Lois Eldred

Results From a Randomized Controlled Trial of a Peer-Mentoring Intervention to Reduce HIV Transmission and Increase Access to Care and Adherence to HIV Medications Among HIV-Seropositive Injection Drug Users

Background:There is a lack of effective behavioral interventions for HIV-positive injection drug users (IDUs). We sought to evaluate the efficacy of an intervention to reduce sexual and injection transmission risk behaviors and to increase utilization of medical care and adherence to HIV medications among this population. Methods:HIV-positive IDUs (n = 966) recruited in 4 US cities were randomly assigned to a 10-session peer mentoring intervention or to an 8-session video discussion intervention (control condition). Participants completed audio computer-assisted self-interviews and had their blood drawn to measure CD4 cell count and viral load at baseline and at 3-month (no blood), 6-month, and 12-month follow-ups. Results:Overall retention rates for randomized participants were 87%, 83%, and 85% at 3, 6, and 12 months, respectively. Participants in both conditions reported significant reductions from baseline in injection and sexual transmission risk behaviors, but there were no significant differences between conditions. Participants in both conditions reported no change in medical care and adherence, and there were no significant differences between conditions. Conclusions:Both interventions led to decreases in risk behaviors but no changes in medical outcomes. The characteristics of the trial that may have contributed to these results are examined, and directions for future research are identified.

Health services utilization for people with HIV infection : Comparison of a population targeted for outreach with the U.S. population in care

Background:Many persons with HIV infection do not receive consistent ambulatory medical care and are excluded from studies of patients in medical care. However, these hard-to-reach groups are important to study because they may be in greatest need of services. Objective:This study compared the sociodemographic, clinical, and health care utilization characteristics of a multisite sample of HIV-positive persons who were hard to reach with a nationally representative cohort of persons with HIV infection who were receiving care from known HIV providers in the United States and examined whether the independent correlates of low ambulatory utilization differed between the 2 samples. Methods:We compared sociodemographic, clinical, and health care utilization characteristics in 2 samples of adults with HIV infection: 1286 persons from 16 sites across the United States interviewed in 2001–2002 for the Targeted HIV Outreach and Intervention Initiative (Outreach), a study of underserved persons targeted for supportive outreach services; and 2267 persons from the HIV Costs and Services Utilization Study (HCSUS), a probability sample of persons receiving care who were interviewed in 1998. We conducted logistic regression analyses to identify differences between the 2 samples in sociodemographic and clinical associations with ambulatory medical visits. Results:Compared with the HCSUS sample, the Outreach sample had notably greater proportions of black respondents (59% vs. 32%, P = 0.0001), Hispanics (20% vs. 16%), Spanish-speakers (9% vs. 2%, P = 0.02), those with low socioeconomic status (annual income <

Interventions for Seropositive injectors-research and evaluation: An integrated behavioral intervention with HIV-positive injection drug users to address medical care, adherence, and risk reduction

10,000 75% vs. 45%, P = 0.0001), the unemployed, and persons with homelessness, no insurance, and heroin or cocaine use (58% vs. 47%, P = 0.05). They also were more likely to have fewer than 2 ambulatory visits (26% vs. 16%, P = 0.0001), more likely to have emergency room visits or hospitalizations in the prior 6 months, and less likely to be on antiretroviral treatment (82% vs. 58%, P = 0.0001). Nearly all these differences persisted after stratifying for level of ambulatory utilization (fewer than 2 vs. 2 or more in the last 6 months). In multivariate analysis, several variables showed significantly different associations in the 2 samples (interacted) with low ambulatory care utilization. The variables with significant interactions (P values for interaction shown below) had very different adjusted odds ratios (and 95% confidence intervals) for low ambulatory care utilization: age greater than 50 (Outreach 0.55 [0.35–0.88], HCSUS 1.17 [0.65–2.11)], P = 0.05), Hispanic ethnicity (Outreach 0.81 [0.39–1.69], HCSUS 2.34 [1.56–3.52], P = 0.02), low income (Outreach 0.73 [0.56–0.96], HCSUS 1.35 [1.04–1.75], P = 0.002), and heavy alcohol use (Outreach 1.74 [1.23–2.45], HCSUS 1.00 [0.73–1.37], P = 0.02). Having CD4 count less than 50 was associated with elevated odds of low ambulatory medical visits in the Outreach sample (1.53 [1.00–2.36], P = 0.05). Conclusions:Compared with HCSUS, the Outreach sample had far greater proportions of traditionally vulnerable groups, and were less likely to be in care if they had low CD4 counts. Furthermore, heavy alcohol use was only associated with low ambulatory utilization in Outreach. Generalizing from in care populations may not be warranted, while addressing heavy alcohol use may be effective at improving utilization of care for hard-to-reach HIV-positive populations.

