Longitudinal changes in engagement in care and viral suppression for HIV-infected injection drug users

Mobile Health Tool to Capture Social Determinants of Health and Their Impact on HIV Treatment Outcomes Among People Who Use Drugs: Pilot Feasibility Study

Background

Active substance use, food or housing insecurity, and criminal legal system involvement can disrupt HIV care for people living with HIV and opioid use disorder (OUD). These social determinants of health are not routinely captured in clinical settings.

Objective

We evaluated whether real-time reports of social and behavioral factors using a smartphone app could predict viral nonsuppression and missed care visits to inform future mobile health interventions.

Methods

We enrolled 59 participants from the AIDS Linked to the Intravenous Experience (ALIVE) Study in Baltimore, Maryland, into a 12-month substudy between February 2017 and October 2018. Participants were eligible if they had OUD and had either a measured HIV RNA ≥1000 copies/mL or a ≥1-month lapse in antiretroviral therapy in the preceding 2 years. Participants received a smartphone and reported HIV medication adherence, drug use or injection, and several disruptive life events, including not having a place to sleep at night, skipping a meal due to lack of income, being stopped by police, being arrested, or experiencing violence on a weekly basis, through a survey on a mobile health app. We described weekly survey completion and investigated which factors were associated with viral nonsuppression (HIV RNA ≥200 copies/mL) or a missed care visit using logistic regression with generalized estimating equations adjusted for age, gender, smartphone comfort, and drug use.

Results

Participants were predominantly male (36/59, 61%), Black (53/59, 90%), and had a median of 53 years old. At baseline, 16% (6/38) were virally unsuppressed. Participants completed an average of 23.3 (SD 16.3) total surveys and reported missing a dose of antiretroviral therapy, using or injecting drugs, or experiencing any disruptive life events on an average of 13.1 (SD 9.8) weekly surveys over 1 year. Reporting use of any drugs (adjusted odds ratio [aOR] 2.3, 95% CI 1.4-3.7), injecting drugs (aOR 2.3, 95% CI 1.3-3.9), and noncompletion of all surveys (aOR 1.6, 95% CI 1.1-2.2) were associated with missing a scheduled care visit over the subsequent 30 days. Missing ≥2 antiretroviral medication doses within 1 week was associated with HIV viral nonsuppression (aOR 3.7, 95% CI: 1.2-11.1) in the subsequent 30 days.

Conclusions

Mobile health apps can capture risk factors that predict viral nonsuppression and missed care visits among people living with HIV who have OUD. Using mobile health tools to detect sociobehavioral factors that occur prior to treatment disengagement may facilitate early intervention by health care teams.

Using Machine Learning Techniques to Predict Viral Suppression Among People With HIV

BACKGROUND

This study aims to develop and examine the performance of machine learning (ML) algorithms in predicting viral suppression among statewide people living with HIV (PWH) in South Carolina.

METHODS

Extracted through the electronic reporting system in South Carolina, the study population was adult PWH who were diagnosed between 2005 and 2021. Viral suppression was defined as viral load <200 copies/mL. The predictors, including sociodemographics, a historical information of viral load indicators (eg, viral rebound), comorbidities, health care utilization, and annual county-level factors (eg, social vulnerability), were measured in each 4-month windows. Using historic information in different lag time windows (1-, 3- or 5-lagged time windows with each 4-month window as a unit), both traditional and ML approaches (eg, Long Short-Term Memory Network) were applied to predict viral suppression. Comparisons of prediction performance between different models were assessed by area under curve (AUC), recall, precision, F1 score, and Youden index.

RESULTS

ML approaches outperformed the generalized linear mixed model. In all the 3 lagged analysis of a total of 15,580 PWH, the Long Short-Term Memory Network (Lag 1: AUC = 0.858; Lag 3: AUC = 0.877; Lag 5: AUC = 0.881) algorithm outperformed all the other methods in terms of AUC performance for predicting viral suppression. The top-ranking predictors that were common in different models included historical information of viral suppression, viral rebound, and viral blips in the Lag-1 time window. Inclusion of county-level variables did not improve the model prediction accuracy.

CONCLUSIONS

Supervised ML algorithms may offer better performance for risk prediction of viral suppression than traditional statistical methods.

Relationship between patient activation and utilisation of health care and harm reduction services among people who inject drugs in Baltimore, Maryland

INTRODUCTION

Given structural barriers, access to services is key for preventing drug-related harms and managing chronic disease among people who inject drugs (PWID). The Patient Activation Measure (PAM), a validated scale to assess self-efficacy in navigating one's own health care, was operationalised to improve service utilisation and outcomes but has not been assessed among PWID. We characterised PAM and its association with healthcare and harm reduction utilisation among PWID in the AIDS Linked to IntraVenous Experience cohort in Baltimore.

METHODS

From 2019 to 2020, participants completed surveys on PAM, service utilisation and drug use. We used log-binomial regression to identify correlates of "Lower" PAM and modelled the association between lower PAM and service utilisation, stratified by recent IDU.

RESULTS

Participants (n = 351) were primarily male (67%), Black (85%) and 24% reported recent IDU. Lower PAM was significantly more common in those reporting IDU (aPR 1.45; 95% CI 1.03, 2.04), heavy alcohol (aPR 1.77; 95% CI 1.24, 2.51) and marijuana (aPR: 1.70; 95% CI 1.23, 2.36) but less common among women (aPR 0.57; 95% CI 0.38, 0.84) and those living with HIV (APR 0.52; 95% CI 0.35, 0.78). In modelling service utilisation, lower PAM was associated with a lower prevalence of methadone utilisation (aPR 0.27; 95% CI 0.09, 0.84) among those reporting IDU, but a higher prevalence of methadone utilisation (aPR 2.72; 95% CI 1.46, 5.08) among those not reporting IDU, after controlling for correlates of PAM.

DISCUSSION AND CONCLUSION

PAM-tailored interventions targeting methadone utilisation warrant consideration but should account for socio-structural barriers to utilisation and correlates of PAM among PWID.

Access to healthcare for people living with HIV: an analysis of judgments of the European Court of Human Rights from an ethical perspective

Introduction

Although HIV has been part of our reality for over 30 years, people living with HIV (PLHIV) still experience restrictions regarding their access to healthcare. This poses a significant ethical problem, especially as it endangers achieving the goal of ending the HIV epidemic worldwide. The aim of this paper is to analyze the rulings of the European Court of Human Rights (ECtHR) regarding cases where PLHIV experienced restrictions on their access to healthcare.

Methods

We conducted an analysis of the ECtHR database and were able to identify N = 28 cases dealing with restricted access to healthcare for PLHIV. A descriptive and thematic analysis was conducted to identify ways in which access to healthcare for PLHIV was restricted.

Results

We were able to identify a total of four main categories, with denial of adequate therapeutic support as the main category with N = 22 cases (78.57%). Most of the judgments examined were filed against Russia (N = 12, 42.86%) and Ukraine (N = 9, 32.14%). A large proportion of PLHIV in the cases studied (N = 57, 85.07%) were detainees.

Discussion

The analysis shows a clear condemnation of limited access to healthcare for PLHIV by the ECtHR. Ethical implications of the analyzed cases are discussed in detail.

Barriers and facilitators to primary care engagement for people who inject drugs: A systematic review

INTRODUCTION

People who inject drugs (PWID) have a greater burden of multimorbid chronic diseases than the general population. However, little attention has been paid to the engagement in primary care for services related specifically to injection drug use and management of underlying chronic comorbid diseases for this population. This systematic review identified facilitators and barriers to healthcare engagement in the primary care setting among PWID.

DESIGN AND METHODS

Studies were identified by a literature search of PubMed, CINAHL, and EMBASE, and by searching the references of retrieved articles. Studies were included if they measured active injection drug use, and outcomes related to primary care engagement characterized by: diagnosis of a health condition, linkage or retention in care, health condition-related outcomes, and reported patient-provider relationship.

RESULTS

Twenty-three articles were included. Using the behavioral model, factors within predisposing, enabling, need, and health behavior domains were identified. Having co-located services and a positive patient-provider relationship were among the strongest factors associated with healthcare utilization and engagement while active injection drug use was associated with decreased engagement.

CONCLUSIONS

To our knowledge, this is the only review of evidence that has examined factors related to primary care engagement for people who inject drugs. Most articles were observational studies utilizing descriptive designs. Although the assessment of the evidence was primarily rated 'Good', this review identifies a significant need to improve our understanding of primary care engagement for PWID. Future research and intervention strategies should consider these findings to better integrate the holistic care needs of PWID into primary care to reduce morbidity and mortality associated with injection drug use and chronic disease.

CLINICAL RELEVANCE

Primary care engagement is important for preventative care, early diagnosis of disease, and management of chronic diseases, including addressing problems of substance use. This review highlights factors nurses can utilize to facilitate primary care engagement of PWID.

