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1.
Drug Alcohol Depend ; 228: 109085, 2021 Sep 22.
Artigo em Inglês | MEDLINE | ID: mdl-34600248

RESUMO

BACKGROUND: US rates of overdose deaths involving stimulants (e.g., cocaine or methamphetamine) have increased, but little is known about non-fatal stimulant overdoses, particularly among vulnerable populations. We characterized rates of non-fatal stimulant overdose identified outside of health care settings among women at high risk. METHODS: Homeless and unstably housed women in San Francisco, California using stimulants were administered questionnaires on drug use and outcomes (stimulant overdose, health care utilization) monthly for six months. Based on pilot interviews, stimulant overdose during follow-up was defined as acute toxicity from stimulant use ("over-amping") resulting in "feeling sick, really scared, or like one's life may be in danger". Poisson regression estimated unadjusted incidence rate ratio (IRR) comparing participant characteristics. RESULTS: We included 160 women (41% Black, 26% White, 15% Latina, median age 54 years) using crack cocaine (81%), methamphetamine (48%), and powdered cocaine (36%). Participants reported 67 non-fatal stimulant overdoses over 685 person-months of observation, a rate of 117.4 per 100 person-years (95% CI 85.8-160.5). Rates were higher among participants who were Latina vs. White (IRR 4.18 [1.60-10.94]), used methamphetamine (IRR 1.80 [0.96-3.38]), or used any stimulant daily/almost daily (IRR 2.63 [1.41-4.91]). Among women reporting stimulant overdose, 4% received emergency and 3% inpatient care for overdose of any drug. CONCLUSIONS: Women in this setting, particularly those who used stimulants frequently or used methamphetamine, experienced high non-fatal stimulant overdose and rarely received health care for these events. Efforts should be made to increase awareness and reduce harms of stimulant toxicity in vulnerable populations.

2.
Medicine (Baltimore) ; 100(40): e27423, 2021 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-34622852

RESUMO

ABSTRACT: The COVID-19 pandemic disrupted almost all sectors of academic training and research, but the impact on human immunodeficiency virus (HIV) research mentoring has yet to be documented. We present the perspectives of diverse, experienced mentors in a range of HIV research disciplines on the impact of COVID-19 on mentoring the next generation of HIV researchers.In November to December, 2020, we used an online data collection platform to cross-sectionally query previously-trained HIV mentors on the challenges related to mentoring during the pandemic, surprising/positive aspects of mentoring in that context, and recommendations for other mentors. Data were coded and analyzed following a thematic analysis approach.Respondents (180 of 225 mentors invited [80% response]) reported challenges related to relationship building/maintenance, disruptions in mentees' training and research progress, and mentee and mentor distress, with particular concerns regarding mentees who are parents or from underrepresented minority backgrounds. Positive/surprising aspects included logistical ease of remote mentoring, the relationship-edifying result of the shared pandemic experience, mentee resilience and gratitude, and increased enjoyment of mentoring. Recommendations included practical tips, encouragement for patience and persistence, and prioritizing supporting mentees' and one's own mental well-being.Findings revealed gaps in HIV mentors' competencies, including the effective use of remote mentoring tools, how to work with mentees in times of distress, and the prioritization of mentor well-being. Mentors are in a unique position to identify and potentially address factors that may lead to mentees leaving their fields, especially parents and those from underrepresented backgrounds. We discuss implications beyond the COVID-19 pandemic.


Assuntos
COVID-19/epidemiologia , Infecções por HIV/epidemiologia , Tutoria/organização & administração , Pesquisadores/educação , Estudos Transversais , Educação à Distância , Feminino , Humanos , Masculino , Pandemias , Competência Profissional , Pesquisa Qualitativa , SARS-CoV-2 , Estresse Psicológico/epidemiologia , Estados Unidos/epidemiologia
3.
BMJ Open ; 11(9): e054903, 2021 09 06.
Artigo em Inglês | MEDLINE | ID: mdl-34489299

