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Roman Shrestha, 1 Frederick L Altice, 2 Elizabeth DiDomizio, 2 Brian Sibilio, 3 Yerina S Ranjit, 2 Michael M Copenhaver 3 1Aasaman Nepal, HIV Prevention Group, Lalitpur, Nepal; 2Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; 3Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USACorrespondence: Roman ShresthaAsaman Nepal, HIV Prevention Group, Ring Road, Lalitpur 44700, NepalTel +977-9849783132Email romanshre@gmail.comIntroduction: There has been increasing interest in the use of mHealth technology in health care. To our knowledge, however, there is a lack of empirical evidence on the utilization of text messaging services (short message service; SMS) for HIV prevention among opioid-dependent people who use drugs (PWUD). As part of our formative work, we conducted an in-depth feasibility and acceptability study on the use of SMS reminders for HIV prevention in this risk group.Methods: Forty HIV-negative, opioid-dependent PWUD who are currently taking pre-exposure prophylaxis (PrEP) were enrolled in the study. Participants received daily PrEP text reminders and weekly HIV risk reduction-related messages, which were developed using a user-centered approach. Participants were assessed at baseline and immediately post-intervention. Following the post-intervention assessment, participants completed an in-depth qualitative interview.Results: Feasibility of text messaging service was high, as assessed by participants’ willingness to receive text messages (100%), retention (95%), and successful delivery of text messages (97%). Results further showed that participants were satisfied and perceived the use of daily PrEP reminder text messages as valuable and acceptable [mean: 75.0 (range 0– 100)]. Whereas, acceptability for the weekly text messages on HIV risk reduction was 60.3 (± 15.6), with 58.3% recommending them for future use. Thematic data exploration revealed important information for understanding and refining SMS content as well as logistical preferences.Conclusion: Our findings provide preliminary evidence of the feasibility and acceptability of a text messaging-based approach as a potential tool for primary HIV prevention to improve PrEP adherence and HIV risk reduction among this underserved population. HIV risk reduction text messages need further modifications to become more appealing, with participant feedback taken into consideration.Keywords: opioid use disorder, pre-exposure prophylaxis, text messaging, mobile technology, HIV risk behaviors

Masculine gender role stress (MGRS) occurs in men who are highly committed to the male role. We hypothesized that among substance dependent men, high MGRS men would show more severe alcohol and drug abuse than low MGRS men. Additionally, we explored the types of substance abuse triggers to which high MGRS men are most vulnerable and their confidence in coping with these triggers. Our results indicate that high MGRS males had more severe alcohol dependence and, among drug dependent individuals, more severe drug dependence than did low MGRS men. Additionally, high MGRS men were found to be more likely to abuse substances in response to negative emotions, physical discomfort, conflict, and the belief that they can control their substance use. [ABSTRACT FROM AUTHOR]

Evidence indicates that regular assessment of antiretroviral therapy (ART) adherence is necessary to promote adherence and achieve viral suppression. Self-reported adherence using a visual analog scale (VAS) has been used extensively to measure ART adherence. However, less is known about the accuracy of the VAS for measuring ART adherence among opioid-dependent people living with HIV. In this study, we aimed to evaluate the accuracy of the VAS in measuring ART adherence in opioid-dependent people living with HIV who are enrolled in a methadone maintenance program (MMP). This study was conducted within a larger randomized controlled trial among opioid-dependent people living with HIV (N = 109) who were enrolled in an inner-city MMP. Self-reported VAS ART adherence data were compared to pharmacy refill data, which is a more objective measure. Self-reported VAS ratings and pharmacy refill behavior were significantly correlated at the 6-month post-intervention mark (r = 0.349, p = 0.006) but not at any other time point (i.e., pre-intervention, post-intervention, 3-months, and 9-months post-intervention). Based on the pharmacy refill data, participants did not consistently adhere to their ART medication but self-reported high adherence on the VAS. The self-report VAS may not be an accurate measure for assessing ART adherence among opioid-dependent persons living with HIV and enrolled in a MMP. Based on our findings, it may be more accurate to use pharmacy refill information or other objective measures to quantify ART adherence over extended periods for this patient population., Competing Interests: Declarations. Conflict of interest: The authors have no conflicts of interest to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Few evidence-based interventions have been widely adopted in common clinical settings, particularly for opioid-dependent people with HIV (PWH) seeking drug treatment. We developed a brief evidence-based intervention, Holistic Health for HIV (3H+), specifically for ease of implementation and integration within drug treatment settings. In this study, we compared 3H+ to the gold standard, Holistic Health Recovery Program (HHRP+) using a non-inferiority trial. Between 2012 and 2017, 106 participants were randomly assigned to either the brief 3H+ intervention or the gold standard HHRP+. HIV treatment (ART adherence, viral suppression) and risk behaviors (sharing injection equipment, condom use) were compared between the two arms at baseline, end-of-intervention (EOI-12 weeks) and at follow-up (24 weeks). Average treatment effect was calculated based on the difference-in-difference (DID) estimator and a non-parametric bootstrap was used to assess non-inferiority. At the 12-week EOI point, 3H+ was found to be non-inferior to HHRP+ with respect to multiple outcomes: percent sharing syringes and needles (DID:1.4, 95%CI [-18.6,21.5], p<0.01) and attainment of high ART adherence (DID: 9.7, 95%CI: [-13.1, 32.2], p = 0.04). At the 24-week EOI point, 3H+ was found to be non-inferior to HHRP+ with respect to percent sharing syringes and needles (DID: 8.9, [-10.1, 28.30], p = 0.04) and attainment of viral suppression (DID: 18.9, 95% CI:[-7.1, 42.0], p = 0.01). For other indicators, such as consistent condom use, the hypothesis test for non-inferiority was inconclusive at the 12-week EOI (DID: -20.2, 95%CI [-48.9-10.7], p = 0.51). For HIV treatment as prevention to be effective, PWH need to achieve viral suppression. In the absence of this success, they must reduce HIV risk behaviors. The finding that 3H+ was non-inferior to HHRP+ suggests that brief behavioral interventions can be deployed in real world settings to help more efficiently achieve Ending the HIV Epidemic goals., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Zelenev et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Cognitive profiles of individuals with opioid use disorder (OUD) limit patients' ability to learn, retain, and recall HIV prevention information. It also limits adherence to medications, such as pre-exposure prophylaxis (PrEP). Cognitive dysfunction accommodation strategies have shown promise at reducing HIV-related risk behaviors among individuals with OUD and increasing adherence to PrEP. This study investigated the feasibility, acceptability, and preliminary efficacy of integrating accommodation strategies into a behavioral HIV prevention intervention., Methods: This 2-arm single blind study provided 50 people who inject drugs (PWID) with OUD linkage to PrEP services and randomized them to a 4-week HIV prevention intervention condition. The active control condition received the HIV prevention intervention as treatment per usual, while the experimental condition received the enhanced HIV prevention intervention with added accommodation strategies. Participants completed acceptability ratings of intervention content and accommodation strategies post-intervention; feasibility was measured via participant recruitment and retention. HIV risk reduction information, motivation, and behavior (IMB) assessments and HIV risk reduction skills assessments were completed pre/post-intervention. Participants also completed weekly PrEP adherence assessments., Results: The intervention content received a high acceptability rating (89 %). Intervention feasibility was deemed acceptable, with 80 % of participants completing all study protocols. The accommodation strategies integrated into the HIV prevention sessions were also endorsed by 92 % of participants. Participants in the experimental condition had significant increases in retention and recall of how to perform HIV risk reduction skills including how to properly clean a syringe (p = 0.048) and how to accurately apply a female condom (p = 0.025), compared to the control condition. Weekly PrEP adherence was reported by the three (7.5 %) participants who indicated taking PrEP throughout the study. All three participants reported missing doses throughout each of the 4 weeks., Conclusions: Results from this study highlight the potential for integrating accommodation strategies into behavioral HIV prevention interventions to reduce the risk of HIV among PWID. Future research is needed to evaluate the use of such strategies by larger and diverse samples of PWID, as well as whether accommodation strategies enable the retention and recall of HIV prevention information and HIV prevention skills over longer periods of time., Trial Registration: This trial has been retrospectively registered at ClinicalTrials.gov on June 12, 2023. (NCT05912374)., Competing Interests: Declaration of competing interest The authors have no competing interests to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Neurocognitive dysfunction is common among individuals with opioid use disorders (OUD) and can impede a range of treatment outcomes. We developed the 57-item Brief Inventory of Neuro-cognitive Impairment (BINI) to help detect and monitor neurocognitive dysfunction in the context of drug treatment settings. To date, no study has examined the possible presence of BINI subgroups among OUD patients, which could enhance our ability to tailor intervention strategies to meet individual treatment needs. The purpose of this study was to conduct a latent profile analysis to identify BINI subgroups that differ in terms of their reported and objective neurocognitive dysfunction. We hypothesized that subgroups would emerge, suggesting the potential benefit of implementing tailored strategies for optimal treatment outcomes., Methods: Latent profile analyses included data from opioid-dependent patients (N = 177) enrolled in a methadone maintenance treatment program between July 2018 and October 2019., Results: We found three profiles of self-reported neurocognitive symptoms, including those with 1) minimal concerns 2) moderate concerns, and 3) many concerns across multiple domains., Conclusions: If these results are confirmed, the BINI may be used to rapidly identify persons who require specific accommodation strategies to improve their drug treatment outcomes.

