Physician recognition of active drug use in HIV-infected patients is lower than validity of patient's self-reported drug use

The Patient Reported Outcomes as a Clinical Tool (PROACT) Pilot Study: What Can be Gained by Sharing Computerized Patient-Reported Mental Health and Substance Use Symptoms with Providers in HIV Care?

Substance use and mental health (SU/MH) disorders are insufficiently recognized in HIV care. We examined whether conveying SU/MH screening results to patients and providers increased SU/MH discussions and action plans. Intervention participants completed a computerized patient-reported questionnaire before their HIV visit; screened positive on ≥ 1 measure: depression, anxiety, PTSD symptoms, at-risk alcohol use, or drug use; and reviewed screening results to decide which to prioritize with their provider. Screening results and clinical recommendations were conveyed to providers via medical record. A historic control included patients with positive screens but no conveyance to patient or provider. The patient-provider encounter was audio-recorded, transcribed, and coded. For the overall sample (n = 70; 38 control, 32 intervention), mean age (SD) was 51.8 (10.3), 61.4% were male, and 82.9% were Black. Overall, 93.8% raised SU/MH in the intervention compared to 50.0% in the control (p < 0.001). Action plans were made for 40.0% of intervention and 10.5% of control encounters (p = 0.049). Conveying screening results with clinical recommendations increased SU/MH action plans, warranting further research on this intervention to address SU/MH needs.

Patient acceptability and usability of a self-administered electronic patient-reported outcome assessment in HIV care: relationship with health behaviors and outcomes

We assessed acceptability/usability of tablet-based patient-reported outcome (PRO) assessments among patients in HIV care, and relationships with health outcomes using a modified Acceptability E-Scale (AES) within a self-administered PRO assessment. Using multivariable linear regression, we measured associations between patient characteristics and continuous combined AES score. Among 786 patients (median age=48; 91% male; 49% white; 17% Spanish-speaking) overall mean score was 26/30 points (SD: 4.4). Mean scores per dimension (max 5, 1=lowest acceptability, 5=highest): ease of use 4.7, understandability 4.7, time burden 4.3, overall satisfaction 4.3, helpfulness describing symptoms/behaviors 4.2, and enjoyability 3.8. Higher overall score was associated with race/ethnicity (+1.3 points/African-American patients (95%CI:0.3-2.3); +1.6 points/Latino patients (95%CI:0.9-2.3) compared to white patients). Patients completing PROs in Spanish scored +2.4 points on average (95%CI:1.6-3.3). Higher acceptability was associated with better quality of life (0.3 points (95%CI:0.2-0.5)) and adherence (0.4 points (95%CI:0.2-0.6)). Lower acceptability was associated with: higher depression symptoms (-0.9 points (95%CI:-1.4 to -0.4)); recent illicit opioid use (-2.0 points (95%CI:-3.9 to -0.2)); multiple recent sex partners (-0.8 points (95%CI:-1.5 to -0.1)). While patients endorsing depression symptoms, recent opioid use, condomless sex, or multiple sex partners found PROs less acceptable, overall, patients found the assessments highly acceptable and easy to use.

Treatment Outcomes in Septic Arthritis of the Foot and Ankle in People Who Inject Drugs

Background:

Although injection drug use (IDU) is a known risk factor for septic arthritis (SA) of the foot and ankle (F&A), disease and hospitalization outcomes are poorly characterized. We evaluated national trends, demographic characteristics, and hospitalization outcomes of SA of the F&A in people who inject drugs vs those who do not.

Methods:

Using the Nationwide Inpatient Sample, we identified all patients aged 15-64 with a principal discharge diagnosis of SA of the F&A from 2000 to 2013 and evaluated if they were related or unrelated to IDU. We assessed differences in demographic characteristics and in-hospital outcomes in these groups.

Results:

From 2000 to 2013, there were an estimated 14,198 hospitalizations for SA of the F&A in the United States, and 11% were associated with IDU (SA-IDU). Compared to SA unrelated to IDU, people with SA-IDU were significantly more likely to be younger, black, and have Medicaid or no insurance. People with SA-IDU were significantly more likely to leave against medical advice (9.7% vs 1.4%, P < .001), have a longer length of stay (9.2 vs 6.8 days, P < .001), and incur increased hospital charges ($58 628 vs $38 876, P = .005). People with SA-IDU were significantly less likely to receive an arthroscopy (1.5% vs 6.5%, P < .001) or arthrotomy (2.2% vs 11.0%, P < .001) of the foot.

