Directly observed antidepressant medication treatment and HIV outcomes among homeless and marginally housed HIV-positive adults: a randomized controlled trial.

OBJECTIVES: We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008. METHODS: We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL). RESULTS: The intervention reduced depression symptom severity (b = -1.97; 95% confidence interval [CI] = -0.85, -3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes. CONCLUSIONS: Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.

Testing strategy to identify cases of acute hepatitis C virus (HCV) infection and to project HCV incidence rates.

Surveillance for hepatitis C virus (HCV) is limited by the challenge of differentiating between acute and chronic infections. In this study, we evaluate a cross-sectional testing strategy that identifies individuals with acute HCV infection and we estimate HCV incidence. Anti-HCV-negative persons from four populations with various risks, i.e., blood donors, Veterans Administration (VA) patients, young injection drug users (IDU), and older IDU, were screened for HCV RNA by minipool or individual sample nucleic acid testing (NAT). The number of detected viremic seronegative infections was combined with the duration of the preseroconversion NAT-positive window period (derived from analysis of frequent serial samples from plasma donors followed from NAT detection to seroconversion) to estimate annual HCV incidence rates. Projected incidence rates were compared to observed incidence rates. Projected HCV incidence rates per 100 person-years were 0.0042 (95% confidence interval [95% CI], 0.0025 to 0.007) for blood donors, 0.86 (95% CI, 0.02 to 0.71) for VA patients, 39.8 (95% CI, 25.9 to 53.7) for young IDU, and 53.7 (95% CI, 23.4 to 108.8) for older IDU. Projected rates were most similar to observed incidence rates for young IDU (33.4; 95% CI, 28.0 to 39.9). This study demonstrates the value of applying a cross-sectional screening strategy to detect acute HCV infections and to estimate HCV incidence.

BRIEF REPORT: the aging of the homeless population: fourteen-year trends in San Francisco.

BACKGROUND: Homelessness is associated with high rates of health and substance use problems. OBJECTIVE: To examine trends in the age, housing, health status, health service utilization, and drug use of the homeless population over a 14-year period. DESIGN: Serial cross-sectional. PARTICIPANTS: We studied 3,534 literally homeless adults recruited at service providers in San Francisco in 4 waves: 1990-1994, 1996-1998, 1999-2000, and 2003. MEASUREMENTS: Age, time homeless, self-reported chronic conditions, hospital and emergency department utilization, and drug and alcohol use. RESULTS: The median age of the homeless increased from 37 to 46 over the study waves, at a rate of 0.66 years per calendar year (P<.01). The median total time homeless increased from 12 to 39.5 months (P<.01). Emergency department visits, hospital admissions, and chronic health conditions increased. CONCLUSIONS: The homeless population is aging by about two thirds of a year every calendar year, consistent with trends in several other cities. It is likely that the homeless are static, aging population cohort. The aging trends suggest that chronic conditions will become increasingly prominent for homeless health services. This will present challenges to traditional approaches to screening, prevention, and treatment of chronic diseases in an aging homeless population.

Heroin overdose among young injection drug users in San Francisco.

OBJECTIVES: We sought to identify prevalence and predictors of heroin-related overdose among young injection drug users (IDU). METHODS: A total of 795 IDU under age of 30 years were interviewed in four neighbourhoods in San Francisco, California, USA. Participants were recruited as part of a broader study of HIV, hepatitis B and C among injecting drug users in San Francisco using street outreach and snowball techniques. Independent predictors of recent heroin overdose requiring intervention were determined using regression analysis. RESULTS: Of 795 injecting drug users under age of 30 years, 22% (174/795) of participants reported a heroin overdose in the last year. In stepwise multiple logistic regression, independent predictors of recent heroin overdose were lifetime incarceration exceeding 20 months (odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.52-5.88); heroin injection in the last 3 months (OR = 4.89, 95% CI = 2.03-11.74); cocaine injection in the last 3 months (OR = 1.67, 95% CI = 1.14-2.45); injection of heroin mixed with methamphetamine in the last 3 months (OR = 1.74, 95% CI = 1.15-2.65); ever tested for hepatitis B or C (OR = 1.66 per year, CI = 1.09-2.54) and ever having witnessed another person overdose (OR = 2.89, 95% CI = 1.76-4.73). CONCLUSIONS: Individuals with high levels of incarceration are at great risk of overdose, and prison or jail should be considered a primary intervention site. Further research on the role of cocaine and amphetamine in heroin-related overdose is indicated.

