Risk of HIV Viral Rebound in the Era of Universal Treatment in a Multicenter Sample of Persons With HIV in Primary Care.

Background: Antiretroviral therapy (ART) is recommended for people with HIV (PWH), irrespective of CD4 cell count, to improve their health and reduce the risk of transmission to sexual partners through long-term viral suppression. We identified risk factors for viral rebound among patients with a period of stable viral suppression to inform counseling and monitoring. Methods: We conducted a multisite, retrospective study of PWH with a 2-year period of sustained viral suppression in the United States using the Centers for AIDS Research Network of Integrated Clinical Systems cohort. We used multivariable logistic regression to identify characteristics independently associated with any viral rebound (viral load [VL] ≥200 copies/mL) and sustained viral rebound (VL ≥200 copies/mL followed by a VL that was also ≥200 copies/mL within 6 months), within 2 years of follow-up. Results: Among 3496 eligible patients with a 2-year period of sustained viral suppression, most (90%) continued to have viral suppression over 2 additional years; 10% experienced viral rebound, and 4% experienced sustained viral rebound. In multivariable analyses, Black race, current smoking, integrase strand transfer inhibitor use, and 5- to 9-year duration of ART were positively associated, and being age ≥50 years was negatively associated, with any viral rebound. Only current smoking and 5- to 9-year (vs 2- to 4-year) duration of ART were positively associated, and being age ≥60 years was negatively associated, with sustained viral rebound. Conclusions: Most people retained in clinical care and with HIV viral suppression on ART will have persistent viral suppression. However, some patients may benefit from additional treatment adherence support.

The Implementation of a Text Messaging Intervention to Improve HIV Continuum of Care Outcomes Among Persons Recently Released From Correctional Facilities: Randomized Controlled Trial.

BACKGROUND: Previously incarcerated individuals have suboptimal linkage and engagement in community HIV care. Mobile health (mHealth) interventions have been shown to be effective in addressing these gaps. In Washington, District of Columbia (DC), we conducted a randomized trial of an SMS text messaging-based mHealth intervention (CARE+ Corrections) to increase linkage to community HIV care and antiretroviral treatment adherence among HIV-infected persons involved in the criminal justice system. OBJECTIVE: This study aimed to describe the SMS text messaging-based intervention, participant use of the intervention, and barriers and facilitators of implementation. METHODS: From August 2013 to April 2015, HIV-positive incarcerated individuals were recruited within the DC Department of Corrections, and persons released in the past 6 months were recruited within the community via street-based recruitment, community partnerships, and referrals. Participants were followed for 6 months and received weekly or daily SMS text messages. Formative research resulted in the development of the content of the messages in 4 categories: HIV Appointment Reminders, Medication Adherence, Prevention Reminders, and Barriers to Care following release from jail. Participants could customize the timing, frequency, and message content throughout the study period. RESULTS: Of the 112 participants enrolled, 57 (50.9%) were randomized to the intervention group and 55 (49.1%) to the control group; 2 control participants did not complete the baseline visit, and were dropped from the study, leaving a total of 110 participants who contributed to the analyses. Study retention was similar across both study arms. Median age was 42 years (IQR 30-50), 86% (49/57) were black or African American, 58% (33/57) were male, 25% (14/57) were female, and 18% (10/57) were transgender. Median length of last incarceration was 4 months (IQR 1.7-9.0), and median lifetime number of times incarcerated was 6.5 (IQR 3.5-14.0). Most participants (32/54, 59%) had a baseline viral load of <200 copies/mL. Nearly all participants (52/57, 91%) chose to use a cell phone provided by the study. The most preferred Appointment Reminder message was Hey how you feeling? Don't forget to give a call and make your appointment (19/57, 33%). The most preferred Medication Adherence message was Don't forget your skittles! (31/57, 54%), and 63% (36/57) of participants chose to receive daily (vs weekly) messages from this category at baseline. The most preferred Prevention Reminder message was Stay strong. Stay clean (18/57, 32%). The most preferred Barriers to Care message was Holla at your case manager, they're here to help (12/57, 22%). Minor message preference differences were observed among participants enrolled in the jail versus those from the community. CONCLUSIONS: Participants' ability to customize their SMS text message plan proved helpful. Further large-scale research on mHealth platforms is needed to assess its efficacy among HIV-infected persons with a history of incarceration. TRIAL REGISTRATION: ClinicalTrials.gov NCT01721226; https://clinicaltrials.gov/ct2/show/NCT01721226.

