Outpatient medical care of injection drug use related HIV

Primary care affiliations of adults in a methadone program with onsite care

Methadone maintenance treatment programs (MMTP) often provide onsite primary care. It is unclear whether patients in these settings consider the MMTP their usual source of care. We conducted cross-sectional interviews of 62 adults in an inner-city MMTP with onsite primary care to determine their usual source of care. Program enrollment ranged from 1 to 27 years (median, 4) and 63% attended > or = 5 days per week. Seventy-six percent had > or = 1 chronic disease. Only 53% reported having a usual source of care, which included hospital-based clinics (45%), the MMTP (23%), private physicians (19%), other sites (13%). Patients were more likely to identify the MMTP as their usual source of care if they had cardiovascular disease (RR 6.9, 95% CI 2.2 to 21.9) or HIV (RR 5.6, 95% CI 1.7 to 18.5). Successfully promoting appropriate utilization of onsite primary care may require a better understanding of MMTP patients' perceptions of primary care.

Morphine negatively regulates interferon-gamma promoter activity in activated murine T cells through two distinct cyclic AMP-dependent pathways

To explore the mechanism by which morphine promotes the incidence of HIV infection, we evaluated the regulatory role of morphine on the interferon-gamma (IFN-gamma) promoter in activated T cells from wild type and mu-opioid receptor knockout mice. Our results show that morphine inhibited anti-CD3/CD28-stimulated IFN-gamma promoter activity in a dose-dependent manner. Chronic morphine treatment of T cells increased intracellular cAMP. To evaluate the role of cAMP in morphine's modulatory function, the effects of dibutyryl cyclic AMP and forskolin were investigated. Both dibutyryl cyclic AMP and forskolin treatment inhibited IFN-gamma promoter activity. Treatment with pertussis toxin, but not with a protein kinase A inhibitor, antagonized morphine's inhibitory effects. Morphine inhibited phosphorylation of ERK1/2 and p38 MAPK; in addition, morphine treatment in the presence of either ERK1/2 or p38 MAPK inhibitor (PD98059 or SB203580) resulted in an additive inhibition of IFN-gamma promoter activity. The transcription factor activator protein-1, NF-kappaB, and nuclear factor of activated T cells (NFAT) were negatively regulated by morphine. Overexpression of NF-kappaB p65 rescued the inhibitory effect of morphine on IFN-gamma promoter activity. However, only when NFATc1 was co-overexpressed with c-fos was the inhibitory effect of morphine on IFN-gamma promoter counteracted. The inhibitory effects of morphine were not observed in T cells obtained from mu-opioid receptor knockout mice, suggesting that morphine modulation of IFN-gamma promoter activity is mediated through the mu-opioid receptor. In summary, our data indicate that morphine modulation of IFN-gamma promoter activity is mediated through two distinct cAMP-dependent pathways, the NF-kappaB signaling pathway and the ERK1/2, p38 MAPK, AP-1/NFAT pathway.

Features and outcome of Pneumocystis carinii pneumonia according to risk category for HIV infection

A retrospective study of Pneumocystis carinii pneumonia (PCP) was undertaken to examine differences between the presentation and outcome of PCP in AIDS patients from different risk categories for HIV infection. There were 176 PCP episodes recorded in 126 patients from the following risk categories: 69 intravenous drug misusers (IDMs), 36 homosexually infected men and 21 heterosexually infected patients. Most clinical features did not differ significantly between the 3 groups but hypercapnia was almost exclusively seen in IDMs and, if recorded, was associated with a poorer survival. Pneumothorax was more likely to complicate PCP in IDMs and, although present in all groups, concomitant bacterial respiratory infections were more common in IDMs. Recovery from PCP and the incidence of adverse events during treatment did not differ according to risk category. Subsequent survival time was shorter amongst IDMs, but the uptake of antiretrovirals in this group was significantly lower. We conclude that there are few differences in the presentation of PCP between IDMs and other risk categories for HIV infection and that these do not influence the outcomes of illness. The lower post-PCP survival in IDMs can be accounted for by a reduced uptake of antiretroviral drugs by this group.

Injection drug use-related HIV healthcare--problems and management in Edinburgh

The relatively high numbers of patients with IDU-related HIV in Scotland has resulted in considerable management difficulties not previously experienced by other medical units. Chronic physical ill health in drug users is becoming commoner with the advent of HIV and other centres are now experiencing the type of problems that the Regional Infectious Disease Unit (RIDU) in Edinburgh has faced over the last 10 years. Very little has been published concerning the difficulties of managing patients who use drugs and have a physical illness in medical units in the UK. This paper presents examples of common problems together with the RIDU's experience of management in the hope that it will help others to deliver effective and efficient physical and mental health care to patients with drug problems.