No door to lock: victimization among homeless and marginally housed persons.

BACKGROUND: Homeless persons experience high rates of sexual and physical assault; homeless women are thought to be at highest risk. To determine the prevalence, distribution, and factors associated with sexual and physical assault, we surveyed homeless and marginally housed adults in San Francisco, Calif. METHODS: We interviewed 2577 respondents about their history of recent sexual and physical assault, housing history, sexual practices, substance use, health status, and criminal justice history. The main outcome measures were self-reported sexual and physical assault in the previous 12 months. RESULTS: Overall, 32.3% of women, 27.1% of men, and 38.1% of transgendered persons reported a history of either sexual or physical assault in the previous year; 9.4% of women, 1.4% of men, and 11.9% of transgendered persons reported sexual assault, and 30.6% of women, 26.6% of men, and 33.3% of transgendered persons reported physical assault. In multivariate models, being homeless (as opposed to marginally housed) was associated with sexual assault for women, but not for men (adjusted odds ratio for homeless women, 3.4 [1.2-9.7]). Housing status was not associated with physical assault for women or men. Mental illness and sex work were both common and associated with high rates of assault in multivariate analyses. CONCLUSIONS: Sexual and physical assault are common experiences for homeless and marginally housed persons. Housing is associated with lower rates of sexual assault among women. Strategies to decrease sexual and physical assault and its consequences are needed in this population.

Are untimed antiretroviral drug levels useful predictors of adherence behavior?

We examined cross-sectionally the relationship between untimed drug levels and adherence in 83 individuals. Abnormally low untimed antiretroviral drug levels were sensitive in identifying individuals adherent to 60% or less of medication doses over 3 - 5-week period. An abnormally low drug level was associated with a higher viral load. A single abnormally low untimed antiretroviral drug level can identify an individual with very low adherence at high risk of HIV disease progression and death.

Adherence to highly active antiretroviral therapy in the homeless population in San Francisco: a prospective study.

BACKGROUND: We examined adherence to highly active antiretroviral therapy (HAART) in the homeless population, a population thought to be at high risk for poor adherence to therapy and for development of drug-resistant strains of human immunodeficiency virus (HIV). METHODS: We performed a 12-month prospective study of 148 persons receiving HAART who were identified in a stratified screening of the homeless and marginally housed. We sampled in lunch lines, shelters, and hotels in 3 neighborhoods of San Francisco, California. We used pill counts at unannounced home visits as the primary measure of adherence. RESULTS: Of 148 individuals sampled, 46 (31%) discontinued HAART during the study. Average adherence in the group of those who discontinued HAART was 51%, and 9% of these subjects had undetectable virus loads (i.e., <400 copies/mL) at the last follow-up visit. Predictors of discontinuation of therapy were depressive symptoms, injection drug use, African American ethnicity, and early poor adherence. Of 148 subjects, 102 (69%) continued to receive HAART throughout the study period. Average adherence in the group of those who continued to receive HAART was 74%, and 55% of these subjects had undetectable virus loads at the last follow-up visit. Predictors of lower average adherence in this group were African American ethnicity and use of crack cocaine; men who had sex with men had higher adherence. CONCLUSIONS: One-third of homeless and marginally housed persons receiving HAART discontinued therapy during the follow-up period and would benefit from adherence interventions directed at sustaining therapy; two-thirds continued to receive therapy at adherence levels comparable to those found with other clinical populations.

