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1.  Placebo-Group Responders in Methamphetamine Pharmacotherapy Trials: The Role of Immediate Establishment of Abstinence 
Objective
Treatment responses of placebo groups in addiction medicine trials have important implications for research methodology and clinical practice, however, studies examining placebo group responses in addiction medicine is scarce. Extant data suggests the importance of early treatment responsiveness for long-term outcomes. Among methamphetamine (MA) dependent individuals randomized to placebo pill plus behavioral support conditions in pharmacotherapy development trials, we hypothesized that immediate abstinence would be a necessary but insufficient predictor for end-of-trial (EOT) abstinence.
Methods
The study is a secondary analysis of participants (N=184; 36% female) in the placebo condition of three randomized, placebo-controlled methamphetamine dependence pharmacotherapy trials. Receiver operating characteristic (ROC) curve analyses assessed the predictive power of initial abstinence, assessed by thrice weekly urine samples, for EOT abstinence.
Results
Sixty percent of individuals with complete abstinence in the first two weeks of treatment were abstinent at EOT while 18% of people who failed to meet this standard were abstinent at EOT. Early response was related to retention at EOT and 12 month follow-up. Findings suggested that the inability to achieve at least three MA negative screenings in the first two weeks is associated with greater than 90% likelihood of treatment failure. A third week of screening added minimally to the prediction of EOT outcomes. The prediction of treatment failure was more precise than the prediction of treatment success.
Conclusion
The absence of a clinical response in the first two weeks of treatment among participants in the placebo group signals high risk of treatment failure. The vast majority of information regarding response in the placebo group from a12-week trial is obtained in early in the trial.
doi:10.1037/a0029210
PMCID: PMC4035480  PMID: 22867036
methamphetamine dependence; placebo effects; early response; abstinence; treatment
2.  It Gets Better: Resolution of Internalized Homophobia over Time and Associations with Positive Health Outcomes among MSM 
AIDS and behavior  2013;17(4):1423-1430.
Health disparities research among gay and bisexual men has focused primarily on risk and deficits. However, a focus on resiliencies within this population may greatly benefit health promotion. We describe a pattern of resilience (internalized homophobia (IHP) resolution) over the life-course and its associations with current health outcomes. 1,541 gay and bisexual men from the Multi-Center AIDS Cohort study, an ongoing prospective study of the natural and treated histories of HIV, completed a survey about life-course events thought to be related to health. The majority of men resolved IHP over time independent of demographics. Men who resolved IHP had significantly higher odds of positive health outcomes compared to those who did not. These results provide evidence of resilience among participants that is associated with positive health outcomes. Understanding resiliencies and incorporating them into interventions may help to promote health and well-being among gay and bisexual men.
doi:10.1007/s10461-012-0392-x
PMCID: PMC3708613  PMID: 23283578
Gay men’s health; Resilience; Internalized Homophobia; MSM Health Promotion; Syndemics
3.  Pilot randomized trial of bupropion for adolescent methamphetamine abuse/dependence 
Purpose
To perform a pilot clinical trial of bupropion for methamphetamine abuse/dependence among adolescents
Methods
19 adolescents with methamphetamine abuse (n = 2) or dependence (n = 17) were randomly assigned to bupropion SR 150 mg twice daily or placebo for 8 weeks with outpatient substance abuse counseling.
Results
Bupropion was well tolerated except for one female in the bupropion group who was hospitalized for suicidal ideation during a methamphetamine relapse. Adolescents receiving bupropion and females provided significantly fewer methamphetamine-free urine tests compared to participants receiving placebo (p = 0.043) and males (p = 0.005) respectively.
Conclusions
Results do not support the feasibility of additional trials of bupropion for adolescent methamphetamine abuse/dependence. Future studies should investigate the influence of gender on adolescent methamphetamine abuse and treatment outcomes.
doi:10.1016/j.jadohealth.2012.10.275
PMCID: PMC3608805  PMID: 23333007
methamphetamine; adolescents; female; bupropion; clinical trial
4.  Anal Human Papillomavirus Infection in a Street Based Sample of Drug Using HIV-Positive Men 
HIV facilitates an increase in human papillomavirus (HPV) associated conditions. HIV-positive men living in a substance use context in Los Angeles were recruited using Respondent Driven Sampling, completed a questionnaire and had biological samples including an anal HPV swab taken. 316 evaluable men were enrolled in the study. The prevalence of all HPV, high-risk (HR) infection, and multiple type infection was highest for men who have sex with men (MSM) (93.9%, 64.6%, 29.7% respectively). When all HPV and HR-HPV prevalence in all men was stratified by age, the youngest group had 100% and 68.2% prevalence respectively with similarly high rates maintained up to 49 years. The individual’s use of alcohol, marijuana, cocaine, methamphetamine or heroin was not significantly associated with anal HPV isolation. In this marginalized population, high anal HPV and HR-HPV prevalence rates over a wide age range may increase the individual’s risk for anal dysplasia and anal cancer.
