

Problems of alcohol and drug dependence are costly to society in terms of lost productivity, social disorder, and avoidable health care utilization. The dollar costs of alcohol and drug use run into billions of dollars, and from one-eighth to one-sixth of all deaths can be traced to this source. However, the efficacy of treatment for addiction is often questioned. A rationale for reasonable expectations of addiction treatments is offered, from which are derived three outcome criteria for judging the effectiveness of treatments: reduction in substance use; improvement in personal health and social function; and reduction in public health and safety risks. Based on these criteria, treatment was shown to be effective, especially when compared with alternatives like no treatment or incarceration. These evaluations, which were conducted in a scientific manner, support the continued value of public spending for carefully monitored treatment of addiction.

Cellular microRNA Expression Correlates with Susceptibility of Monocytes/Macrophages to HIV-1 Infection

Although both monocytes and macrophages possess essential requirements for HIV-1 entry, peripheral blood monocytes are infrequently infected with HIV-1 in vivo and in vitro. In contrast, tissue macrophages and monocyte-derived macrophages in vitro are highly susceptible to infection with HIV-1 R5 tropic strains. We investigated intracellular anti-HIV-1 factors that contribute to differential susceptibility of monocytes/macrophages to HIV-1 infection. Freshly isolated monocytes from peripheral blood had significantly higher levels of the anti-HIV-1 microRNAs (miRNA, miRNA-28, miRNA-150, miRNA-223, and miRNA-382) than monocyte-derived macrophages. The suppression of these anti-HIV-1 miRNAs in monocytes facilitates HIV-1 infectivity, whereas increase of the anti-HIV-1 miRNA expression in macrophages inhibited HIV-1 replication. These findings provide compelling and direct evidence at the molecular level to support the notion that intracellular anti-HIV-1 miRNA-mediated innate immunity may have a key role in protecting monocytes/macrophages from HIV-1 infection.

Naltrexone pharmacotherapy for opioid dependent federal probationers

Federal probationers or parolees with a history of opioid addiction were referred by themselves or their probation/parole officer for a naltrexone treatment study. Participation was voluntary and subjects could drop out of the study at any time without adverse consequences. Following orientation and informed consent, 51 volunteers were randomly assigned in a 2:1 ratio to a 6-month program of probation plus naltrexone and brief drug counseling, or probation plus counseling alone. Naltrexone subjects received medication and counseling twice a week; controls received counseling at similar intervals. All therapy and medication were administered in an office located adjacent to the federal probation department. Fifty-two percent of subjects in the naltrexone group continued for 6 months and 33% remained in the control group. Opioid use was significantly lower in the naltrexone group. The overall mean percent of opioid positive urine tests among the naltrexone subjects was 8%, versus 30% for control subjects (p < .05). Fifty-six percent of the controls and 26% of the naltrexone group (p < .05) had their probation status revoked within the 6-month study period and returned to prison. Treatment with naltrexone and brief drug counseling can be integrated into the Federal Probation/Parole system with favorable results on both opioid use and re-arrest rates.

Readiness of high-risk populations in the HIV network for prevention trials to participate in HIV vaccine efficacy trials in the United States

Objective:To determine the willingness of populations at high risk of HIV-1 infection to participate in HIV vaccine efficacy trials, determine factors influencing decision-making, and evaluate knowledge levels of vaccine trial concepts. Design:Cross-sectional study. Methods:HIV-1-negative homosexual men, male and female injecting drug users and non-injecting women at heterosexual risk were recruited in eight cities in the United States (n = 4892). Results:A substantial proportion of the study population (77%) would definitely (27%) or probably (50%) be willing to participate in a randomized vaccine efficacy trial. Increased willingness was associated with high-risk behaviors, lower education level, being uninsured or covered by public insurance, and not having been in a previous vaccine preparedness study. Altruism and a desire for protection from the vaccine were major motivators for participation. Major concerns included positive HIV-1 antibody test due to vaccine, safety of the vaccine, and possible problems with insurance or foreign travel. Baseline knowledge of vaccine trial concepts was low. Conclusions:It is likely that high-risk volunteers will be willing to enroll in HIV vaccine efficacy trials. A variety of participant and community educational strategies are needed to address participant concerns, and to ensure understanding of key concepts prior to giving consent for participation.