Cognitive impairment is common in persons with opioid use disorder and associated with poor treatment outcomes, including elevated risk for relapse. Much less is known about the underlying structure of these deficits and the possible presence of cognitive phenotypes. A total of 177 adults (average 42.2 years of age, 52.0% male, 65.5% Caucasian) enrolled in a methadone maintenance treatment program completed the NIH Toolbox as part of a larger project. Cluster analyses revealed a 2-cluster solution-persons with intact cognitive function in all domains ( n  = 93; Intact) and those with impairments on tests of attention and executive function ( n  = 83; Impaired). Follow-up analyses revealed that the Impaired group was slightly older, more likely to self-identify as a racial/ethnic minority, and less likely to report consuming alcohol four or more times per week. These findings suggest the existence of distinct cognitive profiles in persons with opioid use disorder and encourage further examination, particularly studies to examine the possible benefits of routine screening for cognitive impairment as part of substance use treatment.

Background: Cognitive dysfunction is disproportionately prevalent among persons with opioid use disorder (OUD). Specific domains of cognitive dysfunction (attention, executive functioning, memory, and information processing) may significantly impede treatment outcomes among patients on medication for OUD (MOUD). This limits patient's ability to learn, retain, and apply information conveyed in behavioral intervention sessions. Evidence-based accommodation strategies have been integrated into behavioral interventions for other patient populations with similar cognitive profiles as persons with OUD; however, the feasibility and efficacy of these strategies have not yet been tested among patients on MOUD in a drug treatment setting., Methods: We conducted a series of focus groups with 25 key informants (10 drug treatment providers and 15 patients on MOUD) in a drug treatment program in New Haven, CT. Using an inductive approach, we examined how cognitive dysfunction impedes participant's ability to retain, recall, and utilize HIV prevention information in the context of drug treatment., Results: Two main themes capture the overall responses of the key informants: (1) cognitive dysfunction issues and (2) accommodation strategy suggestions. Subthemes of accommodation strategies involved suggestions about particular evidence-based strategies that should be integrated into behavioral interventions for persons on MOUD. Specific accommodation strategies included: use of a written agenda, mindfulness meditation, multi-modal presentation of information, hands-on demonstrations, and a formal closure/summary of sessions., Conclusions: Accommodation strategies to compensate for cognitive dysfunction were endorsed by both treatment providers and patients on MOUD. These accommodation strategies have the potential to enhance the efficacy of behavioral interventions to reduce HIV transmission among persons on MOUD as well as addiction severity, and overdose., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Mistler, Idiong and Copenhaver.)

Objective: Vaccination against coronavirus disease 2019 (COVID-19) is a promising avenue for arresting the COVID-19 pandemic, yet suboptimal rates of vaccine uptake in at-risk groups may hinder efficacy and worsen existing health disparities. People with opioid use disorder (OUD) are likely to face increased vulnerability to COVID-19 due to a confluence of biological and social risk factors. We sought to assess factors associated with willingness to vaccinate against COVID-19 in people with OUD., Method: Phone surveys were conducted from May to October 2020 with participants enrolled in an urban methadone maintenance program (MMP). Participants were adults who met DSM-5 criteria for OUD and reported injection drug use or sexual risk behavior. Participants were asked about their willingness to receive a highly or partially effective vaccine. Provider trust was assessed using the Trust in Physician scale. Multinomial regression was used to assess demographic and psychosocial factors related to vaccination willingness., Results: We surveyed 109 people with OUD enrolled in a MMP ( M = 47 years; 56% women; 59% White, 23% Black/African American, 14.4% Hispanic/Latinx; 1.8% other). Participants who identified as Black or African American were significantly less likely to endorse willingness to use a partially effective COVID-19 vaccine (adjusted odds ratio [ aOR ] = .10; 95% confidence interval (CI) [.02, .61], p = .012), although not necessarily less willing to receive a highly effective vaccine ( aOR = .40; 95% CI [.09, 1.73], p = .219; n.s .). Trust in physician was positively associated with willingness to use a partially effective vaccine ( aOR = 1.12; 95% CI [1.02, 1.23], p = .017), but was not significantly associated with willingness to receive a highly effective vaccine ( aOR = 1.07; 95% CI [.98, 1.16], p = .162, n.s ) Conclusions: Proactive outreach from trustworthy sources will be needed to counter vaccine hesitancy in people with OUD, especially among Black Americans with OUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Background: COVID-19 is disproportionately affecting disadvantaged populations, including persons with opioid use disorder (OUD). Persons with OUD are at greater risk for direct (e.g., COVID-19 diagnosis, severe symptoms) and indirect consequences (relapse, overdose) of COVID-19. Given stay at home orders, at-home testing options may serve as a viable tool to curb the increase in COVID-19 transmission and adverse effects of COVID-19. Methods: From May to September 2020, we surveyed 110 persons in treatment for OUD about their willingness to use various self-administered at-home COVID-19 testing measures. Participants were stratified by age, gender, and racial-ethnic identity to observe differences in willingness to use COVID-19 tests. The three COVID-19 tests included a throat swab sample, a saliva-based sample, and a blood prick test. Results: A high willingness to use at-home COVID-19 tests was observed in patients in treatment for OUD. A greater proportion of females were willing to use a saliva-based test; greater proportions of White participants were willing to use a saliva based COVID-19 test compared to racial-ethnic minorities. Older aged participants (≥45 years old) reported greater rates of willingness to use a self-administered at home blood prick test for COVID-19. Conclusions: At-home testing measures for COVID-19 appear highly acceptable among people with OUD.

