Prevalence of HIV Viral Load Suppression Among Psychiatric Inpatients with Comorbid Substance Use Disorders.

A consistently suppressed viral load enables HIV (+) patients to live longer, healthier lives and reduces the probability of transmitting the virus. Since the prevalence of HIV is four times higher among those with psychiatric disorders than in the general population, it is likely that this group would also have greater difficulty remaining in care and achieving viral suppression. A secondary data analysis utilizing screening data from the Preventing AIDS Through Health (PATH) for Triples (PFT) Study were examined to assess HIV load suppression among 254 psychiatric inpatients with comorbid substance use disorders in Philadelphia. Viral load results from the past 12 months were obtained from medical records for 63 inpatients identified as HIV (+). The sample was predominately African American (76%), male (56%), and the average age was 43 years. Psychiatric disorders included depression (64%), schizophrenia (21%), and bipolar disorder (13%) with patients reporting use of alcohol (73%), cocaine (64%), cannabis (29%) and opioids (16%) prior to admission. Among this high risk sample of HIV (+) patients, about one-half (52%) achieved viral suppression, with recent opioid users six times more likely to have a detectable viral load than non-opioid users (OR 6.0; CI 1.1-31.7, p = .035). The 52% viral load suppression rate among psychiatric inpatient was higher than expected, given that the CDC's national suppression rate among those diagnosed with HIV in the general population is 58%. However, individuals with mental illness and substance use disorders require constant surveillance, monitoring, and supportive services to achieve viral suppression. Many of those who were virally suppressed were engaged in Philadelphia's extensive treatment network, whereas those who were detectable and enrolled in the PFT intervention were often homeless with unstable psychiatric symptoms and current substance use disorders, particularly opioid abuse.

Travel distance to HIV medical care: a geographic analysis of weighted survey data from the Medical Monitoring Project in Philadelphia, PA.

Decisions regarding where patients access HIV care are not well understood. The purpose of this analysis was to examine differences in travel distance to care among persons receiving care in Philadelphia. A multi-stage sampling design was utilized to identify 400 potential participants. 65 % (260/400) agreed to be interviewed. Participants were asked questions about medical care, supportive services, and geographic location. Distances were calculated between residence and care location. 46.3 % travelled more than three miles beyond the nearest facility. Uninsured travelled further (6.9 miles, 95 % CI 3.9-9.8) than persons with public insurance (3.3 miles, 2.9-3.6). In multivariate analyses, no insurance (20/260) was associated with increased distance (p = 0.0005) and Hispanic ethnicity was associated with decreased distance (p = 0.0462). Persons without insurance travel further but insurance status alone does not explain the variability in distance travelled to care. In Philadelphia, Hispanic populations, and providers that may be most accessible to them, are spatially contained.

What is community? An evidence-based definition for participatory public health.

Increased emphasis on community collaboration indicates the need for consensus regarding the definition of community within public health. This study examined whether members of diverse US communities described community in similar ways. To identify strategies to support community collaboration in HIV vaccine trials, qualitative interviews were conducted with 25 African Americans in Durham, NC; 26 gay men in San Francisco, Calif; 25 injection drug users in Philadelphia, Pa; and 42 HIV vaccine researchers across the United States. Verbatim responses to the question "What does the word community mean to you?" were analyzed. Cluster analysis was used to identify similarities in the way community was described. A common definition of community emerged as a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings. The participants differed in the emphasis they placed on particular elements of the definition. Community was defined similarly but experienced differently by people with diverse backgrounds. These results parallel similar social science findings and confirm the viability of a common definition for participatory public health.

Who will enroll? Predicting participation in a phase II AIDS vaccine trial.