Conclusion:

People with SA-IDU of the F&A had suboptimal hospitalization outcomes with greater costs. Recognizing risk factors and proactively addressing potential complications of substance use disorder in the hospital should be prioritized by the orthopedic community.

Level of Evidence:

Level III, retrospective cohort study.

Injection Drug Use in Patients With Spinal Epidural Abscess: Nationwide Data, 2000 to 2013

STUDY DESIGN

Retrospective review of the Healthcare Cost and Utilization Project National Inpatient Sample, 2000 to 2013.

OBJECTIVE

To determine the proportion of spinal epidural abscess (SEA) cases that were related to injection drug use (IDU) and to compare length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between SEA cases with and without IDU.

SUMMARY OF BACKGROUND DATA

The US opioid epidemic impacts all aspects of healthcare, including spinal surgeons. Although injection drug use (IDU) is a risk factor for spinal epidural abscess (SEA), IDU among SEA patients and its effect on clinical outcomes is not well understood.

METHODS

Cases aged 15 to 64 with principal diagnosis of SEA were classified as IDU-related (IDU-SEA) or non-IDU-related (non-IDU-SEA) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for illicit drug use and hepatitis C. We determined the proportion of SEA patients with IDU and compared length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between IDU-SEA and non-IDU-SEA patients.

RESULTS

From 2000 to 2013, there were 20,425 admissions with a principal diagnosis of SEA (95% confidence interval (CI), 19,281-21,568); 19.1% were associated with IDU (95% CI, 17.7%-20.5%). The proportion of white IDU-SEA cases increased by 2.4 percentage points annually (95% CI, 1.4-3.4). After adjusting for age, sex, and race, IDU-SEA patients stayed a mean of 6.7 more days in the hospital (95% CI, 5.1-8.2) and were 4.8 times more likely to leave against medical advice (95% CI, 2.9-8.0). Mean hospital charges for IDU-SEA patients were $31,603 higher (95% CI: $20,721-$42,485). Patients with IDU-SEA were less likely to have cauda equina syndrome (adjusted odds ratio, 0.48, 95% CI, 0.26-0.87).

CONCLUSION

IDU-SEA patients stay in the hospital longer and more often leave against medical advice. Providers and hospitals may benefit from exploring how to better facilitate completion of inpatient treatment and achieve superior outcomes.

LEVEL OF EVIDENCE

3.

HIV Provider Documentation and Actions Following Patient Reports of At-risk Behaviors and Conditions When Identified by a Web-Based Point-of-Care Assessment

We compared same-day provider medical record documentation and interventions addressing depression and risk behaviors before and after delivering point-of-care patient-reported outcomes (PROs) feedback for patients who self-reported clinically relevant levels of depression or risk behaviors. During the study period (1 January 2006-15 October 2010), 2289 PRO assessments were completed by HIV-infected patients. Comparing the 8 months before versus after feedback implementation, providers were more likely to document depression (74% before vs. 87% after feedback, p = 0.02) in patients with moderate-to-severe depression (n = 317 assessments), at-risk alcohol use (41 vs. 64%, p = 0.04, n = 155) and substance use (60 vs. 80%, p = 0.004, n = 212). Providers were less likely to incorrectly document good adherence among patients with inadequate adherence after feedback (42 vs. 24%, p = 0.02, n = 205). While PRO feedback of depression and adherence were followed by increased provider intervention, other domains were not. Further investigation of factors associated with the gap between awareness and intervention are needed in order to bridge this divide.

