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1.  Nondisclosure of HIV Status in a Clinical Trial Setting: Antiretroviral Drug Screening Can Help Distinguish Between Newly Diagnosed and Previously Diagnosed HIV Infection 
In The HIV Prevention Trials Network 061 study, 155 human immunodeficiency virus (HIV)–infected men reported no prior HIV diagnosis; 83 of those men had HIV RNA levels of <1000 copies/mL at enrollment. Antiretroviral drug testing revealed that 65 of the 83 (78.3%) men were on antiretroviral treatment. Antiretroviral drug testing can help distinguish between newly diagnosed and previously diagnosed HIV infection.
doi:10.1093/cid/cit672
PMCID: PMC3864502  PMID: 24092804
HIV; antiretroviral; self-report; MSM; new diagnosis
2.  Pharmacotherapy of amphetamine-type stimulant dependence: An update 
Drug and alcohol review  2013;32(5):449-460.
Issues
Methamphetamine or amphetamine-type stimulants are the second most frequently used illicit drug worldwide, second only to cannabis. Behavioural treatments are efficacious, but their impact is limited underscoring the need for other treatment options, notably, pharmacotherapy.
Approach
A review of randomised controlled trials of pharmacotherapies for methamphetamine or amphetamine-type stimulants was performed using PubMed and Google Scholar databases. Evidence for efficacy of medications is reported.
Key findings
Clinical trials have yielded no broadly effective pharmacotherapy. Promising signals have been observed for methylphenidate, naltrexone, bupropion and mirtazapine in subgroups of patients in reducing stimulant use (e.g. patients with less severe dependence at baseline, men who have sex with men), though none has produced an unambiguous, replicable signal of efficacy.
Implications
Problems in Phase II trials, including high drop-out rates, missing data and a lack of agreement on outcomes, complicate efforts to find a broadly effective pharmacotherapy for amphetamine-type stimulant disorders. Efforts to address these problems include calls for better validation of pharmacological target exposure, receptor binding and functional modulation. As well, there is a need for agreement in using findings from pre-clinical and early phases of the medication development process for selecting better pharmacotherapy candidates.
Conclusion
After over 20 years of efforts worldwide to develop a broadly effective medication for dependence on methamphetamine or amphetamine-type stimulants, no candidate has emerged. This highlights the need for new compounds, consistent and stringent research methods, better integration between preclinical and clinical stages of medication development, and improved collaboration between government, industry and researchers.
doi:10.1111/dar.12048
PMCID: PMC4251965  PMID: 23617468
amphetamine; methamphetamine; pharmacotherapy; agonists; antagonists; pharmacogenetics
3.  Methamphetamine and Other Substance Use Trends among Street-recruited Men Who Have Sex with Men, from 2008 to 2011 
Drug and alcohol dependence  2013;133(1):262-265.
Background
It is particularly important to survey substance use trends in populations most impacted by the consequences of substance use. Men who have sex with men (MSM) exhibit rates of methamphetamine and other substance use that exceeds those observed among other populations in the United States. Such substance use has been associated with numerous negative health sequelae.
Methods
An outreach program performed street encounters with 5,599 unique substance-using MSM from January 1, 2008 through December 31, 2011 to collect data on self-reported sociodemographics and recent substance use. Data were aggregated into six-month cohorts for comparisons of recent substance use patterns across time.
Results
Participants averaged 33 years of age (SD = 8), most were Caucasian/white (47%) or Hispanic/Latino (32%), and the self-reported HIV seroprevalence rate was 13.4%. Across cohorts, reported use of alcohol (range = 91% to 93%), marijuana (range = 36% to 46%), and/or methamphetamine (range = 23% to 27%) was common; prevalence of amyl nitrite (max = 14%), ecstasy (max = 12%), powder cocaine (max = 8%) and/or crack cocaine (max = 4%) use, although less common, were still elevated relative to the United States general population.
Conclusions
Methamphetamine and other substance use remained common among substance-using MSM, demonstrating the need for continued substance use interventions geared toward this high-risk population.
doi:10.1016/j.drugalcdep.2013.06.007
PMCID: PMC3888192  PMID: 23890490
methamphetamine; MSM; street outreach; HIV; substance use
4.  Depression and Health Risk Behaviors: Towards Optimizing Primary Care Service Strategies for Addressing Risk 
Purpose
Depression and health risk behaviors in adolescents are leading causes of preventable morbidity and mortality. Primary care visits provide prime opportunities to screen and provide preventive services addressing risk behaviors/conditions. This study evaluated the co-occurrence of depression and health risk behaviors (focusing on smoking, drug and alcohol misuse, risky sexual behavior, and obesity-risk) with the goal of informing preventive service strategies.