Scale-up of pre-exposure prophylaxis (PrEP) in people who inject drugs (PWID) remains suboptimal. Patient-level factors are often complex and may contribute to scale-up. Using cross-sectional data from 234 opioid-dependent patients on methadone who met eligibility criteria for PrEP, we conducted logistic regression analyses to assess potential moderators associated with being on PrEP (n = 60). Mean provider trust was significantly higher among Blacks vs Whites (39.4 vs 34.9; p = 0.002) and non-homeless vs homeless participants (37.5 vs 34.8; p = 0.008). Though race/ethnicity was not a significant moderator on provider trust and PrEP use, increased provider trust was marginally associated with increased PrEP use among Blacks (p = 0.058). Additionally, homelessness significantly moderated provider trust and PrEP use (p = 0.024). Provider trust among non-homeless participants was positively correlated with PrEP use (p = 0.013) but not among homeless participants. Strategies that promote provider trust in Blacks and non-homeless PWID on methadone may improve PrEP scale-up., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The COVID-19 pandemic has necessitated restrictive orders and programmatic changes that may be associated with disruptions in services, including those for opioid-dependent people who inject drugs (PWID). This study aims to assess the impact of COVID-19 pandemic on access to and utilization of various HIV prevention services among PWID with opioid use disorder (OUD). We interviewed 110 PWID enrolled in medication for opioid use disorder (MOUD) treatment (e.g., methadone) between May and October, 2020 to identify if this sample experienced changed in access to the following services due to the COVID-19 pandemic: (a) HIV or sexually transmitted infection (STI) testing, (b) pre-exposure prophylaxis (PrEP) services, (c) HIV counselor or doctor appointments, and (d) clean injection equipment. A majority of the sample reported that COVID-19 had not changed their access to HIV testing or access to STI testing. Almost half of the sample reported that getting an appointment with a doctor decreased due to COVID-19. Participants reported that access to a lab or blood testing, access to injection equipment, and sessions with a case manager or counselor decreased. One-fourth of the 32 participants who were taking PrEP before the onset of COVID-19 reported that they had trouble getting their PrEP prescription due to COVID-19, and some reported that they had difficulty getting the PrEP prescription filled at their pharmacy. Our results indicate that PWID did not experience reduced access to HIV or STI testing, but difficulties in obtaining appointments with HIV counselors or doctors and limited access to PrEP were presented. Innovative strategies are needed to reduce the adverse effects of COVID-19 on HIV prevention among PWID., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: The COVID-19 pandemic has exacerbated health disparities, particularly among at-risk people with opioid use disorder (OUD). We sought to characterize the direct and indirect impacts of COVID-19 on this group to understand how the pandemic has affected this group, this group's public health response to COVID-19, and whether there were differences by race/ethnicity., Methods: This study recruited its sample from a drug treatment setting in the northeast region of the United States. We surveyed 110 individuals on methadone as treatment for OUD and assessed COVID-19-related impacts on their health behaviors and other indices of social, physical, and mental well-being, including sexual health behaviors, substance use, mental health status, health care access, income, and employment., Results: Our findings highlight overall increases in depression, anxiety, loneliness, and frustration among the sample of people with OUD; the study also observed decreases in financial stability. Significant differences between groups indicated a greater financial burden among racial-ethnic minorities; this subgroup also reported greater direct adverse effects of COVID-19, including being more concerned about contracting COVID-19, not being able to get a COVID-19 test, and knowing someone who had died from COVID-19. A greater proportion of Whites indicated increases in alcohol consumption and non-prescription drug use than did racial-ethnic minorities., Conclusions: Treatment providers must be vigilant in managing direct and indirect outcomes of COVID-19 among people with OUD. Findings highlight the need to develop culturally competent, differentiated interventions in partnership with community-based organizations to meet the unique challenges that the COVID-19 pandemic presents for people in treatment for OUD., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Treatment for opioid use disorder (OUD) is often in the context of biobehavioural interventions, consisting of medication for OUD (for example, methadone and buprenorphine), which is accompanied by psychoeducation and/or behavioural therapies. Patients with OUD often display weaknesses in cognitive function that may impact the efficacy of such behavioural interventions. A review of the literature was conducted to: (1) describe common cognitive dysfunction profiles among patients with OUD, (2) outline intervention approaches for patients with OUD, (3) consider the cognitive demands that interventions place on patients with OUD and (4) identify potential accommodation strategies that may be used to optimise treatment outcomes. Cognitive profiles of patients with OUD often include weaknesses in executive function, attention, memory and information processing. Behavioural interventions require the patients' ability to learn, understand and remember information (placing specific cognitive demands on patients). Accommodation strategies are, therefore, needed for patients with challenges in one or more of these areas. Research on accommodation strategies for patients with OUD is very limited. We applied research from populations with similar cognitive profiles to form a comprehensive collection of potential strategies to compensate for cognitive dysfunction among patients with OUD. The cognitive profiles and accommodation strategies included in this review are intended to inform future intervention research aimed at improving outcomes among patients with OUD., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cognitive dysfunction is common in persons seeking medication for opioid use disorder (MOUD) and may hinder many addiction-related services. Brief but accurate screening measures are needed to efficiently assess cognitive dysfunction in these resource-limited settings. The study aimed to develop a brief predictive risk score tailored for use among patients in drug treatment., Methods: The present study examined predictors of mild cognitive impairment (MCI), objectively assessed via the NIH Toolbox, among 173 patients receiving methadone as MOUD at an urban New England drug treatment facility. Predictors of MCI were identified in one subsample using demographic characteristics, medical chart data, and selected items from the Brief Inventory of Neuro-Cognitive Impairment (BINI). Predictors were cross-validated in a second subsample using logistic regression. Receiver operating curve (ROC) analyses determined an optimal cut-off score for detecting MCI., Results: A cognitive dysfunction risk score (CDRS) was calculated from patient demographics (age 50+, non-White ethnicity, less than high school education), medical and substance use chart data (history of head injury, overdose, psychiatric diagnosis, past year polysubstance use), and selected self-report items (BINI). The CDRS discriminated acceptably well, with a ROC curve area of 70.6 %, and correctly identified 78 % of MCI cases (sensitivity = 87.5 %; specificity = 55.6 %)., Conclusions: The CDRS identified patients with cognitive challenges at a level likely to impede treatment engagement and/or key outcomes. The CDRS may assist in efficiently identifying patients with cognitive dysfunction while requiring minimal training and resources. Larger validation studies are needed in other clinical settings., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Injection drug use is a key risk factor for the transmission of HIV. Prevention strategies, such as the use of pre-exposure prophylaxis (PrEP), are effective at reducing the risk of HIV transmission in people who inject drugs (PWID). Following PRISMA guidelines, a literature search was conducted to identify the current state of the PrEP care cascade in PWID. Twenty-three articles were evaluated in this systematic review. A decline in engagement throughout the stages of the PrEP care cascade was found. High awareness and willingness to use PrEP was found, yet PrEP uptake was relatively low (0-3%). There is a lack of research on interventions to increase engagement of PrEP across all levels of the care cascade in PWID. Implications from the interventions that have been published provide insight into practice and public policy on efficacious strategies to reduce HIV incidence in PWID. Our findings suggest that more efforts are needed to identify and screen PWID for PrEP eligibility and to link and maintain them with appropriate PrEP care.

Objectives: In obese adults the shape of the glucose response curve during an oral glucose tolerance test (OGTT) predicts future type 2 diabetes. Patients with an incessant increase or monophasic curves have increased risk compared to those with biphasic curves. Since type 2 diabetes is associated with increased cardiometabolic risk, we studied whether differences in OGTT response curve are associated with differences in cardiometabolic risk factors in healthy adolescents across a wide body mass index (BMI) range., Methods: Sixty-nine (33F/36M), white adolescents (age: 15.2 ± 1.7 years; BMI: 21.5 ± 4.7 kg/m 2 ; mean ± SD) were studied. Risk factors measured included percent body fat, blood pressure, lipids, augmentation index, reactive hyperemia, endothelin 1, plasminogen activator 1, inflammatory markers (interleukin 6, c-reactive protein), insulin secretion, insulin sensitivity (Matusda index), and disposition index (DI)., Results: Thirty-two subjects had biphasic responses; 35 subjects had monophasic responses and two females had incessant increases. Sex did not affect the frequency of responses. Glucose area under the curve during OGTT was greater in those with a mono vs. biphasic curves (p=0.01). Disposition index was markedly lower in subjects with a monophasic curve than in those with a biphasic curve (3.6 [2.3-5.0] vs. 5.8 [3.8-7.6], median [25th, 75th%] p=0.003). Triglyceride to high-density lipoprotein cholesterol (HDL) ratio was higher in subjects with a monophasic curve (p=0.046)., Conclusions: The decreased disposition index indicates that in healthy adolescents a monophasic response to OGTT is due to decreased insulin secretion relative to the degree of insulin resistance present. This was not associated with differences in most other cardiometabolic risk markers., Trial Registration: Clinical Trials.gov, NCT02821104., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