Provider perceptions of the value of same-day, electronic patient-reported measures for use in clinical HIV care

Strong evidence suggests that patient-reported outcomes (PROs) aid in managing chronic conditions, reduce omissions in care, and improve patient-provider communication. However, provider acceptability of PROs and their use in clinical HIV care is not well known. We interviewed providers (n = 27) from four geographically diverse HIV and community care clinics in the US that have integrated PROs into routine HIV care, querying perceived value, challenges, and use of PRO data. Perceived benefits included the ability of PROs to identify less-observable behaviors and conditions, particularly suicidal ideation, depression, and substance use; usefulness in agenda setting prior to a visit; and reduction of social desirability bias in patient-provider communication. Challenges included initial flow integration issues and ease of interpretation of PRO feedback. Providers value same-day, electronic patient-reported measures for use in clinical HIV care with the condition that PROs are (1) tailored to be the most clinically relevant to their population; (2) well integrated into clinic flow; and (3) easy to interpret, highlighting chief patient concerns and changes over time.

Predictors of non-prescribed opioid use after one year of methadone treatment: an attributable-risk approach (ANRS-Methaville trial)

BACKGROUND

The effectiveness of methadone as an opioid maintenance treatment (OMT) for opioid dependence has been widely demonstrated. However many patients continue to use other opioids while on methadone treatment. Studies assessing avoidable cases of continued non-prescribed opioid use during methadone treatment are sparse.

METHODS

At 12 months of treatment (M12), 158 subjects had available data on opioid use, measured using the Opiate Treatment Index. We identified variables associated with non-prescribed opioid use at M12, using a univariate logistic regression and two multivariate models, one incorporating only pre-treatment variables, the second adding the in-treatment variables. We also calculated attributable fractions for risk factors.

RESULTS

At M12, 32.3% of the patients had used non-prescribed opioids during the previous month. A good patient-physician relationship was the most influential factor associated with not using non-prescribed opioids after one year. Living with a heroin user after one year of treatment, using cocaine during treatment and hazardous alcohol consumption at enrolment were all associated with an increased risk of non-prescribed opioid use at M12. Analysis of attributable fractions indicated that living with a heroin user at M12 accounted for 21% of patients reporting non-prescribed opioid use at M12, while the lack of a good relationship with the physician accounted for 26%.

CONCLUSIONS

The attributable risk approach suggests that continued non-prescribed opioid use by a considerable proportion of individuals could potentially be reduced by improving patient-physician relationships, enhancing care for co-dependent patients and encouraging patients to modify their social network.

Hepatitis C infection in non-treatment-seeking heroin users: the burden of cocaine injection

BACKGROUND AND OBJECTIVES

In heroin dependent individuals, the HIV epidemic has been controlled in countries where access to opioid maintenance treatment (OMT) and needle exchange programs (NEP) have been implemented. However, despite similar routes of contamination for both viruses, the prevalence of hepatitis C (HCV) infection remains high in drug users. The objective of this analysis was to identify the prevalence of HCV and the correlates of being HCV-positive in a sample of out-of-treatment heroin-dependent individuals.

METHODS

Data were collected from five inpatient studies (n = 120 participants) conducted at the New York State Psychiatric Institute. A logistic regression was used to identify correlates of being HCV-positive at baseline.

RESULTS

Among the 120 heroin-dependent volunteers, 42 were HCV-positive. Participants who had heavier alcohol use, a longer duration of heroin use, or who reported using heroin by injection were more likely to be HCV-positive. Interestingly, participants who had injected cocaine during the previous month had a ninefold greater risk of being HCV-positive compared to non-cocaine users and those who used cocaine by a non-injecting route.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

These findings confirm the risk of being HCV-infected through intravenous drug use, especially with cocaine use. These results underscore the importance of rethinking interventions to prevent HCV infection with combined strategies using pharmacological approaches for cocaine dependence and tailored prevention for cocaine users.

Impact of in-patient research participation on subsequent heroin use patterns: implications for ethics and public health

AIMS

Research on drug dependence often involves the administration of drugs of abuse to experienced drug users under controlled laboratory conditions. The primary objective of this study was to assess whether participation in such research alters the frequency of heroin use by non-treatment-seeking opioid-dependent volunteers after study completion.

DESIGN

Data were examined from four in-patient studies involving controlled opioid administration.

SETTING

Substance Use Research Center at Columbia University, New York State Psychiatric Institute.

PARTICIPANTS

Sixty-nine heroin-dependent volunteers.

MEASUREMENTS

Participants' self-reported heroin use prior to and 1 month after study participation was compared using a Wilcoxon test. Because a number of participants reported that they had stopped using heroin, a logistic regression was used to identify correlates of heroin cessation 1 month after study completion.

