Racial/ethnic and income disparities in neighborhood-level broadband access in 905 US cities, 2017-2021.

OBJECTIVES: Broadband access is an essential social determinant of health, the importance of which was made apparent during the COVID-19 pandemic. We sought to understand disparities in broadband access within cities and identify potential solutions to increase urban access. STUDY DESIGN: This was a descriptive secondary analysis using multi-year cross-sectional survey data. METHODS: Data were obtained from the City Health Dashboard and American Community Survey. We studied broadband access in 905 large US cities, stratifying neighborhood broadband access by neighborhood median household income and racial/ethnic composition. RESULTS: In 2017, 30% of urban households across 905 large US cities did not have access to high-speed broadband internet. After controlling for median household income, broadband access in majority Black and Hispanic neighborhoods was 10-15% lower than in majority White or Asian neighborhoods. Over time, lack of broadband access in urban households decreased from 30% in 2017 to 24% in 2021, but racial and income disparities persisted. CONCLUSIONS: As an emerging social determinant, broadband access impacts health across the life course, affecting students' ability to learn and adults' ability to find and retain jobs. Resolving lack of broadband access remains an urban priority. City policymakers can harness recent infrastructure funding opportunities to reduce broadband access disparities.

Needle exchange use among a cohort of injecting drug users.

OBJECTIVE: To study prospectively injection behavior of injecting drug users (IDU) who did and did not utilize a local needle exchange in the Bronx, New York City. DESIGN: Since 1985, IDU attending a methadone maintenance program have been enrolled in a prospective study of HIV-related risk behaviors. Since 1989, when a needle exchange opened near the methadone program, data have been collected from study participants regarding utilization of the exchange. PARTICIPANTS: Study participants (n = 904) who injected between 1985 and 1993. RESULTS: Of 904 IDU, 21.9% used the needle exchange. Male gender [adjusted odds ratio (AOR), 1.57], HIV seropositivity (AOR, 1.39) and younger age (AOR per 10 years of age, 1.66) were independently associated with needle exchange attendance. The percentage injecting declined each year, preceding the opening of the needle exchange and concurrent with its operation (from 64.6% in 1985 to 43.6% in 1993). Among the 329 participants who injected in the year before the exchange opened, 1988, 53 out of 124 (42.7%) needle exchange users and 168 out of 205 (81.9%) non-users reduced or stopped injecting by 1993 (P < 0.001). Exchange users shared needles less than non-users (P < 0.05 in 1993). HIV infection was unrelated to these reductions in injection. CONCLUSIONS: Methadone-treated IDU with access to a needle exchange reduced injecting and needle-sharing. This pattern of harm reduction, which began at least 4 years before the needle exchange opened, occurred in both those who did and did not utilize the needle exchange. Needle exchange, as a strategy to reduce injection-related harm, should not be viewed as discordant with methadone treatment.

A prospective study of HIV disease progression in female and male drug users.

OBJECTIVE: To compare HIV disease progression and mortality in a cohort of female and male drug users. DESIGN: A prospective cohort study of 222 HIV-seropositive women and 302 HIV-seropositive men who attended a hospital-affiliated methadone maintenance program with on-site primary care. METHODS: Regression slopes of CD4+ cell decline were compared using the two sample t-test, and the distribution of AIDS-defining illnesses evaluated by Mantel-Haenszel chi2 test. Time to AIDS-defining clinical conditions and death were compared using the Kaplan-Meier log-rank test. Multivariate estimates of progression to clinical AIDS or death, for all participants, stratified by sex, were derived from Cox proportional hazards models. RESULTS: Ninety-five persons (43 women and 52 men) developed AIDS-defining conditions. Analyses of the rates of CD4+ cell decline, the distribution of first AIDS-defining illnesses, and the time to clinical AIDS did not differ by sex. In the multivariate model, sex was not associated with an AIDS outcome, whereas crack-cocaine use [hazards ratio (HR), 1.815; 95% confidence interval (CI), 1.151-2.863], CD4+ cell count (100 x 10(6)/l; HR, 0.589; 95% CI, 0.511-0.679), and two or more HIV-related symptoms (HR, 1.702; 95% CI, 1.125-2.576) were associated. Mortality rates (8.71 per 100 person-years in women and 9.85 per 100 person-years in men) were similar, using univariate or multivariate methods. CONCLUSIONS: There was little difference in clinical outcomes or mortality between HIV-seropositive female and male drug users with access to primary care. However, crack-cocaine use was independently associated with progression to clinical AIDS.

