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.

Correlates of health care utilization among HIV-seropositive injection drug users.

This study sought to identify correlates of poor health care utilization among HIV-positive injection drug users (IDUs) using Andersen's behavioural health model. We used baseline data from INSPIRE, a study of HIV-positive IDUs (n=1161) to identify predisposing, enabling, and need factors related to poor utilization (defined as fewer than two outpatient visits in the past six months, or identification of emergency room (ER) as the usual place for care). Using bivariate and multivariate models, we found a number of enabling factors that could facilitate the use of health care services such as having health insurance, having seen a case manager, and better engagement with health care providers. These enabling factors could be modified through interventions targeting HIV-positive IDUs. In addition, health insurance and case management appear to be important factors to address because they contributed in making other factors (e.g. lower education, lack of stable housing) non-significant barriers to outpatient care utilization. In the future, these findings may be used to inform the development of interventions that maximize use of scarce HIV resources and improve health care utilization among HIV-positive IDUs.

Cost-effectiveness of tuberculosis screening and observed preventive therapy for active drug injectors at a syringe-exchange program.

This study examined whether costs associated with tuberculosis (TB) screening and directly observed preventive therapy (DOPT) among drug injectors attending a syringe exchange are justified by cases and costs of active TB cases prevented and examined the impact of monetary incentives to promote adherence on cost-effectiveness. We examined program costs and projected savings using observed adherence and prevalence rates and literature estimates of isoniazid (INH) preventive therapy efficacy, expected INH hepatoxicity rates, and TB treatment costs; we conducted sensitivity analyses for a range of INH effectiveness, chest X-ray (CXR) referral adherence, and different strategies regarding anergy among persons affected with human immunodeficiency virus (HIV). For 1,000 patients offered screening, incorporating real observed program adherence rates, the program would avert $179,934 in TB treatment costs, for a net savings of $123,081. Assuming a modest risk of TB among HIV-infected anergic persons, all strategies with regard to anergy were cost saving, and the strategy of not screening for anergy and not providing DOPT to HIV-infected anergic persons resulted in the greatest cost savings. If an incentive of $25 per person increased CXR adherence from the observed 31% to 50% or 100%, over a 5-year follow-up the net cost savings would increase to $170,054 and $414,856, respectively. In this model, TB screening and DOPT at a syringe exchange is a cost-effective intervention and is cost-saving compared to costs of treating active TB cases that would have occurred in the absence of the intervention. This model is useful in evaluating the cost impact of planned program refinements, which can then be tested. Monetary incentives for those referred for screening CXRs would be justified on a cost basis if they had even a modest beneficial impact on adherence.

Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring.

To compare electronically monitored (MEMS) with self-reported adherence in drug users, including the impact of adherence on HIV load, we conducted a 6-month observational study of 67 antiretroviral-experienced current and former drug users. Adherence (percentage of doses taken as prescribed) was calculated for both the day and the week preceding each of 6 research visits. Mean self-reported 1-day adherence was 79% (median, 86%), and mean self-reported 1-week adherence was 78% (median, 85%). Mean MEMS 1-day adherence was 57% (median, 52%), and mean MEMS 1-week adherence was 53% (median, 49%). One-day and 1-week estimates were highly correlated (r>.8 for both measures). Both self-reported and MEMS adherence were correlated with concurrent HIV load (r=.43-.60), but the likelihood of achieving virologic suppression was greater if MEMS adherence was high than if self-reported adherence was high. We conclude that self-reported adherence is higher than MEMS adherence, but a strong relationship exists between both measures and virus load. However, electronic monitoring is more sensitive than self-report for the detection of nonadherence and should be used in adherence intervention studies.

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.

Regular outpatient medical and drug abuse care and subsequent hospitalization of persons who use illicit drugs.