Population-based community prevalence of methicillin-resistant Staphylococcus aureus in the urban poor of San Francisco.

The study objective was to determine the prevalence and risk factors for nasal colonization with Staphylococcus aureus and methicillin resistance among the urban poor and to compare antibiotic resistance and genetic similarity to concurrently collected clinical isolates of methicillin-resistant S. aureus (MRSA). A population-based community sample of 833 homeless and marginally housed adults were cultured and compared with 363 clinical isolates of MRSA; 22.8% of the urban poor were colonized with S. aureus. Of S. aureus isolates, 12.0% were methicillin resistant. Overall prevalence of MRSA was 2.8%. Significant multivariate risk factors for MRSA were injection drug use (odds ratio [OR], 9.7), prior endocarditis (OR, 4.1), and prior hospitalization within 1 year (OR, 2.4). Resistance to antimicrobials other than beta-lactams was uncommon. Only 2 individuals (0.24%) with MRSA had no known risk factors. A total of 22 of 23 community MRSA genotypically matched clinical MRSA isolates, with 15 of 23 isolates identical to MRSA clones endemic among hospitalized patients.

Witnessing heroin-related overdoses: the experiences of young injectors in San Francisco.

AIMS: Assessment of young injectors' exposure and response to others' heroin-related overdose. DESIGN: Cross-sectional survey. SETTING: San Francisco, CA, United States. PARTICIPANTS: Nine hundred and seventy-three street-recruited current injectors under 30 years old. MEASUREMENTS: Self-reported experiences of witnessing heroin-related overdoses from structured interviews. FINDINGS: Seven hundred and nine of 973 (73%) had ever witnessed at least one heroin-related overdose, and 491 of 973 (50%) had witnessed an overdose in the last 12 months. Fourteen per cent of those who had witnessed an overdose in the past year reported that the outcome of the overdose was death. Emergency services were called to 52% of most recent witnessed overdoses. Cardiopulmonary resuscitation (CPR) or expired air resuscitation (EAR or 'rescue breathing') was performed in 61% of cases. Inappropriate strategies such as injection with stimulants or application of ice were rare. In 67% of cases in which emergency services were not called the witness said this was because the victim regained consciousness. In the remaining 33%, 56% stated emergency services were not called due to fear of the police. CONCLUSIONS: Respondents were willing to act at overdoses at which they were present, but frequently did not do so in the most efficacious manner. Fear of police was identified as the most significant barrier to the ideal first response of calling emergency services.

Depression and drug use impact health status among marginally housed HIV-infected individuals.

A representative sample of HIV-positive homeless and marginally housed individuals completed SF-36 health surveys and responses were analyzed for associations with sociodemographic, health, health care, and drug use variables. Among 330 respondents, 83% were male, 43% were African American, and the median age was 39 years. Negative associations were found between female gender and vitality as well as physical functioning; older age and physical functioning; drug use or drug treatment and role-emotional, social functioning, body pain, as well as vitality; health care utilization and depression with all scales. It appeared that depression and drug-related variables were associated with multiple dimensions of health status in this population. Interventions to treat depression and addiction may improve the health status of HIV-infected HMH.

Tripling of methamphetamine/amphetamine use among homeless and marginally housed persons, 1996-2003.

