Older adults' experiences with using information and communication technology and tech support services in New York City: findings and recommendations for post-pandemic digital pedagogy for older adults.

Introduction: Although Information and Communication Technology (ICT) has great potential to help older adults cope with challenges associated with aging, the intended benefits of ICT are not always realized in this population due to access barriers and low digital literacy. During the COVID-19 pandemic, numerous tech support initiatives for older adults got underway. However, evaluation of the effectiveness of these initiatives is less common. This research partnered with a large, multi-service organization in New York City that gave some groups of their clients ICT devices, unlimited broadband, and access to technology training in response to COVID-19 lockdowns. This study investigates older adults' experiences with ICT and ICT support services to better inform the existing and emerging tech support for older adults during and beyond the pandemic. Methods: Data were obtained from interviewer-administered surveys of 35 older adult recipients of ICT devices, connectivity, and training in New York City. The average age was 74 years (range = 55-90 years). The group was diverse regarding race/ethnicity (Black 29%, Latino 19%, White 43%). All had low incomes. Surveys consisted of multiple-choice items and open-ended responses. Results: The study found that one size does not fit all when it comes to ICT training and support for older adults. While connection to devices and services and tech support led to a degree of ICT adoption, the newly learned skills did not always lead to expanded device usage. The readily available tech support training and support do not guarantee service utilization, as success with tech services is related to one's pre-existing ICT competence. Discussion: The study concludes that customized training based on individuals' skills rather than age is needed. Tech support training should start by understanding an individual's interests and incorporate tech education to help users identify a wide range of existing and emerging online services that can meet their needs. Service organizations should consider including an assessment of ICT access, use, and skills into their standard intake protocols to ensure effective service delivery.

Taking Charge: Social Support Dynamics among Older Adults and Their Significant Others in COVID-19 Vaccination and Mitigation Efforts.

Older people have been disproportionately affected by the COVID-19 pandemic and are often portrayed as passive victims of this global health crisis. However, older adults do take responsibility for their own health and that of others in large part through social network dynamics. The purpose of this study was to understand the processes whereby older adults' social networks shape their own health behaviors, and vice versa, in the context of COVID-19 vaccination and other mitigation efforts. Qualitative data from 77 older adults between ages 65 and 94 obtained through focus groups or individual interview participants were analyzed. Participant narratives demonstrated the reciprocal nature of social support and health behaviors and provided evidence that COVID-19-related health behaviors in this population were motivated by social support, altruism, and life experience. These findings emphasize older adults' active role as health promoters in their families and communities, keeping themselves and their significant others safe from COVID infection. Implications for the role of older adults in community health promotion efforts are discussed.

Grape ASR Regulates Glucose Transport, Metabolism and Signaling.

To decipher the mediator role of the grape Abscisic acid, Stress, Ripening (ASR) protein, VvMSA, in the pathways of glucose signaling through the regulation of its target, the promoter of hexose transporter VvHT1, we overexpressed and repressed VvMSA in embryogenic and non-embryogenic grapevine cells. The embryogenic cells with organized cell proliferation were chosen as an appropriate model for high sensitivity to the glucose signal, due to their very low intracellular glucose content and low glycolysis flux. In contrast, the non-embryogenic cells displaying anarchic cell proliferation, supported by high glycolysis flux and a partial switch to fermentation, appeared particularly sensitive to inhibitors of glucose metabolism. By using different glucose analogs to discriminate between distinct pathways of glucose signal transduction, we revealed VvMSA positioning as a transcriptional regulator of the glucose transporter gene VvHT1 in glycolysis-dependent glucose signaling. The effects of both the overexpression and repression of VvMSA on glucose transport and metabolism via glycolysis were analyzed, and the results demonstrated its role as a mediator in the interplay of glucose metabolism, transport and signaling. The overexpression of VvMSA in the Arabidopsis mutant abi8 provided evidence for its partial functional complementation by improving glucose absorption activity.

Overexpression of ABI5 Binding Proteins Suppresses Inhibition of Germination Due to Overaccumulation of DELLA Proteins.