RESUMO

OBJECTIVES: People living with HIV (PLHIV) in the USA, particularly women, have a higher prevalence of food insecurity than the general population. Cigarette smoking among PLHIV is common (42%), and PLHIV are 6-13 times more likely to die from lung cancer than AIDS-related causes. This study sought to investigate the associations between food security status and smoking status and severity among a cohort of predominantly low-income women of colour living with and without HIV in the USA. DESIGN: Women enrolled in an ongoing longitudinal cohort study from 2013 to 2015. SETTING: Nine participating sites across the USA. PARTICIPANTS: 2553 participants enrolled in the Food Insecurity Sub-Study of the Women's Interagency HIV Study, a multisite cohort study of US women living with HIV and demographically similar HIV-seronegative women. OUTCOMES: Current cigarette smoking status and intensity were self-reported. We used cross-sectional and longitudinal logistic and Tobit regressions to assess associations of food security status and changes in food security status with smoking status and intensity. RESULTS: The median age was 48. Most respondents were African-American/black (72%) and living with HIV (71%). Over half had annual incomes ≤US$12 000 (52%). Food insecurity (44%) and cigarette smoking (42%) were prevalent. In analyses adjusting for common sociodemographic characteristics, all categories of food insecurity were associated with greater odds of current smoking compared with food-secure women. Changes in food insecurity were also associated with increased odds of smoking. Any food insecurity was associated with higher smoking intensity. CONCLUSIONS: Food insecurity over time was associated with smoking in this cohort of predominantly low-income women of colour living with or at risk of HIV. Integrating alleviation of food insecurity into smoking cessation programmes may be an effective method to reduce the smoking prevalence and disproportionate lung cancer mortality rate particularly among PLHIV.


Assuntos
Insegurança Alimentar , Infecções por HIV , Estudos de Coortes , Estudos Transversais , Feminino , Abastecimento de Alimentos , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade , Fumar/epidemiologia , Estados Unidos/epidemiologia
4.
Int J Drug Policy ; 98: 103377, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34481110

RESUMO

BACKGROUND: Individuals who are unsheltered or experiencing homelessness are more likely to smoke than those in the general population and have a higher prevalence of tobacco-related illnesses. Those who are unhoused make quit attempts at rates similar to the general population, however rates of successful quitting are much lower. Women bear a higher burden of smoking-related diseases and are less successful in their cessation efforts than men. Despite these increased risks and challenges, cessation programs specifically designed to meet the needs of women experiencing homelessness are extremely rare. METHODS: To examine perceptions of smoking cessation programs among women who are unstably housed, we conducted in-depth, semi-structured interviews with twenty-nine women experiencing homelessness or unstable housing who had histories of tobacco and substance use. Interviews explored the social context of smoking, as well as interest in, barriers to, and facilitators of quitting. We used a grounded theory approach to analyze the transcripts. RESULTS: Participants reported a number of structural barriers to cessation. They reported obstacles to participating in existing cessation programs, including chronic stress related to experiences of being unsheltered and fear of being exposed to neighborhood violence. These conditions were paired with a strong need to self-isolate in order to maintain personal safety, which runs counter to traditional group-based cessation programs. CONCLUSION: A dissonance exists between current smoking cessation programs and the needs of women who are unsheltered or unstably housed. Alternative cessation treatment delivery models that address extremely high levels of chronic stress violence, and avoidance of group settings are needed, as are programs that provide options for safe participation.

5.
Int J Drug Policy ; 97: 103405, 2021 Aug 03.
Artigo em Inglês | MEDLINE | ID: mdl-34403865

RESUMO

BACKGROUND: The COVID-19 pandemic created a major public health crisis that disrupted economic systems, social networks and individual behaviors, which led to changes in patterns of health care use. Factors associated with emergency department (ED) visits during the pandemic among especially high-risk individuals are unknown. We used a "Big Events" approach, which considers major disruptions that create social instability, to investigate ED use in people experiencing homelessness or housing instability, many of whom use drugs. METHODS: Between July and December 2020, we conducted a community-based San Francisco study to compare homeless and unstably housed (HUH) women who did and did not use an ED during the first 10 months of the pandemic. RESULTS: Among 128 study participants, 34% had ≥1 ED visit during the pandemic. In adjusted analysis, factors significantly associated with ED use included experiencing homelessness, cocaine use and increased difficulties receiving drug use treatment during the pandemic. CONCLUSION: These findings build on the "Big Events" approach to considering risk pathways among people who use drugs. They suggest the importance of ensuring access to housing and low-barrier non-COVID health services, including drug treatment, alongside crisis management activities, to reduce the health impacts of public health crises.