Methamphetamine/amphetamine (MA)-related morbidity and mortality has been increasing in the United States. MA use is associated with high-risk sexual behavior and syringe-sharing practices. Homeless and marginalized housed persons (H/M) have high rates of substance use and mental health disorders. Little is known about trends of MA use among the H/M. The objective of this study was to quantify increases in MA use among H/M in San Francisco and to determine which demographic and behavioral subgroups have experienced the greatest increases in MA use. We conducted serial cross-sectional population-based studies in three waves: 1996-1997, 1999-2000, and 2003 and studied 2,348 H/M recruited at shelters and lunch lines. The main outcome was self-reported current (30-day) MA use. We found a tripling of current MA use among H/M persons from 1996 to 2003, with a sevenfold increase in smoked MA use. MA use doubled to tripled in most demographic and behavioral subgroups, whereas it quadrupled in those under age 35, and there was a fivefold increase among HIV-infected persons. The increase in MA use among H/M places a vulnerable population at additional increased risk for HIV infection and MA-use related morbidity and mortality. Among HIV-infected H/M, the increase in MA use has important public health implications for the development and secondary transmission of drug-resistant HIV caused by synergistic neurocognitive decline, poor adherence to HIV medications, and increased sexual risk behavior. Clinicians caring for H/M persons should inquire about MA use, refer interested MA users to MA dependence treatment programs and provide targeted HIV sexual risk reduction counseling. For HIV-infected H/M MA users, clinicians should closely monitor adherence to HIV or other chronic medications, to avoid unnecessary morbidity and mortality. Further research is needed to elucidate the most effective prevention and treatment for MA use and dependence among the H/M.

Revolving doors: imprisonment among the homeless and marginally housed population.

OBJECTIVES: We studied a sample of homeless and marginally housed adults to examine whether a history of imprisonment was associated with differences in health status, drug use, and sexual behaviors among the homeless. METHODS: We interviewed 1426 community-based homeless and marginally housed adults. We used multivariate models to analyze factors associated with a history of imprisonment. RESULTS: Almost one fourth of participants (23.1%) had a history of imprisonment. Models that examined lifetime substance use showed cocaine use (odds ratio [OR]=1.67; 95% confidence interval [CI]=1.04, 2.70), heroin use (OR=1.51; 95% CI=1.07, 2.12), mental illness (OR=1.41; 95% CI=1.01, 1.96), HIV infection (OR=1.69; 95% CI=1.07, 2.64), and having had more than 100 sexual partners were associated with a history of imprisonment. Models that examined recent substance use showed past-year heroin use (OR = 1.65; 95% CI = 1.14, 2.38) and methamphetamine use (OR=1.49; 95% CI=1.00, 2.21) were associated with lifetime imprisonment. Currently selling drugs also was associated with lifetime imprisonment. CONCLUSIONS: Despite high levels of health risks among all homeless and marginally housed people, the levels among homeless former prisoners were even higher. Efforts to eradicate homelessness also must include the unmet needs of inmates who are released from prison.

Antiretroviral therapy, hepatitis C virus, and AIDS mortality among San Francisco's homeless and marginally housed.

Mortality has declined in most HIV-infected populations yet remains high among those with barriers to accessing antiretroviral (ARV) therapy. We sought to determine predictors of death in a group of HIV-infected homeless persons in San Francisco. Between 1996 and 2002, quarterly interviews and blood draws were conducted. Hazards of death were compared by number of months of the prior 6 months that an individual took any ARV, drug use, hepatitis C virus (HCV) status, and housing status. Among 330 participants, 65% were HCV-seropositive at baseline, 85% received ARV during the study period, and there were 57 deaths (5.3 per 100 person-years). Compared with 0 of the prior 6 months on therapy, the risk of death was not significantly reduced for individuals on 1 to 5 months of therapy (hazard ratio [HR]=0.82, 95% confidence interval [CI]: 0.43-1.57), but the risk of death was reduced 62% for those on ARV therapy for 6 months (HR=0.38, CI: 0.19-0.76). Housing status and HCV status were not significant predictors of death. HIV is the major cause of death in this population, whereas the impact of HCV infection seems to be minimal. Sustained ARV treatment significantly reduces the risk of death among the homeless.

Cash benefits are associated with lower risk behavior among the homeless and marginally housed in San Francisco.