Sleep Tight, Act Right: Negative Affect, Sleep and Behavior Problems During Early Childhood.

Temperamental negative affect and insufficient sleep have been independently associated with behavior problems during early childhood. However, it is unknown whether these factors interact to contribute to behavioral difficulties in young children. The current study examined the interactions between temperamental negative affect and both sleep onset time and sleep midpoint, assessed by actigraphy, in predicting externalizing and internalizing behaviors in a sample of 117 children (34-69 months of age). Children with high temperamental negative affect and either later sleep onset time or later sleep midpoint were more likely to exhibit externalizing and internalizing behaviors. These results emphasize the association between temperamental negative affect and behavioral difficulties, particularly for children with insufficient sleep.

A Pilot Study of Rapid Hepatitis C Testing in Probation and Parole Populations in Rhode Island.

Hepatitis C virus (HCV) affects between five and seven million individuals in the United States and chronic infection can lead to liver disease, cirrhosis, and hepatocellular carcinoma. Probation/parole offices are a novel setting for rapid HCV testing, providing outreach to populations at increased risk for HCV infection and/or transmitting HCV to others. While some correctional facilities offer HCV testing, many individuals who present to probation/parole offices are never or briefly incarcerated and may not access medical services. We conducted a rapid HCV testing pilot at probation/parole offices in Rhode Island. Overall, 130 people accepted rapid HCV testing, of whom 12 had reactive tests. Only four of these individuals presented to a community-based clinic for confirmatory testing, despite being offered a monetary incentive. Identifying and addressing barriers to HCV confirmatory testing and follow-up care is critical to increasing the uptake of HCV care and treatment in this vulnerable population.

A pilot study of rapid hepatitis C virus testing in the Rhode Island Department of Corrections.

BACKGROUND: The correctional population bears a heavy burden of hepatitis C virus (HCV) infection necessitating expansion of HCV testing and treatment opportunities. Rapid HCV testing provides point-of-care antibody results and may be ideal for correctional facilities, particularly jails, where persons are often incarcerated for short periods of time, yet feasibility has not been established. METHODS: We conducted a pilot study of a rapid HCV testing algorithm among short-term inmates with unknown HCV status. Participants completed a questionnaire, viewed an informational video and underwent rapid HCV testing and confirmatory testing, when indicated. Persons with chronic infection were referred to community care after release. Baseline characteristics, risk behaviors, test results and linkage were examined by descriptive analyses. RESULTS: Two hundred and fifty-two inmates were enrolled and 249 completed all study activities. Twenty-five participants (10%) had reactive rapid tests and 23 (92%) completed confirmatory testing. 15/23 (65%) had detectable HCV RNA, but only 4 linked to care after release. Persons with reactive HCV tests were more likely to be White (P = 0.01) and to have ever injected (P < 0.0001) and/or recently injected (P < 0.0001) drugs. CONCLUSIONS: Rapid HCV testing within jails is feasible, identifies previously unrecognized cases of HCV infection, and implementation should be considered. Low rates of linkage to care after release remain a barrier to care.

Prevalence of sexually transmitted infections in female clinic attendees in Honiara, Solomon Islands.

OBJECTIVES: This study sought to determine the prevalence of common bacterial sexually transmitted infections, including Chlamydia trachomatis and Neisseria gonorrhoeae, in women attending clinics in the Solomon Islands. METHODS: We conducted a sexual health survey among women attending three nurse-led community outpatient clinics in August 2014, to establish the prevalence of bacterial sexually transmitted infections in female clinic attenders in Honiara, Solomon Islands. Vaginal swab samples were tested for infection with C. trachomatis and N. gonorrhoeae using a commercial strand displacement amplification assay. Serum samples were tested for syphilis. RESULTS: We enrolled 296 women, aged 16-49, attending three clinics. Knowledge of safe sexual practices was high but reported condom usage was low. The prevalence of infection with C. trachomatis was 20%. The prevalence of infection with N. gonorrhoeae and syphilis were 5.1% and 4.1%, respectively. CONCLUSIONS: Bacterial sexually transmitted infections are a major health problem in the Solomon Islands. Interventions are urgently needed.