7.
AIDS ; 35(8): 1241-1246, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34076613

RESUMO

OBJECTIVE: Homelessness is the greatest risk factor for HIV viremia in San Francisco. Innovative care models for people with HIV (PWH) with homelessness or unstable housing (HUH) are needed to address this inequity. We developed a novel low-barrier clinic-based program for PWH-HUH in an urban safety-net clinic ('POP-UP') and report outcomes on care engagement and viral suppression. DESIGN: A prospective cohort study. SETTING: San Francisco General Hospital HIV Clinic (Ward 86). PARTICIPANTS: We enrolled PWH who are HUH, viraemic and for whom usual care is not working (at least one missed primary care appointment and at least two drop-in visits at Ward 86 in the last year). INTERVENTION: POP-UP provides drop-in comprehensive primary care, housing assistance and case management, financial incentives and patient navigation with frequent contact. MAIN OUTCOME MEASURES: We describe uptake of eligible patients into POP-UP, and cumulative incidence of antiretroviral therapy (ART) initiation, return to care and virologic suppression 6 months post-enrolment, estimated via Kaplan--Meier. RESULTS: Out of 192 referred patients, 152 were eligible, and 75 enrolled. All 75 were off ART and viraemic; 100% had a substance use disorder; and 77% had a mental health diagnosis. Over three-quarters restarted ART within 7 days of enrolment, and 91% returned for follow-up within 90 days. The cumulative incidence of viral suppression at 6 months was 55% (95% confidence interval 43-68). CONCLUSION: A novel care model for PWH-HUH demonstrates early success in engaging viraemic patients in care and improving viral suppression. Low-barrier, high-contact primary care programmes offering comprehensive services and incentives may improve outcomes for this vulnerable population.


Assuntos
Infecções por HIV , Pessoas em Situação de Rua , Infecções por HIV/tratamento farmacológico , Habitação , Humanos , Estudos Prospectivos , São Francisco/epidemiologia , Carga Viral
8.
J Stroke Cerebrovasc Dis ; 30(5): 105675, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33677311

RESUMO

OBJECTIVES: Cocaine use has been linked to stroke in several studies. However, few studies have considered the influence of cocaine use on stroke mechanisms such as small vessel disease (SVD). We conducted a study to assess associations between the toxicology-confirmed use of multiple drugs, including cocaine, and a marker of SVD, white matter hyperintensities (WMH). MATERIALS AND METHODS: We conducted a nested case-control study (n = 30) within a larger cohort study (N = 245) of homeless and unstably housed women recruited from San Francisco community venues. Participants completed six monthly study visits consisting of an interview, blood draw, vital sign assessment and baseline brain MRI. We examined associations between toxicology-confirmed use of multiple substances, including cocaine, methamphetamine, heroin, alcohol and tobacco, and WMH identified on MRI. RESULTS: Mean study participant age was 53 years, 70% of participants were ethnic minority women and 86% had a history of cocaine use. Brain MRIs indicated the presence of WMH (i.e., Fazekas score>0) in 54% (18/30) of imaged participants. The odds of WMH were significantly higher in women who were toxicology-positive for cocaine (Odd Ratio=7.58, p=0.01), but not in women who were toxicology-positive for other drugs or had several other cerebrovascular risk factors. CONCLUSIONS: Over half of homeless and unstably housed women showed evidence of WMH. Cocaine use is highly prevalent and a significant correlate of WMH in this population, while several traditional CVD risk factors are not. Including cocaine use in cerebrovascular risk calculators may improve stroke risk prediction in high-risk populations and warrants further investigation.