Abscisic acid (ABA) and gibberellic acid (GA) antagonistically regulate many aspects of plant growth, including seed dormancy and germination. The effects of these hormones are mediated by a complex network of positive and negative regulators of transcription. The DELLA family of proteins repress GA response, and can promote an ABA response via interactions with numerous regulators, including the ABA-insensitive (ABI) transcription factors. The AFP family of ABI5 binding proteins are repressors of the ABA response. This study tested the hypothesis that the AFPs also interact antagonistically with DELLA proteins. Members of these protein families interacted weakly in yeast two-hybrid and bimolecular fluorescence complementation studies. Overexpression of AFPs in sleepy1, a mutant that over-accumulates DELLA proteins, suppressed DELLA-induced overaccumulation of storage proteins, hyperdormancy and hypersensitivity to ABA, but did not alter the dwarf phenotype of the mutant. The interaction appeared to reflect additive effects of the AFPs and DELLAs, consistent with action in convergent pathways.

ABI5 binding protein2 inhibits ABA responses during germination without ABA-INSENSITIVE5 degradation.

Overexpression of ABA-INSENSITIVE5 binding proteins (AFPs) results in extreme ABA resistance of seeds and failure to acquire desiccation tolerance, at least in part through effects on chromatin modification. We tested the hypothesis that AFPs promote germination in Arabidopsis (Arabidopsis thaliana) by also functioning as adapters for E3 ligases that ubiquitinate ABI5, leading to its degradation. Interactions between AFPs and two well-characterized classes of E3 ligases targeting ABI5, DWD HYPERSENSITIVE TO ABA (DWA)s and KEEP ON GOING, were analyzed by yeast two-hybrid, bimolecular fluorescence complementation, and genetic assays. Although weak direct interactions were detected between AFPs and E3 ligases, loss of function for these E3 ligases did not impair ABA-resistance conferred by overexpression of the YFP-AFP2 fusion. Comparison of ABI5 and AFP2 levels in these lines showed that AFP2 accumulation increased during germination, but that ABI5 degradation followed germination, demonstrating that AFP2 overexpression reduces ABA sensitivity, thereby permitting germination prior to ABI5 degradation. Surprisingly, AFP2 overexpression in the dwa1 dwa2 mutant background produced the unusual combination of extreme ABA resistance and desiccation tolerance, creating an opportunity to separate the underlying biochemical characteristics of ABA sensitivity and desiccation tolerance. Our quantitative proteomics analysis identified at least three-fold more differentially accumulated seed proteins than previous studies. Comparison of dry seed proteomes of wild-type or dwa1 dwa2 mutants with or without AFP2 overexpression allowed us to separate and refine the changes in protein accumulation patterns associated with desiccation tolerance independently of ABA sensitivity, or vice versa, to a subset of cold-induced and defense stress-responsive proteins and signaling regulators.

Phosphorylation of Serine 114 of the transcription factor ABSCISIC ACID INSENSITIVE 4 is essential for activity.

The transcription factor ABA-INSENSITIVE(ABI)4 has diverse roles in regulating plant growth, including inhibiting germination and reserve mobilization in response to ABA and high salinity, inhibiting seedling growth in response to high sugars, inhibiting lateral root growth, and repressing light-induced gene expression. ABI4 activity is regulated at multiple levels, including gene expression, protein stability, and activation by phosphorylation. Although ABI4 can be phosphorylated at multiple residues by MAPKs, we found that S114 is the preferred site of MPK3. To examine the possible biological role of S114 phosphorylation, we transformed abi4-1 mutant plants with ABI4pro::ABI4 constructs encoding wild type (114S), phosphorylation-null (S114A) or phosphomimetic (S114E) forms of ABI4. Phosphorylation of S114 is necessary for the response to ABA, glucose, salt stress, and lateral root development, where the abi4 phenotype could be complemented by expressing ABI4 (114S) or ABI4 (S114E) but not ABI4 (S114A). Comparison of root transcriptomes in ABA-treated roots of abi4-1 mutant plants transformed with constructs encoding the different phosphorylation-forms of S114 of ABI4 revealed that 85 % of the ABI4-regulated genes whose expression pattern could be restored by expressing ABI4 (114S) are down-regulated by ABI4. Phosphorylation of S114 was required for regulation of 35 % of repressed genes, but only 17 % of induced genes. The genes whose repression requires the phosphorylation of S114 are mainly involved in embryo and seedling development, growth and differentiation, and regulation of gene expression.

