"I refused to drink but they still forced me": A mixed-methods approach to understanding the pathways to reduce alcohol use among Vietnamese people with HIV

AIMS

This study explores the effects of two evidence-based alcohol reduction counseling interventions on readiness to change, alcohol abstinence self-efficacy, social support, and alcohol abstinence stigma among people with HIV (PWH) who have hazardous alcohol use in Vietnam.

METHODS

PWH receiving antiretroviral therapy (ART) were screened for hazardous drinking and randomized to one of three study arms: combined intervention (CoI), brief intervention (BI), and standard of care (SOC). A quantitative survey was conducted at baseline (N = 440) and 3-month post-intervention (N = 405), while in-depth interviews were conducted with a subset of BI and CoI participants at baseline (N = 14) and 3 months (N = 14). Data was collected from March 2016 to August 2017. A concurrent mixed-methods model was used to triangulate quantitative and qualitative data to cross-validate findings.

RESULTS

At 3 months, receiving the BI and CoI arms was associated with 2.64 and 3.50 points higher in mean readiness to change scores, respectively, compared to the SOC group (BI: β = 2.64, 95% CI: 1.17-4.12; CoI: β = 3.50, 95% CI 2.02-4.98). Mean alcohol abstinence self-efficacy scores were 4.03 and 3.93 points higher among the BI and CoI arm at 3 months, compared to SOC (BI: β = 4.03, 95% CI: 0.17-7.89; CoI: β = 3.93, 95% CI: 0.05-7.81). The impacts of the interventions on social support and alcohol abstinence stigma were not significant. Perceived challenges to refusing drinks at social events remained due to strong alcohol abstinence stigma and perceived negative support from family and friends who encouraged participants to drink posed additional barriers to reducing alcohol use.

CONCLUSIONS

Both the CoI and BI were effective in improving readiness to change and alcohol abstinence self-efficacy among PWH. Yet, participants still faced significant barriers to reducing their drinking due to social influences and pressure to drink. Interventions at different levels addressing social support and alcohol abstinence stigma are warranted.

Characteristics of persons who inject drugs and who witness opioid overdoses in Vietnam: a cross-sectional analysis to inform future overdose prevention programs

BACKGROUND

Persons who use opioids have a high risk of overdose and associated mortality. In Vietnam, little is known about the characteristics of this population and the persons who are witness to those overdoses. One approach to combatting fatal overdose has been the use of peer interventions in which a friend or injecting partner administers overdose reversal medication, but availability in Vietnam of these medications is limited to pilot programs with aims to expand in the future (Le Minh and V.F. Go, Personal Communication, 2016). The primary objective of this paper is to explore the characteristics associated with witnessing three or more overdoses in a lifetime.

METHODS

This cross-sectional analysis used baseline data from a four-arm randomized control trial conducted in Thai Nguyen, Vietnam, known as the Prevention for Positives project. One thousand six hundred seventy-three PWID were included in the analysis. We conducted bivariable and multivariable logistic regression to identify characteristics associated with witnessing three or more overdoses in a lifetime. Characteristics explored included education, employment, marital status, risky drug use behaviors, locations for accessing syringes, recent overdose, history of incarceration, drug treatment, and having slept outside in the past 3 months.

RESULTS

Seventy-two percent (n = 1203) of participants had witnessed at least one overdose in their lifetime, and 46% had witnessed three or more overdoses (n = 765). In the multivariable model, having less than secondary education (AOR 0.70; 95% CI 0.57, 0.86), having slept outside in the past 3 months (AOR 1.77; 95% CI 1.31, 2.40), having a history of incarceration (AOR 1.33; 95% CI 1.07, 1.65), having a history of drug treatment (AOR 1.41; 95% CI 1.12, 1.77), experiencing a recent non-fatal overdose (AOR 3.84; 95% CI 2.36, 6.25), injecting drugs daily (AOR 1.79; 95% CI 1.45, 2.20), receptive needle sharing (AOR 1.30; 95% CI 1.04, 1.63), and number of years injecting (AOR 1.04; 95% CI 1.02, 1.07) were significantly associated with witnessing three or more overdoses.

CONCLUSIONS

Targeted interventions are needed to train persons witnessing an overdose to administer overdose-reversal medication. This includes targeting persons prior to release from prisons, drug treatment centers, and those accessing syringe exchange programs. Additional research should assess the burden of witnessing an overdose as well as locations for medication distribution. Assessments of the training capacity and needs for implementing these programs among drug using peers in Vietnam are of the utmost importance.