Assuntos
Doenças de Pequenos Vasos Cerebrais/etiologia , Transtornos Relacionados ao Uso de Cocaína/complicações , Usuários de Drogas , Pessoas em Situação de Rua , Habitação , Leucoencefalopatias/etiologia , Populações Vulneráveis , Saúde da Mulher , Adulto , Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Transtornos Relacionados ao Uso de Cocaína/diagnóstico , Feminino , Humanos , Leucoencefalopatias/diagnóstico por imagem , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , São Francisco , Detecção do Abuso de Substâncias
9.
Clin Infect Dis ; 72(11): 2042-2043, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32887980

RESUMO

Job loss and evictions tied to the Coronavirus Disease 2019 (COVID-19) pandemic are expected to increase homelessness significantly in the coming months. Reciprocally, homelessness and the many vulnerabilities that inevitably accompany it are driving COVID-19 outbreaks in US shelters and other congregate living situations. Unless we intervene to address homelessness, these co-existing and synergistic situations will make the current public health crisis even worse. Preventing homelessness and providing permanent affordable housing has reduced the ravages of the HIV epidemic. We must take the lessons learned in 40 years of fighting HIV to respond effectively to the COVID-19 crisis. Housing is an investment that will curb the spread of COVID-19 and help protect all of us from future pandemics.


Assuntos
COVID-19 , Infecções por HIV , Saúde da População , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Habitação , Humanos , SARS-CoV-2 , Estados Unidos/epidemiologia
10.
AIDS ; 35(3): 517-519, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33306555

RESUMO

Coronavirus disease-2019 (COVID-19) threatens to further worsen HIV outcomes among people experiencing homelessness. We conducted an interrupted time-series analysis of care engagement and viral suppression among unhoused individuals in the 'POP-UP' low-barrier, high-intensity HIV primary care program during COVID-19. Among 85 patients, care engagement and viral suppression did not decrease in the 5 months following implementation of San Francisco's 'shelter-in-place' ordinance. Low-barrier, in-person HIV care for homeless individuals may be important for maintaining HIV outcomes during COVID-19.


Assuntos
COVID-19 , Infecções por HIV/terapia , Pessoas em Situação de Rua , Pandemias , Humanos , Análise de Séries Temporais Interrompida , Atenção Primária à Saúde , São Francisco
11.
Drug Alcohol Depend ; 217: 108252, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-32919207

RESUMO

INTRODUCTION: The use of controlled substances like cocaine increases the risk of cardiovascular disease (CVD) and myocardial infarction (MI). However, outside of alcohol and tobacco, substance use is not included in CVD risk assessment tools. We identified the effects of using multiple substances (nicotine/cotinine, cannabis, alcohol, cocaine, methamphetamine, heroin and other opioids) on cardiac injury measured by high-sensitivity troponin (hsTnI) in homeless and unstably housed women. METHODS: We recruited 245 homeless and unstably housed women from shelters, free meal programs and street encampments. Participants completed six monthly study visits. Adjusting for traditional CVD risk factors, we examined longitudinal associations between substance use and hsTnI. RESULTS: Median participant age was 53 years and 74 % were ethnic minority women. At baseline, 76 % of participants had hypertension, 31 % were HIV-positive, 8% had a history of a prior MI and 12 % of prior stroke. The most commonly used substances were cotinine/nicotine (80 %), cannabis (68 %) and cocaine (66 %). HsTnI exceeding the 99th percentile (14.7 ng/L) - a level high enough to signal possible MI - was observed in 14 participants during >1 study visit (6%). In adjusted analysis, cocaethylene and fentanyl were significantly associated with higher hsTnI levels. CONCLUSIONS: Fentanyl use and the co-use of cocaine and alcohol are associated with myocardial injury, suggesting that the use of these substances may act as long-term cardiac insults. Whether risk counseling on these specific substances and/or including their use in CVD risk stratification would improve CVD outcomes in populations where substance use is high merits further investigation.