The effects of sleep dysfunction on cognition, affect, and quality of life in individuals with cerebellar ataxia.

STUDY OBJECTIVE: Cerebellar ataxia comprises a group of debilitating diseases that are the result of progressive cerebellar degeneration. Recent studies suggest that, like other neurodegenerative diseases, sleep impairments are common in cerebellar ataxia. In light of the role of sleep in mood regulation and cognition, we sought to assess interactions between sleep, cognition, and affect in individuals with cerebellar ataxia. METHODS: A survey of 176 individuals with cerebellar ataxia was conducted. The battery of instruments included a modified International Cooperative Ataxia Rating Scale, Pittsburgh Sleep Quality Index, Restless Leg Syndrome Questionnaire, REM Behavior Disorder Questionnaire, Beck Depression Inventory, Epworth Sleepiness Scale, and a Composite Cognitive Questionnaire. RESULTS: Fifty-one percent of individuals indicated significant sleep disturbances on the Pittsburgh Sleep Quality Index, 73% of participants had two or more symptoms of restless leg syndrome, and 88% had two or more symptoms of REM behavior disorder. Ataxia severity, based on the modified International Cooperative Ataxia Rating Scale, predicted scores on the Pittsburgh Sleep Quality Index, the Epworth Sleepiness Scale and REM Behavior Disorder Questionnaire. Median split analyses revealed that cognitive function appeared to be reduced and depressive symptoms were greater for those individuals with poor subjective sleep quality and severe RLS. Importantly, sleep appears to play a mediatory role between disease severity and depressive symptoms. CONCLUSIONS: These results suggest that disturbed sleep may have detrimental effects on cognition and affect in individuals with cerebellar ataxia. While objective measures are needed, such results suggest that treating sleep deficits in these individuals may improve cognitive and mental health as well as overall quality of life.

Linkage to HIV care for jail detainees: findings from detention to the first 30 days after release.

Of people living with HIV in the US, ~16 % or over 150,000 individuals passed through a correctional facility in 2006. Given the enormous impact of HIV within incarcerated populations, facilitating continuity of care from jails to the community is particularly important in reducing morbidity and mortality for releasees. Grantees participating in the Enhancing Linkages to HIV Primary Care in Jail Settings Initiative developed models for identifying HIV-positive detainees during incarceration and linking them to care following release. In this sample of 1,021 HIV-infected releasees, 79 % received clinical services and 74 % received additional community services within 30 days post-release. Our analysis found several significant factors associated with linkage including: receipt of HIV or medication education in jail, having a completed discharge plan at release, staff awareness of clients' release date, and stable housing on the 30th day post-release. In addition, a subset of participants who had both jail and community viral load assessments showed a statistically significant increase in suppressed viral load. EnhanceLink data suggest that jails may be effective settings to engage individuals in care.

Drug treatment outcomes among HIV-infected opioid-dependent patients receiving buprenorphine/naloxone.

BACKGROUND: Buprenorphine/naloxone allows the integration of opioid dependence and HIV treatment. METHODS: We conducted a prospective study in HIV-infected opioid-dependent patients to investigate the impact of buprenorphine/naloxone treatment on drug use. Self-report and chart review assessments were conducted every 3 months (quarters 1-4) for 1 year. Outcomes were buprenorphine/naloxone treatment retention, drug use, and addiction treatment processes. RESULTS: Among 303 patients enrolled between July 2005 and December 2007, retention in buprenorphine/naloxone treatment was 74%, 67%, 59%, and 49% during Quarters 1, 2, 3, and 4, respectively. Past 30-day illicit opioid use decreased from 84% of patients at baseline to 42% in retained patients over the year. Patients were 52% less likely to use illicit opioids for each quarter in treatment (Odds ratio = 0.66; 95% CI: 0.61 to 0.72). Buprenorphine/naloxone doses and office visits approximated guidelines published by the United States Department of Health and Human Services. Urine toxicology monitoring was less frequent than recommended. CONCLUSIONS: Buprenorphine/naloxone provided in HIV treatment settings can decrease opioid use. Strategies are needed to improve retention and address ongoing drug use in this treatment population.