doi:10.1258/ijsa.2011.011169
PMCID: PMC3899933  PMID: 22581874
human papillomavirus (HPV); substance use; anal; HIV; men who have sex with men (MSM)
5.  Cigarette smoking as a target for potentiating outcomes for methamphetamine abuse treatment 
Drug and alcohol review  2012;32(1):96-99.
Introduction and Aims
Cigarette smoking occurs frequently among individuals with methamphetamine dependence. Preclinical and clinical evidence has suggested that the common co-abuse of methamphetamine and cigarettes represents a pharmacologically meaningful pattern.
Methods
The present study is a secondary analysis of a randomised, placebo-controlled trial of bupropion treatment for methamphetamine dependence (bupropion n=36; placebo n=37). A hierarchical logistic modelling approach assessed the efficacy of bupropion for reducing MA use separately among smokers and non-smokers. Among smokers, relations between cigarettes smoked and MA use were assessed.
Results
Smoking status did not affect treatment responsiveness in either the bupropion condition or the placebo condition. In the placebo condition, increased cigarette use was associated with an increased probability of methamphetamine use during the same time period. This effect was not observed in the bupropion condition.
Discussion and Conclusions
Initial smoking status did not impact treatment outcomes. Among smokers, results suggest that bupropion may dissociate cigarette and methamphetamine use. The effect was modest and a precise pharmacologic mechanism remains elusive. Cholinergic systems may be relevant for methamphetamine use outcomes. Future studies should continue to assess the role of smoking in methamphetamine treatment outcomes.
doi:10.1111/j.1465-3362.2012.00423.x
PMCID: PMC3371287  PMID: 22385210
bupropion; methamphetamine dependence; nicotine; cigarettes; comorbidity
6.  Where are the young men in HIV prevention efforts? Comments on HIV prevention programs and research from young men who have sex with men in Los Angeles County 
The journal of primary prevention  2012;33(5-6):271-278.
Despite increasing rates of HIV infection among young men who have sex with men (YMSM), only a minority participate in formal HIV prevention efforts. Semi-structured mixed-methods interviews were conducted in a diverse sample of YMSM (N = 100, Mage = 25.0 years) in Los Angeles, California, to identify facilitators and barriers to participation in HIV prevention programs. Summative content analyses were used to evaluate transcribed field notes from these interviews. Results showed that 28.0% of all participants had previously attended an HIV prevention program, and that 21.3% of those who were also asked if they had ever participated in any research pertaining to HIV prevention had done so. A significantly higher percentage of those who had participated in HIV prevention programs had been tested for HIV in the past 6 months compared to those who had not (p < .05). The most frequently mentioned barriers to participation in such a program were being too busy to attend (12.0%), not perceiving themselves to be at risk for HIV infection (14.0%), and believing that they already knew everything they needed to know about HIV transmission (23.0%). YMSM suggested that future interventions should use technology (e.g., the Internet, mobile devices), engage their social networks, and highlight HIV prevention as a means for community connection. Collectively, these results provide some explanations for why YMSM account for a minority of HIV prevention program participants and offer possible directions for future HIV prevention efforts that target YMSM.
doi:10.1007/s10935-012-0282-z
PMCID: PMC3513361  PMID: 23132515
YMSM; HIV prevention; barriers to participation
7.  Optimizing Pain Management through collaborations with Behavioral and Addiction Medicine in Primary Care 
Primary care  2012;39(4):661-669.