CONTEXT: Patients and the public could benefit from identification of factors that prevent drug users' heavy reliance on inpatient care; however, optimal health care delivery models for illicit drug users remain ill-defined. OBJECTIVE: To evaluate associations of outpatient medical and drug abuse care with drug users' subsequent hospitalization rates. DESIGN AND SETTING: Retrospective cohort study of data from longitudinally linked claims for all ambulatory physician/clinic services and drug abuse services covered by the New York State Medicaid program. SUBJECTS: A total of 11 556 human immunodeficiency virus (HIV)-positive and 46 687 HIV-negative drug users. MAIN OUTCOME MEASURES: Hospitalization in federal fiscal year (FFY) 1997 compared by 4 patterns of care in FFY 1996: regular drug abuse care (>/=6 months in 1 program), regular medical care (>35% of care from 1 clinic, group practice, or individual physician), both, or neither. RESULTS: Hospitalization occurred in 55.6% of HIV-positive and 37.5% of HIV-negative drug users, with a mean of 27.5 and 24.5 inpatient days, respectively. In HIV-positive drug users, the adjusted odds ratio (AOR) for hospitalization was lowest among those with both regular medical and drug abuse care (AOR, 0.76; 95% confidence interval [CI], 0.67-0.85) followed by those with regular medical care alone (AOR, 0.82; 95% CI, 0.74-0.91) and regular drug abuse care alone (AOR, 0.85; 95% CI, 0.76-0.96) vs those with neither. In HIV-negative drug users, the AOR of hospitalization was lower for those with regular medical and drug abuse care (AOR, 0.73; 95% CI, 0.68-0.79), regular drug abuse care alone (AOR, 0.71; 95% CI, 0.66-0.76), and regular medical care (AOR, 0.91; 95% CI, 0.86-0.95) vs those with neither. Both types of care showed favorable effects for all but drug abuse-related hospitalizations. CONCLUSION: Our data indicate that regular drug abuse care with regular medical care for drug users is associated with less subsequent hospitalization.

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.

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.

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.

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.

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.

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.

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

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

A prospective study of tuberculosis and HIV disease progression.

OBJECTIVE: To determine whether active tuberculosis alters the rate of progression of HIV infection in dually infected patients. METHODS: HIV-seropositive patients at two Bronx, New York hospitals with tuberculosis confirmed by culture from July 1992 to February 1995, who survived the initial hospitalization for tuberculosis, were matched on gender, age, CD4+ percentage, and calendar time with HIV-seropositive patients without tuberculosis participating in a study of the natural history of HIV infection. Patients received follow-up observation prospectively until May 23, 1995 to determine survival rates and development of AIDS-defining opportunistic infections (OIs). RESULTS: 70 patients had tuberculosis; 120 did not. Mean CD4+ percentages were 12.4% and 12.5%, respectively. At study entry, 27% of those with tuberculosis had prior AIDS-defining OIs other than tuberculosis, compared with 10% of those without tuberculosis (p = .004). In multivariate survival analysis, controlling for CD4+ level, tuberculosis was not an independent predictor of increased other causes of AIDS-related mortality. However, in a logistic regression model, independent predictors of subsequent OIs included tuberculosis (hazard ratio, 4.1; 95% confidence intervals [CI], 1.9, 8.7), CD4+ count <100/mm3 (hazard ratio, 2.4; 95% CI, 1.1, 5.0) and prior OIs (hazard ration, 3.3; 95% CI, 1.3, 8.3). CONCLUSIONS: Tuberculosis was not an independent predictor of increased non-tuberculosis-related mortality in HIV-seropositive patients but was associated with increased risk of development of OIs.

Temporal trends in the progression of human immunodeficiency virus disease in a cohort of drug users.

We evaluated changes over time in rates of progression to AIDS, mortality, and distribution of AIDS-defining illnesses in 524 human immunodeficiency virus (HIV)-seropositive injection drug users enrolled between 1986 and 1995 in a prospective study of HIV infection in the Bronx, NY. At enrollment, participants attended a hospital-affiliated methadone maintenance program with on-site primary care. Using the 1993 clinical definition of AIDS, we found that the hazard ratio (HR) of progression to AIDS declined for enrollees over time in comparison with the referent group of persons enrolled in 1986-1987. For program enrollees in 1988-1989, the HR was 1.0 [95% confidence interval (CI) = 0.6-1.6]; for enrollees in 1990-1991, the HR was 0.3 (95% CI = 0.1-0.9); for enrollees in 1992-1993, the HR was 0.5 (95% CI = 0.3-0.9); and for enrollees in 1994-1995, the HR was 0.2 (95% CI = 0.1-0.7), after controlling on initial CD4+ cell counts and age. Nevertheless, the greater AIDS-free time of later study entrants was not associated with reduced mortality. The study provides evidence that drug users with access to primary care likely benefited from improved management of HIV disease in prolonging AIDS-free time but, through 1996, did not experience greater survival.

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.

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.

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.