FINDINGS

One hundred and one participants entered laboratory studies and 69 completed them. Self-reported heroin use significantly decreased 1 month after study participation [1.7 (±2.0) bags per day] compared to baseline [6.8 (±4.2) bags per day], P < 0.001 among the 69 completers. In addition, 42% of the completers were heroin-abstinent 1 month after study completion. Being African American, having a history of opioid dependence treatment, reporting heavier heroin use at baseline and a longer history of heroin use were correlated with cessation of heroin use.

CONCLUSIONS

Participation in opioid administration studies does not increase subsequent heroin use and for some individuals leads to accessing opioid dependence treatment and cessation of heroin use in the short term.

Integrating a web-based, patient-administered assessment into primary care for HIV-infected adults

Providers routinely under diagnose at risk behaviors and outcomes, including depression, suicidal ideation, substance abuse, and poor medication adherence. To address this, we developed a web-based, self-administered patient-reported assessment tool and integrated it into routine primary care for HIV-infected adults. Printed results were delivered to providers and social workers immediately prior to patient appointments. The assessment included brief, validated instruments measuring clinically relevant domains including depression, substance use, medication adherence, and HIV transmission risk behaviors. Utilizing the Institute for Healthcare Improvement's Plan-Do-Study-Act (PDSA) approach to quality improvement, we addressed issues with clinic flow, technology, scheduling, and delivery of assessment results with the support of all levels of clinic staff. We found web-based patient-reported assessments to be a feasible tool that can be integrated into a busy multi-provider HIV primary care clinic. These assessments may improve provider recognition of key patient behaviors and outcomes. Critical factors for successful integration of such assessments into clinical care include: strong top-level /ort from clinic management, provider understanding of patient-reported assessments as a valuable clinical tool, tailoring the assessment to meet provider needs, communication among clinic staff to address flow issues, timeliness of delivery, and sound technological resources.

Non-medical use of opioids among HIV-infected opioid dependent individuals on opioid maintenance treatment: the need for a more comprehensive approach

BACKGROUND

Opioid maintenance treatment (OMT) has a positive impact on substance use and health outcomes among HIV-infected opioid dependent patients. The present study investigates non-medical use of opioids by HIV-infected opioid-dependent individuals treated with buprenorphine or methadone.

METHODS

The MANIF 2000 study is a longitudinal study that enrolled a cohort of 476 HIV-infected opioid-dependent individuals. Data were collected in outpatient hospital services delivering HIV care in France. The sample comprised all patients receiving OMT (either methadone or buprenorphine) who attended at least one follow-up visit with data on adherence to OMT (N = 235 patients, 1056 visits). Non-medical use of opioids during OMT was defined as having reported use of opioids in a non-medical context, and/or the misuse of the prescribed oral OMT by an inappropriate route of administration (injection or sniffing). After adjusting for the non-random assignment of OMT type, a model based on GEE was then used to identify predictors of non-medical use of opioids.

RESULTS

Among the 235 patients, 144 (61.3%) and 91 (38.9%) patients were receiving buprenorphine and methadone, respectively, at baseline. Non-medical use of opioids was found in 41.6% of visits for 83% of individual patients. In the multivariate analysis, predictors of non-medical use of opioids were: cocaine, daily cannabis, and benzodiazepine use, experience of opioid withdrawal symptoms, and less time since OMT initiation.

CONCLUSIONS

Non-medical use of opioids was found to be comparable in OMT patients receiving methadone or buprenorphine. The presence of opioid withdrawal symptoms was a determinant of non-medical use of opioids and may serve as a clinical indicator of inadequate dosage, medication, or type of follow-up. Sustainability and continuity of care with adequate monitoring of withdrawal symptoms and polydrug use may contribute to reduced harms from ongoing non-medical use of opioids.

Self-reported side effects in buprenorphine and methadone patients receiving antiretroviral therapy: results from the MANIF 2000 cohort study

AIMS

The aim of the study was to investigate the relationship between methadone and buprenorphine treatment and self-reported symptoms in HIV-infected opioid dependent individuals receiving antiretroviral therapy (ART).

DESIGN

Longitudinal study.

SETTING

The French MANIF2000 cohort was used to compare self-reported symptoms in buprenorphine and methadone patients also receiving ART.