A factorial experiment grounded in the multiphase optimization strategy to promote viral suppression among people who inject drugs on the Texas-Mexico border: a study protocol

BACKGROUND

People who inject drugs living with HIV (PWIDLH) suffer the lowest rates of HIV viral suppression due to episodic injection drug use and poor mental health coupled with poor retention in HIV care. Approximately 44% of PWIDLH along the US-Mexico border are retained in care and only 24% are virally suppressed. This underserved region faces a potential explosion of transmission of HIV due to highly prevalent injection drug use. This protocol describes an optimization trial to promote sustained viral suppression among Spanish-speaking Latinx PWIDLH.

METHODS

The multiphase optimization strategy (MOST) is an engineering-inspired framework for designing and building optimized interventions and guides this intervention. The primary aim is to conduct a 24 factorial experiment in which participants are randomized to one of 16 intervention conditions, with each condition comprising a different combination of four behavioral intervention components. The components are peer support for methadone uptake and persistence; behavioral activation therapy for depression; Life-Steps medication adherence counseling; and patient navigation for HIV care. Participants will complete a baseline survey, undergo intervention, and then return for 3-,6-,9-, and 12-month follow-up assessments. The primary outcome is sustained viral suppression, defined as viral loads of < 40 copies per mL at 6-,9-, and 12-month follow-up assessments. Results will yield effect sizes for each component and each additive and interactive combination of components. The research team and partners will make decisions about what constitutes the optimized multi-component intervention by judging the observed effect sizes, interactions, and statistical significance against real-world implementation constraints. The secondary aims are to test mediators and moderators of the component-to-outcome relationship at the 6-month follow-up assessment.

DISCUSSION

We are testing well-studied and available intervention components to support PWIDLH to reduce drug use and improve their mental health and engagement in HIV care. The intervention design will allow for a better understanding of how these components work in combination and can be optimized for the setting.

TRIAL REGISTRATION

This project was registered at clinicaltrials.gov (NCT05377463) on May 17th, 2022.

Multimorbidity classes indicate differential patterns of health care engagement among people who inject drugs

BACKGROUND

Aging people who inject drugs (PWID) have complex health needs. Health care management could be complicated by persistent substance use, multiple health challenges, and inconsistent access to care. However, we know little about the relationship between chronic multimorbidity and health care engagement in this population. The purpose of this study is to characterize patterns and correlates of chronic disease multimorbidity among PWID.

METHODS

We conducted a latent class analysis (LCA) using data from the AIDS Linked to the IntraVenous Experience (ALIVE) Study, a community-based observational cohort, to determine classes of multimorbid chronic diseases. We then conducted regressions to determine factors associated with class membership and the impact of each multimorbid class on health events and utilization.

RESULTS

Of 1387 individuals included, the majority were male (67%) and Black (81%), with a mean age of 53 years. We identified four classes of multimorbidity: Low Multimorbidity (54%), and Low Multimorbidity Including Psychiatric Comorbidity (26%), Multimorbidity (12%), and Multimorbidity Including Psychiatric Comorbidity (7%). Female sex, baseline age, and receipt of disability were factors significantly associated with membership in all three classes compared to the Low Multimorbidity class. Additionally, PWID in these three classes were significantly more likely to utilize emergency room and outpatient health care. Membership in both classes with psychiatric comorbidity was associated with significantly higher adjusted odds of receiving medication for opioid use disorder.

DISCUSSION

Holistic health care systems can best address the needs of aging PWID with integrated care that provides harm reduction, substance use and mental health treatment together, and wrap around services.

Clinical Follow-Up in People Living with HIV During the COVID-19 Pandemic in Mexico

Clinical follow-up in people living with HIV (PLWH) has individual and public health implications. The objectives of this study were to measure variables related to follow-up failures, identify self-reported reasons to maintain adequate follow-up or for having follow-up failures, and know how the pandemic influenced patients' clinical follow-up. Participants were PLWH receiving HIV-health care at a hospital-based clinic in Mexico City which became an exclusive COVID-19 health service. Participants completed a telephone semi-structured interview and online psychological questionnaires. Lower educational and socioeconomic level, longer times of transportation to the clinic, being attended by different doctors, detectable viral load, having previous dropouts, inadequate antiretroviral adherence, and less HIV knowledge were related to follow-up failures. COVID-19 had a significant negative impact, but it also had positive repercussions for patients with adequate follow-up. These results could help develop effective psychosocial programs and improve healthcare in institutions to facilitate patient retention.

Progress in the quality of care for newly diagnosed people with HIV in Spain (2004-2019)

BACKGROUND

We monitored the quality of care for newly diagnosed people with HIV (PWH) in Spain, including linkage to care within 1 month of HIV diagnosis (LC-1Mo) and viral suppression within 3 months of HIV diagnosis (VS-3Mo).

METHODS

Longitudinal study based on The Cohort of the Spanish AIDS Research Network (CoRIS). We used logistic regression stratified by year of HIV diagnosis (2004-2013 and 2014-2019) to assess differences by sex, country of origin, HIV risk group, age, prior AIDS, HIV Viral Load, and CD4 cell count.

RESULTS

The final analysis included 13,632 PWH: males 85%, men having sex with men (MSM) 61%, median age 35 years. LC-1Mo increased from 42% (95% CI, 38%-46%) in 2004 to 80% (95% CI, 77%-83%) in 2019 (P < 0.001). Median CD4⁺ cell counts at ART initiation increased from <250/mm3 in 2004-2005 to >350/mm3 since 2012 (P < 0.001). The percentage of initial regimens based on integrase strand transfer inhibitors (INSTI) increased from 3% in 2004 to >70% from 2016 onwards (P < 0.001). VS-3Mo increased from 6% (95% CI, 4%-8%) in 2004 to 45% (95% CI, 41%-49%) in 2019 (P < 0.001). Worst results for LC-1Mo were found among PWH acquiring HIV by injection drug use and those born in Latin American Countries across all the study period.

CONCLUSION

Care indicators have improved among newly diagnosed PWH in Spain over the last 15 years. Removal of CD4 cell counts limitations, and probably the increasing use of INSTI-based regimens was decisive for the progress made.

COVID-19 Vaccine Hesitancy and Vaccination Status in a Community-Based Cohort of People Who Inject Drugs in Baltimore, Maryland, March–June 2021

Objective:

People who inject drugs are a population who are often unengaged with health care services. The objective of this study was to characterize COVID-19 vaccine hesitancy and uptake in a community-based sample of people who inject drugs in Baltimore, Maryland.

Methods:

The ALIVE study (AIDS Linked to the IntraVenous Experience) in Baltimore is a community-based cohort study of people with a history of injection drug use. From March 2 through June 28, 2021, 346 ALIVE participants completed a survey on substance use, structural determinants of health, and COVID-19 vaccine hesitancy. The exposure of interest was COVID-19 vaccine hesitancy, and the primary outcome was vaccination status as of June 30, 2021. We extracted data on the dates of vaccination from electronic medical records linked to study participants.

Results:

The median age of the sample was 60 years; most participants were male (66%) and non-Hispanic Black (87%). Most (55%) trusted the COVID-19 vaccine, and 68% had received ≥1 dose. After age standardization, survey participants were more likely than the Maryland general population to be unvaccinated (prevalence ratio = 1.20; 95% CI, 0.97-1.49; P = .10). Participants who somewhat trusted or did not trust the COVID-19 vaccine had 6-fold higher odds of being unvaccinated than participants who trusted the vaccine (odds ratio = 6.30; 95% CI, 3.74-10.60).

Conclusion:

Uptake of COVID-19 vaccine among people with a history of injection drug use was high. Attitudes and knowledge about vaccination were important predictors of vaccine uptake. Education and outreach efforts could be effective in reducing hesitancy and increasing vaccination in substance-using populations.

Periods of Homelessness Linked to Higher VACS Index Among HIV-Positive People Who Use Drugs

We sought to evaluate the impact of homelessness on HIV disease progression among people who use unregulated drugs (PWUD) living with HIV and test if this association was mediated by adherence to antiretroviral therapy (ART). We applied general linear mixed-effects modeling to estimate the longitudinal relationship between homelessness and the Veterans Aging Cohort Study (VACS) Index, a validated measure of HIV disease progression that predicts all-cause mortality, among a prospective cohort of PWUD. In a longitudinal model adjusted for ART adherence, homelessness was significantly associated with increased VACS Index scores and 16% of the association was mediated by ART adherence. These findings indicate that homelessness was a significant risk factor for HIV disease progression and this association was marginally mediated by ART adherence. Future studies are needed to quantify the other mechanisms (e.g., food insecurity, mental health) by which homelessness increases mortality risk among PWUD living with HIV.