Chronic non-cancer pain (CNCP) affects a high proportion of primary care patients and carries a large human and economic burden. In response to the widespread perception that pain has been under-diagnosed and undertreated, regulatory bodies have encouraged more comprehensive services addressing pain syndromes. Significant hurdles exist in treating CNCP in primary care settings including a relative lack of training, lower physician satisfaction in treating pain patients, lack of objective measures and the risks associated with opioid treatment including addiction. Additionally, interventional therapies and pharmacotherapy often do not provide complete symptomatic relief. Here, we describe a multidimensional and interdisciplinary approach to the treatment of CNCP. The utility of collaborations with behavioral and addiction medicine specialists optimizes care and advances models of patient treatment within a primary care patient-centered medical home.
doi:10.1016/j.pop.2012.08.007
PMCID: PMC3677034  PMID: 23148959
chronic non-cancer pain; opioids; interdisciplinary; patient-centered medical home; addiction
8.  Correlates of Hospitalization for Methadone-Maintained Persons with Physical Health Problems 
This cross-sectional study (n = 190) examined correlates of hospitalization for physical health problems among methadone maintenance therapy (MMT) clients with a history of alcohol abuse. The study was derived from baseline data collected for a longitudinal trial assessing the effect of motivational interviewing among alcohol-abusing adults undergoing MMT. The sample included clients who were 18–55 years of age, abusing alcohol, and receiving MMT from five large methadone maintenance clinics in the Los Angeles area. A structured questionnaire was used to collect the data. Correlates of hospitalization in logistic regression analysis included lack of social support, recent victimization, age of first alcohol use, chronic severe pain in the previous six months, not having children, and ethnicity. Identification of hospitalization risk factors among alcohol-abusing MMT clients is a first step to developing risk-reducing interventions designed to lower hospitalization rates in this population.
doi:10.1177/0193945908328784
PMCID: PMC3806279  PMID: 19129517
alcohol abuse; methadone maintenance; hospitalization
9.  A Retrospective Analysis of Two Randomized Trials of Bupropion for Methamphetamine Dependence: Suggested Guidelines for Treatment Discontinuation/Augmentation 
Drug and alcohol dependence  2012;125(1-2):169-172.
Background
Two clinical trials have shown efficacy for bupropion in treating methamphetamine (MA) dependence among those with moderate baseline MA use. However, treatment response is highly variable and it is unclear what duration of treatment is necessary to determine if maintaining the treatment course is indicated or if discontinuation or augmentation is appropriate. The present study assessed the relationship among early bupropion treatment response for moderate MA users and end-of-treatment (EOT) abstinence. These data provide estimates of the duration of treatment and the degree of responsiveness required to persist in bupropion treatment.
Methods
Participants with moderate baseline MA use in the bupropion condition of two randomized double-blind placebo controlled trials were included. The relationship between early treatment response and EOT outcomes was assessed with Receiver Operating Characteristic (ROC) curves.
Results
With thrice weekly urine drug testing, excellent predictive power was established in the first two weeks of treatment. The inability to achieve at least three MA negative samples in the first two weeks is associated with greater than 90% likelihood of treatment failure. More closely approximating clinical settings, once-weekly testing featured reliable predictive power within three weeks, suggesting that the failure to produce at least two clean samples in the first three weekly visits confers high risk of treatment failure.
Discussion
The findings provide preliminary evidence to guide clinical decisions for moderate MA users receiving bupropion. The results are consistent with data from the smoking cessation literature and may highlight the importance of early response in addiction treatment.
doi:10.1016/j.drugalcdep.2012.03.027
PMCID: PMC3418457  PMID: 22534658
methamphetamine dependence; abstinence; early response; bupropion; treatment switching
10.  Correlates of Hepatitis B Virus and HIV Knowledge among Gay and Bisexual Homeless Young Adults in Hollywood 
Homeless gay and bisexual (G/B) young men have multiple risk factors which increase their risk of contracting hepatitis B virus (HBV) and Human Immunodeficiency Virus (HIV). This study used baseline information from structured instruments to assess correlates of knowledge to HIV and HBV infection from a 267 young (18–39 year old) gay/bisexual (G/B) active methamphetamine, cocaine and crack-using homeless men enrolled in a longitudinal trial. The study is designed to reduce drug use and improve knowledge of hepatitis and HIV/AIDS in a community center in Hollywood California. Regression modeling revealed that previous hepatitis education delivered to G/B men was associated with higher levels of HIV/AIDS and hepatitis knowledge. Moreover, higher HIV/AIDS knowledge was associated with combining sex and drinking alcohol. Associations with hepatitis B knowledge was found among G/B men who were engaging in sex while under the influence of marijuana, who were receiving support from non-drug users, and who had been homeless in the last four months. While being informed about HIV/AIDS and hepatitis did not preclude risky sexual and drug use behavior, knowledge about the dangers of concurrent sex with substance use is important. As higher levels of knowledge of hepatitis was associated with more moderate drug use, early access to testing and teaching harm reduction strategies remains critical to reduce exposure and infection of HBV and HIV in this population.
doi:10.1177/1557988312456068
PMCID: PMC3618445  PMID: 22879650
Hepatitis B virus; HIV; Gay/bisexual homeless young men
11.  Correlates of HIV Acquisition in a Cohort of Black Men Who Have Sex with Men in the United States: HIV Prevention Trials Network (HPTN) 061 
PLoS ONE  2013;8(7):e70413.