The evolving opioid epidemic in the United States has increased drug-related overdose rates exponentially (Centers for Disease Control and Prevention in Opioid overdose, 2020c, https://www.cdc.gov/drugoverdose/data/otherdrugs.html#:~:text=Polysubstance%20drug%20use%20occurs%20with,or%20other%20non%2Dopioid%20substances ). Fentanyl, a synthetic opioid, has recently fueled the epidemic, increasing overdose death rates (Centers for Disease Control and Prevention in Drug overdose deaths involving fentanyl, 2011-2016, 2019a, https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68&#95;03-508.pdf ). Harm reduction strategies (drug checking, naloxone administration, etc.) are at the forefront of preventing opioid-related overdoses in high-risk populations (Kennedy et al. in Drug Alcohol Depend 185:248-252, 2018, https://doi.org/10.1016/j.drugalcdep.2017.12.026 ; Laing et al. in Int J Drug Policy 62:59-66, 2018, https://doi.org/10.1016/j.drugpo.2018.10.001 ). Little is known, however, about how people who inject drugs (PWID) may modify their drug use behaviors after suspected fentanyl contamination in their drugs. We conducted a cross-sectional survey among 105 opioid-dependent PWID enrolled in a methadone maintenance program. We assessed their willingness to engage in various harm reduction methods (i.e., slowing down drug use, not using drugs, carrying naloxone, using with someone who has naloxone) after suspected fentanyl contamination of their drugs. In a multivariable analysis, participants who were white, low-income, polysubstance users, and had previously experienced an overdose or had previously administered naloxone were more likely to report a willingness to engage in harm reduction measures. These findings provide an evidence-based understanding of PWID's engagement in harm reduction behaviors after suspecting potential fentanyl exposure as well as a basis for tailoring intervention strategies in the context of fentanyl-adulterated markets.

The current study examined the association between subjective cognitive dysfunction and objective test performance in persons enrolled in drug treatment and stabilized on methadone maintenance therapy (MMT). A total of 177 participants completed the self-reported brief inventory of neurocognitive impairment (BINI) and NIH Toolbox test battery. In participants with neurocognitive dysfunction, scores on all BINI subscales were negatively associated with objective performance on the NIH Toolbox (BINI Global r = -0.26, p  = 0.01; BINI Subscales ranging -0.22 to -0.32, all p 's < 0.03). Using cutoff scores, results showed participants who scored above the cutoff on the BINI Learning subscale demonstrated significant evidence of objective neurocognitive dysfunction on the NIH Toolbox (65% vs. 35%; χ 2 = 6.57, p  = 0.02), suggesting possible clinical utility. Future studies are needed to determine the feasibility of using the BINI to inform the accommodation of patients with specific neurocognitive profiles to optimize treatment outcomes.

Background: People who use drugs (PWUD) continue to experience a disproportionate HIV burden due to drug- and sex-related risk behaviors. Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection, but very little is known about PrEP use among PWUD and their willingness to initiate PrEP., Methods: We conducted a cross-sectional survey among 234 HIV-negative, opioid-dependent individuals recruited from an urban methadone clinic. Participants were assessed using an audio-computer assisted self-interview technique. Bivariate and multiple logistic regressions were used to explore independent correlates of actual PrEP use and willingness to initiate PrEP., Results: One-fourth (25.6 %) of participants had previously used PrEP. Over two-thirds (67.1 %) of participants had previously heard of PrEP, and 65.0 % were willing to take it. In multivariable logistic regression analyses, the number of times participants engaged in HIV testing (aOR = 1.66, p < 0.01) and whether they visited a healthcare provider (aOR=20.81, p = 0.02) were associated with a higher likelihood of PrEP use, while perceived HIV risk (aOR=2.71, p < 0.01) and previous use of PrEP (aOR=3.57, p < 0.01) were significantly associated with willingness to initiate PrEP., Conclusion: PrEP use was low among PWUD, but their willingness to initiate PrEP was moderate, which indicated a significant discrepancy between actual PrEP use and willingness to use it. Our findings highlight the importance of healthcare providers engaging opioid-dependent individuals in discussions about PrEP and the need for innovative strategies to increase their awareness of PrEP and modify their perceptions of HIV risk., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: The number of deaths from drug overdose in the United States has more than doubled in the past decade. In particular, drug overdose deaths involving fentanyl have doubled every year since 2013. Rapid fentanyl test strips (FTS) are a useful strategy for detecting traces of fentanyl in substances and have received overwhelming support from individuals with opioid-dependence., Methods: We investigated fentanyl use, knowledge of FTS, willingness to use FTS, and overdose history among a sample of 105 individuals currently on medication for opioid use disorder (MOUD)., Results: Results showed that the majority (63%) of the sample had experienced a non-fatal overdose and that 85% of participants were willing to use FTS. The majority of participants reported concern about fentanyl in their drug supply (70%) and 77% reported likelihood of past unintentional fentanyl use. Of note, only about half (47%) of participants knew of FTS prior to being surveyed, and only 17% reported ever using FTS., Conclusion: These results expand on previous literature that documents high levels of willingness, yet low uptake of FTS among individuals on MOUD. Widespread education about FTS, in addition to the implementation of the use of FTS, is a highly promising and critical primary prevention alternative to overdose treatment and/or death due to fentanyl., Competing Interests: Declarations The authors have no conflicts of interest to report. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. The authors have no financial or proprietary interests in any material discussed in this article.

Introduction : In recent years, opioid-related mortality has increased steadily in the United States. Fentanyl, a synthetic opioid, has been a primary driver of the current wave of overdose-related deaths. Little is known, however, about fentanyl use among opioid-dependent people who inject drugs (PWID). We, therefore, sought to characterize purposeful fentanyl use among PWID. Methods: A cross-sectional survey was administrated to 104 opioid-dependent PWID on methadone who self-reported drug- or sex-related risk behaviors. Participants were recruited between July 2018 and October 2019 from a methadone clinic in New Haven, Connecticut. Multivariable logistic regressions were used to identify independent correlates of purposeful fentanyl use. Results: Overall, 43.2% and 22.1% of the participants reported any (lifetime) or recent (past 30 days) purposeful fentanyl use, respectively. Independent correlates of any purposeful fentanyl use were younger age (aOR= 0.94; p  = 0.021), recent daily injection (aOR= 3.52; p  = 0.047), recent cocaine use (aOR= 3.54; p  = 0.041), and moderate/severe depression (aOR= 3.82; p  = 0.028). Independent correlates of recent purposeful fentanyl use were moderate/severe depression (aOR= 10.94; p  = 0.031), recently sharing injection equipment (aOR= 2.96; p  = 0.044), and recently engaging in transactional sex (aOR= 3.60; p  = 0.026). Conclusions: These findings indicate that opioid-dependent PWID on methadone remain at increased risk for overdose given the high prevalence of ongoing purposeful fentanyl exposure. Interventions to reduce the harms associated with fentanyl use should target young PWID and active fentanyl users, with an emphasis on achieving adequate methadone dosage and screening and treating depression in methadone-maintained patients who preferentially seek fentanyl.