Assuntos
Doenças Cardiovasculares/sangue , Pessoas em Situação de Rua , Habitação/tendências , Transtornos Relacionados ao Uso de Substâncias/sangue , Troponina I/sangue , Adulto , Biomarcadores/sangue , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/epidemiologia
12.
Harm Reduct J ; 17(1): 17, 2020 03 10.
Artigo em Inglês | MEDLINE | ID: mdl-32156289

RESUMO

BACKGROUND: Numerous reports have led to concerns that fentanyl is added to many street drugs as an adulterant, including to stimulants like cocaine and methamphetamine, and could increase risks for negative health outcomes. METHODS: We collected information regarding recent substance use through self-report and urine toxicology (confirmed with mass spectrometry) once a month for up to 6 monthly study visits from a probability sample of 245 women in San Francisco with a history of housing instability (2016-2019). We compared the presence of fentanyl metabolites with (1) the presence of metabolites for other substances and (2) self-reported past week substance use. RESULTS: Out of 1050 study visits, fentanyl metabolites were detected 35 times (i.e., at 3% of all study visits and among 19/245, or 8% of all women). In most but not all (91%, or 32/35) of these detected cases, heroin or opioid medication use was self-reported. Among women who reported cocaine or methamphetamine use, but did not use heroin or opioid medication, fentanyl was detected in only 1 of 349 cases (0.3%). In adjusted logistic regression, the presence of fentanyl metabolites was independently associated with (1) presence of opiate, heroin, and benzodiazepine metabolites, and (2) self-reported past week use of heroin and opioid medications. Fentanyl metabolite detection was not independently associated with cocaine or methamphetamine use. CONCLUSIONS: The presence of fentanyl metabolites in this population was almost entirely among women who also reported using heroin or opioid pills. These data do not support the hypothesis that fentanyl is being routinely added to stimulants as an adulterant on a large scale in this region.

13.
J Urban Health ; 97(1): 78-87, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31907705

RESUMO

Women who experience housing instability are at high risk for violence and have disproportionately high rates of emergency department (ED) use. However, little has been done to characterize the violence they experience, or to understand how it may be related to ED use. We recruited homeless and unstably housed women from San Francisco shelters, free meal programs, and single room occupancy (SRO) hotels. We used generalized estimating equations to examine associations between violence and any ED use (i.e., an ED visit for any stated reason) every 6 months for 3 years. Among 300 participants, 44% were African-American, and the mean age was 48 years. The prevalence of violence experienced in the prior 6 months included psychological violence (87%), physical violence without a weapon (48%), physical violence with a weapon (18%), and sexual violence (18%). While most participants (85%) who experienced physical violence with a weapon or sexual violence in the prior 6 months had not visited an ED, these were the only two violence types significantly associated with ED use when all violence types were included in the same model (ORphysical/weapon = 1.83, 95% CI 1.02-3.28; ORsexual = 2.15, 95% CI 1.30-3.53). Only violence perpetrated by someone who was not a primary intimate partner was significantly associated with ED use when violence was categorized by perpetrator. The need to reduce violence in this population is urgent. In the context of health care delivery, policies to facilitate trauma-informed ED care and strategies that increase access to non-ED care, such as street-based medicine, could have substantial impact on the health of women who experience homelessness and housing instability.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Pessoas em Situação de Rua/estatística & dados numéricos , Violência/estatística & dados numéricos , Adulto , Feminino , Pessoas em Situação de Rua/psicologia , Habitação , Humanos , Drogas Ilícitas , Pessoa de Meia-Idade , Prevalência , São Francisco/epidemiologia , Delitos Sexuais/estatística & dados numéricos
14.
Drug Alcohol Depend ; 204: 107571, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31581024

RESUMO

BACKGROUND: Single room occupancy (SRO) buildings, also known as residential hotels, are a form of affordable housing common to cities in North America, and residents of these buildings face elevated rates of substance use, physical and mental multimorbidity, and mortality. Identifying distinct populations at greater risk of overdose death is crucial to the planning of interventions aiming to reduce drug-related mortality, yet no studies have assessed the population burden of overdose mortality among SRO residents. The present study quantifies and characterizes drug overdose mortality among residents of SRO buildings in a large U.S. city. METHODS: We used mortality records and a database of SRO buildings to calculate rate ratios comparing overdose mortality due to opioids, cocaine, and methamphetamine among SRO residents and non-SRO residents in San Francisco, CA 2010-2017 and assessed bivariate differences in decedent and death location characteristics between SRO resident and other overdose decedents. RESULTS: There were 1,551 overdose deaths during the study period, with an overall rate of 21.3 per 100,000 residents (95%CI = 20.2-22.6). The rate among SRO residents (278.7, 95%CI = 252.9-306.5) was 19.3 (95%CI = 17.1-21.7) times that of non-SRO residents (21.3, 95%CI = 20.2-22.6). An additional 79 (5%) deaths among non-residents occurred in SRO buildings, and 86% of SRO resident decedents died at home compared to 64% of non-SRO residents (p < 0.05). CONCLUSIONS: Overdose mortality was substantially higher among SRO residents, who were also more likely to die from overdose at home, which highlights the need for resources and targeted interventions directed towards residents of SRO buildings.