A comparison of the effects of controlled-release levodopa (Madopar CR) with conventional levodopa in late Parkinson's disease

In this multicentre study a controlled-release formulation of levodopa and the decarboxylase inhibitor benserazide (Madopar CR) was evaluated in patients with Parkinson's disease exhibiting dose-related fluctuations in motor performance in response to conventional levodopa preparations. The effect of Madopar CR, with or without conventional levodopa/benserazide, on the proportion of time spent "on", "off" or "intermediate" was compared with that of previous conventional levodopa/decarboxylase inhibitor therapy. Evaluation of the two periods of optimum therapy was based on both patient diary data and investigator opinion. Forty seven patients completed the study but full patient diaries were available for only 37. The mean optimum total daily dosage of conventional Madopar was 820 mg taken in a mean of 6.4 doses, compared with a mean optimum daily dosage of combined Madopar CR and conventional Madopar of 1088 mg, taken in a mean of 5.2 doses. Conventional Madopar was taken in addition to Madopar CR in all but eight patients. Madopar CR was felt to be advantageous in 83% and disadvantageous in 11% of patients completing the study. Considering the 37 patients for whom diary data were available, Madopar CR therapy resulted in an increase in the mean time spent "on" (p = 0.016) and a decrease in the mean time spent "off" (p = 0.029) compared with conventional Madopar alone. Individually 25 out of 37 had an increase in "on" time and 19 out of 37 experienced a decrease in "off" time. Thus Madopar CR was found to be beneficial in a significant proportion of patients experiencing fluctuations in response to conventional levodopa.

The nighttime problems of Parkinson's disease

In a national survey conducted among 220 patients with Parkinson's disease (PD), 215 reported experiencing disabilities at night or on waking. The most common problems were inability to turn over or get out of bed and a frequent need to pass urine during the night. For the majority of patients, sleep was disrupted. Despite these difficulties, two-thirds of patients rated sleep quality as acceptable or good. The average duration of sleep was 6.5-7 h but approximately 8% of patients reported less than 5 h sleep per night. Hypnotic or sedative drugs were used by 29% of patients to help them sleep but only 6% took any antiparkinsonian medication during the night. Just over half the patients had told their doctor of nocturnal problems; prescription of hypnotic drugs or changes to antiparkinsonian therapy were the remedies most frequently tried. Problems at night are common in PD and, because of their debilitating effect on performance during the daytime, merit special attention.

Viscosity of food gums determined in vitro related to their hypoglycemic actions

Experiments were carried out in vitro and in normal human subjects to evaluate alternative food-grade viscous polysaccharides as agents for reducing postprandial hyperglycemia and to assess the relationship between the in vitro and in vivo performance of the polysaccharides. A 1:1 mixture of xanthan and locust bean gum (X/LBG) had the greatest viscosity at equivalent concentrations and shear rates and was more effective than guar gum, xanthan, or locust-bean gum at inhibiting glucose movement in vitro. It was not, however, more efficient in lowering postprandial blood glucose and plasma insulin in human subjects when incorporated in a drink containing 50 g glucose. When the different gums were acidified and reneutralized to mimic conditions in the gut, there was a better correlation between viscosity and blood glucose and plasma insulin levels. This effect may explain why X/LBG was no more effective than the other gums in reducing postprandial hyperglycemia in man.

Does guar gum improve post-prandial hyperglycaemia in humans by reducing small intestinal contact area?

The possibility that viscous polysaccharides, such as guar gum, could lower post-prandial blood glucose levels in part by restricting carbohydrate solutions to a smaller area of small intestine was investigated in twenty healthy human volunteers. Addition of guar gum (22.5 g/l) delayed the mouth-to-caecum transit time of a hypotonic lactulose drink, but did not affect gastric emptying. When a 250 ml solution containing 50 g glucose was confined to a 550 mm length of intestine by an occluding balloon attached to an intestinal tube, maximum blood glucose response was significantly reduced (P less than 0.05) though only by 0.9 mmol/l. Addition of guar gum (36 g/l) had no effect on the distribution of a radio-labelled glucose drink (250 ml; 200 g glucose/l) in the small intestine, monitored using a gamma camera, although it significantly delayed gastric emptying (t 1/2 (min): guar gum v. control 115 (SE 15) v. 73 (SE 8)). Reduced contact area is unlikely to be one of the mechanisms by which guar gum improves glucose tolerance.

The effect of ispaghula (Fybogel and Metamucil) and guar gum on glucose tolerance in man

The effects of incorporating Fybogel (3.5 and 7 g doses), Metamucil (7 g) or guar gum (2.5 and 14.5 g doses) in a drink containing 50 g glucose on plasma glucose, plasma insulin and gastric emptying were studied in thirty-eight normal volunteers. In addition, the effects of Fybogel (7 g) on glucose tolerance, plasma insulin and gastric emptying were measured in fourteen non-insulin-dependent diabetics. Both doses of guar gum significantly lowered plasma glucose and plasma insulin responses to the oral glucose load in normal subjects, although 14.5 g guar gum did not delay the half-time for gastric emptying. Neither Fybogel nor Metamucil had significant effects on plasma glucose responses in normal subjects. In addition, Fybogel (at either dose) had no significant effects on plasma insulin levels, or on gastric emptying in normal subjects or on plasma glucose and insulin responses in diabetic patients. The viscosity of ispaghula solutions ( Fybogel ) was lower than that of guar gum solutions.

