Integrated Substance Use Research Articles

An integrated substance use treatment model for young adults with first-episode psychosis: A naturalistic pilot evaluation.

Approximately 50% of individuals with first-episode psychosis meet criteria for a substance use disorder and these concurrent disorders are associated with worse long-term outcomes. Psychosocial interventions, including motivational interviewing as well as cognitive and behavioural therapies, have shown some evidence for effective treatment in substance use disorders; however, there is a paucity of existing studies that have successfully examined these interventions in first-episode psychosis. Participants (n=64) received the concurrent disorders intervention, which included individual support alongside participation in at least one of two groups: a 4-week Motivational Engagement group utilizing motivational interviewing (n=59) and an 8-week Relapse Prevention Training group emphasizing skill acquisition, which some participants entered directly (n=5) and some participants entered following completion of the Motivational Engagement group (n=16). Participants who completed the Motivational Engagement group (n=59) demonstrated significantly increased motivation to change substance use (d=-.0.58; t=-3.02, p < .01) and significantly decreased substance use frequency (d=0.65; t=3.26, p < .01). For participants who completed the Relapse Prevention Training group (n=21), substance use frequency significantly decreased (d=0.92; t=3.46, p < .01) and self-efficacy in one's ability to maintain substance use changes significantly increased (d=-0.85; t=-3.59, p < .01). This pilot evaluation suggests that motivational interviewing and relapse prevention skills training are acceptable and feasible interventions in the treatment of substance use disorders in young adults with first-episode psychosis.

“Take care of their hierarchy of needs first”: strategies used by data-to-care staff to address barriers to HIV care engagement

ABSTRACT Data-to-Care (D2C) is a public health strategy designed to engage out-of-care (OOC) persons with HIV (PWH) in HIV care. OOC PWH are identified through review of state and local HIV data and engaged in care through individualized efforts that address barriers to HIV care. Perspectives of D2C program staff can contribute to D2C program development and sustainability. We conducted semi-structured interviews in 2017 with 20 D2C program staff from Louisiana (n = 10) and Virginia (n = 10), states with distinct D2C programs. We used content and thematic analysis to analyze interview transcripts. In both states, common barriers to care for OOC PWH include limited transportation, stigma, substance use, poverty, homelessness, and mental illness. To address these barriers and engage OOC clients in HIV care, staff and programs provided transportation vouchers and housing assistance, integrated substance use and mental health services into care engagement processes, provided empathy and compassion, and assessed and addressed basic unmet needs. Identifying and addressing social and structural barriers to HIV care is a critical and often a necessary first step in engaging OOC clients in HIV care. These findings can be used for D2C program design and implementation, facilitating engagement in HIV care for OOC PWH.

A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews.

There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews. Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021.We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations,and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types. Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components. A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.

The implementation & sustainment facilitation (ISF) strategy: Cost and cost-effectiveness results from a 39-site cluster randomized trial integrating substance use services in community-based HIV service organizations.

Background: As part of the Substance Abuse Treatment to HIV Care Project, the Implementation & Sustainment Facilitation (ISF) strategy was found to be an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy for integrating a motivational interviewing-based brief intervention (MIBI) for substance use disorders. This study presents the cost and cost-effectiveness results. Methods: Thirty-nine HIV service organizations were randomized to receive the ATTC-only condition or the ATTC + ISF condition. Two staff from each organization received the ATTC-training. In ATTC + ISF organizations, the same two staff and additional support staff participated in facilitation sessions to support MIBI implementation. We estimated costs using primary data on the time spent in each strategy and the time spent delivering 409 MIBIs to clients. We estimated staff-level cost-effectiveness for the number of MIBIs delivered, average MIBI quality scores, and total client days abstinent per staff. We used sensitivity analyses to test how changes to key variables affect the results. Results: Adjusted per-staff costs were $2,915 for the ATTC strategy and $5,371 for ATTC + ISF, resulting in an incremental cost of $2,457. ATTC + ISF significantly increased the number of MIBIs delivered (3.73) and the average MIBI quality score (61.45), yielding incremental cost effectiveness ratios (ICERs) of $659 and $40. Client days abstinent increased by 59 days per staff with a quality-adjusted life-year ICER of $40,578 (95% confidence interval $29,795-$61,031). Conclusions: From the perspective of federal policymakers, ISF as an adjunct to the ATTC strategy may be cost-effective for improving the integration of MIBIs within HIV service organizations, especially if scaled up to reach more clients. Travel accounted for nearly half of costs, and virtual implementation may further increase value. We also highlight two considerations for cost-effectiveness analysis with hybrid trials: study protocols kept recruitment low and modeling choices affect how we interpret the effects on client-level outcomes.

