Brief versus extended counseling along with buprenorphine/naloxone for HIV-infected opioid dependent patients

Untreated opioid dependence adversely affects HIV outcomes. Integrating buprenorphine/naloxone into HIV treatment settings is feasible; however, the optimal level of counseling has not been established. We conducted a 12-week randomized clinical trial of physician management (PM) versus PM plus enhanced medical management (EMM) in 47 subjects. At 12 weeks, there were no differences between the two groups in percentage of opioid negative urines (63.6% PM vs. 69.0% PM + EMM, p = .5), maximum duration of continuous abstinence (4.9 weeks PM vs. 5.2 weeks PM + EMM, p = .8) or retention (80% PM vs. 59% PM + EMM, p = .1). The percentage of subjects with detectable HIV viral loads decreased from 58% at baseline to 40% at 12 weeks across both groups (p = .02 for time) with no between group differences (p = .84 and p = .27 for the interaction). Providing more extensive counseling beyond PM is feasible in an HIV clinic, but we are unable to detect an improvement in outcomes associated with these services.     

Buprenorphine/naloxone reduces the reinforcing and subjective effects of heroin in heroin-dependent volunteers

Rationale Although buprenorphine is effective in treating opioid dependence, optimal maintenance doses of buprenorphine or the buprenorphine/naloxone combination have not yet been established. Objective The present study was designed to evaluate the effects of buprenorphine/naloxone maintenance (2/0.5, 8/2, 32/8 mg sublingual) on the reinforcing and subjective effects of heroin (0, 12.5, 25, 50, and 100 mg intranasal) in heroin-dependent individuals. Methods During test weeks, participants (N=7) first sampled a dose of heroin and $20. During subsequent choice sessions, participants could choose to self-administer heroin and/or money. Participants responded under a modified progressive-ratio schedule (PR 50, ..., 2,800) during a ten-trial self-administration task. Results Heroin break point values and subjective responses were significantly lower under 8/2 and 32/8 mg buprenorphine/naloxone compared to 2/0.5 mg. The self-administration and subjective effects data for heroin in the presence of buprenorphine/naloxone were compared to a separate control group of recently detoxified participants (N=8) in order to obtain estimates for the apparent in vivo dissociation constant (K _A), the efficacy estimate (τ), and the estimated fraction of receptors remaining after buprenorphine/naloxone treatment (q). The apparent in vivo dissociation constant for heroin ranged from 50 to 126 mg (K _A) and the efficacy estimate ranged from 13 to 20 (τ). In addition, 2/0.5, 8/2, and 32/8 mg buprenorphine/naloxone dose-dependently reduced the receptor population by 74, 83, and 91%, respectively. Conclusions These data demonstrate that both 8/2 and 32/8 mg buprenorphine/naloxone were well tolerated and effective in reducing the reinforcing and subjective effects of heroin, relative to the 2/0.5-mg dose. The data also show for the first time in humans that it is possible to quantify the efficacy and affinity of heroin for mu opioid receptors, and that 80–90% of mu receptors need to be inactivated in order to obtain significant reductions in heroin-induced effects. These results have important implications for future studies in which it will be possible to obtain estimates of relative affinity and efficacy of different agonists at mu opioid receptors.     

Educational lectures enhance knowledge about the human immunodeficiency virus (HIV) and reduce risky behavior and fear among methadone maintenance treatment patients

Abstract

Background: The aim of this study was to characterize human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)-related knowledge and stigma among methadone maintenance treatment (MMT) patients and evaluate the contribution of an educational lecture in reducing risky behavior and unjustified overprotective behavior due to fear and stigma among MMT patients. Methods: Patients from an MMT clinic within a tertiary medical center were invited to an educational lecture on HIV/AIDS. Seventy participants (of current 330) were chosen by a random sample (December 2015), plus at-risk patients and HIV patients. Attendee compliance and change in scores of questionnaires on knowledge (modified HIV-K-Q-22) and on sexual and injection behaviors were studied. Results: Forty-six patients (65.7% compliance) attended the lecture, and their knowledge and behavior scores improved 2?weeks post-lecture (knowledge: from 14.2?±?3 to 19.0?±?2.2 [P?<?.0005], sexual behavior: from 12.1?±?2.9 to 8.8?±?3.0 [P?<?.0005], and injection behavior: from 7.3?±?6.2 to 0.2?±?1.3 [P?<?.0005]). The unjustified fear of proximity to HIV carriers reported by 50% attendees fell to 35% post-lecture. Eight months post-lecture, the scores on knowledge and risky behavior of 21 randomly chosen attendees were still better than pre-lecture scores (knowledge: 15.4?±?2.3 vs. 17.2?±?1.8 [paired t test, P?=?.001], sexual behavior: 13.2?±?2.3 vs. 9.7?±?2.9 [P?<?.0005], and injection behavior: 9.3?±?5.6 vs. 2.8?±?3.1 [P?<?.0005]). Drug abuse and treatment adherence were not related to intervention and to risky behavior. Conclusions: More knowledge, less fear, and less risky behavior immediately and at 8?months post-lecture reflect the success and importance of the educational intervention. Future efforts are needed in order to reduce ignorance and fear associated with HIV/AIDS.     