Assuntos
Overdose de Drogas/mortalidade , Instituições Residenciais/estatística & dados numéricos , Adulto , Analgésicos Opioides/toxicidade , Cocaína/toxicidade , Feminino , Humanos , Masculino , Metanfetamina/toxicidade , Pessoa de Meia-Idade , São Francisco/epidemiologia , Fatores de Tempo , Adulto Jovem
15.
AIDS Behav ; 23(9): 2326-2336, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31324996

RESUMO

While poverty is an established barrier to achieving success at each step of the HIV care continuum, less is known about specific aspects of poverty and how they overlap with behavior in exceptionally low-income individuals who live in well-resourced areas. We considered unsuppressed viral load over 3 years among women living with HIV in San Francisco who used homeless shelters, low-income hotels and free meal programs. One-hundred twenty study participants were followed; 60% had > 1 unsuppressed viral load and 19% were unsuppressed at every visit. Across six-month intervals, the odds of unsuppressed viral load were 11% higher for every 10 nights spent sleeping on the street [Adjusted Odds Ratio (AOR) 1.11, 95% CI 1.02-1.20]; 16% higher for every 10 nights spent sleeping in a shelter (AOR/10 nights 1.16, 95% CI 1.06-1.27); 4% higher for every 10 nights spent sleeping in a single-room occupancy hotel (AOR/10 nights 1.04, 95% CI 1.02-1.07); and over threefold higher among women who experienced any recent incarceration (AOR 3.56, 95% CI 1.84-6.86). Violence and recent use of outpatient health care did not significantly predict viral suppression in adjusted analysis. While strategies to promote retention in care are important for vulnerable persons living with HIV, they are insufficient to ensure sustained viral suppression in low-income women experiencing homelessness and incarceration. Results presented here in combination with prior research linking incarceration to homelessness among women indicate that tailored interventions, which not only consider but prioritize affordable housing, are critical to achieving sustained viral suppression in low-income women living with HIV.


Assuntos
Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , Pessoas em Situação de Rua/estatística & dados numéricos , Habitação Popular/estatística & dados numéricos , Carga Viral/efeitos dos fármacos , Adolescente , Adulto , Feminino , Infecções por HIV/epidemiologia , Pessoas em Situação de Rua/psicologia , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Pobreza , São Francisco/epidemiologia , Testes Sorológicos , Adulto Jovem
16.
J Public Health (Oxf) ; 41(4): e283-e289, 2019 12 20.
Artigo em Inglês | MEDLINE | ID: mdl-31044248

RESUMO

BACKGROUND: Well-tolerated, highly effective HCV treatment, known as direct-acting antivirals (DAAs), is now recommended for all people living with HCV, providing the tools for HCV elimination. We sought to understand treatment barriers among low-income HIV/HCV coinfected patients and providers with the goal of increasing uptake. METHODS: In 2014, we conducted 26 interviews with HIV/HCV co-infected patients and providers from a San Francisco clinic serving underinsured and publically-insured persons to explore barriers impacting treatment engagement and completion. Interview transcripts were coded, and a thematic analysis was conducted to identify emerging patterns. RESULTS: Conditions of poverty-specifically, meeting basic needs for food, shelter, and safety-undermined patient perceptions of self-efficacy to successfully complete HCV treatment programs. While patient participants expressed interest in HCV treatment, the perceived burden of taking daily medications without strong social support was an added challenge. This need for support contradicted provider assumptions that, due to the shorter-course regimens, support is unnecessary in the DAA era. CONCLUSIONS: Interferon-free treatments alone are not sufficient to overcome social-structural barriers to HCV treatment and care among low-income HIV/HCV co-infected patients. Support for patients with unmet social needs may facilitate treatment initiation and completion, particularly among those in challenging socioeconomic situations.