Increases in Alcohol and Cannabis Use Associated with Deteriorating Mental Health among LGBTQ2+ Adults in the Context of COVID-19: A Repeated Cross-Sectional Study in Canada, 2020-2021.

Lesbian, gay, bisexual, trans, other queer, and Two-Spirit (LGBTQ2+) people are particularly at risk for the psycho-social consequences of the COVID-19 pandemic, though population-tailored research within this context remains limited. This study examines the extent of, and associations between, increased alcohol and cannabis use and deteriorating mental health among LGBTQ2+ adults in Canada during the COVID-19 pandemic. Data are drawn from LGBTQ2+ respondents to a repeated, cross-sectional survey administered to adults living in Canada (May 2020–January 2021). Bivariate cross-tabulations and multivariable logistic regression models were utilized to examine associations between increased alcohol and cannabis use, and self-reported mental health, overall coping, and suicidal thoughts. Five-hundred and two LGBTQ2+ participants were included in this analysis. Of these, 24.5% reported increased alcohol use and 18.5% reported increased cannabis use due to the pandemic. In the adjusted analyses, increased alcohol use was associated with poor overall coping (OR = 2.28; 95% CI = 1.28–4.07) and worse self-reported mental health (OR = 1.98; 95% CI = 1.21–3.25), whereas increased cannabis use was associated with suicidal thoughts (OR = 2.30; 95% CI = 1.16–4.55). These findings underscore the need for population-tailored, integrated substance use and mental health supports to address interrelated increases in alcohol/cannabis use and worsening mental health among LGBTQ2+ adults, in the context of the COVID-19 pandemic and beyond.

Using the Behaviour Change Wheel to design an intervention for partner abusive men in drug and alcohol treatment

BackgroundWe aimed to establish what core elements were required in a group therapy programme for men who disclose perpetrating intimate partner abuse in a substance use setting and develop, and test the feasibility of delivering an intervention in this setting.MethodsWe describe the theoretical development and feasibility testing of an integrated substance use and intimate partner abuse intervention (‘ADVANCE’) for delivery in substance use services. We employed a comprehensive eight-stage process to guide this development applying the ‘COM-B’ (‘capability’, ‘opportunity’, ‘motivation’ and ‘behaviour’) model for intervention design which specifies the following: (1) define the problem, (2) select the target behaviour, (3) specify the target behaviour, (4) identify what needs to change, (5) identify intervention functions, (6) identify policy categories, (7) select behaviour change techniques, and (8) design a mode of delivery. The development was informed by primary research conducted by the authors, consulting with organisation steering groups and by those with personal experiences. The identified targets for intervention and mode and method of delivery were then refined over 4 intervention development meetings, using the nominal group technique with the ADVANCE experts, then further refined following consultation with service user groups and wider expert groups via a learning alliance meetings.ResultsOur final intervention, the ADVANCE intervention consisted of a group intervention comprising of up to four pre-group individual interviews, followed by 12 × 2-h group sessions supported by integrated safety work for victim/survivors, and risk and safety support and integrity support for the professionals. The main targets for change were personal goal planning, self-regulation, and attitudes and beliefs supporting intimate partner abuse. The intervention was regarded as very acceptable to both staff and clients in substance use services, with group attendees reported positive behaviour changes and development of new skills.ConclusionWe have demonstrated the ability to employ a structured eight-step process to develop an integrated intervention to address substance use-related intimate partner abuse that is acceptable to staff and clients in substance use services. This led to a feasibility study (ISRCTN 79435190) involving 104 men and 30 staff at three different locations across the UK was conducted to assess the feasibility and acceptability of the intervention and to refine the content and approach to delivery (BMC Public Health, 21: 980, 2021).

