Grace E. Macalino

Prevalence and Incidence of HIV, Hepatitis B Virus, and Hepatitis C Virus Infections Among Males in Rhode Island Prisons

OBJECTIVES We evaluated prevalence and intraprison incidence of HIV, hepatitis B virus, and hepatitis C virus infections among male prison inmates. METHODS We observed intake prevalence for 4269 sentenced inmates at the Rhode Island Adult Correctional Institute between 1998 and 2000 and incidence among 446 continuously incarcerated inmates (incarcerated for 12 months or more). RESULTS HIV, hepatitis B virus, and hepatitis C virus prevalences were 1.8%, 20.2%, and 23.1%, respectively. Infections were significantly associated with injection drug use (odds ratio = 10.1, 7.9, and 32.4). Incidence per 100 person-years was 0 for HIV, 2.7 for HBV, and 0.4 for HCV. CONCLUSIONS High infection prevalence among inmates represents a significant community health issue. General disease prevention efforts must include prevention within correctional facilities. The high observed intraprison incidence of HBV underscores the need to vaccinate prison populations.

Successful linkage of medical care and community services for HIV-positive offenders being released from prison.

Human immunodeficiency virus (HIV) infection is more prevalent among the incarcerated than the general population. For many offenders, incarceration is the only time that they may access primary care. Project Bridge is a federally funded demonstration project that provides intensive case management for HIV-positive exoffenders being released from the Rhode Island state prison to the community. The program is based on collaboration between colocated medical and social work staff. The primary goal of the program is to increase continuity of medical care through social stabilization; it follows a harm reduction philosophy in addressing substance use. Program participants are provided with assistance in accessing a variety of medical and social services. The treatment plan may include the following: mental illness triage and referral, substance abuse assessment and treatment, appointments for HIV and other medical conditions, and referral for assistance to community programs that address basic survival needs. In the first 3 years of this program, 97 offenders were enrolled. Injection drug use was reported by 80% of those enrolled. There were 90% followed for 18 months, 7% moved out of state or died, and 3% were lost to follow-up. Reincarceration happened to 48% at least once. Of those expressing a need, 75% were linked with specialty medical care in the community, and 100% received HIV-related medical services. Of those expressing a need for substance abuse treatment, 67% were successful in keeping appointments for substance abuse treatment within the community. Project Bridge has demonstrated that it is possible to maintain HIV-positive ex-offenders in medical care through the provision of ongoing case management services following prison release. Ex-offenders will access HIV-related health care after release when given adequate support.

Human Immunodeficiency Virus in Correctional Facilities: A Review

It is estimated that up to one-fourth of the people living with human immunodeficiency virus (HIV) infection in the United States pass through a correctional facility each year. The majority of persons who enter a correctional facility today will return home in the near future. Most inmates with HIV infection acquire it in the outside community; prison does not seem to be an amplifying reservoir. How correctional health services deal with the HIV-infected person has important implications to the overall care of HIV-infected people in the community. Routine HIV testing is well accepted. Combination antiretroviral therapy has been associated with a reduction in mortality in prisons. A link between area HIV specialists and correctional health care providers is an important partnership for ensuring that HIV-infected patients have optimal care both inside prison and after release.

Needle-exchange attendance and health care utilization promote entry into detoxification.

This study was undertaken to identify factors associated with entry into detoxification among injection drug users (IDUs), and to assess the role of needle-exchange programs (NEPs) as a bridge to treatment. IDUs undergoing semiannual human immunodeficiency virus (HIV) tests and interviews were studied prospectively between 1994 and 1998, during which time an NEP was introduced in Baltimore. Logistic regression was used to identify independent predictors of entry into detoxification, stratifying by HIV serostatus. Of 1,490 IDUs, similar proportions of HIV-infected and uninfected IDUs entered detoxification (25% vs. 23%, respectively). After accounting for recent drug use, hospital admission was associated with four-fold increased odds of entering detoxification for HIV-seronegative subjects. Among HIV-infected subjects, hospital admission, outpatient medical care, and having health insurance independently increased the odds of entering detoxification. After accounting for these and other variables, needle-exchange attendance also was associated independently with entering detoxification for both HIV-infected (adjusted odds ratio [AOR]=3.2) and uninfected IDUs (AOR=1.4). However, among HIV-infected subjects, the increased odds of detoxification associated with needle exchange diminished significantly over time, concomitant with statewide reductions in detoxification admissions. These findings indicate that health care providers and NEPs represent an important bridge to drug abuse treatment for HIV-infected and uninfected IDUs. Creating and sustaining these linkages may facilitate entry into drug abuse treatment and serve the important public health goal of increasing the number of drug users in treatment.