PARTICIPANTS

We selected individuals receiving ART and OAT (342 visits among 106 patients).

MEASUREMENTS

Symptoms were self-reported using a list of 14 symptoms (e.g. nausea, fatigue, fever) perceived during the previous 4 weeks, including three painful symptoms (abdominal or muscular pain, headaches). A two-step Heckman approach enabled us to account for the non-random assignment of OAT: a probit model identified predictors of starting either buprenorphine or methadone. A Poisson regression based on generalized estimating equations (GEE) was then used to identify predictors of the number of symptoms while adjusting for the non-random assignment of OAT.

FINDINGS

The median (interquartile range) number of symptoms was 4 (1-6) and 2 (1-6) among buprenorphine and methadone patients, respectively. After adjustment for non-random assignment of OAT type, depressive and opioid withdrawal symptoms, anxiolytics consumption and daily cannabis use, methadone patients were more likely to report a lower number of symptoms than those receiving buprenorphine.

CONCLUSIONS

Methadone patients on ART report fewer symptoms than buprenorphine patients on ART under current treatment conditions in France. Further experimental research is still needed to identify an OAT-ART strategy which would minimize the burden of self-reported symptoms and potential interactions, while assuring sustainability and response to both treatments.

Withdrawal symptoms as a predictor of mortality in patients HIV-infected through drug use and receiving highly active antiretroviral therapy (HAART)

Even in the highly active antiretroviral therapy (HAART) era, individuals HIV-infected through injecting drug use (IDUs) are at increased risk of death due to the burden of competing events such as liver disease, overdose and suicide. The objective of this study was to explore the role which life events' experience, in particular drug-related events such as detoxification or withdrawal symptoms, may play on the risk of death in HIV-infected IDUs. Our analysis was based on longitudinal data of 296 HIV-infected IDUs from when they started HAART. Data collection included medical records and patient's self-reports detailing, among other information, life events including drug-related problems. Multiple imputations for missing data in the explanatory variables together with Cox models were used to identify predictors of death. During HAART follow-up, 26 deaths occurred, corresponding to 1.8 deaths per 100 person-years. The majority (N=8) were attributable to liver disease while 5 were from unknown causes (found deceased at home or in a car). After adjustment for age and time-dependent viral load (>10,000 cp/ml) individuals experiencing withdrawal symptoms had a fivefold increased risk of death with respect to the others. Withdrawal symptoms in IDUs living with HIV reflect physicians' difficulties in managing their patients' opioid dependence. Early detection and increasing substitution dosages or switching to a more adequate treatment could prevent possible drug-related deaths.

The impact of methadone or buprenorphine treatment and ongoing injection on highly active antiretroviral therapy (HAART) adherence: evidence from the MANIF2000 cohort study

AIMS

To date, no data exist assessing the impact of either methadone or buprenorphine on adherence to highly active antiretroviral therapy (HAART) in the long term. This study was conducted in order to evaluate whether receiving take-home methadone and buprenorphine may ensure better adherence to HAART in individuals infected with human immunodeficiency virus (HIV) through injection drug use (IDU).

DESIGN

Longitudinal data on adherence, opioid substitution treatment (OST) and patient behaviours starting from their first HAART prescription were collected for 276 individuals HIV-infected through drug use (n=1558 visits).

SETTING

Out-patient hospital services delivering HIV care in Marseilles, Avignon, Nice and Ile de France.

MEASUREMENTS

At any given visit, patients were classified both according to the type of OST received and ongoing injection. Patients who reported no injection and no OST over the whole study period were considered as 'abstinent' and used as a reference category. A logit model based on generalized estimation equations (GEE) was used to identify predictors of non-adherence.

FINDINGS

After adjustment for alcohol consumption, depression and self-reported side effects, patients ceasing injection during OST and abstinent patients exhibited comparable adherence. Patients reporting injection, on OST or not, had a twofold and threefold risk, respectively, of non-adherence compared with abstinent patients (P<0.01 linear trend). Duration on OST without injecting was associated significantly with virological success.

CONCLUSIONS

Both access to and effectiveness of OST contribute to sustaining adherence to HAART in HIV-infected IDUs. These results advocate strongly the need of wider use of OST in countries scaling-up HAART where HIV is driven by IDUs.