1.4 UNDERSTANDING SYSTEMIC RACISM AND RACIAL INEQUITY JUVENILE JUSTICE SYSTEM INVOLVEMENT

Black, Latinx, and Native American (BLNA) youth are disproportionately overrepresented and have been for several decades. Barriers to free and appropriate educational resources and community-based mental health and substance use disorder treatment are among the drivers that potentiate disproportionate contact and confinement. This presentation includes a review of literature on juvenile justice and racial disproportionality, with particular focus on relevant legislative trends to address this problem and risk factors for justice involvement that are amplified by systemic racism. Application of the Sequential Intercept Model, which was developed to describe 5 points of justice interception, will be explored to see how this trajectory of juvenile justice contact maps onto the Juvenile Justice Behavioral Health Services Cascade, a framework for measuring gaps between treatment need and receipt. Findings from research conducted by the presenter and colleagues investigating promising practices that apply antiracist praxis in working with justice-involved youth will be presented. BLNA youth are more likely than White youth to have contact with the juvenile justice system and are also less likely to receive treatment for substance use and mental health disorders, which has implications for initial justice contact as well as sustained entrenchment in this system. Numerous studies highlight the long-term adverse health effects of incarceration on justice-involved youth. There are negative effects of justice systems having contact on youth and family well-being. Legislative policies that target race inequity have promise in reducing racial disparities. Given the disruption that justice contact at any stage poses to the healthy psychosocial development of youth, child and adolescent psychiatrists should be at the forefront of advocacy efforts that apply structural competency, antiracist, and trauma-informed frameworks for justice-involved populations. These include primary prevention, school-based and integrated substance use and mental health services, as well as community-based partnership approaches with justice-involved youth, their families, and organizations that serve them to identify and operationalize best practices for engagement.

Integrating substance use care into primary care for adolescents and young adults: Lessons learned

BackgroundSubstance use disorders are common chronic conditions that often begin and develop during adolescence and young adulthood, yet the delivery of primary care is not developmentally tailored for youth who use substances. Very few primary care–based substance use treatment programs exist in the United States for adolescents and young adults and no clear guidance is available about how to provide substance use treatment in primary care. MethodsWe conducted a retrospective evaluation from July 2016 to December 2018 of a newly established primary care–based, multidisciplinary, outpatient program for youth who use substances. Components of the program include primary care, addiction treatment, harm reduction, naloxone distribution, psychotherapy, recovery support, and navigation addressing social determinants of health. We report the following patient characteristics and outcomes: demographics; proportion with substance use and mental health diagnoses; receipt of medications for opioid use disorder; retention in care at three, six, nine, and 12 months; and re-engagement in medical care. ResultsFrom July 2016 through December 2018, 148 patients had at least one visit. Demographic characteristics included: median age 21 years; 40.5% female; 94.0% spoke primarily English; 18.3% Black, 14.9% Hispanic, and 60.8% white. One-third of patients (33.8%) were homeless or housing insecure. The most common substance use disorder was opioid use disorder (60.8%), followed by nicotine (37.2%), cannabis (20.9%), and alcohol (18.2%). Overall, 29.7% of patients had depression, 32.4% had anxiety disorder, and 18.9% had post-traumatic stress disorder. Retention in care was 29.7% at six months and 12.2% at 12 months. Among the 90 patients with OUD, 90.0% received medication for OUD, and 35.5% and 15.5% of patients with OUD were retained at six and 12 months, respectively. For patients lost to follow-up (no contact during a three-month period), the median time to re-engagement was 4.8 months, and 33.3% (37/111) of patients re-engaged. The most common reason for re-engagement was to access mental health treatment (59.5%) and primary care (51.4%). ConclusionsYouth who sought care in a primary care–based substance use program presented most commonly with opioid, nicotine, cannabis, and alcohol use disorders. Co-morbid mental health diagnoses were common. While continuous retention at 12 months was low, one in three of the patients who fell out of care re-engaged. For youth receiving substance use care integrated into primary care, key components for pursing optimal retention in substance use treatment are a flexible model that anticipates the need for the treatment of mental health disorders and the use of re-engagement strategies.

Educational Studies Examining Knowledge of Substance Use Disorders and Career Aspirations Among Medical Trainees in an Inner-City Hospital.