Background
Black men who have sex with men (MSM) in the United States (US) are affected by HIV at disproportionate rates compared to MSM of other race/ethnicities. Current HIV incidence estimates in this group are needed to appropriately target prevention efforts.
Methods
From July 2009 to October 2010, Black MSM reporting unprotected anal intercourse with a man in the past six months were enrolled and followed for one year in six US cities for a feasibility study of a multi-component intervention to reduce HIV infection. HIV incidence based on HIV seroconversion was calculated as number of events/100 person-years. Multivariate proportional hazards modeling with time-dependent covariates was used to identify correlates of HIV acquisition.
Results
Of 1,553 Black MSM enrolled, 1,164 were HIV-uninfected at baseline and included in follow-up. Overall annual HIV incidence was 3.0% (95% confidence interval (CI): 2.0, 4.4%) and 5.9% among men ≤30 years old (95% CI: 3.6, 9.1%). Men ≤30 years old reported significantly higher levels of sexual risk and were more likely to have a sexually transmitted infection diagnosed during follow-up. Younger men also were more likely to not have a usual place for health care, not have visited a health care provider recently, and to have unmet health care needs. In multivariate analysis, age ≤30 years (hazard ratio (HR): 3.4; 95% CI: 1.4, 8.3) and unprotected receptive anal intercourse with HIV-positive or unknown status partners (HR: 4.1; 95% CI: 1.9, 9.1) were significantly associated with HIV acquisition.
Conclusion
In the largest cohort of prospectively-followed Black MSM in the US, HIV incidence was high, particularly among young men. Targeted, tailored and culturally appropriate HIV prevention strategies incorporating behavioral, social and biomedical based interventions are urgently needed to lower these rates.
doi:10.1371/journal.pone.0070413
PMCID: PMC3724810  PMID: 23922989
12.  Adversity and Syndemic Production Among Men Participating in the Multicenter AIDS Cohort Study: A Life-Course Approach 
Objectives
We tested a theory of syndemic production among men who have sex with men (MSM) using data from a large cohort study.
Methods
Participants were 1551 men from the Multicenter AIDS Cohort Study enrolled at 4 study sites: Baltimore, Maryland–Washington, DC; Chicago, Illinois; Los Angeles, California; and Pittsburgh, Pennsylvania. Participants who attended semiannual visits from April 1, 2008, to March 31, 2009, completed an additional survey that captured data about events throughout their life course thought to be related to syndemic production.
Results
Using multivariate analysis, we found that the majority of life-course predictor variables (e.g., victimization, internalized homophobia) were significantly associated with both the syndemic condition and the component psychosocial health outcomes (depressive symptoms, stress, stimulant use, sexual compulsivity, intimate partner violence). A nested negative binomial analysis showed that the overall life course significantly explained variability in the syndemic outcomes (χ2 = 247.94; P < .001; df = 22).
Conclusions
We identified life-course events and conditions related to syndemic production that may help to inform innovative interventions that will effectively disentangle interconnecting health problems and promote health among MSM.
doi:10.2105/AJPH.2012.300810
PMCID: PMC3518355  PMID: 23153154
13.  A Novel Combination HIV Prevention Strategy: Post-Exposure Prophylaxis with Contingency Management for Substance Abuse Treatment Among Methamphetamine-Using Men Who Have Sex with Men 
AIDS Patient Care and STDs  2012;26(6):320-328.