In the Bangkok Tenofovir Study of oral pre-exposure prophylaxis (PrEP; TDF/FTC), adherence was poor. Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) for HIV prevention may help overcome adherence challenges and is currently being tested in clinical trials, but not in people who use drugs (PWUD), an important key population that remains highly vulnerable to HIV. Since PWUD are not currently included in trials of LAI-PrEP, we sought to examine awareness about LAI-PrEP and factors associated with willingness to use LAI-PrEP in this understudied population. Participants included 234 HIV-negative people with opioid use disorder and self-reported HIV-risk behaviors recruited from Connecticut's largest addiction treatment program. We analyzed data from a standardized assessment using audio computer-assisted self-interview (ACASI) to assess the independent factors associated with willingness to use LAI-PrEP. While only 25.6% of participants were aware of LAI-PrEP (67.1% had heard of oral PrEP), after being given a description of it, 73.5% were willing to use it, if it were available. Participants were most commonly concerned about long-term side effects (76.9%) of LAI-PrEP. Independent correlates of willingness to use LAI-PrEP were female sex (aOR = 2.181, p = 0.018), recent visit to healthcare provider (aOR = 2.9, p = 0.023), high perceived risk of acquiring HIV (aOR = 3.3, p = 0.007), and having previously taken oral PrEP (aOR = 3.284, p = 0.017). Findings suggest that PWUD are highly interested in PrEP, especially in LAI-PrEP formulations. Our results indicate the potential for LAI-PrEP, as an alternative to oral daily PrEP, to be implemented into existing evidence-based HIV-based HIV prevention efforts that target high-risk PWUD., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Aim: Experience of stigma towards methadone maintenance treatment (MMT) may be a barrier to the use of this treatment by people with opioid use disorder. We evaluated the factor structure, internal reliability, construct and criterion validity of a theory-based stigma measure, the Methadone Maintenance Treatment Stigma Mechanisms Scale (MMT-SMS) and compared this with the Substance Use Stigma Mechanism Scale (SU-SMS)., Design: Surveys at the beginning and end of a prospective study together with records of drug use and treatment attendance during that study., Setting: Community methadone clinic in the Northeastern USA., Participants: Ninety-three participants who were receiving MMT; the average daily methadone dose was 84.8 mg/day (standard deviation = 28.39 mg/day)., Measurements: The MMT-SMS uses a self-report questionnaire to assess three dimensions reflecting experiences of anticipated (nine items), enacted (nine items) and internalized stigma (seven items) specifically related to receiving MMT. Anticipated and enacted scales include three stigma source subscales (family, employers, health care workers; three items each). Responses are recorded on a five-point Likert-type scale, then averaged to produce the MMT-SMS scale/subscale scores. The SU-SMS is a self-report questionnaire to assess experiences of anticipated, enacted and internalized stigma regarding substance use history. Both scales were administered at the final parent study visit. Other measures included were assessed in the parent study and used to assess life-time and recent MMT (e.g. current MMT dose) and drug use experiences (e.g. past 30-day heroin injection)., Findings: The MMT-SMS demonstrated good internal reliability (α = 0.806-0.952 for components). Confirmatory factor analysis supported the seven-factor scale structure, distinguishing between experiences of anticipated, enacted and internalized stigma, and anticipated and enacted stigma source subscales (family, employers, health care workers) [root mean square error of approximation (RMSEA) = 0.076, 90% confidence interval (CI) = 0.061-0.090, P-close = 0.003; confirmatory fit index (CFI) = 0.974; Tucker-Lewis index (TLI) = 0.971]. Construct validity helped to distinguish the MMT-SMS from established substance use stigma constructs. Criterion validity observed associations with substance use experiences while on MMT, likely to predict future MMT success. Internalized MMT stigma was uniquely associated with daily MMT dose. Regarding criterion validity: anticipated MMT and enacted substance use stigma were associated with past 30-day heroin injection, MMT stigma uniquely associated with opioid use behaviors while receiving MMT, and substance use stigma broadly associated with injection-related behaviors., Conclusions: The Methadone Maintenance Treatment Stigma Mechanisms Scale appears to be a reliable measure of methadone maintenance treatment stigma with robust validity in a sample of people with opioid use disorders receiving methadone maintenance treatment., (© 2019 Society for the Study of Addiction.)

Background: Complement promotes inflammatory and immune responses and may affect cardiometabolic risk. This study was designed to investigate the effect of complement components C3 and C4 on cardiometabolic risk in healthy non-Hispanic white adolescents., Methods: Body mass index (BMI), BMI percentile, waist circumference, and percent body fat were assessed in 75 adolescents. Arterial stiffness was assessed using arterial tomography and endothelial function using reactive hyperemia. Fasting lipids, inflammatory markers, and complement levels were measured and oral glucose tolerance test was performed. A single C3 polymorphism and C4 gene copy number variations were assessed., Results: C3 plasma levels increased with measures of obesity. Endothelial function worsened with increased C3 and C4 levels. Triglycerides and low-density lipoprotein increased and high-density lipoprotein (HDL) and insulin sensitivity decreased with increasing C3 levels, but the relationships were lost when body habitus was included in the model. C4 negatively related to HDL and positively to inflammatory markers. Subjects with at least one C3F allele had increased BMI and fat mass index. HDL was significantly related to C4L, C4S, C4A, and C4B gene copy number variation., Conclusions: C3 levels increase with increasing body mass and increased C4 levels and copy number are associated with increased cardiometabolic risk in healthy adolescents.

Background: Cardiovascular disease has its origins in adolescents. Endothelial dysfunction, arterial stiffness, and decreased endocardial oxygen supply: demand ratios are early functional markers of cardiovascular risk. The goal of this study was to determine the relationships of these markers to physical, inflammatory, and metabolic markers in healthy non-Hispanic, white adolescents., Methods: Thirty-four of the 75 subjects were female. Mean age was 15.0 ± 1.7 years and mean body mass index (BMI) was 22.0 ± 5.8 kg/m 2 (mean ± SD). Reactive hyperemia was measured using venous occlusion plethysmography. Arterial tonometry was used to measure the augmentation index (AIx 75 ) and the Buckberg subendocardial viability ratio. Blood samples were taken to measure inflammatory and lipid markers and oral glucose tolerance test was used to assess insulin sensitivity., Results: Reactive hyperemia decreased as body mass and fat mass increased. It also decreased with increasing neutrophil count. The Buckberg index was higher in males and was positively related to insulin sensitivity even when accounting for age, sex, and resting heart rate. AIx 75 was not related to any of the other variables., Conclusions: These results demonstrate that increased fat mass and decreased insulin sensitivity are related to poorer vascular function and cardiac risk in adolescents before the development of actual cardiovascular disease., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Few primary HIV prevention strategies have successfully integrated both behavioral and biomedical components, with modest HIV risk reduction outcomes among opioid-dependent people who use drugs (PWUD). In response to this unmet need, we developed a brief, bio-behavioral intervention to simultaneously promote PrEP adherence and reduce HIV risk among opioid-dependent PWUD., Methods: Using a Hybrid Type I implementation science design, we will examine the efficacy of the integrated bio-behavioral, Community-friendly Health Recovery Program (CHRP-BB) compared to a time-and-attention matched control condition among HIV-negative, opioid-dependent PWUD who are prescribed PrEP and enrolled in a methadone maintenance program (MMP) using a randomized controlled trial (RCT). Participants are assessed at baseline, immediately post-intervention (8 weeks) and follow-ups at weeks 20, 32, and 44 post-intervention. The primary outcome is biomedical (PrEP adherence), with secondary outcomes including behavioral (self-reported drug- and sex-related HIV risk behaviors), ongoing drug use (confirmed with urine drug testing), and related domains of the theoretical information-motivation-behavioral skills (IMB) model of behavior change related to PrEP adherence and HIV-transmission-risk reduction. Additionally, we will conduct a process evaluation of delivery/implementation of the intervention to collect valuable information to be used in future implementation., Conclusions: This study will be among the first prospective trial to test an integrated bio-behavioral intervention to improve adherence to PrEP and HIV risk reduction among opioid-dependent PWUD., (Copyright © 2019 Elsevier Inc. All rights reserved.)