Individual, Interpersonal, and Structural Correlates of Effective Haart Use Among Urban Active Injection Drug Users

BackgroundBehavioral interventions to address the complex medical and HIV risk reduction needs of HIV-seropositive (HIV-positive) injection drug users (IDUs) are urgently needed. We describe the development of Interventions for Seropositive Injectors—Research and Evaluation (INSPIRE), a randomized controlled trial of an integrated intervention for HIV-positive IDUs, and the characteristics of the baseline sample. MethodsHIV-positive IDUs were recruited from community settings in 4 US cities. After completing a baseline assessment, participants who attended the first session were randomly assigned to (1) a 10-session peer mentoring intervention designed to improve utilization of HIV care, to improve adherence to HIV medications, and to reduce sexual and injection risk or (2) an 8-session videotape control. Periodic follow-up for 12 months is ongoing. ResultsA total of 1161 HIV-positive IDUs completed the baseline assessment, and 966 (83%) were randomized. Retention rates are greater than 80% for all follow-up periods. Approximately 79% of baseline participants reported a recent medical visit, 49% were taking highly active antiretroviral therapy, and 19% had an undetectable viral load. Use of injection and noninjection substances was prevalent, and sexual and injection risks were each reported by more than 25% of participants. ConclusionThere is a need for an integrated intervention for HIV-positive IDUs, and these data show the acceptability of such an approach.

Antiretroviral use among active injection-drug users: the role of patient-provider engagement and structural factors.

Summary: Among individuals receiving highly active antiretroviral therapy (HAART), injection drug users (IDUs) are less likely to achieve HIV suppression. The present study examined individual-level, interpersonal, and structural factors associated with achieving undetectable plasma viral load (UVL) among US IDUs receiving recommended HAART. Data were from baseline assessments of the INSPIRE (Interventions for Seropositive Injectors-Research and Evaluation) study, a 4-site, secondary HIV prevention intervention for heterosexually active IDUs. Of 1113 study participants at baseline, 42% (n = 466) were currently taking recommended HAART (34% were female, 69% non-Hispanic black, 26% recently homeless; median age was 43 years), of whom 132 (28%) had a UVL. Logistic regression revealed that among those on recommended HAART, adjusted odds of UVL were at least 3 times higher among those with high social support, stable housing, and CD4 > 200; UVL was approximately 60% higher among those reporting better patient-provider communication. Outpatient drug treatment and non-Hispanic black race and an interaction between current drug use and social support were marginally negatively significant. Among those with high perceived support, noncurrent drug users compared with current drug users had a greater likelihood of UVL; current drug use was not associated with UVL among those with low support. Depressive symptoms (Brief Symptom Inventory) were not significant. Results suggest the major role of social support in facilitating effective HAART use in this population and suggest that active drug use may interfere with HAART use by adversely affecting social support. Interventions promoting social support functioning, patient-provider communication, stable housing, and drug abuse treatment may facilitate effective HAART use in this vulnerable population.

Integration of pharmacotherapy for opioid addiction into HIV primary care for HIV/hepatitis C virus-co-infected patients.

HIV-seropositive, active injection-drug users (IDUs), compared with other HIV populations, continue to have low rates of highly active antiretroviral therapy (HAART) use, contributing to disparities in their HIV health outcomes. We sought to identify individual-level, interpersonal, and structural factors associated with HAART use among active IDUs to inform comprehensive, contextually tailored intervention to improve the HAART use of IDUs. Prospective data from three semiannual assessments were combined, and logistic general estimating equations were used to identify variables associated with taking HAART 6 months later. Participants were a community sample of HIV-seropositive, active IDUs enrolled in the INSPIRE study, a U.S. multisite (Baltimore, Miami, New York, San Francisco) prevention intervention. The analytic sample included 1,225 observations, and comprised 62% males, 75% active drug users, 75% non-Hispanic blacks, and 55% with a CD4 count <350; 48% reported HAART use. Adjusted analyses indicated that the later HAART use of IDUs was independently predicted by patient-provider engagement, stable housing, medical coverage, and more HIV primary care visits. Significant individual factors included not currently using drugs and a positive attitude about HAART benefits even if using illicit drugs. Those who reported patient-centered interactions with their HIV primary care provider had a 45% greater odds of later HAART use, and those with stable housing had twofold greater odds. These findings suggest that interventions to improve the HIV treatment of IDUs and to reduce their HIV health disparities should be comprehensive, promoting better patient-provider engagement, stable housing, HAART education with regard to illicit drug use, and integration of drug-abuse treatment with HIV primary care.

Isoniazid preventive therapy for HIV-infected people: evidence to support implementation.

Pharmacotherapy for substance abuse is a rapidly evolving field comprising both old and new effective treatments for substance use. Opiate agonist therapy has been shown to diminish and often eliminate opiate use. This behavior change has resulted in the reduced transmission of many infections, including HIV, hepatitis C virus (HCV), and an enhanced quality of life. For the past 35 years, the provision of opioid agonist therapy has been limited to opioid treatment programmes. Opioid treatment programmes treat approximately 200 000 of the estimated million opiate-addicted individuals in the United States. With the need to increase the number of treatment opportunities available for opioid-dependent patients, Congress passed the Drug Addiction Treatment Act of 2000, which allows for the treatment of opioid dependence using buprenorphine by a properly licensed physician, including HIV primary care physicians. The integration of buprenorphine treatment for opioid addiction into HIV primary care thus provides a new treatment paradigm to address substance abuse in patients with HIV and HCV infections.