Effectiveness of isoniazid chemoprophylaxis for HIV-infected drug users at high risk for active tuberculosis.

OBJECTIVE: To define the effectiveness of chemoprophylaxis, outside of a clinical trial setting, in preventing tuberculosis among tuberculin-reactive and anergic HIV-infected drug users at high risk of developing active tuberculosis. DESIGN: An observational cohort study. SETTING: Methadone maintenance treatment program with on-site primary care. PARTICIPANTS: Current or former drug users enrolled in methadone treatment. INTERVENTIONS: Annual skin testing for tuberculosis infection and anergy was performed, and eligible patients were offered daily isoniazid for 12 months and followed prospectively. MAIN OUTCOME MEASURE: The development of active tuberculosis. RESULTS: A total of 155 persons commenced chemoprophylaxis. Among tuberculin reactors, tuberculosis rates were 0.51 and 2.07/100 person-years in those completing 12 months versus those not taking prophylaxis [rate ratio 0.25, 95% confidence interval (CI) 0.06-1.01]. Among anergic individuals, comparable rates were 0 and 1.44/100 person-years. Lower tuberculosis rates among completers were not attributable to differences in immune status between the treated and untreated groups. CONCLUSION: The completion of isoniazid chemoprophylaxis was associated with a marked reduction in tuberculosis risk among tuberculin reactors and anergic persons in this high-risk population. These data support aggressive efforts to provide a complete course of preventative therapy to HIV-infected tuberculin reactors, and lend weight to the findings of others that isoniazid can reduce the rate of tuberculosis in high-risk anergic HIV-infected persons.

Clinical predictors of Pneumocystis carinii pneumonia, bacterial pneumonia and tuberculosis in HIV-infected patients.

BACKGROUND: Clinicians are frequently faced with the differential diagnosis between Pneumocystis carinii pneumonia (PCP), bacterial pneumonia, and pulmonary tuberculosis in HIV-infected patients. OBJECTIVES: To identify features that could help differentiate these three pneumonia types at presentation by evaluating the clinical characteristics of the three diagnoses among patients at two urban teaching hospitals. DESIGN: Retrospective chart review. METHODS: Cases were HIV-infected patients with a verified hospital discharge diagnosis of PCP (n = 99), bacterial pneumonia (n = 94), or tuberculosis (n = 36). Admitting notes were reviewed in a standardized manner; univariate and multivariate analyses were used to determine clinical predictors of each diagnosis. RESULTS: Combinations of variables with the highest sensitivity, specificity, and odds ratios (OR) were as follows: for PCP, exertional dyspnea plus interstitial infiltrate (sensitivity 58%, specificity 92%; OR, 16.3); for bacterial pneumonia, lobar infiltrate plus fever < or = 7 days duration (sensitivity 48%, specificity 94%; OR, 14.6); and for tuberculosis, cough > 7 days plus night sweats (sensitivity 33%, specificity 86%; OR, 3.1). On regression analysis, independent predictors included interstitial infiltrate (OR, 10.2), exertional dyspnea (OR, 4.9), and oral thrush (OR, 2.9) for PCP; rhonchi on examination (OR, 12.4), a chart mention of 'toxic' appearance (OR, 9.1), fever < or = 7 days (OR, 6.6), and lobar infiltrate (OR, 5.8) for bacterial pneumonia; and cavitary infiltrate (OR, 21.1), fever > 7 days (OR, 3.9), and weight loss (OR, 3.6) for tuberculosis. CONCLUSIONS: Simple clinical variables, all readily available at the time of hospital admission, can help to differentiate these common pneumonia syndromes in HIV-infected patients. These findings can help to inform clinical decision-making regarding choice of therapy, use of invasive diagnostic procedures, and need for respiratory isolation.