Abstract
Methamphetamine use has been associated with HIV transmission among men who have sex with men (MSM). However, providers have been hesitant to utilize post-exposure prophylaxis (PEP) in populations of stimulant users. This single-arm, open label pilot study sought to demonstrate the safety, feasibility, and acceptability of PEP combined with the drug abstinence intervention of contingency management (CM) in methamphetamine-using MSM. HIV-uninfected MSM reporting recent methamphetamine use were recruited to a CM intervention. Those who reported a recent high-risk sexual or injection drug exposure to an HIV-infected or serostatus unknown source were initiated on tenofovir/emtricitabine (Truvada)-based PEP. Participants were followed over 3 months for infectious/biologic, behavioral, and drug use outcomes. Fifty-three participants enrolled in the study; 35 participants (66%) initiated PEP after a high-risk exposure. The median time from exposure to medication administration was 37.8 h (range 12.5–68.0 h). Twenty-five (71.4%) PEP initiators successfully completed the treatment course. Median medication adherence was 96% (IQR 57–100%), and medication was generally well tolerated. Methamphetamine abstinence during CM treatment increased PEP adherence (2% [95% CI +1–+3%]) per clean urine toxicology sample provided), and increased the odds of PEP course completion (OR 1.17, 95% CI 1.04–1.31). One incident of HIV seroconversion was observed in a participant who did not complete PEP treatment, and reported multiple subsequent exposures. Findings demonstrate that PEP, when combined with CM, is safe, feasible, and acceptable as an HIV prevention strategy in methamphetamine-using MSM.
doi:10.1089/apc.2011.0432
PMCID: PMC3366332  PMID: 22680280
14.  Seroadaptation in a Sample of Very Poor Los Angeles Area Men Who Have Sex with Men 
AIDS and behavior  2013;17(5):1862-1872.
Data from 635 very poor men who have sex with men (MSM) were used to identify seroadaptation with 1,102 male partners reported between 2005-2007 in Los Angeles as part of the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program. The mean age of the sample was 41.7 years; 53% had experienced homelessness in the past year. Condoms were reported in 51% of sexual events involving anal intercourse. HIV seroconcordance was reported in 41% of sexual partnerships among HIV-positive participants. HIV-positive men were more likely to have oral-only or unprotected receptive anal intercourse and less likely to have unprotected insertive anal intercourse with HIV-negative or unknown partners compared to HIV-positive partners. Even in the face of poverty, HIV-positive MSM report mitigating risks of HIV-transmission though seroadaptation in the context of modest rates of condom use.
doi:10.1007/s10461-012-0213-2
PMCID: PMC3479326  PMID: 22644067
serosorting; seropositioning; oral-only sex; poverty
15.  Development of an Evidence-based, Gay-specific Cognitive Behavioral Therapy Intervention for Methamphetamine-abusing Gay and Bisexual Men 
Addictive behaviors  2011;10.1016/j.addbeh.2011.11.029.
This study compared outcomes in methamphetamine use and sexual risk behaviors from a modified gay-specific, cognitive behavioral therapy (GCBT) combined with a low-cost contingency management (CM; [GCBT+CM]) intervention to prior findings from clinical trials of the original GCBT. Effect sizes for primary outcomes were compared using meta analysis. Comparisons of effect sizes at end of treatment showed the modified GCBT+CM produced significantly fewer consecutive weeks of methamphetamine abstinence (−0.44, CI: −0.79, −0.09) and fewer male sexual partners (−0.36, CI: −0.71, −0.02) than the first trial of GCBT, and more days of methamphetamine use (0.35, CI: 0.02, 0.68) than the second trial of GCBT. At 26-week follow-up, the modified GCBT+CM produced greater effects in reducing the number of male sexual partners (−0.54, CI: −0.89, −0.19; −0.51, CI: −0.84, −0.18). The original GCBT produced more and mostly short-term beneficial drug use outcomes, though sexual behavior changes consistently favored the modified GCBT+CM. On balance, most benefits are retained with the modified GCBT+CM intervention.
doi:10.1016/j.addbeh.2011.11.029
PMCID: PMC3326187  PMID: 22169619
methamphetamine abuse treatment; gay and bisexual men; sexual risk behavior; cognitive behavioral therapy; contingency management
16.  Randomized, placebo-controlled trial of bupropion for the treatment of methamphetamine dependence 
Drug and alcohol dependence  2008;96(3):222-232.
Objective
To compare bupropion to placebo for reducing methamphetamine (MA) use, increasing retention, and reducing the severity of depressive symptoms and MA cravings. A secondary objective compared bupropion to placebo for reducing cigarette smoking among MA dependent participants.
Methods
Following a 2-week, non-medication baseline screening period, 73 treatment-seeking MA dependent participants were randomly assigned to bupropion sustained release (150 mg twice daily; N=36) or placebo (twice daily; N=37) for 12-weeks under double blind conditions. Participants attended clinic thrice weekly to provide urine samples analyzed for MA-metabolite, to complete research measures and assessments, and to receive contingency management and weekly cognitive behavioral therapy sessions.