Studying patterns and predictors of HIV viral suppression using A Big Data approach: a research protocol

Background

Given the importance of viral suppression in ending the HIV epidemic in the US and elsewhere, an optimal predictive model of viral status can help clinicians identify those at risk of poor viral control and inform clinical improvements in HIV treatment and care. With an increasing availability of electronic health record (EHR) data and social environmental information, there is a unique opportunity to improve our understanding of the dynamic pattern of viral suppression. Using a statewide cohort of people living with HIV (PLWH) in South Carolina (SC), the overall goal of the proposed research is to examine the dynamic patterns of viral suppression, develop optimal predictive models of various viral suppression indicators, and translate the models to a beta version of service-ready tools for clinical decision support.

Methods

The PLWH cohort will be identified through the SC Enhanced HIV/AIDS Reporting System (eHARS). The SC Office of Revenue and Fiscal Affairs (RFA) will extract longitudinal EHR clinical data of all PLWH in SC from multiple health systems, obtain data from other state agencies, and link the patient-level data with county-level data from multiple publicly available data sources. Using the deidentified data, the proposed study will consist of three operational phases: Phase 1: “Pattern Analysis” to identify the longitudinal dynamics of viral suppression using multiple viral load indicators; Phase 2: “Model Development” to determine the critical predictors of multiple viral load indicators through artificial intelligence (AI)-based modeling accounting for multilevel factors; and Phase 3: “Translational Research” to develop a multifactorial clinical decision system based on a risk prediction model to assist with the identification of the risk of viral failure or viral rebound when patients present at clinical visits.

Discussion

With both extensive data integration and data analytics, the proposed research will: (1) improve the understanding of the complex inter-related effects of longitudinal trajectories of HIV viral suppressions and HIV treatment history while taking into consideration multilevel factors; and (2) develop empirical public health approaches to achieve ending the HIV epidemic through translating the risk prediction model to a multifactorial decision system that enables the feasibility of AI-assisted clinical decisions.

Use of community healthcare and overdose in the 30 days following release from provincial correctional facilities in British Columbia

BACKGROUND

Interruptions in healthcare services contribute to an elevated risk of overdose in the weeks following release from incarceration. This study examined the association of use of community healthcare with nonfatal and fatal overdose in the 30 days following release.

METHODS

We conducted a retrospective cohort study using linked administrative data from a random sample of 20% of the population of British Columbia. We examined releases from provincial correctional facilities between January 1, 2015-December 1, 2018. We fit multivariate Andersen-Gill models to examine nonfatal overdoses after release from incarceration and applied Standard Cox regression for analyses of fatal overdoses.

RESULTS

There were a combined 16,809 releases of 6721 people in this study. At least one overdose occurred in 2.8% of releases. A community healthcare visit preceded the first nonfatal overdose in 86.4% of releases with a nonfatal overdose event. Only 48.4% of people who had a fatal overdose used community healthcare. In adjusted analysis, people who had used community healthcare had a higher hazard of healthcare-attended nonfatal overdose (aHR 2.83 95% CI 2.13, 3.78) and lower hazard of fatal overdose (aHR 0.58, 95%CI 0.28, 1.19).

CONCLUSIONS

Community healthcare visits after release from custody may be an important opportunity to provide overdose prevention and harm reduction supports. Policies and resourcing are needed to facilitate better connection to primary healthcare during the transition to community. Providers in community should be equipped to offer care to people who have recently experienced incarceration in a way that is accessible, acceptable and trauma-informed.

'You just prefer to die early!': how socioecological context impedes treatment for people living with HIV in Iran

INTRODUCTION

Despite the low prevalence of HIV and broad provision of antiretroviral therapy, the Middle East and North Africa (MENA) remains the only region where new HIV infections and AIDS-related deaths are not declining. There is a dearth of evidence from MENA on antiretroviral therapy engagement. In this qualitative study, we sought to identify the ways in which successful treatment is hindered in Iran, which is home to 24% of HIV infections in MENA.

METHODS

From August 2018 to January 2019, we used purposive sampling and conducted 12 individual interviews and 8 focus group discussions with 27 female and 31 male patients, in addition to 5 individual interviews with HIV care providers and 1 focus group discussion with 8 care providers. Social constructivism augmented with realist-informed thematic analysis was used to understand how the socioecological context triggers cognitive and affective mechanisms that disrupt antiretroviral therapy.

RESULTS

The use of Thematic Network Analysis resulted in the identification of three key cognitive and affective mechanisms that appear to shape treatment experience and are triggered via HIV's socioecological context and changing economic conditions in Iran: denial in response to societal negative perceptions of HIV; fear in response to societal lack of awareness regarding HIV and misinformation; and despair in response to HIV-related stigma and enacted discrimination, economic insecurity and social support.

CONCLUSIONS

To our knowledge, this is the first study within MENA to identify pathways through which successful treatment is hindered. It appears that lack of societal awareness regarding HIV is specific to low prevalence settings, such as MENA countries, where negative perceptions, stigma, discrimination and misinformation regarding HIV and its treatment produce denial, fear and despair, acting as mechanisms that disrupt antiretroviral therapy. The experience of despair, in response to changing economic conditions and social support, further impacts treatment experience.

Substance Use Predicts Sustained Viral Suppression in a Community Cohort of Sexual and Gender Minority Youth Living with HIV

Retention in care and sustained viral suppression are integral outcomes in the care continuum for people living with HIV (PLWH) and HIV prevention; however, less is known about how substance use predicts sustained viral suppression over time. This study seeks to examine the predictive effects of substance use on sustained viral suppression in a sample of cisgender sexual minority men and gender minority PLWH (n = 163) drawn from a longitudinal sample in the Chicago area collected 2015-2019. Using data from 3 visits separated by 6 months, participants were coded persistently detectable, inconsistently virally suppressed, and consistently virally suppressed (< 40 copies/mL at all visits). Multinomial logistic regressions were utilized. About 40% of participants had sustained viral suppression. In multinomial logistic regressions, CUDIT-R predicted persistent detectable status and stimulant use was associated with inconsistent viral suppression. Substance use may create challenges in achieving sustained viral suppression, which has important implications for care and prevention.

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.

Nonstructured Treatment Interruptions Are Associated With Higher Human Immunodeficiency Virus Reservoir Size Measured by Intact Proviral DNA Assay in People Who Inject Drugs

The latent reservoir for human immunodeficiency virus type 1 (HIV-1) in CD4+ T cells is a major barrier to cure. HIV-1-infected persons who inject drugs (PWID) often struggle to maintain suppression of viremia and experience nonstructured treatment interruptions (NTIs). The effects of injecting drugs or NTIs on the reservoir are unclear. Using the intact proviral DNA assay, we found no apparent effect of heroin or cocaine use on reservoir size. However, we found significantly larger reservoirs in those with frequent NTIs or a shorter interval from last detectable HIV RNA measurement. These results have important implications for inclusion of PWID in HIV-1 cure studies.

Time spent with HIV-RNA ≤ 200 copies/ml in a cohort of people with HIV during the U=U era

OBJECTIVE

Zero risk of linked HIV transmission in serodiscordant couples when the HIV-infected partner had viral load less than 200 copies/ml ('U status') was found in observational studies. We aimed at estimating the proportion of time in which 'U status' was maintained and identifying factors associated with the risk of losing it.

DESIGN

Observational cohort study.

METHODS

We included participants in the ICONA cohort who had reached an established 'U status' (viral load ≤200 copies/ml for >6 months) as of December 2010. The outcome was the number of person-days of follow-up (PDFU) above a viral load greater than 200 copies/ml, relative to the total number of PDFU observed. A logistic regression model was used to identify factors independently associated with the risk of losing 'U status'.

RESULTS

Eight thousand, two hundred and forty-one persons living with HIV were included in the analysis who contributed 2 670 888 PDFU. Of these, 1648 (20%) were women, 768 (9%) were people who inject drugs (PWID), and 2066 (25%) were foreign-born. The median of viral load measurements was 9 (IQR: 4-15). Overall, only 3.1% of PDFU were observed when viral load was above 200 copies/ml. The proportion of PDFU with viral load more than 200 copies/ml was higher than average in women (5.3%), unemployed (5.4%), PWID (4.7%), and in people with more than three previous virologic failures (6.3%). These variables were significant predictors of losing 'U status' in the multivariable logistic regression.

CONCLUSION

Our results reinforce the validity of the U=U message in real-world setting. However, we identified subsets of our study population at higher risk of losing the 'U status' for whom additional efforts are needed.

Alcohol Consumption and Hepatitis C Virus (HCV) RNA Levels in HIV/HCV Coinfected Patients

BACKGROUND

The impact of Hepatitis C virus (HCV) RNA levels on the evolution of chronic HCV infection-related liver damage is controversial. Heavy alcohol use is believed to have a deleterious impact on the course of HCV disease, but current knowledge about the possible effect of alcohol use on HCV RNA levels in HIV/HCV coinfected patients is limited.

METHODS

We examined 107 HIV/HCV-infected individuals with current or past unhealthy alcohol use to assess the association between alcohol consumption (any drinking vs. abstinent) and HCV RNA levels.

