Assessing Problematic Substance Use in HIV Care: Which Questions Elicit Accurate Patient Disclosures?

Recent Substance Use and Probability of Unsuppressed HIV Viral Load Among Persons on Antiretroviral Therapy in Continuity Care

Among persons with human immunodeficiency virus (HIV) infection, illegal drug use and hazardous alcohol use are hypothesized to be strong risk factors for failure to achieve or maintain a suppressed HIV viral load, but accurate quantification of this association is difficult because of challenges involved in measuring substance use as part of routine clinical care. We estimated the associations of recent cocaine use, opioid/heroin use, and hazardous alcohol use with unsuppressed viral load among 1,554 persons receiving care at the John G. Bartlett Specialty Practice (Baltimore, Maryland) between 2013 and 2017. We accounted for measurement error in substance use using Bayesian models and prior estimates of the sensitivity and specificity of 2 imperfect measures of substance use derived from a previous analysis in this cohort. The prevalence difference for unsuppressed viral load associated with recent cocaine use was 11.3% (95% credible interval (CrI): 6.4, 17.0); that associated with recent opioid/heroin use was 13.2% (95% CrI: 6.6, 20.7); and that associated with recent hazardous alcohol use was 8.5% (95% CrI: 3.2, 14.4). Failure to account for measurement error resulted in clinically meaningful underestimates of the prevalence difference. Time-varying substance use is prevalent and difficult to measure in routine care; here we demonstrate a method that improves the utility of imperfect data by accounting for measurement error.

Adolescent and young adult women's recommendations for establishing comfort with family planning providers' communication about and assessment for intimate partner violence

BACKGROUND

Intimate partner violence (IPV) is a serious public health problem that disproportionately affects adolescent women seeking family planning services. Current clinical guidelines recommend routine IPV assessment yet provide limited guidance on how to establish patient comfort in addressing this sensitive issue. Few studies exist describing the perspectives of adolescent female patients who have experienced IPV and their suggestions on how providers should communicate about IPV.

METHODS

This study is a subset of a larger IPV intervention trial in family planning clinics. For this study, we chose a qualitative approach using individual interviews to explore patient perspectives in an open, in-depth manner without limiting potential responses with predetermined answers or investigator-imposed assumptions. We audio recorded clinic encounters for participating providers and patients and interviewed patient participants, asking them to listen to and reflect on how their provider talked about IPV in their audiorecorded clinic encounters.

RESULTS

The mean age for the 44 participants was 22.8 years old. Participants named 'comfort' as a main component for discussing and disclosing IPV in the clinical setting. The sub-themes associated with how to create patient comfort include: Build the patient-provider relationship, Provider should communicate like a friend/be on the patient's level, Patient needs to feel cared for by provider, and Appropriate timing and space.

CONCLUSION

Methods for establishing patient comfort via communication should be incorporated into and examined within sensitive healthcare areas such as IPV and can be extended to HIV, palliative, and oncological care to improve patient health outcomes.

The Impact of Alcohol Use on Antiretroviral Therapy Adherence in Koreans Living with HIV

PURPOSE

This study aimed to examine the impact of alcohol use on the antiretroviral therapy (ART) adherence of Koreans living with human immunodeficiency virus (HIV).

METHODS

A total of 144 HIV-infected Koreans older than the age of 19 years who had been receiving antiretroviral drugs for at least 3 months were surveyed. Alcohol use was identified as nonhazardous, binge, hazardous, and alcohol dependent as determined by the Alchol Use Disorder Identification Test-Korea (AUDIT-K). ART adherence was defined according to the components of adherence motivation, adherence knowledge, and 95% medication adherence using the modified Morisky scale. Collected data were analyzed using logistic regression analysis for each component of therapy adherence.

RESULTS

Of all participants, 13.9% were binge drinkers, 17.4% were hazardous drinkers, and 4.2% were alcohol dependent. For low adherence motivation, the odds ratio for the hazardous drinkers was 7.47 [95% confidence interval (CI): 1.72-32.41; p = .007] and for the alcohol dependent, it was 12.61 (95% CI: 1.38-115.38; p = .025) when compared with the nonhazardous drinkers. For medication adherence under 95%, the odds ratio for binge drinkers was 4.65 (95% CI: 1.15-18.92; p = .032), for hazardous drinkers was 8.05 (95% CI: 2.08-31.20; p = .003), and for the alcohol dependent was 27.67 (95% CI: 2.12-360.51; p = .011).

CONCLUSION

It is recommended that Korean institutions and governments develop specific mediation and counseling programs that include alcohol use-related monitoring for the improvement of the ART adherence of people living with HIV.

Measurement of Current Substance Use in a Cohort of HIV-Infected Persons in Continuity HIV Care, 2007-2015

Accurate, routine measurement of recent illicit substance use is challenging. The Johns Hopkins Human Immunodeficiency Virus Clinical Cohort (Baltimore, Maryland) collects 2 imperfect but routine measurements of recent substance use: medical record review and self-interview. We used Bayesian latent class modeling to estimate sensitivity and specificity of each measurement as well as prevalence of substance use among 2,064 patients engaged in care during 2007-2015. Sensitivity of medical record review was higher than sensitivity of self-interview for cocaine and heroin use; posterior estimates ranged from 44% to 76% for cocaine use and from 39% to 67% for heroin use, depending on model assumptions and priors. In contrast, sensitivity of self-interview was higher than sensitivity of medical record review for any alcohol use, hazardous alcohol use, and cigarette smoking. Posterior estimates of sensitivity of self-interview were generally above 80%, 85%, and 87% for each substance, respectively. Specificity was high for all measurements. From one model, we estimated prevalence of substance use in the cohort to be 12.5% for cocaine, 9.3% for heroin, 48.5% for alcohol, 21.4% for hazardous alcohol, and 55.4% for cigarettes. Prevalence estimates from other models were generally comparable. Measurement error of substance use is nontrivial and should be accounted for in subsequent analyses.