梧州市娱乐场所406名暗娼HIV／STI感染调查及高危行为分析

目的：了解暗娼性病、艾滋病感染状况以及高危行为的影响。方法：采取整群随机抽样方法抽取娱乐场所406名暗娼,进行面对面无关联匿名从业基本情况以及艾滋病知识问卷调查并采血做HIV和梅毒抗体的检测、采宫颈拭子进行淋球菌以及沙眼衣原体检测。结果：艾滋病基本知识总正确回答率为82．54％（2681／406×8）,最小年龄为17岁,年龄小于或等于20岁的占16％,年龄大于或等于40岁的占6．4％。第一次发生商业性行为年龄小于或等于20岁占34．24％（139／406）。性伴侣数平均每天2．6个,最近一次发生商业性行为安全套使用率72．91％（296／406）;不使用安全套的主要原因有客人／本人不愿用占34．73％（141／406）。HIV抗体阳性率0．74％（3／406）,梅毒ELISA阳性率10．34％（42／406）,梅毒TRUST阳性率4．68％（19／406）,衣原体阳性88人,占21．67％,淋球菌阳性31人,占7．63％。56．00％的人选择到专科医院或综合医院就诊,27％的人自行购买药物治疗,17％到私人诊所就诊。结论：暗娼人群性病感染率较高,应加强对暗娼人群开展性病艾滋病的官传教育工作。     

Genotype and phenotype of cytochrome P450 2D6 in human immunodeficiency virus-positive patients and patients with acquired immunodeficiency syndrome

Objective: To examine the distribution of the cytochrome P ₄₅₀ (CYP) CYP2D6 phenotype and its relation to genotype, concomitant medication, and disease state in human immunodeficiency virus (HIV)-positive patients. Design: A cross sectional study with a longitudinal component compared individual genotypes for CYP2D6 to the CYP2D6 phenotype. Methods: Sixty-one predominately male Caucasian, HIV-positive patients were recruited and CYP2D6 genotypes [extensive metabolizer (EM) or poor metabolizer (PM)] determined by polymerase chain reaction (PCR)-based amplification, followed by restriction fragment-length analysis. The patients were also phenotyped using dextromethorphan (DM) to determine their respective enzyme activity and assigned either a CYP2D6 EM or PM phenotype. Complete medical and treatment histories were compiled. A total of 44 patients were tested longitudinally. Results: Fifty-nine patients (97%) possessed an EM genotype, consistent with previously observed distributions in demographically similar populations. In healthy seronegative populations, genotype and phenotype have been shown to be essentially interchangeable measures of CYP2D6 activity. In this cohort, 2 of the 59 patients with an EM genotype expressed a PM phenotype. In addition, 4 EM patients were less extensive DM metabolizers than any of the patients receiving medication known to inhibit CYP2D6. This apparent shift toward the PM phenotype from the EM genotype was associated with the presence of active illness. Conclusion: Changes may occur in HIV-positive patients such that their CYP2D6 activity approaches that of PMs, despite having an EM genotype. Neither active disease nor drug interactions alone explain the shift. Received: 1 September 1999 / Accepted in revised form: 10 February 2000     

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19–0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29–0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45–0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24–5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22–3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28–2.87), homelessness (AOR = 2.40, CI = 1.60–3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88–3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08–2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.     