HIV sero-status disclosure among people living with HIV (PLWH) is an important component of preventing HIV transmission to sexual partners. Due to various social, structural, and behavioral challenges, however, many HIV-infected opioid-dependent patients do not disclose their HIV status to all sexual partners. In this analysis, we therefore examined non-disclosure practices and correlates of non-disclosure among high-risk HIV-infected opioid-dependent individuals. HIV-infected opioid-dependent individuals who reported HIV-risk behaviors were enrolled (N = 133) and assessed for HIV disclosure, risk behaviors, health status, antiretroviral therapy (ART) adherence, HIV stigma, social support and other characteristics. Multivariable logistic regression was used to identify significant correlates of non-disclosure. Overall, 23% reported not disclosing their HIV status to sexual partners, who also had high levels of HIV risk: sharing of injection equipment (70.5%) and inconsistent condom use (93.5%). Independent correlates of HIV non-disclosure included: being virally suppressed (aOR 0.19, p = 0.04), high HIV-related stigma (aOR 2.37, p = 0.03), and having multiple sex partners (aOR 5.87, p = 0.04). Furthermore, a significant interaction between HIV-related stigma and living with family/friends suggests that those living with family/friends were more likely to report not disclosing their HIV status when higher levels of perceived stigma was present. Our findings support the need for future interventions to better address the impact of perceived stigma and HIV disclosure as it relates to risk behaviors among opioid-dependents patients in substance abuse treatment settings.

Background: Opioid agonist therapies with methadone are associated with higher levels of adherence to antiretroviral therapy (ART); yet, no studies have explored factors associated with optimal ART levels in HIV-positive patients on methadone maintenance treatment, including explanatory pathways using mediation analysis., Setting: Participants included 121 HIV-positive, methadone-maintained patients who reported HIV-risk behaviors and were taking ART., Methods: Participants were assessed using an audio computer-assisted self-interview. Multivariable logistic regression was used to identify significant correlates and PROCESS macro to test the explanatory pathway (ie, mediational effect) for optimal ART adherence., Results: Among 121 participants, almost 40% reported suboptimal adherence to ART. Optimal ART adherence was significantly associated with being virally suppressed [adjusted odds ratio (aOR) = 6.470, P = 0.038], higher motivation to adhere to ART (aOR = 1.171, P = 0.011), and lower anticipated HIV-related stigma (aOR = 0.384, P = 0.015). Furthermore, results revealed an indirect effect of motivation on the relationship between HIV stigma and ART adherence (effect = -0.121, P = 0.043), thus supporting the mediation effect., Conclusions: Our findings underscore the complexities surrounding ART adherence, even in patients on methadone maintenance treatment. These findings provide insights on how to more effectively intervene to optimize HIV treatment outcomes, including HIV treatment-as-prevention initiatives, in methadone-maintained patients.

Introduction: Methadone maintenance therapy (MMT) is associated with improved virologic outcomes, yet no studies have explored factors associated with viral suppression in HIV-infected patients on MMT. Given the critical role of sustained viral suppression in maximizing benefits of antiretroviral therapy (ART), we sought to assess factors associated with viral suppression in patients stabilized on MMT., Methods: A sample of 133 HIV-infected, methadone-maintained patients who reported HIV-risk behaviors were assessed using an audio-computer assisted self-interview (ACASI). Multivariable logistic regression was used to identify significant correlates of viral suppression., Results: Among all participants, self-reported HIV risk behaviors were highly prevalent and over 80% had achieved viral suppression. Independent correlates of viral suppression were: having optimal adherence to ART (aOR = 4.883, p = .009), high CD4 count (aOR = 2.483, p = .045), and ongoing injection drug use (aOR = 0.081, p = .036). Furthermore, results revealed a significant interaction effect that involved optimal ART adherence and injection of drug use on viral suppression (aOR = 2.953, p = .029)., Conclusion: Overall, our findings highlight unaddressed HIV-related treatment challenges faced by certain group of methadone-maintained patients. These findings have significant implications for the HIV treatment as prevention efforts and, thus, indicate the need for comprehensive efforts to promote viral suppression in this risk population., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

This study reports the feasibility, acceptability, and preliminary efficacy of the bio-behavioral community-friendly health recovery program-an integrated, HIV prevention intervention to improve pre-exposure prophylaxis (PrEP) adherence and HIV-risk reduction behaviors among high-risk people who use drugs. We used a within-subjects, pretest-posttest follow-up design to recruit participants, who were HIV-uninfected, methadone-maintained and reported HIV-risk behaviors and had initiated PrEP (n = 40; males: 55%). Participants were assessed at baseline (T 0 ), immediately post-intervention (4 weeks: T 4 ) and 4 weeks post-intervention (T 8 ). Immediately after completing the four weekly intervention groups, participants underwent a post-intervention assessment including in-depth qualitative interviews. Feasibility was high, assessed by participant willingness to enroll (90.1%) and retention (95%). Results showed that participants were highly satisfied and perceived the intervention as valuable and acceptable [mean: 81.3 (range 0-100)]. Significant enhancements in self-reported PrEP adherence [F(2,74) = 7.500, p = 0.001] and PrEP-related knowledge [F(2,74) = 3.828, p = 0.026] were observed. Drug-related (e.g., injection of drugs, sharing of injection equipment) and sex-related (e.g., number of sexual partners, condomless sex) risk behaviors were reduced, while information, motivation, and behavioral skills (IMB) constructs increased. The results support feasibility and high acceptability and support further examination of the efficacy of this combination bio-behavioral intervention in a prospective clinical trial.

Incarcerated people living with HIV and opioid dependence face enormous challenges to accessing evidence-based treatment during incarceration and after release into the community, placing them at risk of poor HIV treatment outcomes, relapse to opioid use and accompanying HIV transmission risk behaviors. Here we describe in detail the design and implementation of Project Harapan, a prospective clinical trial conducted among people living with HIV and opioid dependence who transitioned from prison to the community in Malaysia from 2010 to 2014. This trial involved 2 interventions: within-prison initiation of methadone maintenance therapy and an evidence-based behavioral intervention adapted to the Malaysian context (the Holistic Health Recovery Program for Malaysia, HHRP-M). Individuals were recruited and received the interventions while incarcerated and were followed for 12months after release to assess post-release HIV transmission risk behaviors and a range of other health-related outcomes. Project Harapan was designed as a fully randomized 2×2 factorial trial where individuals would be allocated in equal proportions to methadone maintenance therapy and HHRP-M, methadone maintenance therapy alone, HHRP-M alone, or control. Partway through study implementation, allocation to methadone maintenance therapy was changed from randomization to participant choice; randomization to HHRP-M continued throughout. We describe the justification for this study; the development and implementation of these interventions; changes to the protocol; and screening, enrollment, treatment receipt, and retention of study participants. Logistical, ethical, and analytic issues associated with the implementation of this study are discussed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Intimate partner violence (IPV) is a significant global health issue and has been associated with an increased HIV-related risk and vulnerability to HIV infection. This study examined the potential relationship between IPV and HIV-risk behaviors among women in Nepal. Our findings revealed that IPV against women was associated with the presence of HIV-risk behaviors, such as history of sexually transmitted infections (STIs), multiple sex partners, inconsistent condom use, partner with known HIV risks, and inability to negotiate safer sexual practices. This highlights a need to develop effective interventions aimed at eliminating IPV to decrease the disproportionate burden of adverse health outcomes, including STIs/HIV among women., (© The Author(s) 2016.)