To address the widespread debate about the role of public assistance to the urban poor, the authors determined characteristics of individuals receiving cash assistance and explored the link between cash subsidies and risk behavior. From 1999 to 2000, a representative sample of homeless and marginally housed (HMH) adults living in San Francisco was recruited and interviewed about subsidies, shelter, jail, and drug use. Among 1,156 adults, 87% were ever homeless, 22% currently injected drugs, and 14% were HIV positive. Sixty percent of participants reported that most of their income came from subsidies [mostly subsidized (MS)]. The MS had lower odds of receiving any income from selling drugs or trading sex. Adjusting for HIV infection, the MS had higher odds of sleeping in a hotel [odds ratio (OR) = 2.39] or shelter (OR = 1.61) compared to the street. The MS had lower odds of injection drug use (OR = 0.69) and recent incarceration (OR = O.77). Among San Francisco's homeless, being MS was positively associated with having shelter and negatively associated with injection drug use and incarceration. These data suggest that government subsidies are associated with positive health behaviors among the urban poor.

Paradoxes of adherence and drug resistance to HIV antiretroviral therapy.

Public health debates about providing HIV antiretroviral therapy to impoverished populations have centred on the relationship between adherence and risk of drug resistance. Recent data indicate that each antiretroviral therapeutic class has a unique adherence-resistance relationship. Resistance to single protease inhibitor therapy occurs most frequently at moderate to high levels of adherence, resistance to non-nucleoside reverse transcriptase inhibitor therapy occurs at low to moderate levels of adherence, and resistance to ritonavir-boosted protease inhibitor therapy is most likely to occur at middle ranges of adherence. These dynamic relationships should be considered in balancing the individual and public health benefits of therapy.

Emergency department use among the homeless and marginally housed: results from a community-based study.

OBJECTIVES: This study examined factors associated with emergency department use among homeless and marginally housed persons. METHODS: Interviews were conducted with 2578 homeless and marginally housed persons, and factors associated with different patterns of emergency department use were assessed in multivariate models. RESULTS: Findings showed that 40.4% of respondents had 1 or more emergency department encounters in the previous year; 7.9% exhibited high rates of use (more than 3 visits) and accounted for 54.5% of all visits. Factors associated with high use rates included less stable housing, victimization, arrests, physical and mental illness, and substance abuse. Predisposing and need factors appeared to drive emergency department use. CONCLUSIONS: Efforts to reduce emergency department use among the homeless should be targeted toward addressing underlying risk factors among those exhibiting high rates of use.

HIV seroconversion among the homeless and marginally housed in San Francisco: a ten-year study.

HIV seroprevalence was previously found to be 9-11% among the urban homeless in San Francisco, with most infections among injection drug users, men who have sex with men, and those who exchange sex for money or drugs. In this study, HIV incidence and risk factors for seroconversion were estimated among persons who repeatedly participated in cross-sectional serosurveys over a period of 10 years. There were 6 seroconversions among 799 HIV-negative persons, for an incidence rate of 0.30% per person-year (95% CI: 0.12-0.61% per person-year). The seroconversion rate among men who had had recent sex with men was 1.22% per person-year (95% CI: 0.29-3.18) and was 0.52% per person-year (95% CI: 0.19-1.13% per person-year) among those who ever injected drugs. The seroconversion rate among those who were aged <30 years at baseline was 1.67% per person-year (95% CI: 0.40-4.36% per person-year), which was significantly higher than for those age > or =30 years. Policy implications are that HIV resources aimed at the more stable, older homeless population should probably focus on treatment, while prevention efforts, conversely, should probably be targeted to younger homeless persons.

Hepatitis C virus infection in San Francisco's HIV-infected urban poor.