Testing for HIV, sexually transmitted infections, and viral hepatitis in jails: still a missed opportunity for public health and HIV prevention.

Jails provide an underutilized public health opportunity for screening for HIV, sexually transmitted infections (STIs), and viral hepatitis, and for such other infectious diseases as tuberculosis. Incarcerated individuals are more likely to be men, poor, persons of color, and at high risk for HIV. The vast majority of jails in the United States do not screen routinely for HIV or STIs, thereby missing an opportunity for HIV and STI diagnosis, treatment, and prevention. Nesting HIV testing within STI testing and treatment in conjunction with testing and treatment for other infectious diseases, as appropriate based on community prevalence, provides a public health opportunity and will enhance HIV prevention. HIV testing and linkage to care, both within corrections and in the community, comprise an important component of the "seek and treat" strategy to further prevent HIV infection. Jail-based screening of infectious diseases, especially for HIV and STIs, in conjunction with treatment and linkage to community care has thus far been a neglected component of HIV prevention among high-risk communities.

HIV risk behavior before and after HIV counseling and testing in jail: a pilot study.

OBJECTIVES: Jail incarceration represents an opportunity to deliver HIV counseling and testing (C&T) services to persons at increased risk of infection. However, jails can be chaotic with rapid turnover of detainees. We conducted a pilot study to investigate the feasibility of comparing the effect of different approaches to HIV C&T in jail on subsequent HIV risk behaviors among persons testing HIV negative. METHODS: Consecutive cohorts of newly incarcerated jail detainees were recruited with 132 subjects completing standard HIV C&T as per jail protocol and 132 subjects completing rapid testing with an individualized counseling session. Risk behavior was assessed and compared at baseline and 6 weeks after jail release. RESULTS: Among the 264 male participants, preincarceration substance use and sexual risk were common. The follow-up visit was completed by 59% of eligible participants. There were no differences in postrelease HIV risk behavior between the 2 arms but there was an overall decrease in risk behavior after jail release for the cohort. In addition, all participants in the rapid arm received rapid HIV test results compared with participants receiving 28% of conventional test results. CONCLUSIONS: Jail incarceration represents an important public health opportunity to deliver HIV C&T. This study demonstrated (1) feasibility in delivering rapid HIV testing combined with individualized counseling to jail detainees, (2) improved test result delivery rates, and (3) success with evaluating risk behaviors during the transition from jail to the community. Further research is needed to determine the optimal approach to HIV C&T in jail with the goal of increasing awareness of HIV serostatus and decreasing HIV risk behavior.

Decrease in the proportion of injecting drug use-related HIV/AIDS in Massachusetts, New York, Connecticut, and Rhode Island.

Injection drug use (IDU) has been a route for HIV transmission since the beginning of the epidemic. This review focuses on an apparent decrease in the proportion of IDU-related HIV/AIDS in Massachusetts, New York, Connecticut, and Rhode Island from 1999 to the present. Although there are differences in HIV/AIDS reporting requirements among these states, the dramatic reduction in the proportion of HIV and AIDS cases related to IDU is notable and is comparable to the 42% decline in HIV diagnoses among injection drug users reported by the CDC in other areas of the country.

A randomized clinical trial of community-based directly observed therapy as an adherence intervention for HAART among substance users.

BACKGROUND: Adherence interventions for HAART can impact challenging populations, such as active substance users. Community-based modified directly observed therapy (MDOT) is a promising approach that needs to be critically evaluated. METHODS: This study was a randomized clinical trial. HIV seropositive substance users were randomized to either standard of care (SOC) or MDOT, stratified by HAART experience. All participants were placed on a once-daily regimen and were met by an outreach worker for all 7 days during the first 3 months. We used an intent-to-treat analysis to evaluate differences in viral load suppression [> 2 log drop in plasma viral load (PVL) or PVL < 50] and changes in PVL and CD4 cell count from baseline to 3 months. RESULTS: A total of 87 participants were enrolled (43 in SOC, 44 in MDOT), Using repeated measures logistic regression, MDOT participants were more likely to achieve PVL suppression (odds ratio, 2.16; 95% confidence interval, 1.0-4.7), driven primarily by those HAART experienced (odds ratio, 2.88; 95% confidence interval, 1.2-7.0). A significant treatment effect was also found in CD4 cell count change (P < 0.05). No differences were found by arm in undetectable PVL. CONCLUSION: This study provides evidence that MDOT is an effective strategy to reduce viral load and increase CD4 cell counts in HAART experienced substance users. MDOT should be included in the spectrum of options to enhance adherence in this population.