Prevalence of peripheral neuropathy in injection drug users.

BACKGROUND: Nucleoside analogue reverse transcriptase inhibitors are a critical component of antiretroviral therapy in HIV-infected persons. Several of these medications cause painful, dose-limiting peripheral neuropathy (PN), which may develop earlier and more intensely in persons with preexisting neuropathy. The prevalence of baseline peripheral neuropathy in injection drug users (IDUs), one of the largest populations of HIV-infected persons, has not been described, yet has important implications for the selection of antiretroviral therapy. METHODS: The authors performed a cross-sectional study of PN in 212 HIV-seronegative and HIV-seropositive IDUs using detailed neurologic histories, physical examinations, quantitative electrophysiologic study, and quantitative sensory testing. Data were used to assign patients to one of four positive categories of PN or one of two negative categories. RESULTS: PN was present in 24.5% of HIV-seronegative IDUs, three to four times the reported frequency for HIV-seronegative persons in the general or male homosexual population. PN was present in 32.1% of HIV-seropositive patients. PN was axonal in nature and associated with increased age and alcohol use. PN was asymptomatic in 81% of HIV-seronegative and 71% of HIV-seropositive patients with PN. CONCLUSIONS: There is a high prevalence of PN in HIV-seronegative IDUs. Although these PNs do not seem to predispose HIV-seropositive IDUs to HIV-related PN, they may increase the likelihood of iatrogenic neuropathy. Intravenous drug users may need more diligent monitoring when administered nucleoside analogues than patients in risk groups with lower endemic rates of PN.

Humoral immune response to polymorphic epithelial mucin (MUC-1) in patients with benign and malignant breast tumours.

To investigate the clinical significance of an immune response to the MUC-1 encoded polymorphic epithelial mucin (PEM) breast cancer, circulating immune complexes containing PEM (PEM.CIC) were measured in sera from 96 healthy women, in pretreatment serum samples from 40 patients with benign breast tumours and from 140 patients with breast cancer and in serum samples from 61 breast cancer patients with recurrent or progressive disease. PEM.CIC were measured using a sandwich enzyme-linked immunoassay, and PEM serum levels were measured with CA 15.3 IRMA (Centocor Inc., Malvern, Pennsylvania, U.S.A.). Cut-off levels used for PEM.CIC and CA 15.3 were 120 Optical Density Units (O.D.) x 10(3) and 30 U/ml, respectively. In benign tumours, positivity for PEM.CIC was 37.5% (15/40). 36 of the 140 patients (25.7%) in the breast cancer pretreatment group had elevated PEM.CIC values. In patients with advanced metastatic disease, positivity for PEM.CIC was 18% (11/61). PEM.CIC was elevated in 32% (24/74) of node-negative patients, but only in 20% (12/59) of node-positive patients and absolute values were higher in node-negative patients (Mann-Whitney U test, two-tailed P = 0.0168). There was an inverse correlation between positivity for PEM.CIC and extent of disease: while 3 of the 6 patients with a carcinoma in situ were positive, only 1 of the 15 patients with more than five nodes involved had elevated levels of PEM.CIC. All 7 patients with distant metastases at first diagnosis were PEM.CIC negative. 28 out of 133 patients had a recurrence during the observation period (median 55 months, range 27-84 months). 23 of these 28 patients (82%) were PEM.CIC negative at the moment of first diagnosis. None of the patients with pretreatment elevation of both PEM.CIC and CA 15.3 (n = 13) relapsed. Our preliminary clinical results suggest that a humoral immune response to PEM protects against disease progression, and further support the idea of using synthetic peptides or glycopeptides containing the immunogenic core of the mucin as cancer vaccines.