Results
There were no statistically significant effects for bupropion relative to placebo on MA use verified by urine drug screens, for reducing the severity of depressive symptoms or MA cravings, or on study retention. In a post hoc analysis, there was a statistically significant effect of bupropion treatment on MA use among participants with lighter (0–2 MA-positive urines), but not heavier (3–6 MA-positive urines) MA use during baseline (OR=2.81, 95% CI=1.61–4.93, p<0.001 for MA-free week with bupropion among light users). Bupropion treatment was also associated with significantly reduced cigarette smoking, by almost 5 cigarettes per day (p=0.0002).
Conclusion
Bupropion was no more effective than placebo in reducing MA use in planned analyses, though bupropion did reduce cigarette smoking. Post hoc findings of an effect for bupropion among baseline light, but not heavy, MA users suggests further evaluation of bupropion for light MA users is warranted.
doi:10.1016/j.drugalcdep.2008.03.010
PMCID: PMC3652530  PMID: 18468815
bupropion; methamphetamine dependence; randomized clinical trial
17.  Gender, BDNF Val66Met, and Methamphetamine Use Frequency 
Gender Medicine  2012;9(2):112-120.
Pre-treatment methamphetamine (MA) use frequency is an important predictor of outcomes of treatment for MA dependence. Preclinical studies suggest females self-administer more MA than males but few clinical studies have examined potential sex differences in MA use frequency. Estrogen increases expression of brain-derived neurotrophic factor (BDNF) which has effects on MA-induced striatal dopamine release and protects against MA-induced neurotoxicity. Therefore, we examined potential effects of sex, the Val66Met polymorphism in BDNF, and their interaction, on MA use frequency among 60 Caucasian MA dependent volunteers screening for a clinical trial. Females reported significantly more pre-treatment days with methamphetamine use in the past 30 than males. There was a significant interaction between sex and BDNF Val66Met with the highest frequency of MA use among females with Val/Val genotype. These results, although preliminary, add to the literature documenting sexual dimorphism in response to stimulants including methamphetamine and suggest a potential biological mechanism involving BDNF that may contribute to these differences. Additional research characterizing the biological basis of altered response to methamphetamine among females is warranted.
doi:10.1016/j.genm.2012.02.005
PMCID: PMC3322259  PMID: 22445683
BDNF Val66Met; Brain-derived neurotrophic factor; Gender; Methamphetamine
19.  Cumulative exposure to stimulants and immune function outcomes among HIV-positive and HIV-negative men in the Multicenter AIDS Cohort Study 
SUMMARY
We examined associations between stimulant use (methamphetamine and cocaine) and other substances (nicotine, marijuana, alcohol, inhaled nitrites) with immune function biomarkers among HIV-seropositive (HIV+) men using highly active antiretroviral therapy (ART) and -seronegative (HIV−) men in the Multicenter AIDS Cohort Study (MACS). Among HIV+ men, cumulative adherence to ART (4.07, 95% CI: 3.52, 4.71, per 10 years of adherent HAART use), and recent cohort enrollment (1.38; 95% CI: 1.24, 1.55) were multiplicatively associated with increases in CD4+/CD8+ ratios. Cumulative use of methamphetamine (0.93; 95% CI: 0.88, 0.98, per 10 use years), cocaine (0.93; 95% CI: 0.89, 0.96, per 10 use years), and cumulative medical visits (0.99; 95% CI: 0.98, 0.99, per 10 visit years), each showed small negative associations with CD4+/CD8+ ratios. Among HIV- men, cumulative medical visits (0.996; 95% CI: 0.993, 0.999), cumulative number of male sexual partners (0.999; 95% CI: 0.998, 0.9998, per 10 partner years) and cigarette pack years (1.10; 95% CI: 1.02, 1.18, per 10 pack years) were associated with CD4+/CD8+ ratios over the same period. ART adherence is associated with a positive immune function independent of stimulant use, underscoring the influence of ART on immune health for HIV+ men who engage in stimulant use.
doi:10.1258/ijsa.2012.011322
PMCID: PMC3576843  PMID: 22930295
HIV; men; methamphetamine; cocaine; CD4+/CD8+ ratio; antiretroviral therapy; adherence; Multicenter AIDS Cohort Study
20.  NIDA’s Clinical Trials Network: An Opportunity for HIV Research in Community Substance Abuse Treatment Programs 
Background/Objectives
HIV continues to be a significant problem among substance users and their sexual partners in the United States. The National Drug Abuse Treatment Clinical Trials Network (CTN) offers a national platform for effectiveness trials of HIV interventions in community substance abuse treatment programs. This article presents the HIV activities of the CTN during its first 10 years.