Non-injection substance use correlates with risky sex among men having sex with men: data from HIVNET.

Associations between substance use and sexual behavior were examined among 3220 seronegative men who have sex with men (MSM) in a HIV vaccine preparedness study. Relationships between current and past substance use and current sexual risk were evaluated using crude odds ratios and logistic regression to adjust for confounding variables. Heroin and injection drug use were uncommon (< 2%). Substances most often used were alcohol (89%), marijuana (49%), nitrite inhalants (29%), amphetamines or similarly acting stimulants (21%), cocaine 14% and hallucinogens (14%). Increased adjusted odds for unprotected sex were significantly associated with current heavy alcohol use (OR 1.66; CI 1.18, 2.33), past alcohol problems (OR 1.25; CI 1.05, 1.48), and current drug use (OR 1.26; CI 1.08, 1.48). When associations with specific drugs and nitrite inhalants were examined separately, current use of cocaine and other stimulants (OR 1.25; CI 1.01, 1.55), hallucinogens (OR 1.40; CI 1.10, 1.77), and nitrite inhalants (some (OR 1.61; CI 1.35, 1.92); heavy (OR 2.18; CI 1.48, 3.20)), were independently associated with unprotected sex. Those with past drug use or past heavy alcohol use but not currently using demonstrated no increase in sexual risk, suggesting an important role for substance-focused interventions in risk reduction efforts among MSM.

Willingness to volunteer in future preventive HIV vaccine trials: Issues and perspectives from three U.S. communities

Summary: This study examined perceived risks, benefits, and desired information related to willingness to volunteer in preventive HIV vaccine trials. Sample: Purposive sampling was used to select 90 participants among injecting drug users (Philadelphia, PA, U.S.A.); gay men (San Francisco, CA, U.S.A.); and black Americans (Durham, NC, U.S.A.). Methods: A qualitative interview guide elicited perceived benefits, risks, and desired information relating to trial participation. Themes were developed from the transcribed texts and from freelists. Results: Stated willingness to volunteer in a preventive HIV vaccine trial was similar across the three communities. Eight perceived benefits were reported, including self‐benefits, altruism, and stopping the spread of AIDS. Seven perceived risks were reported, including negative side effects and vaccine safety issues, contracting HIV from the vaccine, and social stigmatization. Participants voiced the desire for eight types of information about issues relating to trust and confidentiality in the research process, health complications and later assistance, and vaccine trial methodology. Conclusions: In this study, many benefits as well as risks of preventive HIV vaccine trial participation were cited. Scientists conducting preventive HIV vaccine trials need to address community perceptions of risks and provide information about the research if trial enrollment is to be diverse and successful.

Examining Racial Disparities in HIV : Lessons From Sexually Transmitted Infections Research