Depression and Clinical Progression in HIV-Infected Drug Users Treated with Highly Active Antiretroviral Therapy

Objective

To disentangle the impact of adherence from that of injecting drug status and depressive syndrome on HIV clinical progression in a cohort of highly active anti-retroviral therapy (HAART)-treated HIV patients infected through drug use.

Design

MANIF 2000 is a French cohort of HIV-infected drug users with scheduled medical visits every 6 months. Only patients enrolled in the MANIF 2000 cohort who had a CD4 cell count >200 cells/μl at HAART initiation were selected. The follow-up period included all post-HAART initiation visits.

Methods

HIV clinical progression was defined as either AIDS-related death or reaching a CD4 level <200 cells/μl. Adherence was assessed using a self-administered questionnaire and a structured face-to-face interview. Depressive symptoms were evaluated by a Center for Epidemiologic Studies Depression Scale (CES-D) score at each visit. Cox proportional hazards model was used to calculate crude and adjusted relative hazards and 95% confidence intervals and thus identify independent predictors of clinical progression.

Results

Of the 305 HAART-treated patients in the cohort, 243 had CD4 cell count >200 cells/μl at HAART initiation. At the first visit after HAART initiation, median CD4 cell count was 466 cells/μl and 45% had undetectable viral load. Injecting drug users accounted for 17% of the study group. Over the follow-up period, 32 patients experienced HIV clinical progression. Probable depression was encountered in 46% of patients and non-adherence in 31% of the sample. After adjustment on baseline CD4 cell count, predictors of clinical progression were: having a higher level of cumulative non-adherence over the follow-up period [HR (95% CI)=1.2 (1.1–1.3) per 10% increase] and having a high score of depressive symptoms following HAART initiation [HR (95% CI)=5.3 (2.21–3.0)]. Conclusions: Although depressive syndrome is known to influence non-adherence behaviours that are amongst the major reasons for clinical progression, it is also a predictor of clinical progression in HIV-infected intravenous drug users on HAART, independently of non-adherence behaviours. HIV care providers should be more sensitive to depressive symptoms in order to detect them early and supply HIV patients with specific care. Further research is needed to determine whether treating depressive symptoms may improve adherence and thus delay disease progression and mortality.

Patient-reported and physician-estimated adherence to HAART: social and clinic center-related factors are associated with discordance

OBJECTIVES

To evaluate the rate of discordance between patients and physicians on adherence to highly active antiretroviral therapy (HAART) and identify factors related to discordance in these two assessments.

DESIGN

Prospective, multicenter, cohort study (AdICONA) nested within the Italian Cohort Naive Antiretrovirals (ICONA) study.

SETTING

Tertiary clinical centers.

PARTICIPANTS

The patients filled out a 16-item self-administered questionnaire on adherence to HAART. At the same time, physicians estimated the current HAART adherence of their patient.

MAIN OUTCOME MEASURE

Discordance between patient and physician on adherence to antiretroviral therapy.

RESULTS

From May 1999 to March 2000, 320 paired patient-physician assessments were obtained. Patients had a mean plasma HIV RNA of 315 copies/ml (64% had undetectable HIV RNA) and a mean CD4+ cell count of 577 cells x 10(6)/L. Nonadherence was reported by 30.9% of patients and estimated by physicians in 45.0% cases. In 111 cases (34.7%), patients and physicians were discordant on adherence to HAART. Kappa statistics was 0.27. Using patient-assessed adherence as reference, sensitivity, specificity, positive predictive value, and negative predictive value of physician-estimated adherence were 64.7%, 66.6%, 81.2%, and 45.8%, respectively. On multivariable analysis, low education level, unemployment, absence of a social worker in the clinical center, and unavailability of afternoon visits were significantly correlated with patient-physician discordance on adherence to antiretrovirals.

CONCLUSIONS

Physicians did not correctly estimate patient-reported adherence to HAART in more than one third of patients. Both social variables and factors related to the clinical center were important predictors of discordance between patients and physicians. Interventions to enhance adherence should include strategies addressed to improve patient-physician relationship.