Gaps in addiction medicine training are a reason for poor substance use care in North America. Hospital addiction medicine consult services (AMCS) provide critical medical services, including screening and treatment of substance use disorders. Although these programs often feature an educational component for medical learners, the impact of AMCS teaching on objective knowledge and career aspirations in addiction medicine has not been well described. The authors report findings from two sequential studies conducted at a large academic hospital in Vancouver, Canada. The first study assessed the impact of an AMCS clinical rotation on medical trainee addiction medicine objective knowledge using an online survey of 6 true/false questions before and after the rotation. The second study examined the impact of an AMCS rotation on career aspirations using 4 seven-point Likert-type questions. One-sample t tests on mean differences (MD) with Benjamini-Hochberg adjustment for multiple comparisons were employed for statistical analyses. Between May 2017 and June 2018, knowledge scores were significantly higher postrotation (MD = 4.78, standard deviation [SD] = 19.5, P = 0.034) among 115 medical trainees. Between July 2018 and July 2019, aspirations to practice addiction medicine were significantly more favorable postrotation (MD = 3.48, SD = 3.15, P < 0.001) among 101 medical trainees. AMCS rotations appear to improve addiction medicine knowledge and aspirations to practice addiction medicine among medical trainees. Larger-scale evaluations and outcomes research on integrating substance use disorders teaching in these settings will help move the discipline forward.

Integrated substance use and prenatal care delivery in the era of COVID-19

The COVID-19 pandemic has directly impacted integrated substance use and prenatal care delivery in the United States and has driven a rapid transformation from in-person prenatal care to a hybrid telemedicine care model. Additionally, changes in regulations for take home dosing for methadone treatment for opioid use disorder due to COVID-19 have impacted pregnant and postpartum women. We review the literature on prenatal care models and discuss our experience with integrated substance use and prenatal care delivery during COVID-19 at New England's largest safety net hospital and national leader in substance use care. In our patient-centered medical home for pregnant and postpartum patients with substance use disorder, patients' early responses to these changes have been overwhelmingly positive. Should clinicians continue to use these models, thoughtful planning and further research will be necessary to ensure equitable access to the benefits of telemedicine and take home dosing for all pregnant and postpartum patients with substance use disorder.

Improving Medication Access within Integrated Treatment for Individuals with Co-Occurring Disorders in Substance Use Treatment Agencies.

The best approach to provide comprehensive care for individuals with co-occurring disorders (CODs) related to substance use and mental health is to address both disorders through an integrated treatment approach. However, only 25% of behavioral health agencies offer integrated care and less than 7% of individuals who need integrated treatment receive it. A project used a cluster-randomized waitlist control group design to evaluate the effectiveness of Network for the Improvement of Addiction Treatment (NIATx) implementation strategies to improve access to addiction and psychotropic medications. This study represents a secondary analysis of data from the NIATx project. Forty-nine agencies were randomized to Cohort1 (active implementation group, receiving the NIATx strategy [n=25]) or Cohort2 (waitlist control group [n=24]). Data were collected at three time points (Baseline, Year1 and Year2). A two-level (patient within agency) multinomial logistic regression model investigated the effects of implementation strategy condition on one of four medication outcomes: both medication types, only psychotropic medication, only addiction medication, or neither medication type. A per-protocol analysis included time, NIATx fidelity, and agency focus as predictors. The intent-to-treat analysis found a statistically significant change in access to addiction versus neither medication, but Cohort1 compared to Cohort2 at Year1 showed no differences. Changes were associated with the experimental intervention and occurred in the transition from Year 1 to Year 2, where greater increases were seen for agencies in Cohort2 versus Cohort1. The per-protocol analysis showed increased access to both medications and addiction medications from pre- to post-intervention for agencies in both cohorts; however, differences in change between high- and low-implementation agencies were not significant. Access to integrated services for people with CODs is a long-standing problem. NIATx implementation strategies had limited effectiveness in improving medication access for individuals with CODs. Implementation strategy adherence is associated with increased medication access.

Causes of death among U.S. Veterans with a prior nonfatal opioid overdose

BackgroundFor over a decade, there has been a surge in opioid-related morbidity and mortality among Veterans. To better understand the impact of the growing epidemic, it is important to identify the cause-specific mortality rates among Veterans with a prior nonfatal opioid overdose. MethodsWe followed 8370 Veterans who received medical care for a nonfatal opioid overdose between 2011 through 2015.Mortality records were linked to clinical records from the Veterans Health Administration (VHA). We compared the mortality rates among those with a nonfatal opioid overdose to a 5 % stratified random sample of patients accessing services during the same time period. SMRs were calculated using age-adjusted cause-specific mortality rates for the l U.S. population obtained from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER). ResultsThe crude mortality for Veterans with a history of a nonfatal overdose was 370.6 per 10,000 person years. Those with a prior nonfatal overdose had a higher risk of substance-related mortality (aHR [adjusted Hazard Ratio] 5.0), including a higher risk of death from drugs (aHR 6.9) and alcohol (aHR 2.7). Similarly, cause-specific mortalities assessed between Veterans and the U.S. population, SMRs were also highest for deaths associated with substances (114.0). ConclusionVeterans with a prior nonfatal overdose experienced substantially higher mortality rates compared to other Veterans or the general U.S. population. Causes of death related to substance use and mental health were significantly higher than other causes of death, highlighting the importance of integrated treatment and substance use services.