Results
While emphasizing CTN HIV protocols, this article reviews the (1) HIV context for this work; (2) the collaborative process among providers, researchers, and National Institute on Drug Abuse CTN staff, on which CTN HIV work was based; (3) results of CTN HIV protocols and HIV secondary analyses in CTN non-HIV protocols; and (4) implications for future HIV intervention effectiveness research in community substance abuse treatment programs.
Conclusion/Significance
While the feasibility of engaging frontline providers in this research is highlighted, the limitations of small to medium effect sizes and weak adoption and sustainability in everyday practice are also discussed.
doi:10.3109/00952990.2011.596977
PMCID: PMC3361073  PMID: 21854270
Clinical Trials Network; effectiveness research; HIV/AIDS; substance abuse
21.  Effect of Motivational Interviewing on Reduction of Alcohol Use 
Drug and Alcohol Dependence  2010;107(1):23-30.
Background
Methadone-Maintained (MM) clients who engage in excessive alcohol use are at high risk for HIV and Hepatitis B virus (HBV) infection. Nurse-led Hepatitis Health Promotion (HHP) may be one strategy to decrease alcohol use in this population.
Objective
To evaluate the impact of nurse-led HHP, delivered by nurses compared to Motivational Interviewing (MI), delivered by trained therapists in group sessions or one-on-one on reduction of alcohol use.
Methods
A three-arm randomized, controlled trial, conducted with 256 MM adults attending one of five MM outpatient clinics in the Los Angeles area. Within each site, moderate-to-heavy alcohol-using MM participants were randomized into one of three conditions: 1) nurse-led hepatitis health promotion group sessions (n=87); 2) MI delivered in group sessions (MI-group; n=90), or 3) MI delivered one-on-one sessions (MI-single, n=79).
Results
Self-reported alcohol use was reduced from a median of 90 drinks/month at baseline to 60 drinks/month at six month follow-up. A Wilcoxon sign-rank test indicated a significant reduction in alcohol use in the total sample (p < .05). In multiple logistic regression analysis controlling for alcohol consumption at baseline and other covariates, no differences by condition were found.
Discussion
As compared to two programs delivered by MI specialists, a culturally-sensitive and easy to implement nurse-led HHP program produced similar reductions in alcohol use over six months. Employing nurse-led programs may allow cost savings for treatment programs as well as a greater integration of alcohol reduction counseling along with a more comprehensive focus on general health-related issues than previously conducted.
doi:10.1016/j.drugalcdep.2009.08.021
PMCID: PMC3383096  PMID: 19836904
Alcohol use; Methadone Maintained; Motivational Interviewing; nurse-led hepatitis health promotion
22.  Preventive HIV Vaccine Acceptability and Behavioral Risk Compensation among a Random Sample of High-Risk Adults in Los Angeles (LA VOICES) 
Health Services Research  2009;44(6):2167-2179.
Objective
To assess HIV vaccine acceptability among high-risk adults in Los Angeles.
Study Setting
Sexually transmitted disease clinics, needle/syringe exchange programs, Latino community health/HIV prevention programs.
Study Design
Cross-sectional survey using conjoint analysis. Participants were randomly selected using three-stage probability sampling.
Data Collection
Sixty-minute structured interviews. Participants rated acceptability of eight hypothetical vaccines, each with seven dichotomous attributes, and reported post-vaccination risk behavior intentions.
Principal Findings
Participants (n=1164; 55.7 percent male, 82.4 percent ethnic minority, mean age=37.4 years) rated HIV vaccine acceptability from 28.4 to 88.6; mean=54.5 (SD=18.8; 100-point scale). Efficacy had the greatest impact on acceptability, followed by side effects and out-of-pocket cost. Ten percent would decrease condom use after vaccination.
Conclusions
Findings support development of social marketing interventions to increase acceptability of “partial efficacy” vaccines, behavioral interventions to mitigate risk compensation, and targeted cost subsidies.
doi:10.1111/j.1475-6773.2009.01039.x
PMCID: PMC2796320  PMID: 19780857
HIV; AIDS; HIV vaccine; conjoint analysis; risk compensation; venue-based probability sampling
23.  Smoking-induced change in intrasynaptic dopamine concentration: Effect of treatment for Tobacco Dependence 
Psychiatry research  2010;183(3):218-224.