Rethinking the urban physical environment for century-long lives: from age-friendly to longevity-ready cities.

In response to increasing life expectancies and urbanization, initiatives for age-friendly cities seek to facilitate active and healthy aging by strengthening supports and services for older people. While laudable, these efforts typically neglect early-life exposures that influence long-term well-being. With a focus on the urban physical environment, we argue that longevity-ready cities can accomplish more than initiatives focused solely on old age. We review features of cities that cumulatively influence healthy aging and longevity, discuss the need for proactive interventions in a changing climate, and highlight inequities in the ambient physical environment, especially those encountered at early ages, that powerfully contribute to disparities in later life stages. Compared with strategies aimed largely at accommodating older populations, longevity-ready cities would aim to reduce the sources of disadvantages across the life course and simultaneously improve the well-being of older people.

PRPs localized to the middle lamellae are required for cortical tissue integrity in Medicago truncatula roots.

KEY MESSAGE: A family of repetitive proline-rich proteins interact with acidic pectins and play distinct roles in legume root cell walls affecting cortical and vascular structure. A proline-rich protein (PRP) family, composed of tandemly repeated Pro-Hyp-Val-X-Lys pentapeptide motifs, is found primarily in the Leguminosae. Four distinct size classes within this family are encoded by seven tightly linked genes: MtPRP1, MtPRP2 and MtPRP3, and four nearly identical MtPRP4 genes. Promoter fusions to ß-glucuronidase showed strong expression in the stele of hairy roots for all 4 PRP genes tested, with additional expression in the cortex for PRP1, PRP2 and PRP4. All except MtPRP4 are strongly expressed in non-tumorous roots, and secreted and ionically bound to root cell walls. These PRPs are absent from root epidermal cell walls, and PRP accumulation is highly localized within the walls of root cortical and vascular tissues. Within xylem tissue, PRPs are deposited in secondary thickenings where it is spatially exclusive to lignin. In newly differentiating xylem, PRPs are deposited in the regularly spaced paired-pits and pit membranes that hydraulically connect neighboring xylem elements. Hairpin-RNA knock-down constructs reducing PRP expression in Medicago truncatula hairy root tumors disrupted cortical and vascular patterning. Immunoblots showed that the knockdown tumors had potentially compensating increases in the non-targeted PRPs, all of which cross-react with the anti-PRP antibodies. However, PRP3 knockdown differed from knockdown of PRP1 and PRP2 in that it greatly reduced viability of hairy root tumors. We hypothesize that repetitive PRPs interact with acidic pectins to form block-copolymer gels that can play distinct roles in legume root cell walls.

ABI5-binding proteins (AFPs) alter transcription of ABA-induced genes via a variety of interactions with chromatin modifiers.

KEY MESSAGE: Overexpression of ABI5/ABF binding proteins (AFPs) results in extreme ABA resistance of seeds via multiple mechanisms repressing ABA response, including interactions with histone deacetylases and the co-repressor TOPLESS. Several ABI5/ABF binding proteins (AFPs) inhibit ABA response, resulting in extreme ABA resistance in transgenic Arabidopsis overexpression lines, but their mechanism of action has remained obscure. By analogy to the related Novel Interactor of JAZ (NINJA) protein, it was suggested that the AFPs interact with the co-repressor TOPLESS to inhibit ABA-regulated gene expression. This study shows that the AFPs that inhibit ABA response have intrinsic repressor activity in a heterologous system, which does not depend on the domain involved in the interaction with TOPLESS. This domain is also not essential for repressing ABA response in transgenic plants, but does contribute to stronger ABA resistance. Additional interactions between some AFPs and histone deacetylase subunits were observed in yeast two-hybrid and bimolecular fluorescence assays, consistent with a more direct mechanism of AFP-mediated repression of gene expression. Chemical inhibition of histone deacetylase activity by trichostatin A suppressed AFP effects on a small fraction of the ABI5-regulated genes tested. Collectively, these results suggest that the AFPs participate in multiple mechanisms modulating ABA response, including both TOPLESS-dependent and -independent chromatin modification.

A Global View on the Effects of Work on Health in Later Life.