Self-assessment of tuberculin skin test reactions by drug users with or at risk for human immunodeficiency virus infection.

SETTING: Self-assessment of tuberculin test results, if accurate, could enhance tuberculosis screening efforts by reducing the need for follow-up visits for skin test reading. We investigated tuberculin test self-assessment in a longitudinal study of tuberculosis infection among drug users. OBJECTIVE: To determine the accuracy of tuberculin reaction self-assessment by drug users at high risk for tuberculosis infection. DESIGN: Two readings were compared of the same skin test, performed 48-72 hours after placement: 1) self-assessment using a simple yes-no approach to induration, versus 2) trained examiner reading. Self-assessments were performed immediately prior to trained examiner readings. RESULTS: Participants were 137 human immunodeficiency virus (HIV) seropositive and 344 HIV-seronegative current and former drug users. Ten per cent (35/344) of reactions read by participants as 'flat' were read by trained examiners as > or =5 mm (54% of which were > or =10 mm). Twenty-three per cent (19/82) of reactions read by trained examiners as > or =10 mm and 32% (35/110) of reactions read by trained examiners as being > or =5 mm were self-read by participants as 'flat'. Sensitivity (0.68) and specificity (0.83) of self-read tuberculin reactions were sub-optimal. Inter-reader reliability was poorer between participants and trained examiners than between trained examiners. CONCLUSION: Self-assessments of tuberculin skin test responses by drug users with or at risk for HIV infection are not reliable.

Cost-effectiveness of directly observed chemoprophylaxis of tuberculosis among drug users at high risk for tuberculosis.

SETTING: A methadone treatment program with on-site medical care in the Bronx, New York. OBJECTIVE: To define whether costs associated with directly observed preventive therapy (DOPT) of tuberculosis are justified by cases and costs of tuberculosis prevented among persons at high risk for active disease. DESIGN: Detailed data were collected on drug users in treatment regarding human immunodeficiency virus (HIV) and tuberculosis infection and disease, and costs of screening, chemoprophylaxis, direct observation and treatment of active disease. The cost-effectiveness of providing DOPT to this population was modeled. RESULTS: We assessed the impact of providing DOPT to 151 eligible persons. Assuming 65% isoniazid effectiveness, and incorporating costs of screening, observed chemoprophylaxis and clinical monitoring, a net savings in tuberculosis-related hospital costs of $285,284 ($563 per person screened) was associated with DOPT ($10,274 per case prevented). Direct observation of chemoprophylaxis proved cost-effective if associated with even a 10% increment in overall isoniazid effectiveness compared with self-administered chemoprophylaxis. DOPT costs per tuberculosis case averted remained below the in-patient costs of a single case of drug-sensitive disease across a range of parameter values. CONCLUSIONS: Providing DOPT is a highly cost-effective intervention for drug users in treatment. Commitment of additional resources required for DOPT should be given priority in this and other populations at high risk for tuberculosis.

The incidence of tuberculosis in drug users with small tuberculin reaction sizes.