昭通市艾滋病流行现状与防治策略

目的了解昭通市艾滋病流行特征,为制定有效的防治策略提供依据。方法回顾性分析昭通市1996～2010年艾滋病疫情、监测和流行病学资料。结果截至2010年12月底,昭通市累计报告HIV/AIDS共计1619例,其中AIDS患者309例,死亡报告186例;传播途径的构成中性传播占39.87%,注射吸毒39.57%,母婴传播1.09%,义务献血人群0.42%,不详19.06%;外出流动人口感染者占总数的44.09%。结论传播途径以性传播为首,艾滋病流行由高危人群向普通人群扩散,感染者以外出人群为主,提高外出流动人口对艾滋病的防护意识,切实加强外出流动人口高危行为干预措施是当前昭通市防治艾滋病主要策略。     

Primary care patient characteristics associated with completion of 6-month buprenorphine treatment

Background

Opioid addiction is prevalent in the United States. Detoxification followed by behavioral counseling (abstinence-only approach) leads to relapse to opioids in most patients. An alternative approach is substitution therapy with the partial opioid receptor agonist buprenorphine, which is used for opioid maintenance in the primary care setting. This study investigated the patient characteristics associated with completion of 6-month buprenorphine/naloxone treatment in an ambulatory primary care office.

Methods

A retrospective chart review of 356 patients who received buprenorphine for treatment of opioid addiction was conducted. Patient characteristics were compared among completers and non-completers of 6-month buprenorphine treatment.

Results

Of the 356 patients, 127 (35.7%) completed 6-month buprenorphine treatment. Completion of treatment was associated with counseling attendance and having had a past injury.

Conclusions

Future research needs to investigate the factors associated with counseling that influenced this improved outcome. Patients with a past injury might suffer from chronic pain, suggesting that buprenorphine might produce analgesia in addition to improving addiction outcome in these patients, rendering them more likely to complete 6-month buprenorphine treatment. Further research is required to test this hypothesis. Combination of behavioral and medical treatment needs to be investigated for primary care patients with opioid addiction and chronic pain.     

Substance use is independently associated with pneumonia severity in persons living with the human immunodeficiency virus (HIV)

Background: Pneumonia is common in persons living with the human immunodeficiency virus (HIV) (PLWH). Alcohol, cocaine, and marijuana impact pneumonia pathogenesis. We hypothesized that substance use was independently associated with pneumonia severity in PLWH and modified the effect of alcohol on pneumonia severity. Methods: Retrospective data analysis of PLWH admitted with a diagnosis of pneumonia was conducted. Alcohol use disorder was defined by the Alcohol Use Disorders Identification Test score ≥14. Drug use was quantified by self-report. Pneumonia severity was defined by the pneumonia severity index (PSI). Multivariable linear regression was used to test independent associations with pneumonia severity and effect modification by sex. Results: Of 196 PLWH, the mean age was 44?(SD?=?9) years and the majority were men (71%). Ten percent (n?=?19) of subjects met criteria for an alcohol use disorder (AUD). In subjects reporting alcohol use, 25% reported concomitant crack/cocaine use and 16% reported marijuana use. PSI scores were higher with lifetime use of crack/cocaine (mean PSI: 63.1 vs. 57.3, P?=?.06) and/or injection drug use (68.4 vs. 54.9, P?=?.04). PSI scores were lower with active marijuana use (51.5 vs. 62.2, P?=?.01). There was no significant difference in clinical outcomes. Sex modified the effect of drug use on PSI, with greater PSI scores in women with an AUD (β?=?58.1, 95% confidence interval [CI]: 46.7 to 69.5, P?<?.01), whereas active marijuana use mitigated the effect of AUD on PSI in men (β?=??12.7, 95% CI: ?18.8 to ?6.6, P?<?.01). Conclusions: Active alcohol and/or crack/cocaine use was associated with increased pneumonia severity in PLWH, with less severe pneumonia with marijuana use. Alcohol and marijuana effects on pneumonia severity differed by sex, with increased PSI in women and decreased PSI in men with concomitant marijuana and AUD.     

306例吸毒者吸毒行为及HIV/AIDS的KAB调查

目的 :了解吸毒者的吸毒行为及有关HIV AIDS的知识、态度和行为情况。方法 :采用自制问卷匿名填表方法于 1998年 6月对昆明市两戒毒机构的戒毒人员进行横断面调查。调查结果用SPSS10 .0版本进行统计分析。结果 :77.1%的吸毒者以静脉注射的方式吸毒 ,其中 ,6 8.3%的人共用过注射器 ,仅 6 .2 %人采用正确方法消毒注射器。吸毒者中 79.6 %的人有两个以上的性伴侣 ,经常或每次使用安全套的人仅占 16 .9%。大多数吸毒者能正确回答艾滋病的传播途径但缺乏预防艾滋病的知识。结论 :吸毒人群感染HIV AIDS的危险行为非常普遍 ,且知晓知识到行为改变仍有很大距离 ,建议开展减少伤害的干预项目。     

Predictors of attrition with buprenorphine/naloxone treatment in opioid dependent youth

Background

In opioid dependent youth there is substantial attrition from medication-assisted treatment. If youth at risk for attrition can be identified at treatment entry or early in treatment, they can be targeted for interventions to help retain them in treatment.