PURPOSE OF THE STUDY: Work is an important environment shaping the aging processes during the adult years. Therefore, the cumulative and acute effects of work characteristics on late-life health deserve great attention. Given that population aging has become a global trend with ensuing changes in labor markets around the world, increased attention is paid to investigating the effects of the timing of retirement around the world and the macroeconomic benefits often associated with delaying retirement. It will be essential for societies with aging populations to maintain productivity given an aging workforce and for individuals it will be crucial to add healthy and meaningful years rather than just years to their lives. DESIGN AND METHODS: We first describe the available evidence about participation of older workers (65+) in the labor force in high, middle, and low-income countries. Second, we discuss the individual-level and societal influences that might govern labor-force participation of older adults. Thirdly, we review evidence on the association between work on the one and physical, mental, and cognitive health in later life on the other. RESULTS AND IMPLICATIONS: Globally, both is true: work supports healthy aging and jeopordizes it. We draw implications for policymaking in terms of social protection, HR policies, and older employee employability.

Abscisic Acid synthesis and response.

Abscisic acid (ABA) is one of the "classical" plant hormones, i.e. discovered at least 50 years ago, that regulates many aspects of plant growth and development. This chapter reviews our current understanding of ABA synthesis, metabolism, transport, and signal transduction, emphasizing knowledge gained from studies of Arabidopsis. A combination of genetic, molecular and biochemical studies has identified nearly all of the enzymes involved in ABA metabolism, almost 200 loci regulating ABA response, and thousands of genes regulated by ABA in various contexts. Some of these regulators are implicated in cross-talk with other developmental, environmental or hormonal signals. Specific details of the ABA signaling mechanisms vary among tissues or developmental stages; these are discussed in the context of ABA effects on seed maturation, germination, seedling growth, vegetative stress responses, stomatal regulation, pathogen response, flowering, and senescence.

Direct interactions of ABA-insensitive(ABI)-clade protein phosphatase(PP)2Cs with calcium-dependent protein kinases and ABA response element-binding bZIPs may contribute to turning off ABA response.

Abscisic acid (ABA) signaling via the pyrabactin-resistant and related (PYR/PYL/RCAR) receptors begins with ABA-dependent inactivation of the ABA-insensitive(ABI)-clade protein phosphatases(PP)2Cs, thereby permitting phosphorylation and activation of the Snf1-related (SnRK)2 clade of protein kinases, and activation of their downstream targets such as ABA-response element binding basic leucine zipper (bZIP) transcription factors (ABF/AREB/ABI5 clade). Several of these are also activated by calcium-dependent protein kinases such as CPK11. Turning off ABA response requires turnover and/or inactivation of these transcription factors, which could result from their dephosphorylation. To address the hypothesis that the ABI-clade PP2Cs regulate the bZIPs directly, in addition to their indirect effects via SnRKs, we have assayed interactions between multiple members of the ABF/AREB clade and the PP2Cs by yeast two-hybrid, in vitro phosphatase, and bimolecular fluorescence complementation assays. In addition, we have expanded the list of documented specific interactions among these bZIP proteins and the kinases that could activate them and found that some PP2Cs can also interact directly with CPK11. These studies support specific interactions among kinases, phosphatases and transcription factors that are co-expressed in early seedling development.

Roundtable on Urban Living Environment Research (RULER).