BACKGROUND: The problems of underenrollment and selective enrollment may undermine AIDS vaccine trials. If prospective study subjects' stated willingness to participate (WTP) in hypothetical vaccine trials predicts future enrollment, then measuring WTP before recruitment may enhance the enrollment in, and ethics of, such trials. METHODS: We prospectively studied changes over an 18-month period in the stated WTP in, and knowledge of, a hypothetical AIDS vaccine trial among 610 Philadelphia residents at high risk for HIV infection. Of these people, 499 were subsequently recruited to participate in an actual, phase II AIDS vaccine trial. We used multivariable logistic regression and the area under the receiver-operating characteristic (ROC) curve to model predictors of actual enrollment. RESULTS: Actual enrollment rates were 8.3%, 6.8%, 15.8%, and 29.0% among those who had initially said they were "definitely not," "probably not," "probably," and "definitely" willing to participate, respectively (p =.006). The area under the ROC curve was 0.65, indicating a modest ability of stated WTP to differentiate those who enroll from those who do not. Knowledge of basic vaccine trial concepts, though unrelated to enrollment, increased over an 18-month period with repeated education sessions (p <.0001), whereas stated WTP declined over this same period (p <.0001). CONCLUSION: Although other factors not captured by stated WTP may also influence future enrollment, prospectively assessing stated WTP may augment the validity of the informed consent process, help prevent underenrollment, and clarify the population from which the study sample is drawn.

Determinants of risk behavior for human immunodeficiency virus/acquired immunodeficiency syndrome in people with severe mental illness.

We examined the prevalence and correlates of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) risk behaviors in a large sample of severely mentally ill (SMI) patients. Risk levels were correlated with demographic factors, diagnosis, symptom severity, trauma history, post-traumatic stress disorder (PTSD), substance use disorder (SUD), and sexual orientation. SMI clients from urban and rural settings (N = 275) were assessed regarding HIV/AIDS risk behaviors, and hypothesized risk factors. Patients exhibited substantial levels of risky behavior, particularly sexual risk. Correlates of increased risk included SUD, trauma, male homosexual orientation, younger age, and symptom severity. Structural equation modeling identified SUD and sexual orientation as the primary determinants of both drug and sexual risk behavior. We conclude that specific illness related variables appear to have less impact on risk behavior among people with SMI than previously hypothesized. Substance abuse prevention and treatment may be the most effective means of reducing HIV risk in this population.

Randomized controlled trial of audio computer-assisted self-interviewing: utility and acceptability in longitudinal studies. HIVNET Vaccine Preparedness Study Protocol Team.

Recent studies have reported on the utility of audio computer-assisted self-interviewing (ACASI) in surveys of human immunodeficiency virus (HIV) risk behaviors that involve a single assessment. This paper reports the results of a test of ACASI within a longitudinal study of HIV risk behavior and infection. Study participants (gay men (n = 1,974) and injection drug users (n = 903)) were randomly assigned to either ACASI or interviewer-administered assessment at their second follow-up visit 12 months after baseline. Significantly more of the sexually active gay men assessed via ACASI reported having sexual partners who were HIV antibody positive (odds ratio = 1.36, 95% confidence interval: 1.08, 1.72), and a higher proportion reported unprotected receptive anal intercourse. Among injection drug users (IDUs), our hypothesis was partially supported. Significantly more IDUs assessed via ACASI reported using a needle after another person without cleaning it (odds ratio = 2.40, 95% confidence interval: 1.34, 4.30). ACASI-assessed IDUs reported similar rates of needle sharing and needle exchange use but a lower frequency of injection. Participants reported few problems using ACASI, and it was well accepted among members of both risk groups. Sixty percent of the participants felt that the ACASI elicited more honest responses than did interviewer-administered questionnaires. Together, these data are consistent with prior research findings and suggest that ACASI can enhance the quality of behavioral assessment and provide an acceptable method for collecting self-reports of HIV risk behavior in longitudinal studies and clinical trials of prevention interventions.

Feasibility of chemoprophylaxis studies in high risk HIV-seronegative populations.

Administration of antiretroviral medications-recommended to prevent HIV infection after occupational exposure-has not been evaluated for safety or efficacy following nonoccupational exposure. HIV-seronegative persons at increased risk for HIV exposure completed a self-administered questionnaire assessing their willingness to join studies of this approach. Of 4,572 respondents, 60% were willing to join a study of a "morning-after" pill; dosing three times a day and mild side effects reduced willingness to 30%. Men who have sex with men (MSM) who reported unprotected anal intercourse in the prior 6 months were significantly more likely to be willing to join a morning-after study than MSM who did not (p = 0.006). MSM favored a preventive HIV vaccine over oral chemoprophylaxis; other populations preferred oral chemoprophylaxis. Interest in studies declined as the hypothetical regimen became more demanding. Studies must emphasize the unknown efficacy of this approach, given increased interest among MSM at greater risk of exposure.