RESULTS

Participants were 75% male, with a mean age of 43 years, and 63% were on antiretroviral therapy. Mean (SD) log HIV RNA was 3.1 (1.4) and mean (SD) log HCV RNA was 6.1 (0.8). Past-month alcohol use was present in 38% of participants. In a multivariable linear regression analysis we found no significant differences in mean log HCV RNA levels between those reporting alcohol use and those who were abstinent [β (95%CI): -0.04 (-0.34, 0.26), p = 0.79)]. There was no significant association between any heavy drinking day and HCV RNA level (0.07, 95% CI: (-0.24, 0.38), p = 0.66).

CONCLUSIONS

We did not detect significant associations between alcohol use and HCV RNA levels among HIV/HCV coinfected patients.

Human Immunodeficiency Virus Testing, Diagnosis, Linkage to Care, and Prevention Services Among Persons Who Inject Drugs, United States, 2012-2017

BACKGROUND

Human immunodeficiency virus (HIV) testing and early diagnosis is associated with effective disease management and reduction in HIV transmission among persons who inject drugs (PWID). We examined trends in HIV testing outcomes among PWID during 2012-2017.

METHODS

Centers for Disease Control and Prevention (CDC)-funded HIV testing data submitted by 61 health departments and 150 directly-funded community-based organizations during 2012-2017 were analyzed. We calculated estimated annual percentage changes (EAPC) to assess trends for HIV testing and testing outcomes.

RESULTS

A total of 19 739 857 CDC-funded HIV tests were conducted during 2012-2017. Of these, 529 349 (2.7%) were among PWID. The percentage of newly diagnosed HIV increased from .7% in 2012 to .8% in 2017 (EAPC, 4.15%). The percentage interviewed for partner services increased from 46.7% in 2012 to 66.3% in 2017 (EAPC, 1.81%). No significant change was identified in trends for linkage to HIV medical care ≤90 days after diagnosis (EAPC, 0.52%) or referral to HIV prevention services (EAPC, 0.98%).

CONCLUSIONS

Human immunodeficiency virus testing data revealed an increasing trend in newly diagnosed HIV among PWID but not linkage to HIV medical care or referral to prevention services. Expanding efforts to increase HIV testing and enhance linkage to services can lead to reductions in HIV transmission and improved health outcomes.

Trajectories of Viral Suppression in People Living With HIV Receiving Coordinated Care: Differences by Comorbidities

BACKGROUND

In March of 2013, the Los Angeles County (LAC) Division of HIV and STD Programs implemented a clinic-based Medical Care Coordination (MCC) Program to increase viral suppression (VS) (<200 c/mL) among people living with HIV (PLWH) at high risk for poor health outcomes.

OBJECTIVE

This study aimed to estimate trajectories of VS and to assess whether these trajectories differed by stimulant use, housing instability, and depressive symptom severity as reported by PLWH participating in MCC.

METHODS

Data represent 6408 PLWH in LAC receiving services from the MCC Program and were obtained from LAC HIV surveillance data matched to behavioral assessments obtained across 35 Ryan White Program clinics participating in MCC. Piecewise mixed-effects logistic regression with a random intercept estimated probabilities of VS from 12 months before MCC enrollment through 36 months after enrollment, accounting for time by covariate interactions for 3 comorbid conditions: housing instability, stimulant use, and depressive symptoms.

RESULTS

The overall probability of VS increased from 0.35 to 0.77 within the first 6 months in the MCC Program, and this probability was maintained up to 36 months after enrollment. Those who reported housing instability, stimulant use, or multiple comorbid conditions did not achieve the same probability of VS by 36 months as those with none of those comorbidities.

CONCLUSIONS

Findings suggest that MCC improved the probability of VS for all patient groups regardless of the presence of comorbidities. However, those with comorbid conditions will still require increased support from patient-centered programs to address disparities in VS.

Mortality and Attrition Rates within the First Year of Antiretroviral Therapy Initiation among People Living with HIV in Guangxi, China: An Observational Cohort Study

Objective

To assess the mortality and attrition rates within the first year of antiretroviral therapy (ART) initiation among people living with human immunodeficiency virus (PLHIV) in rural Guangxi, China.

Design

Observational cohort study. Setting. The core treatment indicators and data were collected with standard and essential procedures as per the Free ART Manual guidelines across all the rural health care centers of Guangxi. Participants. 58,115 PLHIV who were under ART were included in the study. Interventions. The data collected included sociodemographic characteristics that consist of age, sex, marital status, route of HIV transmission, CD4 cell count before ART, initial ART regimen, level of ART site, and year of ART initiation. Primary and Secondary Outcome Measures. Mortality and attrition rate following ART initiation.

Results

The average mortality rate was 5.94 deaths, and 17.52 attritions per 100 person-years within the first year of ART initiation among PLHIV. The mortality rate was higher among intravenous drug users (Adjusted Hazard Ratio (AHR) 1.27, 95% Confidence Interval (CI) 1.14-1.43), prefecture as a level of ART site (AHR 1.14, 95% CI 1.02-1.28), and county as the level of ART site (AHR 2.12, 95% CI 1.90-2.37). Attrition was higher among intravenous drug users (AHR 1.87, 95% CI 1.75-2.00), the first-line ART containing AZT (AHR 1.09, 95% CI 1.03-1.16), and first-line ART containing LVP/r (AHR 1.34, 95% CI 1.23-1.46).

Conclusion

The mortality and attrition rates were both at the highest level in the first year of post-ART; continued improvement in the quality of HIV treatment and care is needed.

Trends in Hepatocellular Carcinoma Incidence and Risk Among Persons With HIV in the US and Canada, 1996-2015

IMPORTANCE

People with HIV (PWH) are often coinfected with hepatitis B virus (HBV) and/or hepatitis C virus (HCV), leading to increased risk of developing hepatocellular carcinoma (HCC), but few cohort studies have had sufficient power to describe the trends of HCC incidence and risk among PWH in the combination antiretroviral therapy (cART) era.

OBJECTIVE

To determine the temporal trends of HCC incidence rates (IRs) and to compare rates by risk factors among PWH in the cART era.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) study, which was conducted between 1996 and 2015. NA-ACCORD pooled individual-level data from 22 HIV clinical and interval cohorts of PWH in the US and Canada. PWH aged 18 years or older with available CD4 cell counts and HIV RNA data were enrolled. Data analyses were completed in March 2020.

EXPOSURES

HBV infection was defined as detection of either HBV surface antigen, HBV e antigen, or HBV DNA in serum or plasma any time during observation. HCV infection was defined by detection of anti-HCV seropositivity, HCV RNA, or detectable genotype in serum or plasma at any time under observation.

MAIN OUTCOMES AND MEASURES

HCC diagnoses were identified on the basis of review of medical records or cancer registry linkage.

RESULTS

Of 109 283 PWH with 723 441 person-years of follow-up, the median (interquartile range) age at baseline was 43 (36-51) years, 93 017 (85.1%) were male, 44 752 (40.9%) were White, 44 322 (40.6%) were Black, 21 343 (19.5%) had HCV coinfection, 6348 (5.8%) had HBV coinfection, and 2082 (1.9%) had triple infection; 451 individuals received a diagnosis of HCC by 2015. Between the early (1996-2000) and modern (2006-2015) cART eras, the crude HCC IR increased from 0.28 to 0.75 case per 1000 person-years. HCC IRs remained constant among HIV-monoinfected persons or those coinfected with HBV, but from 1996 to 2015, IRs increased among PWH coinfected with HCV (from 0.34 cases/1000 person-years in 1996 to 2.39 cases/1000 person-years in 2015) or those with triple infection (from 0.65 cases/1000 person-years in 1996 to 4.49 cases/1000 person-years in 2015). Recent HIV RNA levels greater than or equal to 500 copies/mL (IR ratio, 1.8; 95% CI, 1.4-2.4) and CD4 cell counts less than or equal to 500 cells/μL (IR ratio, 1.3; 95% CI, 1.0-1.6) were associated with higher HCC risk in the modern cART era. People who injected drugs had higher HCC risk compared with men who had sex with men (IR ratio, 2.0; 95% CI, 1.3-2.9), adjusted for HBV-HCV coinfection.

CONCLUSIONS AND RELEVANCE

HCC rates among PWH increased significantly over time from 1996 to 2015. PWH coinfected with viral hepatitis, those with higher HIV RNA levels or lower CD4 cell counts, and those who inject drugs had higher HCC risk.

Psychosocial Barriers to Viral Suppression in a Community-based Sample of Human Immunodeficiency Virus-infected Men Who Have Sex With Men and People Who Inject Drugs in India

BACKGROUND

Little is known about the impact of psychosocial factors and substance use on viral suppression among human immunodeficiency virus (HIV)-infected key populations in resource-limited settings. Accordingly, we examined the association and interactions between depression, alcohol use, and recreational drug use on viral suppression among men who have sex with men (MSM) and people who inject drugs (PWID) in India.