For 18 months in 2009-2010, the Rockefeller Foundation provided support to establish the Roundtable on Urban Living Environment Research (RULER). Composed of leading experts in population health measurement from a variety of disciplines, sectors, and continents, RULER met for the purpose of reviewing existing methods of measurement for urban health in the context of recent reports from UN agencies on health inequities in urban settings. The audience for this report was identified as international, national, and local governing bodies; civil society; and donor agencies. The goal of the report was to identify gaps in measurement that must be filled in order to assess and evaluate population health in urban settings, especially in informal settlements (or slums) in low- and middle-income countries. Care must be taken to integrate recommendations with existing platforms (e.g., Health Metrics Network, the Institute for Health Metrics and Evaluation) that could incorporate, mature, and sustain efforts to address these gaps and promote effective data for healthy urban management. RULER noted that these existing platforms focus primarily on health outcomes and systems, mainly at the national level. Although substantial reviews of health outcomes and health service measures had been conducted elsewhere, such reviews covered these in an aggregate and perhaps misleading way. For example, some spatial aspects of health inequities, such as those pointed to in the 2008 report from the WHO's Commission on the Social Determinants of Health, received limited attention. If RULER were to focus on health inequities in the urban environment, access to disaggregated data was a priority. RULER observed that some urban health metrics were already available, if not always appreciated and utilized in ongoing efforts (e.g., census data with granular data on households, water, and sanitation but with little attention paid to the spatial dimensions of these data). Other less obvious elements had not exploited the gains realized in spatial measurement technology and techniques (e.g., defining geographic and social urban informal settlement boundaries, classification of population-based amenities and hazards, and innovative spatial measurement of local governance for health). In summary, the RULER team identified three major areas for enhancing measurement to motivate action for urban health-namely, disaggregation of geographic areas for intra-urban risk assessment and action, measures for both social environment and governance, and measures for a better understanding of the implications of the physical (e.g., climate) and built environment for health. The challenge of addressing these elements in resource-poor settings was acknowledged, as was the intensely political nature of urban health metrics. The RULER team went further to identify existing global health metrics structures that could serve as platforms for more granular metrics specific for urban settings.

Accumulation of the transcription factor ABA-insensitive (ABI)4 is tightly regulated post-transcriptionally.

ABA-INSENSITIVE (ABI)4 is a transcription factor implicated in response to ABA in maturing seeds, and seedling responses to ABA, salt, and sugar. Previous studies have shown that ABI4 transcripts are high in seeds and in seedlings exposed to high concentrations of glucose and, to a lesser extent, osmotic agents and ABA, but that transcript levels are very low through most of vegetative growth. This study examined ABI4 protein accumulation indirectly, using transgenic lines expressing fusions to GFP and GUS. The GFP fusions were active, but undetectable visually or immunologically. Comparison of transcript and activity levels for GUS expression showed that inclusion of the ABI4 coding sequence reduced the ratio of activity to transcript ∼40-fold when driven by the CaMV 35S promoter, and nearly 150-fold when controlled by the ABI4 promoter. At least part of this discrepancy is due to proteasomal degradation of ABI4, resulting in a half-life of 5-6 h for the ABI4-GUS fusion. Comparison of the spatial localization of transcripts and fusion proteins indicated that the protein preferentially accumulated in roots such that transcript and protein distribution had little similarity. The components mediating targeting to the proteasome or other mechanisms of spatial restriction have not yet been identified, but several domains of ABI4 appear to contribute to its instability.

HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study.

BACKGROUND: Having opioid dependence and HIV infection are associated with poor HIV-related treatment outcomes. METHODS: HIV-infected, opioid-dependent subjects (N = 295) recruited from 10 clinical sites initiated buprenorphine/naloxone (BUP/NX) and were assessed at baseline and quarterly for 12 months. Primary outcomes included receiving antiretroviral therapy (ART), HIV-1 RNA suppression, and mean changes in CD4 lymphocyte count. Analyses were stratified for the 119 subjects not on ART at baseline. Generalized estimating equations were deployed to examine time-dependent correlates for each outcome. RESULTS: At baseline, subjects on ART (N = 176) were more likely than those not on ART (N = 119) to be older, heterosexual, have lower alcohol addiction severity scores, and lower HIV-1 RNA levels; they were less likely to be homeless and report sexual risk behaviors. Subjects initiating BUP/NX (N = 295) were significantly more likely to initiate or remain on ART and improve CD4 counts over time compared with baseline; however, these improvements were not significantly improved by longer retention on BUP/NX. Retention on BUP/NX for three or more quarters was, however, significantly associated with increased likelihood of initiating ART (ß = 1.34 [1.18, 1.53]) and achieve viral suppression (ß = 1.25 [1.10, 1.42]) for the 64 of 119 (54%) subjects not on ART at baseline compared with the 55 subjects not retained on BUP/NX. In longitudinal analyses, being on ART was positively associated with increasing time of observation from baseline and higher mental health quality of life scores (ß = 1.25 [1.06, 1.46]) and negatively associated with being homo- or bisexual (ß = 0.55 [0.35, 0.97]), homeless (ß = 0.58 [0.34, 0.98]), and increasing levels of alcohol addiction severity (ß = 0.17 [0.03, 0.88]). The strongest correlate of achieving viral suppression was being on ART (ß = 10.27 [5.79, 18.23]). Female gender (ß = 1.91 [1.07, 3.41]), Hispanic ethnicity (ß = 2.82 [1.44, 5.49]), and increased general health quality of life (ß = 1.02 [1.00,1.04]) were also independently correlated with viral suppression. Improvements in CD4 lymphocyte count were significantly associated with being on ART and increased over time. CONCLUSIONS: Initiating BUP/NX in HIV clinical care settings is feasible and correlated with initiation of ART and improved CD4 lymphocyte counts. Longer retention on BPN/NX was not associated with improved prescription of ART, viral suppression, or CD4 lymphocyte counts for the overall sample in which the majority was already prescribed ART at baseline. Among those retained on BUP/NX, HIV treatment outcomes did not worsen and were sustained. Increasing time on BUP/NX, however, was especially important for improving HIV treatment outcomes for those not on ART at baseline, the group at highest risk for clinical deterioration. Retaining subjects on BUP/NX is an important goal for sustaining HIV treatment outcomes for those on ART and improving them for those who are not. Comorbid substance use disorders (especially alcohol), mental health problems, and quality-of-life indicators independently contributed to HIV treatment outcomes among HIV-infected persons with opioid dependence, suggesting the need for multidisciplinary treatment strategies for this population.