SETTING: In persons infected with the human immunodeficiency virus (HIV), a decreased tuberculin reaction cut-point of > or = 5 mm induration is recommended. OBJECTIVE: To determine tuberculosis risk in non-anergic HIV-infected persons with 5-9 mm tuberculin reactions. DESIGN: A prospective study with semi-annual tuberculin and anergy testing, HIV antibody and T cell subset assays, and active surveillance for tuberculosis. RESULTS: Participants were 572 HIV-seronegative and 241 HIV-seropositive non-anergic drug users. No tuberculosis occurred in HIV-seronegative persons. Tuberculosis incidence among HIV-seropositive drug users was 3.3, 7.7, 0, and 0.34 per 100 person-years in those with tuberculin reaction sizes of > or = 10 mm, 5-9 mm, 1-4 mm, and 0 mm, respectively, and was significantly increased in persons with 5-9 mm induration compared with those with 0-4 mm induration (rate ratio 27.7, 95%CI 2.9-268). Among persons with reaction sizes of 5-9 mm, tuberculosis occurred exclusively in those with CD4+ lymphocyte counts <500/mm3 at the time of their 5-9 mm tuberculin reactions. CONCLUSION: HIV-infected persons with tuberculin reaction sizes of 5-9 mm are at increased risk for tuberculosis compared to non-anergic persons with smaller (0-4 mm) reaction sizes. However, this increased risk may be limited to those with low CD4+ lymphocyte counts at the time of tuberculin testing.

The epidemiology of HIV and AIDS. Current trends.

Nationally and globally the HIV/AIDS pandemic shows little sign of abating as it arrives at the midpoint of its second decade. In many communities, however, successful steps have been taken to limit its progression. The challenge of the years ahead lies in engaging individuals and communities to join in arresting and ultimately reversing the tide of this plague.

Overview of HIV and AIDS: biology and epidemiology of the virus.

HIV-1 infects mononuclear cells using the CD4+ molecule and the chemical receptors of those cells. After a prolonged clinical latency period, the ability to replace destroyed cells is outpaced by ongoing cellular destruction, leading to the characteristic immunodeficiency of AIDS and its opportunistic infections and neoplasms. In the United States, the number of new cases of AIDS has diminished in recent years, although in some groups, such as women, the number of new cases continues to rise. In the developing world, AIDS remains a pandemic of huge proportions. In the absence of an effective vaccine, culturally appropriate efforts at education and behavior modification offer the best hope of controlling AIDS.

Interactions between methadone and medications used to treat HIV infection: a review.

BACKGROUND: It is critical for providers caring for HIV-positive methadone recipients to have accurate information on pharmacologic interactions between methadone and antiretroviral therapy. If providers do not have these data, symptoms of narcotic withdrawal or excess due to medication interactions may be mismanaged, and antiretroviral regimens may be suboptimal in efficacy or associated with increased side effects and toxicities. This review was undertaken to clarify what is known about interactions between pharmacotherapies of opiate dependence and HIV-related medications, to suggest clinically useful approaches to these issues, and to outline areas which need further study. METHOD: A search for relevant published papers and abstracts presented at scientific meetings was conducted using electronic databases. These documents were obtained and reviewed, and additional publications referenced in them were also reviewed. RESULTS: Pharmacokinetic interactions between methadone and zidovudine, didanosine, stavudine, abacavir, nevirapine, efavirenz and nelfinavir have been documented. The mechanisms, clinical implications and management of these interactions are reviewed. CONCLUSIONS: Interactions between methadone and some HIV-related medications are known to occur, yet their characteristics cannot reliably be predicted based on current understanding of metabolic enzyme induction and inhibition, or through in vitro studies. Only carefully designed and conducted pharmacologic studies involving human subjects can help us define the nature of the interactions between methadone (and other pharmacotherapies for opiate dependence) and specific HIV-related medications. Clinicians must be aware of known interactions and be alert to the possibility that interactions which are still undocumented may be present among their patients.

Three oral formulations of methadone. A clinical and pharmacodynamic comparison.

This study was done to determine whether there were any differences in subjective symptoms of opiate withdrawal or methadone pharmacodynamics among patients as they were switched between three different oral formulations of methadone. Patients enrolled in a three-way double-blind crossover trial of three methadone formulations. Subjective symptoms and pharmacodynamic measures were assessed throughout the study period. Eighteen patients were enrolled the study. No statistically significant differences in any of the pharmacodynamic parameters studied were found among the three methadone preparations. There was no significant difference among preparations in the rate and extent of rise and fall in plasma methadone levels during a 24-hour intensive sampling period. Subjective symptoms also did not correlate with methadone formulation. Intolerance to changes in methadone formulation, often observed clinically, do not appear to have a pharmacodynamic basis. Our findings support the notion that such change intolerance reflects factors other than the pharmacologic properties of the different formulations of methadone.