"He Would Take My Shoes and All the Baby's Warm Winter Gear so We Couldn't Leave": Barriers to Safety and Recovery Experienced by a Sample of Vermont Women With Partner Violence and Opioid Use Disorder Experiences.

This qualitative study explored themes about barriers to substance use treatment for women who experience intimate partner violence (IPV) and opioid use in rural Vermont. The goal was to collect descriptive information to aid in the development of intervention ideas to facilitate better treatment access for women in this situation. One-on-one telephone interviews with 33 rural Vermont women who experienced both IPV and opioid use took place between February and August 2019. There were 5 main themes that emerged as barriers to accessing needed services: (1) geographic isolation and transportation difficulties, (2) inaccessibility of existing services, (3) lack of integrated substance use treatment and domestic violence services, (4) social isolation, and (5) amplification of stigma in small rural communities. Improved access to care and increased collaboration between IPV and substance use service providers are required to better serve rural communities in which IPV and opioid use disorder are concurrent problems.

Alcohol, Tobacco, and Comorbid Psychiatric Disorders and Associations With Sexual Identity and Stress-Related Correlates.

The authors examined psychiatric comorbidities associated with alcohol use disorders and tobacco use disorders among heterosexual, bisexual, and gay and lesbian men and women in the United States and whether stress-related factors were predictive of comorbidities. The authors used data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013, N=36,309) to examine the co-occurrence of past-year alcohol or tobacco use disorder with past-year anxiety disorders, mood disorders, and posttraumatic stress disorder by sexual identity (heterosexual, bisexual, gay or lesbian) and sex. The authors also examined the association of stress-related factors and social support with the presence of comorbidities. Comorbidities were more prevalent among women and sexual minorities, particularly bisexual women. More than half of bisexual (55%) and gay or lesbian (51%) individuals who met criteria for a past-year alcohol use disorder had a psychiatric comorbidity, while only one-third of heterosexual individuals who met criteria for a past-year alcohol use disorder did. Similar differences were found among those who met criteria for a past-year tobacco use disorder. Among sexual minorities, the frequency of sexual orientation discrimination (adjusted odds ratio range=1.08-1.10), number of stressful life events (adjusted odds ratio range=1.25-1.43), and number of adverse childhood experiences (adjusted odds ratio range=1.04-1.18) were significantly associated with greater odds of comorbidities. Greater social support was significantly inversely associated with tobacco use disorder comorbidities (adjusted odds ratio range=0.96-0.97). This research suggests that integrated substance use and mental health prevention and treatment programs are needed, particularly for individuals who identify as sexual minorities. The increased stressors experienced by sexual minority individuals may be important drivers of these high levels of comorbidities.

Substance use service availability in HIV treatment programs: Data from the global IeDEA consortium, 2014-2015 and 2017.

BackgroundSubstance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes.MethodsWe report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014–2015 survey and 237 sites in 44 countries participated in the 2017 survey. We compared changes over time for 147 sites that participated in both surveys.ResultsIn 2014–2015, most sites (75%) reported providing substance use-related education on-site (i.e., at the HIV clinic or the same health facility). Approximately half reported on-site screening for substance use (52%) or referrals for substance use treatment (51%). In 2017, the proportion of sites providing on-site substance use-related education, screening, or referrals increased by 9%, 16%, and 8%, respectively. In 2017, on-site substance use screening and referral were most commonly reported at sites serving only adults (compared to only children/adolescents or adults and children/adolescents; screening: 86%, 37%, and 59%, respectively; referral: 76%, 47%, and 46%, respectively) and at sites in high-income countries (compared to upper middle income, lower middle income or low-income countries; screening: 89%, 76%, 68%, and 45%, respectively; referral: 82%, 71%, 57%, and 34%, respectively).ConclusionAlthough there have been increases in the proportion of sites reporting substance use education, screening, and referral services across IeDEA sites, gaps persist in the integration of substance use services into HIV care, particularly in relation to screening and referral practices, with reduced availability for children/adolescents and those receiving care within resource-constrained settings.