Assuntos
Antivirais/uso terapêutico , Coinfecção/tratamento farmacológico , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde , Hepatite C/tratamento farmacológico , Feminino , Infecções por HIV/complicações , Hepatite C/complicações , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Provedores de Redes de Segurança , Estados Unidos
17.
AIDS Care ; 31(11): 1340-1347, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-30829533

RESUMO

HIV/HCV coinfected patients are a priority for direct acting antiretroviral (DAA) treatment, yet barriers to treating vulnerable patients persist. This study surveyed safety net clinic patients and providers to quantify their preferences for DAA treatment and prioritize modifiable barriers. Preferences were assessed using best-worst scaling. General linear mixed models were used to determine whether attributes differed in importance and whether patients and providers valued attributes differently. 158 HIV/HCV coinfected patients and 49 providers participated. Patients and providers had strong preferences for treatment within the medical homes where patients receive HIV care. Support such as reminders and advice numbers were also important, but were more important to providers than patients. Providers identified lack of insurance coverage for DAA as the most significant barrier. Providers rated HIV primary care providers as best suited to deliver DAA to HIV+ patients. Addressing structural barriers is essential for increasing DAA treatment in safety net settings.


Assuntos
Antivirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Hepatite C Crônica/tratamento farmacológico , Preferência do Paciente , Relações Médico-Paciente , Adulto , Feminino , Infecções por HIV/complicações , Hepatite C Crônica/complicações , Humanos , Masculino , Pessoa de Meia-Idade , São Francisco , Resultado do Tratamento
18.
J Acquir Immune Defic Syndr ; 80(1): 89-93, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30272634

RESUMO

BACKGROUND: HIV-positive persons who use stimulants such as methamphetamine experience difficulties navigating the HIV care continuum that undermine the benefits of antiretroviral therapy (ART). However, few studies have examined the association of stimulant use with viral suppression in the era of universal ART. SETTING: Zuckerberg San Francisco General Hospital. METHODS: HIV-positive persons participating in a clinical cohort study and taking ART completed assessments every 4-6 months. The exposure was the cumulative, time-varying proportion of assessments with any self-reported stimulant use. The time-varying outcome, HIV viral suppression (ie, <200 copies/mL), was measured at assessments or extracted from the clinical record. RESULTS: In total, 1635 HIV-positive participants on ART contributed 17,610 person-visits over a median of 2.3 [interquartile range (IQR) = 1.0-5.3] years of follow-up. Participants were middle-aged (median = 45.0; IQR = 38.0-52.0), predominantly white (57%), sexual minority men (78%), with a median CD4 T-cell count of 409 (IQR = 225-640) cells/mm at enrollment. Significant increases in odds of viral suppression over time were less pronounced among stimulant users compared with nonusers, particularly before the advent of universal ART. Increasing odds of viral suppression were paralleled by declining stimulant use over time. In the universal ART era, increasing odds of viral suppression were observed at lower levels of stimulant use, but not when participants reported using stimulants at every visit. CONCLUSIONS: Although ART benefits are still not achieved as rapidly in stimulant users, this disparity is not as large in the era of universal ART.


Assuntos
Transtornos Relacionados ao Uso de Anfetaminas/epidemiologia , Fármacos Anti-HIV/uso terapêutico , Estimulantes do Sistema Nervoso Central/administração & dosagem , Infecções por HIV/tratamento farmacológico , Metanfetamina/administração & dosagem , Carga Viral/efeitos dos fármacos , Adulto , Transtornos Relacionados ao Uso de Anfetaminas/psicologia , Contagem de Linfócito CD4 , Linfócitos T CD4-Positivos , Estimulantes do Sistema Nervoso Central/efeitos adversos , Estudos de Coortes , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/psicologia , Humanos , Masculino , Adesão à Medicação/estatística & dados numéricos , Metanfetamina/efeitos adversos , Pessoa de Meia-Idade , Razão de Chances , Estados Unidos/epidemiologia , Carga Viral/imunologia
19.
AIDS Behav ; 23(3): 802-812, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30267368