Drug abuse treatment as AIDS prevention.

OBJECTIVE: As the acquired immunodeficiency syndrome (AIDS) epidemic among drug users enters its third decade in the United States, it is important to consider the role playing by substance abuse treatment in the prevention of human immunodeficiency virus (HIV) infection. METHODS: The authors review the research literature, examining findings from studies with behavioral and serologic measures on the association among treatment participation, HIV risk reduction, and HIV infection. RESULTS: Numerous studies have now documented that significantly lower rates of drug use and related risk behaviors are practiced by injecting drug users (IDUs) who are in treatment. Importantly, these behavioral differences, based primarily on self-report, are consistent with studies that have examined HIV seroprevalence and seroincidence among drug users. CONCLUSION: The underlying mechanism of action suggested by the collective findings of the available literature is rather simple-- individuals who enter and remain in treatment reduce their drug use, when leads to fewer instances of drug-related risk behavior. This lower rate of exposure results in fewer infections with HIV. The protective effects of treatment, however, can only be achieved when programs are accessible and responsive to the changing needs of drug users. Future research needs to be directed at developing a better understanding of the factors that enhance treatment entry and retention.

Patterns of service use and treatment involvement of methadone maintenance patients.

Although methadone maintenance is an effective treatment for opiate addiction, variations in treatment outcome are evident. These variations may be explained in part by the rehabilitative experiences of patients as reflected in their use of collateral services. This study examined service involvement of 409 methadone maintenance patients at four clinics in order to identify the types of services used and the extent to which potentially rehabilitative services were used. Aside from welfare, there was a strikingly low level of service utilization. Even when services were used, the levels of this use were so low as to be virtually ineffective. These findings regarding treatment and social service utilization suggest that there may not be any attempt to match service provision with patient needs for services. A more rational approach to matching patient needs and available services is thus called for.

Will preventive HIV vaccine efficacy trials be possible with female injection drug users?

This article examines whether preventive HIV vaccines trials will be viable among female injection drug users (IDUs). Of the 137 women who completed baseline serologic and behavioral assessments, 121 (88%) were seronegative; all enrolled in Project Jumpstart in Philadelphia (PA, U.S.A.), a vaccine preparedness initiative cosponsored by NIAID and NIDA. Subjects were seen every 3 months for risk and vaccine opinion assessment, risk reduction counseling, and HIV antibody testing. The baseline prevalence rate of HIV infection was 12% (16 of 137) with an annual incidence rate of 3.5% (4 of 114) during the first year. Of the 121 baseline seronegative women, 28% shared needles and 52% engaged in unprotected intercourse. Sixty percent of the baseline seronegative women reported being willing to be one of the first people to try an HIV vaccine. According to logistic regression, needle sharers were 12.8 times more likely, women who engaged in sex for drugs or money 6.6 times more likely, out-of-treatment women 3.5 times more likely, and those who believed that vaccines can prevent disease acquisition 3 times more likely to report willingness to try an HIV vaccine than their respective counterparts. At 1-year postbaseline assessment, 98% of the women had behavioral data collected and 95% had serologic specimens collected. Given that seroconversions occur and that these women engage in risk behaviors, report willingness to try an HIV vaccine, and can be retained for longitudinal assessment, they appear to be suitable participants for preventive HIV vaccine efficacy trials. Nonetheless, work is required to insure that these women make informed and knowledgeable decisions regarding trial enrollment.

Long-term changes in psychological symptomatology associated with HIV serostatus among male injecting drug users.