Meeting Kids Where They Are At-A Substance Use and Sexual Risk Prevention Program via Telemedicine for African American Girls: Usability and Acceptability Study.

BackgroundRural African American youth lack access to drug and sexual risk–taking prevention programs available in more urban areas. Recent data indicate that rural youth now use substances at higher rates and at younger ages than their urban peers.ObjectiveThis study aims to evaluate the initial usability and acceptability of a low-cost, technology-based approach to delivering effective, culturally tailored, integrated substance use disorder (SUD) and HIV risk behavior prevention programs to African American female youth to inform the use of this intervention via telemedicine for rural youth.MethodsEffective SUD prevention strategies and emotion regulation skills were integrated into an existing evidence-based HIV risk reduction program culturally tailored for African American female adolescents—Sisters Informing, Healing, Living, and Empowering (SIHLE)—and delivered to 39 African American female youth via group telehealth. The evaluation of the resulting program, 12-session SIHLEplus, was completed by 27 girls who also completed self-report measures that assessed sexual risk behaviors (eg, number of partners and age of sex initiation), substance use, exposure to traumatic events, and emotion regulation.ResultsThe descriptive and qualitative results of the pilot study demonstrate the initial usability and acceptability of delivering evidence-based prevention successfully via telehealth to help address health disparities in this vulnerable population.ConclusionsAlthough more research is needed, the findings from this study suggest that SIHLEplus has demonstrated initial usability and acceptability.

Substance use, self-rated health and HIV status in Brazil

ABSTRACT We compared the prevalence of of non-injecting drug use (NIDU) and Self-Rated Health (SRH) among individuals self-reporting as HIV-positive (PLWHA), HIV-negative and unknown at the III Brazilian Household Survey on Substance Use. Overall, 16,273 individuals, 12–65 years old, were interviewed in 2015. Prevalence and Standard Error (SE) were estimated considering the complex sample design and weight calibration. Chi-square tests with Rao-Scott adjustment were used to test independence between NIDU, SRH and HIV status. PLWHA presented higher frequencies of 12-month use for most substances than those reporting to be HIV-negative: alcohol use prevalence was 49.5% (SE 12.8) vs. 43.1% (SE 0.7), p = 0.34; tobacco 45.3% (SE 12.7) vs. 15.3% (SE 0.4), p < 0.01; amphetamines 1.7% (SE 1.7) vs. 0.3% (SE 0.1), p = 0.51; cannabis 10.5%(SE 6.7) vs. 2.5%(0.2), p = 0.06; powder cocaine 3.6% (SE 3.0) vs. 0.9% (SE 0.1), p = 0.45; crack-cocaine 5.3% (SE 3.2) vs. 0.3% (SE 0.1), p < 0.01; inhalants 3.6% (SE 3.0) vs. 0.2% (SE 0), p = 0.03; ketamine 1.7%(SE 1.7) vs. 0.1% (SE 0), p = 0.23; and opioids 1.7% (SE 1.7) vs. 1.4% (SE 0.2), p = 0.93. PLWHA also reported worse SRH. Our results and the scarcity of integrated substance use and HIV treatments call for innovative, cost-effective approaches to tackle these public health challenges.

Differences in Substance Use and Sexual Risk by Sexual Orientation and Gender Identity Among University and Community Young Adults in a U.S.-Mexico Border City.

Ethnic and sexual minority young adults in El Paso, Texas, are at high risk for substance use, human immunodeficiency virus (HIV), and hepatitis C virus (HCV). In 2014, a Hispanic-serving higher education institution partnered with two community-based organizations to implement integrated substance use interventions and HIV and HCV prevention among young adults on campus and in surrounding communities. Among the 95 young adults, aged 18-24 years, who responded to a needs assessment survey, 91.5% were Hispanic, 53.7% were female, and 27.4% were sexual or gender minorities (SGMs) as defined by behavior and identity. SGMs had significantly higher rates of current smoking, drinking when bored, and of being told they had a drinking problem. Compared with the other young adult survey respondents, SGMs had lower health risk perceptions for tobacco, alcohol, and marijuana use and reported similar or higher rates of lifetime drug use during sex and higher rates of HIV risk behaviors. Study findings have implications for including measures for sexual orientation and gender identity in substance use studies, examining regional and cultural norms that may intersect to shape substance use among SGMs, and incorporating unique risk contexts for SGMs in interventions for substance use.