Background: Substance use disorders consistently rank among the most stigmatized conditions worldwide. Thus, substance use stigma fosters health inequities among persons with substance use disorders and remains a key barrier to successful screening and treatment efforts. Current efforts to measure substance use stigma are limited. This study aims to advance measurement efforts by drawing on stigma theory to develop and evaluate the Substance Use Stigma Mechanisms Scale (SU-SMS). The SU-SMS was designed to capture enacted, anticipated, and internalized Substance Use Stigma Mechanisms among persons with current and past substance use disorders, and distinguish between key stigma sources most likely to impact this target population., Methods: This study was a cross-sectional evaluation of the validity, reliability, and generalizability of the SU-SMS across two independent samples with diverse substance use and treatment histories., Results: Findings support the structural and construct validity of the SU-SMS, suggesting the scale was able to capture enacted, anticipated, and internalized stigma as distinct stigma experiences. It also further differentiated between two distinct stigma sources (family and healthcare providers). Analysis of these mechanisms and psychosocial metrics suggests that the scale is also associated with other health-related outcomes. Furthermore, the SU-SMS demonstrated high levels of internal reliability and generalizability across two independent samples of persons with diverse substance use disorders and treatment histories., Conclusion: The SU-SMS may serve as a valuable tool for better understanding the processes through which substance use stigma serves to undermine key health behaviors and outcomes among persons with substance use disorders., Competing Interests: Author Disclosure Statements: Conflict of Interest: The authors have no conflicts of interests to declare., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Alcohol use is highly prevalent globally with numerous negative consequences to human health, including HIV progression, in people living with HIV (PLH). The HIV continuum of care, or treatment cascade, represents a sequence of targets for intervention that can result in viral suppression, which ultimately benefits individuals and society. The extent to which alcohol impacts each step in the cascade, however, has not been systematically examined. International targets for HIV treatment as prevention aim for 90 % of PLH to be diagnosed, 90 % of them to be prescribed with antiretroviral therapy (ART), and 90 % to achieve viral suppression; currently, only 20 % of PLH are virally suppressed. This systematic review, from 2010 through May 2015, found 53 clinical research papers examining the impact of alcohol use on each step of the HIV treatment cascade. These studies were mostly cross-sectional or cohort studies and from all income settings. Most (77 %) found a negative association between alcohol consumption on one or more stages of the treatment cascade. Lack of consistency in measurement, however, reduced the ability to draw consistent conclusions. Nonetheless, the strong negative correlations suggest that problematic alcohol consumption should be targeted, preferably using evidence-based behavioral and pharmacological interventions, to indirectly increase the proportion of PLH achieving viral suppression, to achieve treatment as prevention mandates, and to reduce HIV transmission.

We adopted an intersectionality framework and examined whether the relationship between internalized HIV stigma and depressive symptoms is moderated by internalized substance use stigma. A total of 85 people living with HIV with a history of substance use in the Bronx, New York, completed a survey. Results revealed evidence of moderation: Participants who internalized HIV stigma experienced greater depressive symptoms only if they also internalized substance use stigma. Researchers should examine stigma associated with multiple socially devalued characteristics to best understand how stigma impacts mental health among people living with HIV. Healthcare providers should address stigma associated with the full range of socially devalued characteristics with which people living with HIV live., (© The Author(s) 2013.)

Background: Previous research has suggested possible sex-related differences in executive functioning among cocaine users; however, no studies specifically explain sex-related differences in neurocognitive impairment (NCI) among cocaine users receiving clinical care. Knowledge about this association can aid in the development of targeted prevention strategies to reduce adverse health outcomes. This study was designed to examine the sex-related differences in NCI among high-risk cocaine users receiving substance-abuse treatment., Methods: The Neuropsychological Impairment Scale (NIS) was administered to 199 cocaine users (98 men; 101 women), receiving methadone maintainance treatment, to assess self-reported NCI by identifying the patients' awareness of neuropsychological symptoms. We used T-test comparison to find differences in NCI between men and women and multiple regression analysis to explore the relative contribution of sex to NCI., Results: Consistent with prior work, high NCI was evident within this sample, as indicated by high scores on most of the NIS subscales. Women reported greater impairment than men, as evidenced by significantly higher scores on several NIS subscales, after controlling for demographic and other confounding variables. Interestingly, cocaine craving significantly predicted NCI among men but not among women, as suggested by the significant association between cocaine craving and all except one of the NIS subscales., Conclusions: These findings suggest that cocaine users enter into treatment with a range of NCI - with women having significantly more neurocognitive deficits than men - that may contribute to differential treatment outcomes. This highlights the need to include additional services such as neuropsychological screening and sex-specific treatment programs to optimally reduce adverse health outcomes in these high-risk, cognitively impaired patients.

Aims: Two behavioral HIV prevention interventions for people who inject drugs (PWID) infected with HIV include the Holistic Health Recovery Program for HIV+ (HHRP+), a comprehensive evidence-based CDC-supported program, and an abbreviated Holistic Health for HIV (3H+) Program, an adapted HHRP+ version in treatment settings. We compared the projected health benefits and cost-effectiveness of both programs, in addition to opioid substitution therapy (OST), to the status quo in the U.S., Methods: A dynamic HIV transmission model calibrated to epidemic data of current US populations was created. Projected outcomes include future HIV incidence, HIV prevalence, and quality-adjusted life years (QALYs) gained under alternative strategies. Total medical costs were estimated to compare the cost-effectiveness of each strategy., Results: Over 10 years, expanding HHRP+ access to 80% of PWID could avert up to 29,000 HIV infections, or 6% of the projected total, at a cost of $7,777/QALY gained. Alternatively, 3H+ could avert 19,000 infections, but is slightly more cost-effective ($7,707/QALY), and remains so under widely varying effectiveness and cost assumptions. Nearly two-thirds of infections averted with either program are among non-PWIDs, due to reduced sexual transmission from PWID to their partners. Expanding these programs with broader OST coverage could avert up to 74,000 HIV infections over 10 years and reduce HIV prevalence from 16.5% to 14.1%, but is substantially more expensive than HHRP+ or 3H+ alone., Conclusions: Both behavioral interventions were effective and cost-effective at reducing HIV incidence among both PWID and the general adult population; however, 3H+, the economical HHRP+ version, was slightly more cost-effective than HHRP+.

As international guidelines increase access to antiretroviral therapy (ART) globally, ART adherence becomes increasingly important to achieve HIV treatment as prevention (TasP) goals. In the concentrated HIV epidemic among men who have sex with men (MSM) and transgendered women (TGW) in Lima, Peru, the independent correlates of ART nonadherence were examined to inform treatment intervention priorities. Cross sectional survey of HIV-infected MSM and TGW who are engaged in clinical care in Lima, Peru. From June to August 2012, 302 HIV-infected Peruvian MSM/TGW from three clinical care sites were recruited using convenience sampling to participate in a cross-sectional computer-assisted adherence survey. Several standardized screening measures associated with ART nonadherence were examined in order to determine the independent correlates of optimal (≥90%) and perfect (100%) adherence, which were assessed using logistic regression. Of the 302 participants recruited, 263 (87.1%) were prescribed ART. Among those prescribed ART, 229 (87.1%) reported optimal and 146 (55.5%) reported perfect adherence. The prevalence of alcohol use disorders (AUD; 43.2%), alcohol dependence (5.3%), recent drug use (6.0%), and depression (44.5%) was high, and most participants had some evidence of neurocognitive impairment. Meeting criteria for having an AUD and depression were collinear (p < 0.001). On multivariate analysis, having an AUD was inversely related and the only independent correlate of optimal (AOR = 0.427; 95% CI = 0.187-0.976) and perfect (AOR = 0.552; 95% CI = 0.327-0.930) ART adherence. AUDs are highly prevalent among Peruvian HIV-infected MSM and contribute significantly to ART nonadherence. These findings support the need for screening and treating underlying AUDs. In order to meet HIV TasP goals, evidence-based strategies targeting AUDs are likely to directly improve ART adherence and indirectly improve overall individual health, HIV treatment engagement, and reduce transmission to sexual partners among this vulnerable and disproportionally affected population.

Existing evidence-based HIV risk reduction interventions have not been designed for implementation within clinical settings, such as methadone maintenance programs, where many high-risk drug users seek treatment services. We therefore systematically developed an adapted, significantly shortened, version of a comprehensive evidence-based intervention called the Community-friendly Health Recovery Program (CHRP) which has demonstrated preliminary evidence of efficacy in a feasibility/acceptability study already published. In a randomized controlled trial reported here, we tested the efficacy of the CHRP intervention among high-risk drug users newly enrolled in drug treatment at an inner-city methadone maintenance program. The CHRP intervention produced improvements in drug risk reduction knowledge as well as demonstrated sex- and drug-risk reduction skills. Support was found for the IMB model of health behavior change. Implications for future intervention research and practice are considered.