Directly observed therapy for the treatment of people with human immunodeficiency virus infection: a work in progress.

The principle of directly observed therapy (DOT) has its roots in the treatment of tuberculosis (TB), for which DOT programs have improved cure rates in hard-to-reach populations. Human immunodeficiency virus (HIV) and TB affect similar populations, and there are concerns about both regarding the development of drug resistance associated with poor adherence to therapy. Accordingly, DOT may benefit certain HIV-infected people who have difficulty adhering to highly active antiretroviral therapy. However, important differences exist in the treatment of these diseases that raise questions about how DOT can be adapted to HIV therapy. DOT for management of HIV infection has been effective among prisoners and in pilot programs in Haiti, Rhode Island, and Florida. Although DOT can successfully treat HIV infection in marginalized populations in the short term, a multitude of questions remain. This review provides an account of the preliminary development of DOT programs for the treatment of HIV-infected individuals.

Immunogenicity of a Monovalent 2009 Influenza A (H1N1) Vaccine in an Immunocompromised Population: A Prospective Study Comparing HIV-Infected Adults with HIV-Uninfected Adults

BACKGROUND Limited data exist on the immunogenicity of the 2009 influenza A (H1N1) vaccine among immunocompromised persons, including those with human immunodeficiency virus (HIV) infection. METHODS We compared the immunogenicity and tolerability of a single dose of the monovalent 2009 influenza A (H1N1) vaccine (strain A/California/7/2009H1N1) between HIV-infected and HIV-uninfected adults 18-50 years of age. The primary end point was an antibody titer of ≥ 1:40 at day 28 after vaccination in those with a prevaccination level of ≤ 1:10, as measured by hemagglutination-inhibition assay. Geometric mean titers, influenza-like illnesses, and tolerability were also evaluated. RESULTS One hundred thirty-one participants were evaluated (65 HIV-infected and 66 HIV-uninfected patients), with a median age of 35 years (interquartile range, 27-42 years). HIV-infected persons had a median CD4 cell count of 581 cells/mm(3) (interquartile range, 476-814 cells/mm(3)) , and 82% were receiving antiretroviral medications. At baseline, 35 patients (27%) had antibody titers of >1:10. HIV-infected patients (29 [56%] of 52), compared with HIV-uninfected persons (35 [80%] of 44), were significantly less likely to develop an antibody response (odds ratio, .20; P = .003). Changes in the median geometric mean titer from baseline to day 28 were also significantly lower in HIV-infected patients than in HIV-uninfected persons (75 vs 153; P = .001). Five influenza-like illnesses occurred (2 cases in HIV-infected persons), but none was attributable to the 2009 influenza H1N1 virus. The vaccine was well tolerated in both groups. CONCLUSIONS Despite high CD4 cell counts and receipt of antiretroviral medications, HIV-infected adults generated significantly poorer antibody responses, compared with HIV-uninfected persons. Future studies evaluating a 2-dose series or more-immunogenic influenza A (H1N1) vaccines among HIV-infected adults are needed (ClinicalTrials.gov NCT00996970).

A randomized clinical trial of community-based directly observed therapy as an adherence intervention for HAART among substance users.

Background:Adherence interventions for HAART can impact challenging populations, such as active substance users. Community-based modified directly observed therapy (MDOT) is a promising approach that needs to be critically evaluated. Methods:This study was a randomized clinical trial. HIV seropositive substance users were randomized to either standard of care (SOC) or MDOT, stratified by HAART experience. All participants were placed on a once-daily regimen and were met by an outreach worker for all 7 days during the first 3 months. We used an intent-to-treat analysis to evaluate differences in viral load suppression [> 2 log drop in plasma viral load (PVL) or PVL < 50] and changes in PVL and CD4 cell count from baseline to 3 months. Results:A total of 87 participants were enrolled (43 in SOC, 44 in MDOT), Using repeated measures logistic regression, MDOT participants were more likely to achieve PVL suppression (odds ratio, 2.16; 95% confidence interval, 1.0–4.7), driven primarily by those HAART experienced (odds ratio, 2.88; 95% confidence interval, 1.2–7.0). A significant treatment effect was also found in CD4 cell count change (P < 0.05). No differences were found by arm in undetectable PVL. Conclusion:This study provides evidence that MDOT is an effective strategy to reduce viral load and increase CD4 cell counts in HAART experienced substance users. MDOT should be included in the spectrum of options to enhance adherence in this population.