Barriers to optimal antiretroviral therapy adherence among HIV-infected formerly incarcerated individuals in New York City.

In the United States (U.S.), the HIV infection rate is disproportionately high among incarcerated individuals. HIV-infected individuals typically receive antiretroviral therapy (ART) to suppress HIV and reduce the threat of transmission. Although HIV-infected individuals are generally ART-adherent while incarcerated, the public health benefits experienced during incarceration are often lost as HIV-infected individuals struggle to maintain optimal adherence post-incarceration. While the importance of maintaining adherence in the post-incarceration period has been acknowledged, research on barriers to ART adherence during this period is limited. To better understand post-release barriers to ART adherence, we conducted in-depth interviews with 20 HIV-infected formerly incarcerated individuals in New York City; we also followed up with 18 (90%) participants after three months to explore whether their adherence challenges changed over time. Viral load testing results from their most recent physician visit were also recorded at each interview. Interviews were transcribed using transcription software and reviewed for accuracy by a researcher. Thematic coding based on discussion guide prompts were then used to identify commonly mentioned barriers to adherence. The results identified four overarching themes that affected study participants’ efforts to adhere to their ART regimen: medication burden, forgetfulness, mental health and emotional difficulties, and perceived conflict between substance use and medication adherence. These barriers were the most commonly cited and largely persisted at three-month follow-up. The results suggest that interventions addressing these challenges are essential for promoting ART adherence among HIV-infected formerly incarcerated individuals. Effective interventions may include mobile-based text messaging reminders and those that facilitate patient-provider communication. Additionally, interventions or programs that integrate substance use and mental health treatment into HIV-related care, along with other types of behavioral health support, may also be beneficial for this population. Such interventions should be a routine part of discharge planning and support for incarcerated individuals returning to the community.

Integrating HIV pre-exposure prophylaxis and harm reduction among men who have sex with men and transgender women to address intersecting harms associated with stimulant use: a modelling study.

IntroductionAmong men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular disease (CVD) mortality. We used epidemic modelling to investigate these intersecting health harms among MSM/TW in Lima, Peru and assess whether they could be mitigated by prioritizing HIV pre‐exposure prophylaxis (PrEP) and harm reduction interventions among MSM/TW who use stimulants.MethodsWe adapted a dynamic model of HIV transmission among MSM/TW in Lima to incorporate stimulant use and increased HIV risk, suicide and CVD mortality. Among 6% to 24% of MSM/TW using stimulants (mostly cocaine), we modelled an increased risk of unprotected anal sex (RR = 1.35 [95%CI: 1.17 to 1.57]) obtained from local data, and increased risk of suicide (SMR = 6.26 [95%CI: 2.84 to 13.80]) and CVD (SMR = 1.83 [95%CI: 0.39 to 8.57]) mortality associated with cocaine use based on a global systematic review. We estimated the proportion of health harms occurring among MSM/TW who use stimulants in the next year (01‐2020/01‐2021). We also investigated the 10‐year impact (01‐2020/01‐2030) of: (1) PrEP prioritization for stimulant‐using MSM/TW compared to random allocation, and (2) integrating PrEP with a theoretical intervention halving stimulant‐associated risk.ResultsMSM/TW in Lima will experience high HIV incidence, suicide mortality and CVD mortality (1.6/100 py, and 0.018/100 py, 0.13/100 py respectively) in 2020. Despite stimulant using MSM/TW comprising an estimated 9.5% (95%CI: 7.8 to 11.5) of all MSM/TW, in the next year, 11% 95%CI (i.e. 2.5% to 97.5% percentile) 10% to 13%) of new HIV infections, 39% (95%CI: 18% to 60%) of suicides and 15% (95%CI: 3% to 44%) of CVD deaths could occur among this group. Scaling up PrEP among all stimulant using MSM/TW could prevent 19% (95%CI: 11% to 31%) more HIV infections over 10 years compared to random allocation. Integrating PrEP and an intervention to halve stimulant‐associated risks could reduce new HIV infections by 20% (95%CI: 10% to 37%), suicide deaths by 14% (95%CI: 5% to 27%) and CVD deaths by 3% (95%CI: 0% to 16%) over a decade.ConclusionsMSM/TW who use stimulants experience a disproportionate burden of health harms. Prioritizing PrEP based on stimulant use, in addition to sexual behaviour/gender identity criteria, could increase its impact. Integrated substance use, harm reduction, mental health and HIV care among MSM/TW is needed.