Racial differences in the prevalence and incidence of HIV infection and AIDS diagnoses in the United States are striking. These differences have been recognized for nearly 20 years, yet they are not well investigated. In this article, we examine 15 factors identified in the sexually transmitted infection (STI) literature to explain the presence of racial/ethnic disparities in STIs. We review findings from these studies and offer suggestions for future research, with the goal of further understanding and reducing disparities in HIV. In general, the STI literature shows that an evaluation of individual behavior is necessary but insufficient on its own to account for racial/ethnic disparities in STIs. Population parameters should be included within models that traditionally include individual-level factors. The 15 factors can be categorized into 3 broad overarching themes: behavioral, prevention participation, and biologic explanations of differentials in STI transmission and infection. Future research that focuses on only 1 of the 15 factors discussed in this review, to the exclusion of others, is likely to yield poor outcomes. Conversely, an emphasis on the interactions of several factors is more likely to produce effective public health interventions and reductions in HIV transmission.PURPOSE To clarify the roles of objective signs and subjective symptoms in the diagnosis and management of dry eye by describing their use by a group of expert practitioners. Dry eye signs and symptoms do not always correlate well, and there is currently some controversy over the ideal roles of signs and symptoms and their actual use in clinical practice. METHODS A balanced panel of 16 participants in a scientific roundtable on dry eye reviewed 4 patient case studies and completed surveys ranking common diagnostic procedures assessing symptoms and signs by the order in which they would be used. RESULTS Symptom assessment was the predominant diagnostic method. The objective tests most commonly used during the initial examination were tear breakup time (93%), corneal staining (85%), tear film assessment (76%), conjunctival staining (74%), and the Schirmer test (54%). Most panelists used multiple tests, with a median of 6 tests used in the initial examination. CONCLUSIONS Subjective symptoms and objective signs are both important in the diagnosis and management of dry eye, with the patients symptoms and history playing a critical role. Most clinicians use objective signs in dry eye management. However, currently available diagnostic tests do not correlate reliably with symptom severity. Research aimed at developing accurate, objective, responsive measures of dry eye severity is needed.

The efficacy of a network intervention to reduce HIV risk behaviors among drug users and risk partners in Chiang Mai, Thailand and Philadelphia, USA

This HIV Prevention Trials Network study assessed the efficacy of a network-oriented peer education intervention promoting HIV risk reduction among injection drug users and their drug and sexual network members in Chiang Mai, Thailand and Philadelphia, USA. The study was designed to test impact on HIV infection, but the infection rate was low and the study was terminated early. This paper reports efficacy on outcomes of self-reported HIV risk behaviors. We enrolled 414 networks with 1123 participants. The experimental intervention consisted of six small group peer educator training sessions and two booster sessions delivered to the network index only. All participants in both arms received individual HIV counseling and testing. Follow-up visits occurred every six months for up to 30 months. There were 10 HIV seroconversions, 5 in each arm. The number of participants reporting injection risk behaviors dropped dramatically between baseline and follow-up in both arms at both sites. Index members in the intervention arm engaged in more conversations about HIV risk following the intervention compared to control indexes. There was no evidence of change in sexual risk as a result of the intervention. Reductions in injection risk behaviors were observed: 37%, 20%, and 26% reduction in odds of sharing cottons, rinse water and cookers, respectively, and 24% reduction in using a syringe after someone else. Analysis of the individual sites suggested a pattern of reductions in injection risk behaviors in the Philadelphia site. In both sites, the intervention resulted in index injection drug users engaging in the community role of discussing reduction in HIV injection risk behaviors. The intervention did not result in overall reductions in self-reported sexual risk behaviors, and although reductions in injection risk behaviors were observed, the overall efficacy in reducing risk was not established.

Rapid Assessment of the HIV/AIDS Crisis in Racial and Ethnic Minority Communities: An Approach for Timely Community Interventions

OBJECTIVES The US Department of Health and Human Services, in collaboration with the Congressional Black Caucus, created a new initiative to address the disproportionate ongoing HIV/AIDS crisis in racial/ethnic minority populations. METHODS This initiative included deploying technical assistance teams through the Office of HIV/AIDS Policy. The teams introduced rapid assessment and response methodologies and trained minority communities in their use. RESULTS The first 3 eligible cities (Detroit, Miami, and Philadelphia) focused assessments in small geographic areas, using multiple methodologies to obtain data. CONCLUSIONS Data from the first 3 eligible cities provided critical information about changing the dynamics of the HIV/AIDS epidemic at the local level, including program and policy changes and infrastructure redeployment targeted at the most serious social and environmental conditions.