Patient perspectives on buprenorphine/naloxone treatment in the context of HIV care.

BACKGROUND: Research has shown that buprenorphine/naloxone (bup/nx) is a safe and effective treatment for opioid dependence. Few reports, however, describe the patient perspective on bup/nx treatment and its integration into HIV care settings. METHODS: We conducted qualitative interviews with 33 patients to further investigate patient satisfaction and experience with bup/nx treatment and integrated care. Interviews focused on drug use/cessation history; attitudes toward and satisfaction with bup/nx treatment; and perspectives on integrated bup/nx treatment and HIV care. RESULTS: Patients were overwhelmingly satisfied with the pharmacologic effects and treatment outcomes of bup/nx, including effectiveness in blocking cravings and controlling opioid use; decreased fear of withdrawal and/or missing doses; and an overall improvement in quality of life. Patients also described being more engaged with both their substance abuse treatment and HIV care, including greater ability to manage their own treatment, keep, appointments, and adhere to antiretroviral medication regimes. Counseling was seen by some patients as an important component of bup/nx treatment. Nearly all were positive about their experience with integrated care, appreciative of an improved drug treatment environment, convenience, and quality of care. CONCLUSIONS: Findings suggest that patients report bup/nx to be a viable treatment and many prefer it to other opioid replacement therapies.

Integration of buprenorphine/naloxone treatment into HIV clinical care: lessons from the BHIVES collaborative.

BACKGROUND: Replication of effective practices requires detailed descriptions of implementation processes, barriers and facilitators, and lessons learned. The experiences of physicians leading the Buprenorphine HIV Evaluation and Support initiative provides valuable information for other HIV providers seeking to integrate medication-assisted treatment services into HIV clinical care. METHODS: Evaluation staff conduced site visits to the 10 funded Buprenorphine HIV Evaluation and Support programs to better understand buprenorphine/naloxone (bup/nx) integration practices; services offered; staffing; provider experiences with and perceptions of bup/nx; perceived barriers, facilitators, and sustainability; and recommendations regarding replication of integrated care program components. Interviews with site principal investigators conducted during the last year of program implementation were transcribed, coded, and analyzed according to both pre-identified and emerging themes. RESULTS: Integrated bup/nx and HIV treatment was successfully introduced to community and hospital-based clinics under the direction of infectious disease, psychiatry, and general internal medicine physicians. All but 1 of the principal investigators interviewed were highly satisfied with integrated HIV and bup/nx treatment, and all anticipated continued provision of the service. Multiple prescribers were necessary to ensure sufficient coverage and a bup/nx coordinator (eg, nurse, counselor) was seen as essential to the provision of quality care. Ongoing challenges included multisubstance use and mental health issues among patients; limited adoption of bup/nx treatment among colleagues; and the necessity of incorporating new procedures, including urine toxicology testing into established practice. CONCLUSIONS: Findings suggest that integrated bup/nx treatment and HIV care is acceptable to providers and feasible in a variety of practice settings.