METHODS

MSM and PWID were recruited across India using respondent-driven sampling (RDS). Correlates of viral suppression were determined using Poisson regression models incorporating RDS-II weights. Two-way multiplicative interactions were assessed with separate models of all combinations of the 3 variables of interest using interaction terms; 3-way interactions were evaluated by stratifying 2-way interactions by the third variable.

RESULTS

Among 1454 treatment-eligible HIV-infected MSM and 1939 PWID, older age (adjusted prevalence ratio [aPR], 1.14 for MSM; 1.41 for PWID) and higher HIV treatment literacy (aPR, 1.58 for MSM; 3.04 for PWID) were positively associated with viral suppression. Among MSM, there was evidence of a synergistic negative association between severe depression and recreational drug use (aPR, 0.37 [95% confidence interval {CI}, .16-.84]), alcohol dependence and recreational drug use (aPR, 0.45 [95% CI, .20-.99]), and severe depression, alcohol dependence, and recreational drug use (aPR, 0.23 [95% CI, .09-.57]). Among PWID, daily injection (aPR, 0.51 [95% CI, .31-.82]) was the primary barrier to suppression.

CONCLUSIONS

Incorporating psychosocial and harm-reduction services into differentiated care models targeting MSM and PWID in low-resource settings is critical to achieving the 90-90-90 HIV/AIDS targets.

HIV treatment cascade among people who inject drugs in Ukraine

The HIV treatment cascade is an effective tool to track progress and gaps in the HIV response among key populations. People who inject drugs (PWID) remain the most affected key population in Ukraine with HIV prevalence of 22% in 2015. We performed secondary analysis of the 2017 Integrated Bio-Behavioral Surveillance (IBBS) survey data to construct the HIV treatment cascade for PWID and identify correlates of each indicator achievement. The biggest gap in the cascade was found in the first "90", HIV status awareness: only 58% [95% CI: 56%-61%] of HIV-positive PWID reported being aware of their HIV-positive status. Almost 70% [67%-72%] of all HIV-infected PWID who were aware of their status reported that they currently received antiretroviral therapy (ART). Almost three quarters (74% [71%-77%]) of all HIV-infected PWID on ART were virally suppressed. Access to harm reduction services in the past 12 months and lifetime receipt of opioid agonist treatment (OAT) had the strongest association with HIV status awareness. Additionally, OAT patients who were aware of HIV-positive status had 1.7 [1.2-2.3] times the odds of receiving ART. Being on ART for the last 6 months or longer increased odds to be virally suppressed; in contrast, missed recent doses of ART significantly decreased the odds of suppression. The HIV treatment cascade analysis for PWID in Ukraine revealed substantial gaps at each step and identified factors contributing to achievement of the outcomes. More intensive harm reduction outreach along with targeted case finding could help to fill the HIV awareness gap among PWID in Ukraine. Scale up of OAT and community-level linkage to care and ART adherence interventions are viable strategies to improve ART coverage and viral suppression among PWID.

Brief Report: Racial and Ethnic Disparities in Sustained Viral Suppression and Transmission Risk Potential Among Persons Aged 13-29 Years Living With Diagnosed HIV Infection, United States, 2016

BACKGROUND

In 2016, persons aged 13-29 years represented 23.1% of the US population, yet accounted for 41.7% of HIV diagnoses. Racial/ethnic minorities are disproportionally affected by HIV. Sustaining viral suppression helps persons living with diagnosed HIV infection (PLWDH) stay healthy and reduces the risk of transmitting HIV. We examined racial/ethnic disparities in sustained viral suppression and transmission risk potential among PLWDH aged 13-29 years.

METHODS

We analyzed data from the National HIV Surveillance System reported through December 2018 from 42 jurisdictions with complete laboratory reporting. We included persons aged 13-29 years who received an HIV diagnosis by December 31, 2015, most recently resided in one of the 42 jurisdictions, and were alive at the end of 2016. Sustained viral suppression was defined as viral load <200 copies/mL for all tests in 2016. Transmission risk potential was estimated using the number of days with viral loads >1500 copies/mL.

RESULTS

Of the 90,812 PLWDH aged 13-29 years included in the analysis, 41.5% had sustained viral suppression in 2016. Across age, sex, and most transmission categories, blacks had the lowest prevalence of sustained viral suppression. Among the 28,154 who were in care but without sustained viral suppression, the average number of days with viral load >1500 copies/mL was 206 days (56.4% of the 12-month period).

CONCLUSIONS

Sustained viral suppression was suboptimal and transmission risk potential was high for PLWDH aged 13-29 years. Racial/ethnic disparities were apparent, calling for strengthening tailored interventions to improve care outcomes.

Falling Through the Cracks: Risk Factors for Becoming Lost to HIV Care After Incarceration in a Southern Jail

Using a retrospective cohort analysis of inmates released from Dallas County Jail between January 2011 and November 2013, this study characterizes people living with HIV/AIDS (PLWHA) who are lost to care after release from jail. We used Kaplan-Meier analysis to estimate the risk of becoming lost to post-release HIV care and a Cox proportional hazards regression model to identify associated factors. The majority of individuals (78.2%) were men and 65.5% were black. Of the incarcerations that ended with release to the community, approximately 43% failed to link to community HIV care. Non-Hispanic Whites were more likely than Hispanics or Blacks to drop out of care after release. Individuals with histories of substance use or severe mental illness were more likely to become lost, while those under HIV care prior to incarceration and/or who had adhered to antiretroviral therapy (ART) were more likely to resume care upon release. Targeted efforts such as rapid linkage to care and re-entry residence programs could encourage formerly incarcerated individuals to re-engage in care.

Frailty transitions, inflammation, and mortality among persons aging with HIV infection and injection drug use

OBJECTIVE

Frailty is a critical aging-related syndrome marked by diminished physiologic reserve and heightened vulnerability to stress, predictive of major adverse clinical outcomes in HIV-infected and uninfected adults. Frailty is a dynamic state, yet little data exist on predictors and consequences of frailty transitions.

DESIGN/METHODS

Frailty was assessed semiannually among HIV-infected and uninfected persons with prior injection drug use using the five Fried phenotype domains. An inflammatory index score was constructed from IL-6 and soluble TNF-α receptor-1 data. Markov transition models assessed determinants of frailty transitions. Cox proportional hazards models estimated mortality risk.

RESULTS

Among 1353 AIDS Linked to the IntraVenous Experience participants with 9559 frailty transition assessments, 33% were HIV-infected. Younger age, higher education, employment, reduced comorbidity, HIV virologic suppression, elevated CD4 nadir (>500 cells/μl) and absence of a prior AIDS diagnosis were significantly associated with both reduced frailty progression and greater frailty recovery. Each SD decrease in inflammatory index score was associated with decreased frailty progression [odds ratio 0.78; 95% confidence interval (CI), 0.65, 0.92] and increased frailty recovery (odds ratio 1.29; 95% CI, 1.08, 1.53). Being frail at one of two consecutive visits was associated with increased mortality, compared with maintenance of a nonfrail state. Being frail at both of two consecutive visits demonstrated the highest mortality risk (hazard ratio 3.23; 95% CI, 2.1, 4.96).

CONCLUSION

Sustained, and to a lesser degree, intermittent frail states are associated with increased mortality. HIV virologic suppression with earlier antiretroviral therapy, reduced comorbidity, and reduced inflammation may prevent frailty progression and promote frailty recovery, consequently improving survival for persons aging with HIV and persons with prior injection drug use.

Sustained HIV viral suppression among men who have sex with men in the Miami-Dade County Ryan White Program: the effect of demographic, psychosocial, provider and neighborhood factors

Background

HIV viral suppression is associated with health benefits for people living with HIV and a decreased risk of HIV transmission to others. The objective was to identify demographic, psychosocial, provider and neighborhood factors associated with sustained viral suppression among gay, bisexual, and other men who have sex with men.

Methods

Data from adult men who have sex with men (MSM) enrolled in the Miami-Dade County Ryan White Program (RWP) before 2017 were used. Sustained viral suppression was defined as having an HIV viral load < 200 copies/ml in all viral load tests in 2017. Three-level (individual, medical case management site, and neighborhood) cross-classified mixed-effect models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for sustained viral suppression.

Results

Of 3386 MSM, 90.8% were racial/ethnic minorities, and 84.4% achieved sustained viral suppression. The odds of achieving sustained viral suppression was lower for 18–24 and 25–34 year-old MSM compared with 35–49 year-old MSM, and for non-Latino Black MSM compared with White MSM. Those not enrolled in the Affordable Care Act, and those with current AIDS symptoms and a history of AIDS had lower odds of achieving sustained viral suppression. Psychosocial factors significantly associated with lower odds of sustained viral suppression included drug/alcohol use, mental health symptoms, homelessness, and transportation to appointment needs. Individuals with an HIV physician who serves a larger volume of RWP clients had greater odds of sustained viral suppression. Neighborhood factors were not associated with sustained viral suppression.