Physicians' Knowledge of and Willingness to Prescribe Naloxone to Reverse Accidental Opiate Overdose: Challenges and Opportunities

Naloxone, the standard treatment for heroin overdose, is a safe and effective prescription drug commonly administered by emergency room physicians or first responders acting under standing orders of physicians. High rates of overdose deaths and widely accepted evidence that witnesses of heroin overdose are often unwilling or unable to call 9-1-1 has led to interventions in several US cities and abroad in which drug users are instructed in overdose rescue techniques and provided a “take-home” dose of naloxone. Under current Food and Drug Administration (FDA) regulations, such interventions require physician involvement. As part of a larger study to evaluate the knowledge and attitudes of doctors towards providing drug treatment and harm reduction services to injection drug users (IDUs), we investigated physician knowledge and willingness to prescribe naloxone. Less than one in four of the respondents in our sample reported having heard of naloxone prescription as an intervention to prevent opiate overdose, and the majority reported that they would never consider prescribing the agent and explaining its application to a patient. Factors predicting a favorable attitude towards prescribing naloxone included fewer negative perceptions of IDUs, assigning less importance to peer and community pressure not to treat IDUs, and increased confidence in ability to provide meaningful treatment to IDUs. Our data suggest that steps to promote naloxone distribution programs should include physician education about evidence-based harm minimization schemes, broader support for such initiatives by professional organizations, and policy reform to alleviate medicolegal concerns associated with naloxone prescription. FDA re-classification of naloxone for over-the-counter sales and promotion of nasal-delivery mechanism for this agent should be explored.

Community-based programs for safe disposal of used needles and syringes

OBJECTIVES To review issues related to discarded syringes in the community and to describe community-based programs for the safe disposal of used needles and syringes. METHODS We used the medical literature and chain referral to identify community-based syringe disposal programs other than syringe exchange programs (SEPs). We held a workshop in June 1996 involving staff from disposal programs; manufacturers of syringes, sharps containers, and other disposal devices; solid waste companies; public health staff; and researchers. RESULTS Fifteen programs for the safe disposal of syringes were identified in the United States, Canada, and Australia. Of these, 12 primarily served persons with diabetes who use insulin, and 3 primarily served injection drug users (IDUs). The programs used three major strategies: puncture-resistant containers discarded in trash, community drop boxes, and sharps containers turned in for biohazard disposal at community sites, hospitals, or pharmacies. Participants in the workshop described key points in developing syringe disposal programs. Programs should involve pharmacists, physicians, waste disposal companies, public health departments, hospitals, diabetes educators, persons with diabetes who use insulin, and IDUs. For IDUs, criminal penalties for possession of syringes are a substantial deterrent to participation in community efforts to safely dispose of used syringes. The multiple and sometimes conflicting local, state, and federal laws and regulations concerning medical waste hinder development of multistate or national approaches to the safe disposal of syringes. More information is needed on community-based syringe disposal programs. CONCLUSION Communities in the United States, Canada, and Australia have developed different approaches to achieve safe disposal of used syringes.

Self-Treatment of Opioid Withdrawal with a Dietary Supplement, Kratom

We examined the use of Kratom (Mitragyna sp.), a dietary supplement with mu-opioid agonist activity, by members of a cybercommunity who self-treat chronic pain with opioid analgesics from Internet pharmacies. Within one year, an increase in the number of mentions on Drugbuyers.com, a Web site that facilitates the online purchase of opioid analgesics, suggested that members began managing opioid withdrawal with Kratom. This study demonstrates the rapidity with which information on psychoactive substances disseminates through online communities and suggests that online surveillance may be important to the generation of effective opioid analgesic abuse prevention strategies.