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

Prevalence and correlates of psychological distress among drug users in Phnom Penh, Cambodia

BACKGROUND

Compared to the general population, drug users are at increased risk of both poor mental health and HIV infection. The aim of this study was to determine the prevalence and correlates of high psychological distress among drug users in Cambodia.

METHODS

In April 2014, a two-stage cluster sampling method was used to randomly select 169 drug users from hotspots in Phnom Penh. Psychological distress was measured using General Health Questionnaire (GHQ-12). Bivariate and multivariable analyses were conducted to identify factors associated with levels of psychological distress among this population.

RESULTS

Our study found high prevalence of attempted suicide (15.3%), drug related arrests (46.2%), and incarceration (31.4%). Of the 169 participants, 42.0% were found to have high levels of psychological distress, indicating poor mental health. After adjustment, high levels of psychological distress were independently associated with suicidal ideation (p<0.001), higher frequency of drug use (p=0.02), sharing of needles or syringes (p=0.005), and having been sent to a rehabilitation centre (p=0.02). In addition, participants who perceived their overall health as being poor or very poor were more likely to have high levels of psychological distress (p=0.002).

CONCLUSION

Integration of mental health within HIV and needle and syringe exchange programmes is required to address psychological distress among drug users in Cambodia. Health system interventions, such as screening, referral, and training of health providers, need to be strengthened. In addition, interventions addressing social determinants of mental health and mitigation of frequent arrests and improving conditions in rehabilitation centres are required.

Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST)

In the era of highly effective anti-retroviral therapy (ART), data show a significant difference in treatment outcomes between injecting drug users (IDUs) and non-IDUs. Factors that may contribute to suboptimal treatment outcomes in IDUs include delayed access to ART, competing comorbid diseases, psychosocial barriers and poor long-term adherence to ART. This review describes and compares several studies on adherence to ART and its correlates in HIV-infected individuals in general, then IDUs and finally those IDUs on opioid substitution treatment (OST). It highlights how ongoing drug use or OST can modify the pattern of these correlates. The aim is to extend all the experience acquired from these studies in order to optimise both access to care and adherence in those countries where HIV infection is mainly driven by IDUs and where ART and OST are only starting to be scaled up. The role of OST in fostering access to care and adherence to ART together with the promising results achieved to date using modified directly observed therapy (DOT) programs for patients taking methadone, allow us to emphasize the efficacy of a comprehensive care model which integrates substance dependence treatment, psychiatric treatment, social services, and medical treatment. The review concludes by suggesting areas of future research targeted at improving the understanding of both the role of perceived toxicity and patient-provider relationship for patients on ART and OST.

Buprenorphine Use: The International Experience

The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article. In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care.

Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches

Patients with chronic viral infections such as HIV/AIDS or hepatitis C often have multiple co-existing problems such as psychiatric and addictive disorders, as well as social problems such as lack of housing, transportation and income that present challenging obstacles to successful management. Because services for these different problems are usually provided by different disciplines in varying locations, fragmentation of care can lead to treatment dropouts, lack of adherence, and poor outcomes. Integration strategies, ranging from simple efforts to improve communication and coordinate care to fully integrated multidisciplinary teams have been used to improve disease management. Although evidence for effectiveness is comprised primarily of observational studies of demonstration programmes, integration may be desirable on a pragmatic basis alone. Quality improvement strategies are attractive vehicles for implementing care integration and measuring its impact. Careful assessment of the problem to be solved and the development of targeted strategies will maximize chances of a successful outcome.

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.