Conclusion

Despite access to treatment, age and racial disparities in sustained viral suppression exist among MSM living with HIV. Addressing substance use, mental health, and social services’ needs may improve the ability of MSM to sustain viral suppression long-term. Furthermore, physician characteristics may be associated with HIV outcomes and should be explored further.

Prior incarceration associated with missed HIV care visits among young people living with HIV in the US

Maintenance in HIV care is important to achieve optimal personal health and HIV viral load suppression for young people living with HIV (PLWH). We assessed the relationship between incarceration and missed visits in a longitudinal data cohort of PLWH (n = 910), ages 12-24, from 14 adolescent trial network sites across the US. The time from study entry to missed visits was modeled using Cox proportional hazards models. The cohort was mostly male (78%) and African American (75%) with a median age of 22. Prior incarceration had been experienced by 39% of the cohort, with a median number of times incarcerated of 2 (IQR: 1-3). The crude and adjusted hazard ratios for missed HIV care visits comparing those with incarceration histories to those without were 1.27 (95% CI: 1.06, 1.54) and 1.53 (95% CI: 1.26, 1.86). Among those returning to care, HIV viral loads were more likely to be unsuppressed among those with incarceration history compared to those without (RR: 1.28, 95% CI: 0.95, 1.74). This association was attenuated to the null after adjustment for suppression of viral load prior to the missed visit. Young PLWH with incarceration histories are at higher risk of missing HIV care visits.

Durable HIV Suppression Among People Who Inject Drugs From a Community-Based Cohort Study in Baltimore, Maryland, 1997-2017

People who inject drugs (PWID) face disparities in human immunodeficiency virus (HIV) treatment outcomes and may be less likely to achieve durable viral suppression. We characterized transitions into and out of viral suppression from 1997 to 2017 in a long-standing community-based cohort study of PWID, the AIDS Link to Intravenous Experience (ALIVE) Study, analyzing HIV-positive participants who had made a study visit in or after 1997. We defined the probabilities of transitioning between 4 states: 1) suppressed, 2) detectable, 3) lost to follow-up, and 4) deceased. We used multinomial logistic regression analysis to examine factors associated with transition probabilities, with a focus on transitions from suppression to other states. Among 1,061 participants, the median age was 44 years, 32% were female, 93% were African-American, 59% had recently injected drugs, and 28% were virologically suppressed at baseline. Significant improvements in durable viral suppression were observed over time; however, death rates remained relatively stable. In adjusted analysis, injection drug use and homelessness were associated with increased virological rebound in earlier time periods, while only age and race were associated with virological rebound in 2012-2017. Opioid use was associated with an increased risk of death following suppression in 2012-2017. Despite significant improvements in durable viral suppression, subgroups of PWID may need additional efforts to maintain viral suppression and prevent premature mortality.

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.

Methamphetamine use drives decreases in viral suppression for people living with HIV released from a large municipal jail: Results of the LINK LA clinical trial

BACKGROUND

People living with HIV (PLWH) often experience decreases in HIV viral suppression (VS) after release from jail. The Linking Inmates to Care in LA (LINK LA) peer navigation intervention helped maintain VS 12 months after release from jail compared to standard of care. In this study, we analyzed correlates of substance use and tested whether substance use was an independent correlate of decreased VS in LINK LA participants.

METHODS

We analyzed LINK LA data collected at baseline, 3, and 12 months. We defined high-risk drug use as any reported methamphetamine, cocaine, or opioid use in the 30 days prior to a study visit (or jail entry at baseline). We used generalized linear mixed models to test associations of sociodemographic variables with type of substance used, and we tested correlates of VS while controlling for time, the intervention, and their interaction.

RESULTS

At baseline (n = 356), 71% of participants reported high-risk drug use: 58%, methamphetamine; 17%, cocaine; 7%, heroin; and 4%, prescription opioids. Non-Hispanic Whites and those younger than 35 were most likely to use methamphetamine; Blacks were most likely to use cocaine; people who inject drugs were most likely to use opioids. Participants who used high-risk drugs had 53% lower adjusted odds than non-users of maintaining VS (AOR 0.47, 95% CI 0.31-0.70, p < 0.001).

CONCLUSION

High-risk drug use, dominated by methamphetamine use, independently correlated with decreased VS among recently incarcerated PLWH. Improving HIV care continuum outcomes among populations leaving jail requires attention to efforts to address high-risk drug use.

Mental health and HIV/AIDS: the need for an integrated response

Tremendous biomedical advancements in HIV prevention and treatment have led to aspirational efforts to end the HIV epidemic. However, this goal will not be achieved without addressing the significant mental health and substance use problems among people living with HIV (PLWH) and people vulnerable to acquiring HIV. These problems exacerbate the many social and economic barriers to accessing adequate and sustained healthcare, and are among the most challenging barriers to achieving the end of the HIV epidemic. Rates of mental health problems are higher among both people vulnerable to acquiring HIV and PLWH, compared with the general population. Mental health impairments increase risk for HIV acquisition and for negative health outcomes among PLWH at each step in the HIV care continuum. We have the necessary screening tools and efficacious treatments to treat mental health problems among people living with and at risk for HIV. However, we need to prioritize mental health treatment with appropriate resources to address the current mental health screening and treatment gaps. Integration of mental health screening and care into all HIV testing and treatment settings would not only strengthen HIV prevention and care outcomes, but it would additionally improve global access to mental healthcare.

Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study

BACKGROUND

Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide.

METHODS

We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death.

RESULTS

We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00-1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79-1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35-0.99) decreased after adjustments for demographic variables.

CONCLUSION

This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.

A conceptual model for understanding post-release opioid-related overdose risk

Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons (PRJP). Informed by the proximate determinants framework, this paper presents the Post-Release Opioid-Related Overdose Risk Model. It explores the underlying, intermediate, proximate and biological determinants which contribute to risk of post-release opioid-related overdose mortality. PRJP share the underlying exposure of incarceration and the increased prevalence of several moderators (chronic pain, HIV infection, trauma, race, and suicidality) of the risk of opioid-related overdose. Intermediate determinants following release from the criminal justice system include disruption of social networks, interruptions in medical care, poverty, and stigma which exacerbate underlying, and highly prevalent, substance use and mental health disorders. Subsequent proximate determinants include interruptions in substance use treatment, including access to medications for opioid use disorder, polypharmacy, polydrug use, insufficient naloxone access, and a return to solitary opioid use. This leads to the final biological determinant of reduced respiratory tolerance and finally opioid-related overdose mortality. Mitigating the risk of opioid-related overdose mortality among PRJP will require improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, and reduce interruptions in care continuity and reduce stigma. Healthcare services and harm reduction strategies, such as safe injection sites, should be tailored to the needs of PRJP. Expanding access to opioid agonist therapy and naloxone around the post-release period could reduce overdose deaths. Programs are also needed to divert individuals with substance use disorder away from the criminal justice system and into treatment and social services, preventing incarceration exposure.

Identifying, linking, and treating people who inject drugs and were recently infected with HIV in the context of a network-based intervention

Identifying and linking people to care soon after HIV infection could limit viral transmission and protect their health. This work aims at describing the continuum of care among recently HIV-infected people who inject drugs (PWID) and participated in an intervention in the context of an HIV outbreak in Athens, Greece. The Transmission Reduction Intervention Project (TRIP) conducted risk network-based contact tracing and screened people for recent HIV infection. A comprehensive approach with a case management component that aimed to remove barriers to accessing care was adopted. Follow-up data on antiretroviral treatment (ART) and HIV-RNA levels were obtained from HIV clinics. TRIP enrolled 45 recently HIV-infected PWID (80% male) with a median viral load at recruitment of 5.43 log₁₀ copies/mL. Of the recently infected persons in TRIP, 87% were linked to care; of these, 77% started ART; and of those on ART, 89% achieved viral load <200 copies/mL. TRIP and its public health allies managed to get most of the recently HIV-infected PWID who were identified by the program into care and many of them onto ART. This resulted in very low HIV-RNA levels. Treatment as prevention can work if individuals are aided in overcoming difficulties in entry to, or attrition from care.

Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions

BACKGROUND

People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). However, PrEP has been underutilized in this population, and PrEP adherence intervention needs are understudied.

METHODS

To inform PrEP intervention development, we reviewed evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID. Guided by a behavioral model of healthcare utilization and using the PICOS framework, we conducted a systematic review in four electronic databases to identify original research studies of ART adherence in HIV-infected PWID in the United States and Canada between Jan 1, 2006-Dec 31, 2016. We synthesized and interpreted findings related to developing recommendations for PrEP adherence interventions for PWID.