Methods

Opioid dependent adolescents and young adults (n = 152), aged 15–21, were randomized to 12 weeks (BUP, n = 74) or 2 weeks of detoxification (DETOX, n = 78) with buprenorphine/naloxone (Bup/Nal), both in combination with 12 weeks of psychosocial treatment. Baseline and early treatment related predictors of treatment attrition were identified in each group using bivariate and multivariate logistic regression.

Results

In the DETOX group 36% left between weeks 2 and 4, at the end of the dose taper, while in the BUP group only 8% left by week 4. In the BUP group, early adherence to Bup/Nal, early opioid negative urines, use of any medications in the month prior to treatment entry, and lifetime non-heroin opioid use were associated with retention while prior 30-day hallucinogen use was associated with attrition. In the DETOX group, only use of sleep medications was associated with retention although not an independent predictor. A broad range of other pre-treatment characteristics was unrelated to attrition.

Conclusions

Prompt attention to those with early non-adherence to medication or an early opioid positive urine, markers available in the first 2 weeks of treatment, may improve treatment retention. Extended Bup/Nal treatment appeared effective in improving treatment retention for youth with opioid dependence across a wide range of demographics, and pre-treatment clinical characteristics.     

Antibody response to tetravalent influenza subunit vaccine in patients infected with human immunodeficiency virus type 1

The capacity of patients infected with human immunodeficiency virus (HIV) to develop an adequate antibody response to influenza vaccination in relation to the CD4 cell count has been studied in a prospective study. A total of 73 subjects (54 HIV-infected patients and 19 healthy control persons) were vaccinated with influenza subunit vaccine containing 15 μg hemagglutinin of each of the following strains: A/Beijing/353/89(H3N2), A/Singapore/6/86(H1N1), B/Panama/45/90, and B/Beijing/1/87. Hemagglutinin inhibition (HI) antibody titers were determined prior to vaccination, 3 weeks afterwards, and at the end of the influenza season. The percentage of subjects with HI antibody titers above the assumed protective level was significantly lower in the HIV-infected patients for all 4 vaccine strains compared with those in the control group (7–26% and 42–74%, respectively). There was an association between CD4 cell count and antibody response to the B/Panama strain only. The serologic response to tetravalent subunit influenza vaccine is severely impaired in the majority of HIV-infected patients compared with control subjects. The results of this study challenges the recommendation to vaccinate HIV-infected patients.     

Assessing criminal justice involvement as an indicator of human immunodeficiency virus risk among women in methadone treatment

This study examines the relationship between criminal justice involvement and high-risk sexual partnerships among a random sample of 416 women in methadone treatment in New York City. Logistic regression models were used to estimate the associations between recent criminal justice involvement (arrest or incarceration in the past 6 months) and recent high-risk partnerships (multiple sex partners, sex trading, or sex with a risky partner in the past 6 months) when adjusting for sociodemographic factors and recent regular drug use. Women with recent criminal justice involvement demonstrated higher odds of engaging in high-risk sex partnerships. Although regular drug use was a significant confounder of several of these relationships, recent arrest or incarceration remained significantly associated with multiple sex partnerships, sex with a risky partner, and engaging in unprotected sex and a high-risk partnership even after controlling for regular drug use and other social stressors. This study highlights the vulnerability of drug-involved women offenders to human immunodeficiency virus (HIV) risk and points to the need for investigation into the role of arrest and incarceration as factors that may contribute to HIV infection.     

Steady-state pharmacokinetics of tenofovir disoproxil fumarate in human immunodeficiency virus-infected Chinese patients

Background: The pharmacokinetic (PK) profile of tenofovir disoproxil fumarate in Chinese adults infected with HIV is unknown.

Methods: A pilot, prospective, open-label study was performed to investigate the steady-state PK profile of tenofovir disoproxil fumarate in 15 Chinese HIV-infected patients among whom eight patients were treated with 300 mg tenofovir disoproxil fumarate, 300 mg lamivudine and 400/100 mg lopinavir/ritonavir, and seven with 300 mg tenofovir disoproxil fumarate, 300 mg lamivudine and 400 mg nevirapine. The plasma concentrations of tenofovir over the 24-h dosing interval were determined by HPLC. The PK parameters were calculated using the non-compartmental model in WinNonlin software.