The current work evaluates the HIV Stigma Framework in a sample of 95 people living with HIV recruited from an inner-city clinic in the Bronx, NY. To determine the contributions of each HIV stigma mechanism (internalized, enacted, and anticipated) on indicators of health and well-being, we conducted an interviewer-delivered survey and abstracted data from medical records. Results suggest that internalized stigma associates significantly with indicators of affective (i.e., helplessness regarding, acceptance of, and perceived benefits of HIV) and behavioral (i.e., days in medical care gaps and ARV non-adherence) health and well-being. Enacted and anticipated stigma associate with indicators of physical health and well-being (i.e., CD4 count less than 200 and chronic illness comorbidity respectively). By differentiating between HIV stigma mechanisms, researchers may gain a more nuanced understanding of how HIV stigma impacts health and well-being and better inform targeted interventions to improve specific outcomes among people living with HIV.

Although research continues to demonstrate that HIV stigma is associated with decreased HIV testing, the psychological processes implicated in this association remain unclear. The authors address this gap by differentiating between the HIV stigma mechanisms of stereotypes, prejudice, and discrimination. They hypothesize that HIV stereotypes specifically, more so than prejudice or discrimination, are associated with HIV testing among at-risk populations. Ninety-three HIV-negative people receiving methadone maintenance therapy at a clinic in the northeastern United States participated by completing a survey. Results demonstrated that HIV stereotypes are associated with HIV testing via the mediator of perceived HIV risk. As hypothesized, prejudice, discrimination, and objective HIV risk were not associated with perceived HIV risk. Differentiating between HIV stigma mechanisms in future work can provide critical insight into how to intervene in HIV stigma to increase HIV testing and improve HIV prevention among at-risk populations.

Findings to date indicate that it is feasible to deliver a brief behavioral risk reduction/medication adherence group intervention to HIV-infected injection drug users in a community-based setting. HIV infection and substance abuse can result in neurocognitive impairment and this is directly relevant to intervention development, because a significant number of people living with HIV/AIDS have a positive history of substance abuse and being able to successfully participate in behavioral interventions often requires a relatively high level of cognitive performance. The aim of the current study was to evaluate if changes in information, motivation, and behavior skills with respect to medication adherence, sex- and drug-risk behavior outcomes from baseline to post-intervention are predicted by cognitive impairment following the brief four-session Holistic Health for HIV intervention for HIV-infected Drug Users (3H+). Significant associations were found between change in motivation and certain neurocognitive performance domains. Findings suggest that it may be helpful to specifically tailor such behavioral interventions to accommodate cognitive impairment.

HIV-infected prisoners in Malaysia represent a critical target population for secondary HIV risk reduction interventions and care. We report on the process and outcome of our formative research aimed at systematically selecting and adapting an EBI designed to reduce secondary HIV risk and improve adherence to antiretroviral therapy among soon-to-be-released HIV-infected prisoners. Our formative work involved a critical examination of established EBIs and associated published reports complemented by data elicited through structured interviews and focus groups with key stakeholders, members of the target population, and their family members. Based on all information, we adapted the Holistic Health Recovery Program targeting people living with HIV (HHRP+), an EBI, to consist of eight 2-hour sessions that cover a range of specified topics so that participants may individually apply intervention content as needed to accommodate their particular substance abuse, HIV risk, and antiretroviral adherence issues. This study provides a complete example of the process of selecting and adapting an EBI-taking into account both empirical evidence and input from target organization stakeholders and target population members and their families-for use in real world prison settings where high-risk populations are concentrated.

The authors conducted a preliminary study of the 4-session Holistic Health for HIV (3H+), which was adapted from a 12-session evidence-based risk reduction and antiretroviral adherence intervention. Improvements were found in the behavioral skills required to properly adhere to HIV medication regimens. Enhancements were found in all measured aspects of sex-risk reduction outcomes, including HIV knowledge, motivation to reduce sex-risk behavior, behavioral skills related to engaging in reduced sexual risk, and reduced risk behavior. Improvements in drug use outcomes included enhancements in risk reduction skills as well as reduced heroin and cocaine use. Intervention effects also showed durability from post-intervention to the follow-up assessment point. Females responded particularly well in terms of improvements in risk reduction skills and risk behavior. This study suggests that an evidence-based behavioral intervention may be successfully adapted for use in community-based clinical settings where HIV-infected drug users can be more efficiently reached.

Cognitive impairment among populations at risk for HIV poses a significant barrier to managing risk behaviors. The impact of HIV and several cofactors, including substance abuse and mental illness, on cognitive function is discussed in the context of HIV risk behaviors, medication adherence, and risk-reduction interventions. Literature suggests that cognitive impairment is intertwined in a close, reciprocal relationship with both risk behaviors and medication adherence. Not only do increased risk behaviors and suboptimal adherence exacerbate cognitive impairment, but cognitive impairment also reduces the effectiveness of interventions aimed at optimizing medication adherence and reducing risk. In order to be effective, risk-reduction interventions must therefore take into account the impact of cognitive impairment on learning and behavior.

Risky behavior related to injection drug use accounts for a considerable proportion of incident HIV infection in the United States. Large numbers of injection drug users (IDUs) currently receive antiretroviral therapy in clinical settings and are accessible for risk-reduction interventions to reduce transmission of drug-resistant HIV and spread of HIV to uninfected others. The current study examined attitudes toward needle- or equipment-sharing among 123 HIV-positive IDUs in clinical care in an effort to understand the dynamics of such behavior and to create a basis for clinic-based risk-reduction interventions. Results indicate that at baseline, participants who reported extremely negative attitudes toward needle-sharing were less likely to have shared during the past month than those with less-extreme negative attitudes. Demographic, behavioral, and attitudinal variables were entered into a logistic regression model to examine needle-sharing group membership among HIV-positive IDUs. Being female and having less-extreme negative attitudes toward sharing were independent and significant correlates of sharing behavior. Interventions targeting needle-sharing attitudes deployed within the clinical care setting may be well-positioned to reduce HIV transmission among HIV-positive IDUs.

It has become crucial for risk reduction interventions targeting injection drug users (IDUs) in treatment to be "community-friendly" and potent over time so that limited resources may be optimally utilized. This study examined (1) the extent to which observed post-intervention effects--including enhanced HIV-related knowledge, motivation, behavioral skills, and drug- and sex-risk reduction behavior--decayed over time and (2) whether repeating the intervention atfollow-up provided additional benefit. Approximately 10 months after completing an adapted, substantially shortened, version of an evidence-based intervention, participants completed a follow-up assessment and then repeated the intervention. No evidence of decay was found. Even so, after repeating the intervention, a trend toward additional sex-risk reduction was observed for participants at higher risk for HIV. Findings point to the potential for an adapted evidence-based intervention for IDUs to be both community-friendly and potent over time within community-based treatment settings.

A number of evidence-based HIV risk reduction interventions are now widely available to clinicians. However, difficulties with intervention transportability have historically impeded the integration of evidence-based interventions into clinical settings. In this article, we discuss one successful approach to transportability through appropriate intervention selection, adaptation, placement, and evaluation. Our intervention adaptation process required substantially reducing the content and duration of an evidence-based intervention. Findings from 226 assessed participants suggested significant drug- and sex-related risk reduction outcomes, particularly among participants at greatest risk. Results point to a need to examine the relative costs/benefits of comprehensive, evidence-based interventions vs. shortened, adapted versions thereof.

There is growing empirical evidence of buprenorphine's effectiveness in treating opioid dependence in community-based settings in the U.S. Decades of research indicates that in order for buprenorphine to have a sizable effect, it must be appropriately supported by behavioral counseling. Studies to date have not established the optimal behavioral counseling content for supporting buprenorphine treatment. The objective of this article is: 1) to review evidence of the key treatment-relevant issues posed by opioid-dependent patients in community-based settings in the U.S.; and 2) to review behavioral counseling content that may optimize the use of buprenorphine for treating opioid dependence in such settings. Evidence points toward the use of behavioral counseling aimed at enhancing patients' motivation during treatment entry followed by an emphasis on improving coping/relapse prevention skills during the primary phase of treatment.