The medical management of opioid dependence in HIV primary care settings
Positive Health Program, Department of Medicine, University of California, San Francisco General Hospital, CA 94110, USA. Current HIV/AIDS Reports
(Impact Factor: 3.8).
12/2006; 3(4):195-204. DOI: 10.1007/s11904-006-0016-z
Injecting drug use is a common mode of transmission among persons with HIV/AIDS. Many HIV-infected patients meet diagnostic criteria for opioid dependence, a chronic and relapsing brain disorder. Most HIV providers, however, receive little training in substance use disorders. Opioid agonist therapy (OAT) has a stabilizing effect on opioid-dependent patients and is associated with greater acceptance of antiretroviral (ARV) therapy, higher ARV adherence, and greater engagement in HIV-related health care. Although methadone maintenance has been the OAT gold standard, methadone is available for the treatment of opioid dependence only in strictly regulated narcotic treatment programs. Buprenorphine, a partial opioid agonist approved for the office-based treatment of opioid dependence in 2002, may result in better health and substance use treatment outcomes for patients with HIV disease.
Available from: Alla V Shaboltas
- "In Brazil, an integrated system of mobile case management and ART and primary care treatment at the same location as substance abuse treatment including substitution therapy was successfully implemented . Integrating office-based opioid dependence treatment in HIV primary care has been promoted as an effective method to improve treatment for HIV-infected drug users . "
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ABSTRACT: The majority of HIV-infected individuals requiring antiretroviral therapy (ART) in Russia are Injection Drug Users (IDU). Substitution therapy used as part of a comprehensive harm reduction program is unavailable in Russia. Past data shows that only 16 % of IDU receiving substance abuse treatment completed the course without relapse, and only 40 % of IDU on ART remained on treatment at 6 months. Our goal was to determine if it was feasible to improve these historic outcomes by adding intensive case management (ICM) to the substance abuse and ART treatment programs for IDU.
IDU starting ART and able to involve a "supporter" who would assist in their treatment plan were enrolled. ICM included opiate detoxification, bi-monthly contact and counseling with the case, weekly group sessions, monthly contact with the "supporter" and home visits as needed. Full follow- up (FFU) was 8 months. Stata v10 (College Station, TX) was used for all analysis. Descriptive statistics were calculated for all baseline demographic variables, baseline and follow-up CD4 count, and viral load. Median baseline and follow-up CD4 counts and RNA levels were compared using the Kruskal-Wallis test. The proportion of participants with RNA < 1000 copies mL at baseline and follow-up was compared using Fisher's Exact test. McNemar's test for paired proportions was used to compare the change in proportion of participants with RNA < 1000 copies mL from baseline to follow-up.
Between November 2007 and December 2008, 60 IDU were enrolled. 34 (56.7 %) were male. 54/60 (90.0 %) remained in FFU. Overall, 31/60 (52 %) were active IDU at enrollment and 27 (45 %) were active at their last follow-up visit. 40/60 (66.7 %) attended all of their ART clinic visits, 13/60 (21.7 %) missed one or more visit but remained on ART, and 7/60 (11.7 %) stopped ART before the end of FFU. Overall, 39/53 (74 %) had a final 6--8 month HIV RNA viral load (VL) < 1000 copies/mL.
Despite no substitution therapy to assist IDU in substance abuse and ART treatment programs, ICM was feasible, and the retention and adherence of IDU on ART in St. Petersburg could be greatly enhanced by adding ICM to the existing treatment programs.
Available from: Gerald Delorenze
- "Although the number of deaths was small, the alcohol disorder only group in our study appeared to have proportionately more deaths owing to liver disease and infection, which may have been preventable and may have been directly related to substance abuse. To address this problem, the best solution may be integrating SU treatment with HIV/AIDS medical care, which has been shown to produce beneficial results (Basu et al., 2006; Lum and Tulsky, 2006; Sullivan et al., 2006). "
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ABSTRACT: We examined the association between substance use (SU) disorder and mortality among HIV-infected patients in a large, private medical care program.
In a retrospective cohort design, HIV-infected patients (≥14 years old) from a large health plan (Northern California) were studied to examine mortality associated with diagnosis of SU dependence or abuse over an 11-year period.
At study entry or during follow-up, 2,279 (25%) of 9,178 HIV-infected patients had received a diagnosis of SU disorder. Diagnoses were categorized as alcohol dependence/abuse only, illicit drugs only, or both. Cause of death differed by the category of SU diagnosis. Mortality rates ranged from 35.5 deaths per 1,000 person-years in patients with an SU disorder to 17.5 deaths among patients without an SU disorder. Regression results indicated mortality risk was significantly higher in all categories of SU disorder compared to no SU diagnosis (hazard ratios ranging from 1.65 to 1.67) after adjustment for SU treatment and confounders.
A diagnosis of SU dependence/abuse is associated with higher mortality among HIV-infected patients for whom access to medical services is not a significant factor.
Available from: Richard Saitz
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ABSTRACT: To assess the impact of recent heavy alcohol use, heroin/cocaine use, and homelessness on short-term mortality in HIV-infected persons.
Survival in a longitudinal cohort of 595 HIV-infected persons with alcohol problems was assessed at 6-month intervals in 1996-2005. The time-varying main independent variables were heavy alcohol use (past 30 days), heroin/cocaine use (past 6 months), and homelessness (past 6 months). Date of death was determined using the Social Security Death Index. Outcomes were limited to deaths occurring within 6 months of last assessment to ensure recent assessments of the main independent variables. Cox proportional hazards models were fit to the data.
Death within 6 months of their last assessment occurred in 31 subjects (5.2%). Characteristics at study entry included mean age 41 years, 25% female, 41% African-American, 24% with CD4 cell count < 200 cells/mul; 41% taking antiretroviral therapy, 30% heavy alcohol use, 57% heroin or cocaine use, and 28% homelessness. Heroin or cocaine use [hazard ratio (HR), 2.43; 95% confidence interval (CI), 1.12-5.30)] and homelessness (HR, 2.92; 95% CI, 1.32-6.44), but not heavy alcohol use (HR, 0.57; 95% CI, 0.23-1.44), were associated with increased mortality in analyses adjusted for age, injection drug use ever, CD4 cell count, and current antiretroviral therapy.
Recent heroin or cocaine use and homelessness are associated with increased short-term mortality in HIV-infected patients with alcohol problems. Optimal management of HIV-infected patients requires regular assessments for drug use and homelessness and improved access to drug treatment and housing.
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