The aim of this study was to determine whether standard treatments for Tobacco Dependence affect smoking-induced changes in intrasynaptic dopamine (DA) concentration. Forty-three otherwise healthy adult cigarette smokers (10 to 40 cigarettes per day) were treated with either practical group counseling (PGC) psychotherapy (n = 14), bupropion HCl (n = 14), or matching pill placebo (n = 15) (random assignment) for 8 weeks. Before and after treatment, each subject underwent a bolus-plus-continuous-infusion 11C-raclopride positron emission tomography (PET) scanning session, during which he or she smoked a regular cigarette. The PET scanning outcome measure of interest was percent change in smoking-induced 11C-raclopride binding potential (BPND) in the ventral caudate/nucleus accumbens (VCD/NAc), as an indirect measure of DA release. Although the entire study sample had a smaller mean smoking-induced reduction in VCD/NAc BPND after treatment (compared to before treatment), this change was highly correlated with smaller total cigarette puff volumes (and not other treatment variables). These data indicate that smoking-induced DA release is dose-dependent, and is not significantly affected by reductions in daily smoking levels or treatment type.
doi:10.1016/j.pscychresns.2009.06.004
PMCID: PMC2947623  PMID: 20682457
tobacco dependence; 11C-raclopride; positron emission tomography; dopamine; ventral striatum; cigarette craving
24.  Challenges in providing service in methadone maintenance therapy clinics in China: Service providers’ perceptions 
Background
The Methadone Maintenance Therapy (MMT) program has been initiated in China since 2004. As of the end of November, 2008, 558 MMT clinics had been established countrywide. The objective of this study was to elucidate the difficulties and challenges as perceived by service providers working in MMT clinics.
Methods
One service provider from each of the 28 MMT study clinics in Zhejiang and Jiangxi Provinces of China participated in a face-to-face in-depth interview for about 1–2 hours to describe their perceptions of working in MMT clinics. Qualitative data were analyzed using ATLAS.ti. The grounded theory was used to guide the data analysis.
Results
Participants identified major problems in providing services in MMT clinics including lack of resources, professional training, and institutional support. Difficulties in pursuit of career, concern for personal safety, low income, heavy working load, and poor opinion of MMT by Chinese society often contributed to greater stress and burnout among the service providers.
Conclusion
The MMT programs in China desperately need additional resource allocation and institutional support for the current and perhaps future expansion of the programs. The service providers are in urgent need of professional training to improve the quality of care they can offer MMT clients.
doi:10.1016/j.drugpo.2009.09.002
PMCID: PMC2847064  PMID: 19818591
Methadone Maintenance Therapy; China; qualitative; service providers
25.  Effects of a Nurse-Managed Program on Hepatitis A and B Vaccine Completion Among Homeless Adults 
Nursing research  2009;58(1):13-22.
Background
Hepatitis B virus (HBV) infection constitutes a major health problem for homeless persons. Ability to complete an HBV vaccination series is complicated by the need to prioritize competing needs, such as addiction issues, safe places to sleep, and food, over health concerns.
Objectives
The objectives of this study were to evaluate the effectiveness of a nurse-case-managed intervention compared with that of two standard programs on completion of the combined hepatitis A virus (HAV) and HBV vaccine series among homeless adults and to assess socio-demographic factors and risk behaviors related to the vaccine completion.
Methods
A randomized, three-group, prospective, quasi-experimental design was conducted with 865 homeless adults residing in homeless shelters, drug rehabilitation sites, and outdoor areas in the Skid Row area of Los Angeles. The programs included (a) nurse-case-managed sessions plus targeted hepatitis education, incentives, and tracking (NCMIT); (b) standard targeted hepatitis education plus incentives and tracking (SIT); and (c) standard targeted hepatitis education and incentives only (SI).
Results
Sixty-eight percent of the NCMIT participants completed the three-series vaccine at 6 months, compared with 61% of SIT participants and 54% of SI participants. NCMIT participants had almost 2 times greater odds of completing vaccination than those of participants in the SI program. Completers were more likely to be older, to be female, to report fair or poor health, and not to have participated in a self-help drug treatment program. Newly homeless White adults were significantly less likely than were African Americans to complete the vaccine series.
Discussion
The use of vaccination programs incorporating nurse case management and tracking is critical in supporting adherence to completion of a 6-month HAV/HBV vaccine. The finding that White homeless persons were the least likely to complete the vaccine series suggests that programs tailored to address their unique cultural issues are needed.
doi:10.1097/NNR.0b013e3181902b93
PMCID: PMC3076026  PMID: 19092551
HAV/HBV vaccine completion; homeless adults; nurse case managed program; substance abuse

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