Addition of intravenous iron to epoetin beta increases hemoglobin response and decreases epoetin dose requirement in anemic patients with lymphoproliferative malignancies: a randomized multicenter study.

This randomized study assessed if intravenous iron improves hemoglobin (Hb) response and permits decreased epoetin dose in anemic (Hb 9-11 g/dl), transfusion-independent patients with stainable iron in the bone marrow and lymphoproliferative malignancies not receiving chemotherapy. Patients (n=67) were randomized to subcutaneous epoetin beta 30 000 IU once weekly for 16 weeks with or without concomitant intravenous iron supplementation. There was a significantly (P<0.05) greater increase in mean Hb from week 8 onwards in the iron group and the percentage of patients with Hb increase >or=2 g/dl was significantly higher in the iron group (93%) than in the no-iron group (53%) (per-protocol population; P=0.001). Higher serum ferritin and transferrin saturation in the iron group indicated that iron availability accounted for the Hb response difference. The mean weekly patient epoetin dose was significantly lower after 13 weeks of therapy (P=0.029) and after 15 weeks approximately 10 000 IU (>25%) lower in the iron group, as was the total epoetin dose (P=0.051). In conclusion, the Hb increase and response rate were significantly greater with the addition of intravenous iron to epoetin treatment in iron-replete patients and a lower dose of epoetin was required.

Tuberculosis prevention and control in large jails: a challenge to tuberculosis elimination.

BACKGROUND: This study assessed the extent to which 20 large jail systems have implemented national recommendations for tuberculosis (TB) prevention and control in correctional facilities. METHODS: Data were collected through questionnaires to jail medical directors and TB control directors, observation at the jails, and abstraction of medical records of inmates with TB disease and latent TB infection. RESULTS: Twenty percent of jail systems (4/20) had conducted an assessment of risk for TB transmission in their facilities, and 55% (11/20) monitored tuberculin skin test conversions of inmates and staff. Sixty-five percent (13/20) of jails had an aggregate record-keeping system for tracking TB status and treatment, which was usually paper based. Forty-five percent of jails (9/20) had policies to offer HIV counseling and testing to tuberculin skin test-positive patients, and 75% (15/20) screen HIV-infected inmates with chest radiographs. Three quarters of jails (15/20) had policies to always isolate patients with suspected or confirmed pulmonary TB in an airborne infection isolation room. Half of jails with airborne infection isolation rooms (6/12) conformed to Centers for Disease Control and Prevention (CDC) guidelines for monitoring negative pressure. CONCLUSIONS: Improvements are needed in conducting TB risk assessments and evaluations to determine priorities and reduce risk of transmission. Inadequate medical information systems are impeding TB control and evaluation efforts. Although HIV infection is the greatest cofactor for development of TB disease, jails have inadequate information on patients' HIV status to make informed decisions in screening and management of TB and latent TB infection. Jails need to improve the use of environmental controls.

Adherence among women with HIV infection in Puerto Rico: the potential use of modified directly observed therapy (MDOT) among pregnant and postpartum women.

Women are the fastest growing segment of the adult population acquiring HIV, and most women infected with HIV are in their reproductive years. The success of HAART is highly dependent upon the ability and willingness of the individual to adhere to complex antiretroviral regimens. Improved adherence among HIV-infected pregnant women will delay disease progression in the mother and should also reduce HIV transmission to the baby. Modified directly observed therapy (MDOT), may benefit this population. MDOT has been shown to be an acceptable and feasible intervention among HIV substance users; however, no-one has yet evaluated the use of MDOT in pregnant and postpartum women. Based on semi-structured interviews with 17 Latina women with HIV infection, we explored women's adherence patterns and barriers to adherence and their perceptions of a hypothetical MDOT program. The vast majority of women positively appraised the MDOT program as an effective means to increase and reinforce adherence to demanding drug regimens. Respondents cited the face-to-face contact, the supportive nature of the relationship, and the practical approach of the program as the primary reasons for the effectiveness of MDOT. Results indicate that MDOT could be an acceptable intervention for pregnant and postpartum Latina women to improve adherence to HAART.