Integrating primary care and methadone maintenance treatment: implementation issues.

Linking primary medical care with methadone maintenance treatment brings critical services to drug users, many with HIV/AIDS, tuberculosis and other illnesses. However, a variety of important philosophical, ethical, and systems issues may impede the process of implementing a "linked" service delivery model. Conflicting paradigms, such as the traditional "doctor-patient" relationship with its emphasis on continuity of care and the substance abuse treatment model of limit-setting and behavioral consequences, create tension in the treatment system. This article describes these tensions and uses clinical vignettes to demonstrate how to address these implementation issues. In conclusion, solutions are proposed for successfully integrating services for medically ill substance abusers.

Successful adherence to observed prophylaxis and treatment of tuberculosis among drug users in a methadone program.

Incomplete antituberculous chemoprophylaxis and treatment are major causes of the resurgence of tuberculosis, often drug-resistant, among drug users. We offered directly observed antituberculous chemoprophylaxis (n = 102) or treatment (n = 12) to tuberculous chemoprophylaxis (n = 102) or treatment (n = 12) to eligible methadone maintenance treatment patients. Methadone dosing was not contingent upon ingestion of antituberculous medication(s). No material incentives were provided. Ninety (88%) prophylaxis and 9 (75%) treatment patients were administered > or = 5 weekly doses of antituberculous medications during > or = 80% of 4740 patient-weeks. The majority of patients were HIV-seropositive. Active substance abuse was not associated with diminished adherence. Over 80% of patients completed or were still receiving therapy at the end of the study. Adherence to and completion of directly observed antituberculous therapy can thus be attained by drug users in treatment, despite ongoing drug misuse. Substance abuse treatment programs provide opportunities for enhanced compliance, and should thus be viewed as critical components of strategies to address the tuberculosis epidemic in drug users.

Methadone and antiretroviral medications, part I.

AIDS: The interactions of Methadone with NRTIs and NNRTIs are presented in the first of a two-part article. Methadone is an effective treatment for heroin addiction; however, insufficient information is available on its interactions with HAART. Methadone is metabolized by the cytochrome P450 system, and NRTIs do not appear to be inducers or inhibitors of the cytochrome P450 system. Pharmacokinetics between Methadone and AZT have been studied in detail, and AZT appears to have no effect on plasma Methadone levels. However, NNRTIs do share metabolic pathways with Methadone, indicating that important interactions between Methadone and these drugs are possible, but formal study is still needed. A table of current information is presented on NRTI and NNRTI interactions with Methadone.^ieng

Methadone and antiretroviral medications, part II.

AIDS: The second installment in a two-part series on Methadone and antiretroviral medications is presented. The use of methadone and potential drug interactions between Methadone and anti-HIV medications are reviewed. Several studies about drug interactions, other substance-abuse therapies and opiates, and the future direction of antiretroviral and opiate interaction studies are discussed. Physicians are advised to consider the potential effects of Methadone on HIV-related medications when designing a treatment regimen.^ieng

[Charles Durand, Charles Daremberg and Gérard Marchant, or the patient, the historian of medicine and the psychiatrist]. / Charles Durand, Charles Daremberg et Gérard Marchant, ou le malade, l'historien de la médecine et le psychiatre.

Between 1850 and 1870, a pathetic patient by the name of Charles Durand meets the famous historian of medicine Charles Daremberg and the dedicated psychiatrist Georges Marchant. Thus, relying upon every day life events, the authors tell the story of French psychiatry for the generation that came after the 1838 law on Mental Patient Care.