Evaluation of a statewide non-name-based HIV surveillance system.

Tuberculosis (TB) is a common and deadly disease in people living with HIV worldwide. In most HIV prevalent countries, HIV is the predominant driver of the TB epidemic. Decades of progress in TB control have been reversed or slowed by failure to identify, prevent and treat TB in HIV-infected persons, their family and communities. Although successful antiretroviral therapy (ART) reduces TB risk, opportunities for detection and prevention of TB in HIV care settings are often missed. In countries with high TB and HIV burdens, the World Health Organization recommends intensified TB case finding, isoniazid preventive therapy (IPT) and infection control for TB, which are branded as the three I’s for HIV/ TB [1,2]. Comstock et al. [3] conducted the first trials of community-wide IPT in Bethel, Alaska, in the 1950s and 1960s, demonstrating a 70% reduction in TB incidence with widespread provision of isoniazid. Recommendations for use of IPT for persons with HIV infection were first made by International Union Against Tuberculosis and Lung Disease (IUATLD) and WHO in 1993 [4], revised in 1998 [5] and further strengthened in 2004 [2]. The WHO issued new evidence-based guidelines that reconceptualized IPTand combined it with TB screening in 2010 [6]. Yet in the 2009 WHO TB Control Report, the WHO estimates that fewer than 0.5% of HIV-infected persons worldwide have received IPT [7].

Antiretroviral therapy, interferon sensitivity, and virologic setpoint in human immunodeficiency virus/hepatitis C virus coinfected patients

Recent advances in AIDS-related therapies have delayed the onset of AIDS-defining illnesses and reduced the usefulness of AIDS surveillance in assessing the incidence of early HIV disease and estimating future needs of the HIV-infected population. These changes have prompted renewed interest in expanding surveillance to include HIV and have engendered national debate on whether an HIV surveillance system should be based on reports of the names of infected individuals or employ non-name-based data codes. In 1994, the state of Maryland implemented a program to require HIV surveillance by unique identifier (UI) patient code. This evaluation of Marylands program found that when complete, the 12-digit UI number provided a virtually unduplicated count 99.8% unique, was 99.9% unique with only the last four digits of the U.S. government Social Security Number (SSN), date of birth (DOB), and race, and 77.7% unique if the last four digits of the SSN were missing. Health care providers were willing to create the UI, with DOB and gender present 98.3% and 98.8% of the time, race was complete 84.1% and last four digits of SSN were complete 72.4%. The overall completeness of reporting for HIV tests was 87.8%.and 84.8%, respectively, using different methodologies. Evidence from the Maryland UI evaluation demonstrates that a non-name-based system can provide accurate, timely and valid data concerning the scope of the HIV epidemic, without the creation of state-wide name-based registry.

Factors associated with the successful implementation of a quality improvement project in human immunodeficiency virus ambulatory care clinics.

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) cause substantial mortality, especially in persons chronically infected with both viruses. HIV infection raises plasma HCV RNA levels and diminishes the response to exogenous alpha interferon (IFN). The degree to which antiretroviral therapy (ART) control of infection overcomes these HIV effects is unknown. Participants with HIV‐HCV coinfection were enrolled in a trial to measure HCV viral kinetics after IFN administration (ΔHCVIFN) twice: initially before (pre‐ART) and then after (post‐ART) HIV RNA suppression. Liver tissue was obtained 2‐4 hours before each IFN injection to measure interferon stimulated genes (ISGs). Following ART, the ΔHCVIFN at 72 hours (ΔHCVIFN,72) increased in 15/19 (78.9%) participants by a median (interquartile range [IQR]) of 0.11 log10 IU/mL (0.00‐0.40; P < 0.05). Increases in ΔHCVIFN,72 post‐ART were associated with decreased hepatic expression of several ISGs (r = −0.68; P = 0.001); a 2‐fold reduction in a four‐gene ISG signature predicted an increase in ΔHCVIFN,72 of 0.78 log10 IU/mL (95% confidence interval [CI] 0.36,1.20). Pre‐ and post‐ART ΔHCVIFN,72 were closely associated (r = 0.87; P < 0.001). HCV virologic setpoint also changed after ART (ΔHCVART): transient median increases of 0.28 log10 IU/mL were followed by eventual median decreases from baseline of 0.21 log10 IU/mL (P = 0.002). A bivariate model of HIV RNA control (P < 0.05) and increased expression of a nine‐gene ISG signature (P < 0.001) predicted the eventual decreased ΔHCVART. Conclusion: ART is associated with lower post‐IFN HCV RNA levels and that change is linked to reduced hepatic ISG expression. These data support recommendations to provide ART prior to IFN‐based treatment of HCV and may provide insights into the pathogenesis of HIV‐HCV coinfection. (Hepatology 2014;60:477–486)