Inpatient health care utilization for patients with HIV and AIDS in the Edinburgh City Hospital

A retrospective analysis of HIV-positive patients admitted to the City Hospital, Edinburgh by 31st December 1992, 7 years after the inception of the HIV clinic, revealed that 373 patients, 72% of them injection drug users (IDUs), had required 2069 admissions (5.5/admitted patient, 3.3/clinic patient or 0.5/clinic patient/year) and had utilized 21,934 bed days (59 bed days/admitted patient, 35 days/clinic patient or 5 bed days/clinic patient/year). The average length of stay (ALOS) was significantly longer for AIDS than HIV (non-AIDS) admissions (14.0 vs 9.5, P < 0.0001) as it was for admissions with a CD200 diagnosis (a CD4 count below 200 cells per mm3 on two consecutive occasions) compared to those without (12.1 vs 10.0 days, P = 0.004). There was no gender effect on ALOS but there was a significant effect of risk activity; homo/bisexuals had a significantly longer ALOS than drug users (P < 0.0001). Homo/bisexual patients with AIDS or a CD200 diagnosis had longer ALOS than drug users (15.7 vs 13 days and 15.8 vs 10.8). By 1992 each member of the clinic was on average utilizing one admission per year and 11.6 bed days per year. The number of admissions in that year for patients without a CD200 or AIDS diagnosis was however low (0.5 and 0.75 admissions/patient/year) compared to patients with an AIDS or CD200 diagnosis (2.6 and 1.6 admissions/patient/year). The annual number of occupied bed days/living patient was greatest for those with AIDS (60 vs 5 days) or with a CD200 diagnosis (23.5 vs 4.1 days).(ABSTRACT TRUNCATED AT 250 WORDS)

Out-patient medical care in Edinburgh for IDU-related HIV

Using combined medical and drug clinics, by the end of 1990 we had initiated contact with 511 HIV positive individuals, 75% injection drug use (IDU) related. We have previously reported a significant reduction in the number of missed appointments from 1985-89 following the introduction of methadone and an all day clinic, but between 1989 and 1990 the appointment default rate rose from 17 to 25%. A significant percentage increase in missed appointments was, however, only seen in those not attending the all day clinic (chi 2(3) = 121.3, p < 0.001). An analysis of the patients missing appointments during 1989-90 revealed that 36-45% of patients attending each year missed only 1 or 2 appointments, that the majority of missed appointments each year were accounted for by less than 20% of the patients, around 60% of these patients missed appointments in both years and that only 2% of patients attending both years consistently miss 3 or more appointments per year. Laboratory monitoring of HIV, that is at least one sampling episode in a year, was achieved, however, in 92-95% of the patients attending each year. The annual number of patients lost to follow-up varied between 7 and 11% per year, but did not change significantly over time, whilst the cumulative number of HIV infected individuals lost to follow-up after 5 years was only 14%. Between 1986 and 1990 self-reported reduction in IDU was more likely in HIV positive than negative individuals; the number of HIV positive individuals who reported injecting for more than 50% of the year fell from 40 to 5% (chi 2(4) = 15.23, p < 0.01) whilst the number who reported at least one injection per year fell from 51 to 23% (chi 2(4) = 62.06, p < 0.001). By comparison amongst non-HIV-infected patients the percentage who reported opiate use for more than 50% of the visits during a year rose from 54% in 1986 to a peak of 70% in 1989 (chi 2(4) = 10.22, p < 0.05) and those who reported opiate use at least once during the year rose from 57% in 1986 to a peak of 75% in 1989 (chi 2(4) = 14.3, p = 0.006). Combined medical and drug clinics from 1986 to 1990 together with a multi-disciplinary team approach to medical care was successful in delivering health care to HIV-infected injection drug users.(ABSTRACT TRUNCATED AT 400 WORDS)

Clinical management of HIV disease in intravenous drug-users

Intravenous drug-users comprise a major group of HIV-infected individuals in the developed world and, whilst progression of HIV disease in them appears little different from other risk groups, their medical presentations may be altered by continuing drug use. Drug-users are particularly susceptible to bacterial infections irrespective of their HIV status; they may present with symptoms directly caused by their drugs, which can be difficult to differentiate from non-drug-related causes and may closely resemble symptoms directly attributable to HIV. In addition, the life style associated with drug use can make compliance difficult, but in clinics combining HIV care and methadone prescribing these problems can be overcome.