Results: The PK parameters of tenofovir in the 15 patients were determined as follows (mean ± SD): AUC_{(0-24 h)}, 4074.7 ± 1551.9 ng?h/mL; C_max,ss, 447.1 ± 217.4 ng/mL; C_trough,ss, 98.7 ± 36.7 ng/mL; t_max,ss, 1.3 ± 0.4 h; plasma t_1/2, 21.8 ± 7.6 h; and CL_ss/F, 45.8 ± 13.0 L/h.

Conclusion: Tenofovir demonstrated slower elimination rate and increased plasma concentration in Chinese patients compared to previously published data from Caucasian or African subjects, which may be associated with the higher incidences of renal and bone resorption dysfunction observed in our patient population. Clinicians should be cautious of the differing PK characteristics of tenofovir among people of different races.     

HIV/AIDS感染合并肺结核患者单纯抗结核治疗效果分析

目的 观察单纯抗结核治疗HIV/AIDS感染合并肺结核患者的疗效,为科学治疗提供参考.方法 将47例HIV/AIDS感染合并肺结核患者单纯抗结核治疗,比较其治疗前后症状改善情况、辅助检查结果变化,特别是CD4细胞计数.结果 47例HIV/AIDS感染合并肺结核患者中,除6例死亡外,其余41例患者症状均有改善,痰涂(+)转(-)明显,PPD皮试阳性率增高,CD4细胞均数明显增加.结论 单纯抗结核治疗HIV/AIDS感染合并肺结核可改善患者症状,降低其合并肺结核的传染性;同时增加CD4细胞均数,提高免疫应答水平,增强机体免疫力,降低患者病死率.     

咪喹莫特联合微波治疗HIV/AIDS合并肛门尖锐湿疣的临床效果观察

目的：探讨咪喹莫特联合微波治疗HIV/AIDS合并肛门尖锐湿疣的临床效果。方法选取96例HIV/AIDS合并肛门尖锐湿疣患者,随机分为观察组和对照组,分别给予咪喹莫特乳膏联合微波治疗和单纯微波治疗,观察两组的治疗效果和不良反应情况。结果观察组治愈率为87.5%,明显高于对照组的54.2%,复发率较对照组低（P<0.05）;两组均未发生明显不良反应,观察组用药期间经停药或对症处理后不良反应症状缓解。结论咪喹莫特联合微波治疗HIV/AIDS合并肛门尖锐湿疣的效果确切,安全可靠,值得临床推广应用。     

Psychosocial stressors and alcohol use,severity, and treatment receipt across human immunodeficiency virus (HIV) status in a nationally representative sample of US residents

Background: Human immunodeficiency virus (HIV) is stigmatized and disproportionately impacts vulnerable populations. Thus, people living with HIV (PLWH) may have greater exposure to psychosocial stressors than those without HIV. Exposure to psychosocial stressors may increase alcohol use and serve as barriers to alcohol treatment receipt. The authors evaluate whether psychosocial stressors and alcohol use, symptom severity, and treatment receipt vary across HIV status in a general population sample of US residents and assess whether psychosocial stressors mediate identified associations. Methods: Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were used to assess associations between HIV status and psychosocial stressors (perceived stress, alcohol-related stigma, and perceived discrimination based on race/ethnicity, sexual orientation, or sex) and alcohol-related outcomes (any use, heavy drinking, symptom severity, and treatment receipt). For each outcome, regression models were fit and iteratively adjusted for sociodemographic characteristics and comorbidities. Indirect effects of HIV on alcohol-related outcomes through stressors were estimated to assess mediation when main effects were significant. Results: Among 34,653 NESARC Wave 2 respondents, 161 were PLWH. PLWH were more likely than those without HIV to experience discrimination and had higher levels of perceived stress than those without HIV (P values <.05), but the 2 groups did not differ regarding alcohol-related stigma. PLWH were less likely to use alcohol and had similar rates of heavy drinking relative to participants without HIV, but alcohol symptom severity and treatment receipt were greater among PLWH. Perceived stress but not discrimination mediated associations. Conclusions: Findings from this first study of variation in psychosocial stressors and alcohol use, severity, and treatment receipt across HIV status further highlight PLWH as a population that is particularly vulnerable to experiences of psychosocial stress and certain adverse alcohol-related outcomes. Future longitudinal research is needed in a larger sample of PLWH to identify intervention targets.