OBJECTIVE: To measure Hepatitis C Virus (HCV) prevalence, incidence, and initiation of HCV therapy in a representative HIV-infected cohort of the urban poor. DESIGN: Cohort analysis. SETTING: The Research and Access to Care for the Homeless (REACH) Cohort is a systematic sample of HIV-infected marginally housed individuals identified from single-room occupancy hotels, homeless shelters, and free lunch programs in San Francisco. PARTICIPANTS: Two hundred forty-nine participants with 28.9 months (median) of follow-up were studied. Mean age was 44 (range 24 to 75, standard deviation 8.4) years. Eighty-two percent were male, 43% were African-American, 64% were lifetime injection drug users, and 24% had been on the street or in a shelter in the prior month. INTERVENTIONS: We measured HCV testing and treatment history with structured interviews; additionally, participants were tested for HCV antibodies (EIA-2) with RNA viral load confirmation. MAIN RESULTS: At baseline, 172 (69.1%) were HCV-positive and 182 (73.1%) were HCV-positive at follow-up, including 155 (62.2%) with viremia. HCV-positive status was associated with having injected drugs, elevated serum alanine aminotransferase, homelessness in the last 1 year, and more severe depressive symptoms. The incidence of new HCV infection was 4.63% per person-year (ppy; 95% confidence interval, 2.31 to 8.13) in the entire cohort and 16.77% ppy among injection drug users. The prevalence of HCV antibody-negative HCV-viremia was 13.2% (10/76). Nonwhites were less likely to receive HCV testing and subspecialty referral, controlled for drug use and other confounders. Sixty-eight percent (123/182) were aware treatment was available; however, only 3.8% (7/182) or 1.16% ppy received HCV treatment. CONCLUSIONS: While HCV infection is common, HCV treatment is rare in the HIV-HCV coinfected urban poor. Urban poor, nonwhite individuals are less likely to receive HCV testing and subspecialty referral than their white counterparts. Antibody-negative infection may complicate screening and diagnosis in HIV-infected persons. J

Fatal heroin-related overdose in San Francisco, 1997-2000: a case for targeted intervention.

Heroin-related overdose is the single largest cause of accidental death in San Francisco. We examined demographic, location, nontoxicological, and toxicological characteristics of opiate overdose deaths in San Francisco, California. Medical examiner's case files for every opioid-positive death from July 1, 1997, to June 30, 2000, were reviewed and classified as overdose deaths or other. Demographic variables were compared to two street-based studies of heroin users and to census data. From 1997 to 2000, of all heroin-related overdoses in San Francisco, 47% occurred in low-income residential hotels; 36% occurred in one small central area of the city. In 68% of deaths, the victim was reportedly alone. When others were present between last ingestion of heroin and death, appropriate responses were rare. In three cases, police arrested the person who called emergency services or others present on the scene. We recommend the development of overdose response training targeted at heroin users and those close to them, including the staff of residential hotels.

Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco (the UFO Study).

Female injection drug users (IDUs) represent a large proportion of persons infected with HIV in the United States, and women who inject drugs have a high incidence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. Therefore, it is important to understand the role of gender in injection risk behavior and the transmission of blood-borne virus. In 2000-2002, 844 young (<30 years old) IDUs were surveyed in San Francisco. We compared self-reported risk behavior between 584 males and 260 female participants from cross-sectional baseline data. We used logistic regression to determine whether demographic, structural, and relationship variables explained increased needle borrowing, drug preparation equipment sharing, and being injected by another IDU among females compared to males. Females were significantly younger than males and were more likely to engage in needle borrowing, ancillary equipment sharing, and being injected by someone else. Females were more likely than males to report recent sexual intercourse and to have IDU sex partners. Females and males were not different with respect to education, race/ethnicity, or housing status. In logistic regression models for borrowing a used needle and sharing drug preparation equipment, increased risk in females was explained by having an injection partner who was also a sexual partner. Injecting risk was greater in the young female compared to male IDUs despite equivalent frequency of injecting. Overlapping sexual and injection partnerships were a key factor in explaining increased injection risk in females. Females were more likely to be injected by another IDU even after adjusting for years injecting, being in a relationship with another IDU, and other potential confounders. Interventions to reduce sexual and injection practices that put women at risk of contracting hepatitis and HIV are needed.