RESUMO

We sought to identify the prevalence and independent correlates of condomless sex within a cohort of community-recruited homeless and unstably housed cisgender adult women who were followed biannually for 3 years (N = 143 HIV+ , N = 139 HIV-). Nearly half (44%) of participants reported condomless sex in the 6 months before baseline, which increased to 65% throughout the study period. After adjusting for having a primary partner, longitudinal odds of condomless sex among women with HIV were significantly higher among those reporting < daily use of alcohol or cannabis (AOR = 2.09, p =.002, and 1.88, p =.005, respectively) and PTSD (AOR = 1.66, p =.034). Among women without HIV, adjusted longitudinal odds of condomless sex were significantly higher for those reporting < daily methamphetamine use (AOR = 2.02, p =.012), panic attack (AOR = 1.74, p =.029), and homelessness (AOR = 1.67, p = .006). Associations were slightly attenuated when adjusting for sex exchange. Targeted HIV/STI programs for unstably housed women should address anxiety and trauma disorders, infrequent substance use, and housing challenges.


Assuntos
Comportamento de Escolha , Preservativos , Infecções por HIV/prevenção & controle , Pessoas em Situação de Rua/estatística & dados numéricos , Habitação , Pobreza , Sexo sem Proteção/estatística & dados numéricos , Adulto , Estudos de Coortes , Comorbidade , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/psicologia , Humanos , Estudos Longitudinais , Masculino , Saúde Mental , Pessoa de Meia-Idade , Transtorno de Pânico/epidemiologia , Transtorno de Pânico/psicologia , Prevalência , Fatores de Risco , Parceiros Sexuais , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/psicologia , Sexo sem Proteção/psicologia
20.
Brain Behav Immun ; 71: 108-115, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29679637

RESUMO

Stimulant use may accelerate HIV disease progression through biological and behavioral pathways. However, scant research with treated HIV-positive persons has examined stimulant-associated alterations in pathophysiologic processes relevant to HIV pathogenesis. In a sample of 55 HIV-positive, methamphetamine-using sexual minority men with a viral load less than 200 copies/mL, we conducted RNA sequencing to examine patterns of leukocyte gene expression in participants who had a urine sample that was reactive for stimulants (n = 27) as compared to those who tested non-reactive (n = 28). Results indicated differential expression of 32 genes and perturbation of 168 pathways in recent stimulant users. We observed statistically significant differential expression of single genes previously associated with HIV latency, cell cycle regulation, and immune activation in recent stimulant users (false discovery rate p < 0.10). Pathway analyses indicated enrichment for genes associated with inflammation, innate immune activation, neuroendocrine hormone regulation, and neurotransmitter synthesis. Recent stimulant users displayed concurrent elevations in plasma levels of tumor necrosis factor - alpha (TNF-α) but not interleukin 6 (IL-6). Further research is needed to examine the bio-behavioral mechanisms whereby stimulant use may contribute to HIV persistence and disease progression.


Assuntos
Infecções por HIV/imunologia , Leucócitos/efeitos dos fármacos , Carga Viral/efeitos dos fármacos , Adulto , Cocaína/efeitos adversos , Cocaína/metabolismo , Progressão da Doença , Expressão Gênica/efeitos dos fármacos , Expressão Gênica/genética , HIV/efeitos dos fármacos , HIV/patogenicidade , Infecções por HIV/complicações , Infecções por HIV/fisiopatologia , Soropositividade para HIV/metabolismo , Humanos , Interleucina-6/análise , Interleucina-6/sangue , Masculino , Metanfetamina/metabolismo , Metanfetamina/farmacologia , Pessoa de Meia-Idade , Análise de Sequência de RNA , Fator de Necrose Tumoral alfa/análise , Fator de Necrose Tumoral alfa/sangue , Fator de Necrose Tumoral alfa/efeitos dos fármacos
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