The mechanism of action of guar gum in improving glucose tolerance in man

Experiments were carried out in human volunteers to investigate the mechanism by which guar gum improves glucose tolerance. Guar reduced both plasma glucose and insulin responses to an oral glucose load, and delayed gastric emptying. However, there was no correlation between changes in individual blood glucose responses and changes in gastric emptying rates induced by guar. With a steady-state perfusion technique, glucose absorption was found to be significantly reduced during perfusion of the jejunum with solutions containing guar, but returned to control values during subsequent guar-free perfusions. Preperfusing the intestine with guar did not affect electrical measurements of unstirred layer thickness in the human jejunum in vivo. Experiments in vitro established that glucose diffusion out of a guar/glucose mixture was delayed under conditions of constant stirring. We conclude that guar improves glucose tolerance predominantly by reducing glucose absorption in the small intestine. It probably does this by inhibiting the effects of intestinal motility on fluid convection.

The influence of guar gum on intestinal cholesterol transport in the rat

Everted sacs of rat proximal small intestine were used to determine the effect of guar gum (5 g/l) on the uptake of cholesterol (0.1 mM) from a solution of micelles. The uptake of cholesterol was found to be linear both in the presence and absence of guar gum. When guar was present throughout the whole of the incubation medium, the uptake of cholesterol was reduced to approximately 40% of control values. Sacs which had been pre-incubated in guar gum before exposure to cholesterol in a guar-free medium also showed a reduction in cholesterol uptake but this was less pronounced. A two-stage perfusion technique, previously described (Blackburn & Johnson, 1981), was used to determine the effect of a guar layer adsorbed to the mucosal surface on cholesterol absorption in vivo. Such a layer leads to a reduction of approximately 36%; it was concluded that guar slows the absorption of cholesterol from micelles by a mechanism, or mechanisms, involving an increased resistance to diffusion in the aqueous medium. Groups of rats were meal-fed for at least 30 d on semi-synthetic diets with or without the inclusion of guar gum (20 g/kg). Rates of intestinal absorption of cholesterol, glucose and fluid were then determined by the perfusion technique in vivo. There was no reduction in absorption in the test animals compared with the controls. It is proposed that guar gum is able to slow the intestinal transport of cholesterol from a suspension of pre-formed micelles, but only when both are present in the lumen together. No evidence was obtained to suggest that the consumption by rats of a diet containing guar gum, at a level similar to that used in human studies, leads to any adaptive reduction in their rates of cholesterol or glucose absorption.

The influence of guar gum on the movements of inulin, glucose and fluid in rat intestine during perfusion in vivo

A two-stage perfusion technique was used to study the effect of guar gum on the inulin-accessible space and the uptake of water and glucose in rat intestine. Pre-perfusion of test loops with low concentrations of guar, dispersed in saline, modified the rate of equilibration of inulin with the mucosal fluid space during a subsequent perfusion. The glucose absorption rate in such loops was reduced at a concentration of 50 mM, but not at 100 or 150 mM glucose. Fluid absorption was inhibited by pre-treatment with guar gum at all glucose concentrations tested. These results suggest that guar forms a layer closely associated with the mucosal surface which modifies the viscosity of the immediate fluid compartment, so that its resistance to diffusion is increased by means of an unstirred layer effect.

The effect of guar gum on the viscosity of the gastrointestinal contents and on glucose uptake from the perfused jejunum in the rat

1. Male Wistar rats were meal-fed for at least 10 d a control semi-synthetic diet containing no guar gum, or one of three similar test diets containing 3, 10 or 20 g dry guar gum/kg. 2. Rats were killed 6 h after feeding, and contents of stomach, small and large intestine were collected separately. The apparent viscosities of stomach and small intestine contents from animals fed on diets containing 10 and 20 g guar gum/kg were increased relative to control animals, but large intestine contents were unchanged. 3. In the second part of this study, male Wistar rats were anaesthetized and two consecutive lengths of jejunum were perfused, initially with Ringer only (control) or Ringer plus 5 or 6 g guar gum/1 (test). Following this pre-perfusion, both segments were perfused with Ringer containing glucose (10 mM), [3H]glucose and [14C]inulin, and the rate of glucose absorption was determined. 4. The rate of glucose absorption was decreased relative to control values in segments pre-perfused with both 5 and 6 g guar gum/1 solution, but this reduction was significant only in the instance of the 6 g/l solution (P less than 0.001). 5. These results provide evidence to support previous assumptions that ingestion of guar gum will increase the apparent viscosity of the contents of the stomach and small intestine. We propose that a possible mechanism by which guar reduces post-prandial glycaemia is a reduction of glucose absorption from the small intestine, resulting from an increase in viscosity of the contents.