OBJECTIVE: To examine long-term changes in psychological symptomatology from 6 to 24 months after notification of HIV serostatus among male injecting drug users (IDU). DESIGN: Self-report and interview data were collected at 6-month intervals as part of a longitudinal study monitoring HIV infection and risk-associated behaviors among IDU. SETTING: A community-based methadone-maintenance clinic. PARTICIPANTS: Ninety-seven male IDU (81 HIV-seronegative, 16 HIV-seropositive), including both methadone-maintained and out-of-treatment IDU. MAIN OUTCOME MEASURES: Analyses of long-term changes in psychological symptomatology associated with HIV serostatus among male IDU. RESULTS: Analyses of long-term changes in psychological symptomatology between groups revealed no significantly greater levels of overall psychological distress or significant elevations on subscales of the Symptom Checklist-90 for HIV-seropositive compared with HIV-seronegative male IDU. Also, no significantly higher scores on the Beck Depression Inventory or the psychiatric composite score of the Addiction Severity Index were observed between groups. CONCLUSIONS: Our results suggest that HIV-seropositive male IDU do not express greater levels of psychological symptomatology from 6 to 24 months following notification of seropositivity compared with HIV-seronegative male IDU. Several explanations for these findings are considered. Future work should examine why male IDU do not report significant and long-term elevations in symptoms post-notification of HIV seropositivity. Also, studies of changes in psychological symptomatology as a function of HIV serostatus among female IDU need to be conducted to assess implications for treatment interventions among this underserved population.

Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: role of treatment services.

This study examined the patient and treatment factors associated with 6-month outcome in 649 opiate-, alcohol-, and cocaine-dependent (male and female) adults, treated in inpatient and outpatient settings, in 22 publicly and privately funded programs. Outcomes were predicted by similar factors, regardless of the drug problem of the patient or the type of treatment setting or funding. Greater substance use at follow-up was predicted only by greater severity of alcohol and drug use at treatment admission, not by the number of services received during treatment. Better social adjustment at follow-up was negatively predicted by more severe psychiatric, employment, and family problems at admission and positively predicted by more psychiatric, family, employment, and medical services provided during treatment.

Parental relationships and substance use among methadone patients. The impact on levels of psychological symptomatology.

The relationship between parental substance use problems (SUPs) and the quality of parental relationships with levels of psychological symptomatology was examined in 155 female and 324 male methadone maintenance patients. Subjects completed the Beck Depression Inventory (BDI), SCL-90, and the Treatment Effectiveness Questionnaire (TEQ), which included questions regarding demographics, drug use, family/social relationships, and substance use in relatives. Of those completing the questionnaire, 40% were randomly selected for an Addiction Severity Index (ASI) interview. As hypothesized, parental SUPs were associated with greater levels of psychological symptomatology, more family/social, and medical problems. Positive parental relationships were associated with significantly lower levels of psychological symptomatology and fewer family/social problems. Males were significantly more likely than females to report positive parental relationships and no parental SUPs. No differences based on race were revealed related to reports of the quality parental relationships or parental SUPs.

Factors associated with employment among methadone patients.

We examined the patient characteristics of 340 subjects in methadone treatment to determine if these characteristics could differentiate among three "stages" of work during the past year (stable unemployment, intermittent work, and stable employment). A multiple discriminant function analysis was able to classify correctly 14% of the cases beyond chance. Results of these analyses found lower depression scores, cocaine abstinence, education, and marital status correlated with stable employment conditions. Interventions designed to change these characteristics may improve employment conditions among methadone patients.

HIV vaccine trials: will intravenous drug users enroll?

OBJECTIVES: The purpose of this study was to assess the willingness of intravenous drug users to participate in a preventive human immunodeficiency virus (HIV) vaccine efficacy trial. METHODS: Of the 347 intravenous drug users in methadone treatment who were approached for participation, 257 completed a battery of self-administered questionnaires assessing risk behaviors, interest in vaccine trials, and other vaccine-related information. Data from 16 known seropositives and 1 inconsistent responder were dropped from analyses (n = 240). RESULTS: Fifty-two percent of the subjects expressed a willingness to be one of the first individuals to participate in a preventive HIV vaccine efficacy trial. Subjects who had recently shared needles or works and subjects who trusted the government to ensure vaccine safety were both twice as likely to report interest in participation. Twenty-two percent of subjects reported that they would increase needle sharing if vaccinated. Thirty percent did not know what a vaccine was. CONCLUSIONS: These findings suggest that some in-treatment intravenous drug users would volunteer for a preventive HIV vaccine efficacy trial. Education and counseling will be required to ensure that subjects fully understand the trial's purposes, methods, risks and benefits.

Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up.

Our objective was to determine the prevalence and incidence of human immunodeficiency virus (HIV) infection and related risk behaviors among opiate-abusing intravenous drug users (IVDUs) either in or out of methadone treatment. The subjects, 152 in-treatment and 103 out-of-treatment intravenous opiate users, were followed prospectively for 18 months. Behavioral and serologic assessments were made at 6-month intervals, with complete information available on 89% of the sample. Subjects were recruited from a single methadone maintenance program and the surrounding neighborhood in north-central Philadelphia. At baseline, the HIV seroprevalence rate for the total sample was 12%: 10% for the methadone-maintained group and 16% for the out-of-treatment group. Out-of-treatment subjects were injecting drugs, sharing needles, visiting shooting galleries, and practicing unsafe sex at significantly higher rates than in-treatment subjects. Follow-up of HIV-negative subjects over the next 18 months showed conversion rates of 3.5% for those who remained in methadone maintenance versus 22% for those who remained out of treatment. The sixfold difference in rate of seroconversion between the two groups suggests that although rapid transmission of HIV still occurs, opiate-abusing IVDUs who enter methadone treatment are significantly less likely to become infected. In contrast, those opiate addicts who do not enter treatment are at significantly higher risk of contracting and spreading the disease. Implications for developing additional risk interventions for out-of-treatment IVDUs are discussed.

Private substance abuse treatments: are some programs more effective than others?

There have been few studies of treatments for substance dependence among private programs. The present study compared the patient populations, treatment services provided and six-month outcomes of employed, insured patients referred by an employee assistance program to four private treatment programs (two inpatient and two outpatient). Subjects were alcohol and/or cocaine dependent males referred from a single employer. Ninety-four percent were successfully contacted at six-month follow-up, with confirmatory urinalysis and breathalyzer samples taken. Three results were obtained. First, there were significant and pervasive improvements shown in the total sample at follow-up. Fifty-nine percent were completely abstinent, 82% were working and only 8% required re-treatment. Second, there were significant differences among the programs in levels of improvement and six-month outcomes. Finally, the differences in efficacy were related to the differences in the nature and amount of treatment services provided.

The effects of psychosocial services in substance abuse treatment.

OBJECTIVE: To examine whether the addition of counseling, medical care, and psychosocial services improves the efficacy of methadone hydrochloride therapy in the rehabilitation of opiate-dependent patients. DESIGN: Random assignment to one of three treatment groups for a 6-month clinical trial: (1) minimum methadone services (MMS)--methadone alone (a minimum of 60 mg/d) with no other services; (2) standard methadone services (SMS)--same dose of methadone plus counseling; or (3) enhanced methadone services (EMS)--same dose of methadone plus counseling and on-site medical/psychiatric, employment, and family therapy. SETTING: The methadone maintenance program of the Philadelphia (Pa) Veterans Affairs Medical Center. SUBJECTS: Ninety-two male intravenous opiate users in methadone maintenance treatment. RESULTS: While methadone treatment alone (MMS) was associated with reductions in opiate use, 69% of these subjects had to be "protectively transferred" from the trial because of unremitting use of opiates or cocaine, or medical/psychiatric emergencies. This was significantly different from the 41% of SMS subjects and 19% of EMS subjects who met the criteria. End-of-treatment data (at 24 weeks) showed minimal improvements among the 10 MMS patients who completed the trial. The SMS group showed significantly more and larger improvements than did the MMS group; and the EMS group showed significantly better outcomes than did the SMS group. Minimum methadone services subjects who had been "protectively transferred" to standard care showed significant reductions in opiate and cocaine use within 4 weeks. CONCLUSIONS: Methadone alone (even in substantial doses) may only be effective for a minority of eligible patients. The addition of basic counseling was associated with major increases in efficacy; and the addition of on-site professional services was even more effective.