The BHIVES collaborative: organization and evaluation of a multisite demonstration of integrated buprenorphine/naloxone and HIV treatment.

Substance abuse is associated with poor medical and quality-of-life outcomes among HIV-infected individuals. Although drug treatment may reduce these negative consequences, for many patients, options are limited. Buprenorphine/naloxone, an opioid agonist treatment that can be prescribed in the United States in office-based settings, can be used to expand treatment capacity and integrate substance abuse services into HIV care. Recognizing this potential, the US Health Resources and Services Administration funded the development and implementation of demonstration projects that integrated HIV care and buprenorphine/naloxone treatment at 10 sites across the country. An Evaluation and Technical Assistance Center provided programmatic and clinical support as well as oversight for an evaluation that examined the processes for and outcomes of integrated care. The evaluation included patient-level self-report and chart abstractions as well as provider and site level data collected through surveys and in-depth interviews. Although multisite demonstrations pose implementation and evaluation challenges, our experience demonstrates that these can, in part, be addressed through ongoing communication and technical assistance as well as a comprehensive evaluation design that incorporates multiple research methods and data sources. Although limitations to evaluation findings persist, they may be balanced by the scope and "real-world" context of the initiative.

Policy implications of integrating buprenorphine/naloxone treatment and HIV care.

Researchers, practitioners, and policymakers have long recognized the potential benefits of providing integrated substance abuse and medical care services, particularly for special populations such as people living with HIV/AIDS. Buprenorphine, an office-based pharmacological treatment for opioid dependence, offers new opportunities for integrating drug treatment into HIV care settings. However, the historical separation between the drug treatment and medical care systems has resulted in a host of policy barriers. The Buprenorphine and HIV Care Evaluation and Support initiative, a multisite demonstration project to assess the feasibility and effectiveness of integrating buprenorphine/naloxone into HIV care settings, provided an opportunity to evaluate if and how policy barriers affect efforts to integrate HIV care and addiction treatment. We found that financing issues, workforce and training issues, and the operational consequences of some conceptual differences between HIV care and addiction treatment are barriers to the full integration of buprenorphine into HIV care. We recommend changes to financing and reimbursement policies, programs to strengthen the addiction treatment skills of physicians, and cross training between the fields of addiction, medicine, drug treatment, and HIV medicine. By addressing some of the policy barriers to integration, this promising new treatment can help the thousands of people living with HIV/AIDS who are also opioid dependent.

The cost of integrated HIV care and buprenorphine/naloxone treatment: results of a cross-site evaluation.

BACKGROUND: Implementing integrated HIV and buprenorphine/naloxone treatment requires cost estimates to plan and obtain funding. METHODS: We identified costs incurred at HIV clinical sites participating in a cross-site evaluation of integrated care that followed patients for 1 year. Costs include labor, overhead, and urine toxicology analyses (clinic perspective), buprenorphine/naloxone (payer perspective) and patient time and transportation (patient perspective). Sites provided resource utilization quarterly, and providers estimated time required for each activity. With site as the unit of analysis, results are reported as median (range) of average site costs in 2008 US dollars. RESULTS: The median number of monthly provider encounters for integrated care patients was 3.2 (1.5-13.3) compared with 1.7 (1.1-4.2) for similar patients not in integrated care, but integrated care patients had fewer physician encounters. Median monthly clinic costs per integrated care patient were $136 ($67-$677) for labor and overhead and $8 ($2-$23) for toxicology analyses, $22 higher than clinic costs for patients not in integrated care. Median monthly costs for buprenorphine/naloxone were $209 ($165-$272), and monthly patient costs in integrated care were $11 ($1-$54) higher. CONCLUSIONS: Integrated HIV and buprenorphine/naloxone treatment requires different resources, including costs that are not third-party reimbursed. Implementing integrated care will require funding for training and for new staff such as buprenorphine coordinators, in addition to reimbursement for buprenorphine/naloxone. Further research is needed to identify potential cost offsets outside of the clinic setting.