Factors associated with liver biopsy performance in HCV-HIV coinfected injecting drug users with HCV viremia: results from a five-year longitudinal assessment

The last international consensus conference about hepatitis C virus (HCV) treatment emphasized the importance of treatment for persons coinfected with HCV and human immunodeficiency virus (HIV). As liver biopsy precedes treatment, we aimed to identify factors associated with the performance of liver biopsy among HIV-HCV coinfected drug users during a 5-year follow-up to study their access to HCV treatment. Of the 296 patients followed in the HIV hospital departments of Nice and Marseilles and with retrievable records about HCV diagnosis and care, 166 were eligible for analysis having had detectable HCV RNA at least once during the study period. Overall, 45.2% of patients underwent liver biopsy during follow-up. Using proportional hazard models, predictors of having had a liver biopsy were high social support, complete abstinence from drug injection, and lack of immunosuppression as well as male gender, no history of multiple incarcerations, more recent onset of drug use, and an increase of liver enzyme levels. These results suggest that specific efforts should be devoted to HIV-HCV coinfected drug users to assist with stabilizing these patients to optimize their access to HCV care whenever possible.

Evaluation of buprenorphine maintenance treatment in a French cohort of HIV-infected injecting drug users

BACKGROUND

Buprenorphine was approved in France for treating opiate dependence in July 1995 and can be prescribed by general practitioners (GPs). Most studies assessing buprenorphine maintenance treatment (BMT) outcomes have taken place in GP settings. An evaluation of BMT outcomes in patients already followed for their HIV-infection could supply additional information about the changes in addictive practices in a non-GP setting.

METHODS

We assessed BMT discontinuations and the course of self-reported addictive behaviours and characteristics associated with buprenorphine-injection misuse in 114 HIV-infected patients on BMT who were followed in a hospital-based outpatient department.

RESULTS

The continuous series of follow-up visits at which these 114 patients reported regular buprenorphine prescriptions accounted for 237.5 person-years of observation, i.e. 475 follow-up visits. Of the 114 patients on BMT, 43% continued BMT throughout the follow-up, 40% stopped it, and results for 17% were not available either because they did not answer the self-administered questionnaire (5%) or because they were lost to follow-up (12%). Addictive behaviours declined but buprenorphine injection misuse remained stable. Depression measured by the CESD score (RR=1.04 95%CI [1.01-1.06]), cocaine use (RR=2.48 95%CI [1.31-4.68]) and alcohol consumption exceeding 4 alcohol units (AU) per day (RR=2.29, 95%CI [1.17-4.46]) were independently associated with buprenorphine injection misuse among stabilised BMT patients.

CONCLUSIONS

Despite the reduction in drug injection after starting BMT, buprenorphine injection misuse mainly involves patients with characteristics of severe addiction. Better monitoring of the illicit drug use patterns of patients on BMT may suggest new medical strategies for GPs to improve BMT outcomes.

Hospitalization for depressive syndrome in a cohort of HIV-infected patients contaminated through injecting drug use: MANIF 2000 cohort, France, 1995-1999

The objective of this study was to estimate the relative impact of hospitalization for depressive syndrome (DS) on all causes of hospitalization and characterize individuals more likely to experience hospitalization for DS in the French cohort study, Manif 2000, of patients HIV infected through injection drug use. We selected all patients followed-up to the 24-month visit (C24) who missed no more than one visit. Using medical records, dates and causes of hospitalizations, were collected retrospectively. A Poisson regression model based on generalized estimating equations was used to identify factors associated with hospitalization for DS. During the study period, 223 hospitalizations were recorded for 120 of the 335 selected patients. DS was the second reason for hospitalization after infections, accounting for 14.3% of the total number of hospitalizations. DS was reported in 32 hospitalizations and involved 24 patients, five of them being hospitalized more than once for the same cause. Factors independently associated with hospitalization for DS were history of multiple incarceration (RR = 2.1, 95% CI: 1.0-4.7), polydrug use (RR = 2.6, 95% CI: 1.1 -5.9) and lack of stable relationship (RR = 4.2, 95% CI: 1.6- 11. 1). In the HAART era, DS represents an important cause of hospitalization of HIV-infected injecting drug users, mainly concerning patients presenting no stable relationship and signs of social instability. Scheduled psychiatric consultations for these patients would permit us to identify those for whom major depression might lead to hospitalization and provide them with timely and appropriate care.