RESULTS

After excluding 618 duplicates and screening 1049 unique records, we retained 20 studies of PWID (mean n = 465) with adherence-related outcomes (via pharmacy records: n = 9; self-report: n = 8; biological markers: n = 5; electronic monitoring: n = 2). Predisposing factors (patient-level barriers to adherence) included younger age, female sex, and structural vulnerability (e.g., incarceration, homelessness). Enabling resources (i.e., facilitators) that could be leveraged or promoted by interventions included self-efficacy, substance use treatment, and high-quality patient-provider relationships. Competing needs that require specific intervention strategies or adaptations included markers of poor physical health, mental health comorbidities (e.g., depression), and engagement in transactional sex.

CONCLUSIONS

HIV treatment adherence research carries important lessons for efforts to optimize PrEP adherence among PWID. Despite limitations, this systematic review suggests that strategies are needed to engage highly vulnerable and marginalized sub-groups of this underserved population (e.g., younger PWID, women who inject drugs) in PrEP adherence-related research and programming.

Utilization of Pap testing among women living with HIV enrolled in primary care in Baltimore, Maryland: A 10-year longitudinal study, 2005-2014

Frequent Pap testing is recommended among women living with HIV (WLWH) due to their elevated risk for cervical cancer. However, there are few recent longitudinal evaluations of utilization and determinants of Pap testing among WLWH. Medical and pathology records of WLWH seen at Johns Hopkins Hospital between 2005 and 2014 were assessed using Prentice, Williams, Peterson models. Of 554 WLWH in care for ≥ 18 months, 79% received Pap testing, however only 11% consistently received Pap testing at the recommended interval. Some women (5%) were consistently under-screened (tested at longer intervals) and 21% did not receive any Pap testing at during follow-up. WLWH with decreased likelihood of screening included older women, injection drug users, whites and those who had lived for longer with HIV. In contrast, only women with a prior abnormal Pap result were more likely to receive Pap testing. CD4 cell count and health insurance were not significant determinants. Although many WLWH in care received Pap testing, some WLWH were unscreened or underscreened. Determinants of Pap testing for WLWH include socio-demographic factors and a prior abnormal result; these present potential targets in an urban HIV care setting for closer monitoring and directed interventions to improve utilization among WLWH.

Retention in HIV care during the 3 years following release from incarceration: A cohort study

BACKGROUND

Sustained retention in HIV care (RIC) and viral suppression (VS) are central to US national HIV prevention strategies, but have not been comprehensively assessed in criminal justice (CJ) populations with known health disparities. The purpose of this study is to identify predictors of RIC and VS following release from prison or jail.

METHODS AND FINDINGS

This is a retrospective cohort study of all adult people living with HIV (PLWH) incarcerated in Connecticut, US, during the period January 1, 2007, to December 31, 2011, and observed through December 31, 2014 (n = 1,094). Most cohort participants were unmarried (83.7%) men (77.0%) who were black or Hispanic (78.1%) and acquired HIV from injection drug use (72.6%). Prison-based pharmacy and custody databases were linked with community HIV surveillance monitoring and case management databases. Post-release RIC declined steadily over 3 years of follow-up (67.2% retained for year 1, 51.3% retained for years 1-2, and 42.5% retained for years 1-3). Compared with individuals who were not re-incarcerated, individuals who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p < 0.001) but less likely to have VS (72% versus 81%; p = 0.048). Using multivariable logistic regression models (individual-level analysis for 1,001 individuals after excluding 93 deaths), both sustained RIC and VS at 3 years post-release were independently associated with older age (RIC: adjusted odds ratio [AOR] = 1.61, 95% CI = 1.22-2.12; VS: AOR = 1.37, 95% CI = 1.06-1.78), having health insurance (RIC: AOR = 2.15, 95% CI = 1.60-2.89; VS: AOR = 2.01, 95% CI = 1.53-2.64), and receiving an increased number of transitional case management visits. The same factors were significant when we assessed RIC and VS outcomes in each 6-month period using generalized estimating equations (for 1,094 individuals contributing 6,227 6-month periods prior to death or censoring). Additionally, receipt of antiretroviral therapy during incarceration (RIC: AOR = 1.33, 95% CI 1.07-1.65; VS: AOR = 1.91, 95% CI = 1.56-2.34), early linkage to care post-release (RIC: AOR = 2.64, 95% CI = 2.03-3.43; VS: AOR = 1.79; 95% CI = 1.45-2.21), and absolute time and proportion of follow-up time spent re-incarcerated were highly correlated with better treatment outcomes. Limited data were available on changes over time in injection drug use or other substance use disorders, psychiatric disorders, or housing status.

CONCLUSIONS

In a large cohort of CJ-involved PLWH with a 3-year post-release evaluation, RIC diminished significantly over time, but was associated with HIV care during incarceration, health insurance, case management services, and early linkage to care post-release. While re-incarceration and conditional release provide opportunities to engage in care, reducing recidivism and supporting community-based RIC efforts are key to improving longitudinal treatment outcomes among CJ-involved PLWH.

Patterns of Substance Use and Arrest Histories Among Hospitalized HIV Drug Users: A Latent Class Analysis

Using baseline data from the NIDA Clinical Trials Network 0049 study (Project HOPE), we performed latent class analyses (LCA) to identify discrete classes, or clusters, of people living with HIV (PLWH) based on their past year substance use behaviors and lifetime arrest history. We also performed multinomial logistic regressions to identify key characteristics associated with class membership. We identified 5 classes of substance users (minimal drug users, cocaine users, substantial cocaine/hazardous alcohol users, problem polysubstance users, substantial cocaine/heroin users) and 3 classes of arrest history (minimal arrests, non-drug arrests, drug-related arrests). While several demographic variables such as age and being Black or Hispanic were associated with class membership for some of the latent classes, participation in substance use treatment was the only covariate that was significantly associated with membership in all classes in both substance use and arrest history LCA models. Our analyses reveal complex patterns of behaviors among substance using PLWH and suggest that HIV intervention strategies may need to take into consideration such nuanced differences to better inform future studies and program implementation.

HIV Linkage to Care and Retention in Care Rate Among MSM in Guangzhou, China

Quantifying HIV service provision along the HIV care continuum is increasingly important for monitoring and evaluating HIV interventions. We examined factors associated with linkage and retention in care longitudinally among MSM (n = 1974, 4933 person-years) diagnosed and living in Guangzhou, China, in 2008-2014. We measured longitudinal change of retention in care (≥2 CD4 tests per year) from linkage and antiretroviral therapy initiation (ART). We examined factors associated with linkage using logistic regression and with retention using generalized estimating equations. The rate of linkage to care was 89% in 2014. ART retention rate dropped from 71% (year 1) to 46% (year 2), suggesting that first-year retention measures likely overestimate retention over longer periods. Lower CD4 levels and older age predicted retention in ART care. These data can inform interventions to improve retention about some subgroups.

Changes in Specific Substance Involvement Scores among SBIRT recipients in an HIV primary care setting

Background

Substance use is common among people living with HIV (PLHIV) and is associated with worse outcomes along the HIV care continuum. One potentially effective clinic-based approach to addressing unhealthy substance use is screening, brief intervention, and referral to treatment (SBIRT).

Methods

We conducted a two-arm randomized trial to examine the effects of a self-administered, computerized SBIRT intervention compared to a clinician-administered SBIRT intervention in an HIV primary clinic. Patients were surveyed before receiving the intervention and again at 1, 3, and 6 months. We administered the WHO Alcohol, Smoking and Substance Involvement Screening Test to determine Specific Substance Involvement Scores (SSIS) and to assign participants to categories of lower, moderate, or high risk to health and other problems for each substance. We collapsed moderate or severe risk responses into a single moderate–high risk category. Based on low rates of participation in the computerized arm, we conducted an “as treated” analysis to examine 6-month changes in mean SSIS among SBIRT intervention participants.

Results

For the overall sample (n = 208), baseline mean SSIS were in the moderate risk category for alcohol, tobacco, cannabis, cocaine, amphetamine, sedatives and opioids. Of those enrolled, 134 (64.4%) received the intervention, and 109 (52.4%) completed the 6-month follow up. There was a statistically significant decline in mean SSIS for all substances except tobacco and cannabis among participants who were at moderate–high risk at baseline. We also observed a statistically significant increase in mean SSIS for all substances except amphetamines and sedatives among participants who were at lower risk at baseline.

Conclusions

Substance use among patients in this urban, safety-net, HIV primary care clinic was near universal, and moderate risk substance use was common. Among participants who received the SBIRT intervention, mean SSISs decreased among those at moderate–high risk at baseline, but increased among those at lower risk at baseline over the 6-month study period. Additional research should examine the clinical significance of SSIS changes for PLHIV, which SBIRT components drive changes in substance use scores, and what other interventions might support those patients at lower risk to maintain health and engagement along the HIV care continuum.