The use of community-based modified directly observed therapy for the treatment of HIV-infected persons.

Directly observed therapy, which has been successful in the treatment of tuberculosis, is being adapted for the treatment of HIV to decrease long-term morbidity and mortality. We describe the experiences of 69 HIV-infected individuals who were enrolled in a community-based modified directly observed therapy (MDOT) program. Participants were referred by their primary care physicians based on nonadherence to antiretroviral therapy, and/or active substance use. A near-peer outreach worker initially delivered medications to participants 5 to 7 days per week, with visits subsequently tapered to 1 to 3 days per week after 3 or more months. Questionnaires were completed and laboratory values were obtained at baseline, 1 month, and every 3 months after enrollment. At enrollment, 96% of participants had a history of substance use, 71% had a history of incarceration, and 93% were experienced with highly active antiretroviral therapy (HAART). At the time of their 6-month assessment visit, 31 of 69 participants were receiving observed therapy visits. The median baseline plasma viral load (PVL) was 4.8 log, and the median individual change in PVL from baseline to 6 months among participants receiving MDOT was a decrease of 2.7 log. Reasons why participants were not receiving visits included medication holidays, hospitalization or assisted living, incarceration, discontinuation of program involvement, and death. These results support that MDOT should be included in the spectrum of options available to enhance adherence to HAART among patients who are unsuccessful with self-administration of their medications.

Public health and correctional collaboration in tuberculosis control.

OBJECTIVE: To assess the extent that 20 large jail systems and their respective public health departments collaborate to prevent and control tuberculosis (TB). METHODS: Data were collected through questionnaires sent to jail medical directors and TB control directors, interviews, and on-site observation in each of the jails. RESULTS: Only 35% of jail systems and health departments reported having effective collaboration in TB prevention and control activities. Four barriers were reported by a majority of the jail systems: funding (65%), staffing (60%), staff training (55%), and communication (55%). Lack of advance notice of a patient's release was rated as the greatest barrier to discharge planning. Fifty percent of the jail systems reported that they scheduled appointments for soon-to-be released patients with TB, and 10% did so for patients being treated for latent TB infection (LTBI). Fewer patients actually received appointments: seven (39%) of 33 released patients with TB had documentation in their medical record of appointments, and one of 46 released patients on treatment for LTBI had them. Characteristics associated with increased collaboration include having designated liaisons between jail systems and health departments and holding periodic meetings of staff. CONCLUSIONS: Health departments and jail systems in the same jurisdiction have implemented recommendations regarding collaboration to a limited extent. Such collaborations need strengthening, especially discharge planning and evaluation of TB control activities.

Modified directly observed therapy for the treatment of HIV-seropositive substance users: lessons learned from a pilot study.

Highly active antiretroviral therapy (HAART) can dramatically decrease human immunodeficiency virus (HIV) load in plasma, increase CD4+ cell counts, and prolong life for HIV-seropositive persons. However, the need for optimal adherence has been recognized. We implemented a pilot community-based program of directly observed therapy (DOT) with HAART among persons with substance use disorders and a history of failure of HAART. A near-peer outreach worker initially delivered and observed once-daily HAART doses on up to 7 days per week. Many participants tapered the frequency of visits. Participants were assessed by a brief questionnaire and determination of their CD4+ cell count and plasma HIV load. Twenty-five HIV-seropositive persons were enrolled and followed-up for a mean of 6.6 months (standard deviation, 3.9 months). We found that once-daily dosing of HAART by DOT is feasible in this population; in addition to observation of the majority of doses, most participants achieved virus suppression and felt favorably about the intervention. Tapering the intensity of visits with maximum flexibility was necessary to enhance the acceptability of the program to participants.