Trial registration ClinicalTrials.gov study NCT01300806

Antiretroviral Therapy Use Among HIV-Infected People Who Inject Drugs-20 Cities, United States, 2009-2015

BACKGROUND

Approximately 16% of infections among those living with diagnosed HIV infection in the United States are attributable to injection drug use. Antiretrovirals (ARVs) are recommended for all infected persons to improve health and prevent transmission. Using data from National HIV Behavioral Surveillance, we evaluated changes in ARV use from 2009 to 2015 among HIV-positive people who inject drugs (PWID).

METHODS

PWID were recruited by respondent-driven sampling in 20 cities. ARV use was defined as self-reported use at the time of interview. Prevalence ratios measuring change in ARV use per 3-year increase in year were estimated using log-linked Poisson regression models with generalized estimating equations.

RESULTS

ARV use was 58% (319/548) in 2009, 67% (410/608) in 2012, and 71% (386/545) in 2015. In all 3 cycle years, a higher percentage of ARV treatment was observed among males, PWID of older age (≥50), and PWID with current health insurance. ARV use increased overall, with an adjusted relative increase of 8% per every 3-year increase in year (adjusted prevalence ratio 1.08, 95% confidence interval: 1.03 to 1.12). ARV use also increased among most subgroups.

CONCLUSIONS

These findings show progress in ARV treatment, although ARV coverage remains low compared with other populations at risk for HIV. Efforts to improve ARV coverage among PWIDs are needed.

Fostering a "Feeling of Worth" Among Vulnerable HIV Populations: The Role of Linkage to Care Specialists

To address barriers to adequate engagement in medical care among people living with HIV, Wisconsin's AIDS/HIV Program created a new position, the Linkage to Care (LTC) Specialist. Specialists provide intensive, short-term case management and patient navigation services for small caseloads of individuals at high risk of disengaging with medical care. Clients are eligible if they are newly diagnosed with HIV or new to medical care, recently released from incarceration, recently out of care, nonadherent to scheduled medical care visits, or have detectable viral load while in care. Interviews with 30 clients of Specialists were conducted to understand experiences with the program and medical care. Common themes included the ability of Specialists to navigate complex systems of care and support services, the unique role Specialists played in their clients' lives, and the challenges of transitioning out of the program. Although the primary goal of Specialists is to address barriers to medical care, they often adopted a holistic approach that also included housing, financial assistance, and other social determinants of health. Descriptions of the Specialist's role in implementation manuals focus on their functional roles and the services provided. However, clients often discussed the emotional support they received, especially for clients without strong social support networks. Many clients also desired an ongoing relationship with their Specialists even after discharge, but had been able to establish independence and self-efficacy. The LTC Specialists are resource-intensive considering their small caseloads, but fill an important gap in existing, often overtaxed case management systems.

The risk of HIV transmission at each step of the HIV care continuum among people who inject drugs: a modeling study

Background

People who inject drugs (PWID) are at continued risk for HIV in the U.S., and experience disparities across the HIV care continuum compared to other high-risk groups. Estimates of the risk of HIV transmission at each stage of the care continuum may assist in identifying public health priorities for averting incident infections among PWID, in addition to transmissions to sexual partners of PWID.

Methods

We created an agent-based model simulating HIV transmission and the HIV care continuum for PWID in New York City (NYC) in 2012. To account for sexual transmission arising from PWID to non-PWID, the simulation included the entire adult NYC population. Using surveillance data and estimates from the National HIV Behavioral Surveillance system, we simulated a dynamic sexual and injecting network. We estimated the proportion of HIV transmission events attributable to PWID in the following categories, those: without an HIV diagnosis (‘Undiagnosed’); diagnosed but not on antiretroviral therapy (ART) (‘Diagnosed − not on ART’); those who initiated ART but were not virally suppressed (‘Unsuppressed’); and, those who achieved viral suppression (‘Suppressed’).

Results

We estimated HIV incidence among PWID to be 113 per 100,000 person-years in 2012, with an overall incidence rate for the entire adult NYC population of 33 per 100,000 person-years. Despite accounting for only 33% of the HIV-infected PWID population, the Undiagnosed were associated with 52.6% (95% simulation interval [95% SI]: 47.1–57.0%) of total transmission events. The Diagnosed − not on ART population contributed the second-largest proportion of HIV transmissions, with 36.6% (95% SI: 32.2–41.5%). The Unsuppressed population contributed 8.7% (95% SI: 5.6–11.8%), and Suppressed 2.1% (95% SI: 1.1–3.9%), relatively little of overall transmission.

Conclusions

Among PWID in NYC, more than half (53%) of transmissions were from those who were unaware of their infection status and more than 36% were due to PWID who knew their status, but were not on treatment. Our results indicate the importance of early diagnosis and interventions to engage diagnosed PWID on treatment to further suppress population-level HIV transmission. Future HIV prevention research should focus on the elimination of identified and potential barriers to the testing, diagnosis, and retention of PWID on HIV treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4528-9) contains supplementary material, which is available to authorized users.

Perceived effectiveness of antiretroviral therapy, self-rated health and treatment adherence among HIV-positive people who inject drugs in Estonia

The HIV epidemic in Estonia affects the population of people who inject drugs (PWID) the most, but factors associated with adherence to antiretroviral therapy (ART) among PWID have not been thoroughly examined in Estonia, with particularly limited data regarding beliefs and attitudes of PWID. The objective of this study was to explore the association between ART adherence and individual beliefs, perceived effectiveness of ART, and self-rated health in particular, in this specific population. The study used baseline survey data from a longitudinal intervention study of HIV prevention among PWID in Estonia, in which 107 HIV-infected participants reported current use of ART. Current adherence was measured through the use of a visual analog scale. Approximately half (49%) of the participants reported optimal (≥95%) adherence. The vast majority (81%) believed in the effectiveness of ART. Less than a quarter of the participants (22%) rated their health as good or very good, and a half (52%) reported average health. Individual beliefs and self-reported health were not associated with ART adherence in both bivariate and multivariable analyses. Participants with problem drinking reported significant suboptimal adherence to ART (adjusted odds ratio [AOR] 0.42, 95% CI 0.19-0.97). Daily injection drug use was also associated with suboptimal adherence (AOR 0.34, 95% CI 0.13-0.91). Problem drinking has not been commonly reported as a factor of suboptimal ART adherence among PWID; further research would be useful to identify the pathways that might be involved.

The societal cost of heroin use disorder in the United States

Objective

Heroin use in the United States has reached epidemic proportions. The objective of this paper is to estimate the annual societal cost of heroin use disorder in the United States in 2015 US dollars.

Methods

An analytic model was created that included incarceration and crime; treatment for heroin use disorder; chronic infectious diseases (HIV, Hepatitis B, Hepatitis C, and Tuberculosis) and their treatments; treatment of neonatal abstinence syndrome; lost productivity; and death by heroin overdose.

Results

Using literature-based estimates to populate the model, the cost of heroin use disorder was estimated to be $51.2 billion in 2015 US dollars ($50,799 per heroin user). One-way sensitivity analyses showed that overall cost estimates were sensitive to the number of heroin users, cost of HCV treatment, and cost of incarcerating heroin users.

Conclusion

The annual cost of heroin use disorder to society in the United States emphasizes the need for sustained investment in healthcare and non-healthcare related strategies that reduce the likelihood of abuse and provide care and support for users to overcome the disorder.

Acceptability of a mobile health intervention to enhance HIV care coordination for patients with substance use disorders

Background

Persons living with HIV and substance use disorders face barriers to sustained engagement in medical care, leading to suboptimal antiretroviral treatment outcomes. Innovative mobile technology tools such as customizable smartphone applications have the potential to enhance existing care coordination programs, but have not been rigorously studied.

Methods

We developed and implemented a two-component intervention consisting of peer health navigation supported by a smartphone application conducting ecologic momentary assessment (EMA) of barriers to care and medication adherence. Patients with a history of antiretroviral treatment failure and substance use were recruited to participate in the 9-month pilot intervention. Three peer health navigators were trained to provide social and logistical support while participants re-engaged in HIV care. We assessed the acceptability of the intervention components using qualitative analysis of in-depth interviews conducted with study participants and peer navigators.

Results

Of 19 patients enrolled in the study, 17 participated for at least 2 months and 15 completed the entire 9-month study protocol. The acceptability of the peer navigation intervention was rated favorably by all participants interviewed, who felt that peer support was instrumental in helping them re-engage in HIV care. Participants also responded favorably to the smartphone application, but described its usefulness mostly as providing reminders to take medications and attend appointments, rather than as a facilitator of patient navigation.

Conclusions

Peer health navigation and smartphone-based EMA are acceptable approaches to facilitating engagement in HIV care for drug using populations. Future studies to evaluate the efficacy of this approach for improving long-term retention in care and antiretroviral treatment outcomes are warranted.

ClinicalTrials.gov Identifier NCT01941108; registered on September 4, 2013