Methods
Consecutive primary care patients (n=217), ages 13 to 18 years, selected to over-sample for depression, completed a Health Risk Behavior Survey and the Diagnostic Interview Schedule for Children and Adolescents (DISC) depression module.
Results
Youths with DISC-defined past-year depression were significantly more likely to report risk across multiple risk-areas, Wald X2(1)=14.39, p<.001, and to have significantly higher rates of past-month smoking, X2(1)=5.86, p=.02, substance misuse, X2(1)=15.12, p<.001, risky sex, X2 (1) =5.04, p=.03, but not obesity-risk, X2 (1) =0.19, p=.66. Cross-sectional predictors of risk behaviors across risk areas were similar. Statistically significant predictors across all risk domains included: youths’ expectancies about future risk behavior; attitudes regarding the risk behavior; and risk behaviors in peers/others in their environments.
Conclusions
Depression in adolescents is associated with a cluster of health risk behaviors that likely contribute to the high morbidity and mortality associated with both depression and health risk behaviors. Consistent with the United States National Prevention Strategy (2011) and the focus on integrated behavioral and medical health care, results suggest the value of screening and preventive services using combination strategies that target depression and multiple areas of associated health risk.
doi:10.4172/2167-1079.1000152
PMCID: PMC4189940  PMID: 25309826
Depression; Health; Sex; Obesity; Smoking; Drug; Marijuana; Alcohol; Primary care
5.  Brain Abnormalities in HIV and Stimulant Users: Interventions and Prevention 
The session, “HIV and other Infectious Diseases,” was chaired by Dr. Jacques Normand, Director of the AIDS Research Program of the U.S. National Institute on Drug Abuse. The two presenters (and their presentation topics) were: Dr. Linda Chang (“Neural Correlates of Cognitive Deficits and Training Effects on Brain Function in HIV-infected Individuals”) and Dr. Steven Shoptaw (“HIV Prevention in Substance Users”).
doi:10.1016/j.jfda.2013.09.021
PMCID: PMC4175912  PMID: 25264417
Stimulant use; HIV prevention; brain abnormalities; neurocognitive disorder
6.  HIV prevention for people who use substances: evidence-based strategies 
Journal of food and drug analysis  2013;21(4):S91-S94.
Evidence-based strategies to guide HIV prevention for people who use substances can be grouped into approaches that lower infectiousness among substance users living with HIV and those that prevent HIV acquisition among those who are uninfected. Dramatic successes in HIV prevention involving access to antiretroviral therapy (ART), opioid substitution therapies, and needle and syringe exchange programs have reduced both prevalence and incidence in the United States for people who use injection drugs, and modeling studies suggest that scale-up of these approaches will have a parallel impact worldwide. Medical HIV-prevention strategies that reduce infectiousness (“treatment as prevention” or early ART initiation) and that block HIV acquisition (pre-exposure prophylaxis, post-exposure prophylaxis) can constitute key elements of novel combination HIV-prevention approaches to the goals of reducing infectiousness and reducing acquisition of HIV among people who use substances. For individuals who use substances but do not inject, drug dependence treatments as HIV prevention have a meager evidence-base, with most consistent findings being reduction of sexual transmission behaviors that correspond with reductions in substance use, though not with prevention of HIV transmission. This approach may have value, however, when working with groups of substance users who face high rates of HIV prevalence and incidence. Some evidence exists to support HIV prevention interventions that target reduction of sexual risk behaviors in the setting of active stimulant use.
doi:10.1016/j.jfda.2013.09.042
PMCID: PMC4158848  PMID: 25214751
Combination HIV prevention; Substance users; Drug treatment
7.  Spend today, clean tomorrow: Predicting methamphetamine abstinence in a randomized controlled trial 
Objective
This secondary analysis of data from a randomized controlled trial tested two behavioral economics mechanisms (substitutability and delay discounting) to explain outcomes using contingency management (CM) for methamphetamine dependence. Frequency and purchase type (hedonic/utilitarian and consumable/durable) of CM payments were also examined.
Methods
82 methamphetamine-dependent gay/bisexual men randomly assigned to conditions delivering CM received monetary vouchers in exchange for stimulant-negative urine samples in a 16-week trial requiring thrice weekly visits (Shoptaw et al., 2005). At any visit participants could redeem vouchers for goods. A time-lagged counting process Cox Proportional Hazards model for recurrent event survival analysis examined aspects of the frequency and type of these CM purchases.
Results
After controlling for severity of baseline methamphetamine use and accumulated CM wealth, as measured by cumulative successful earning days, participants who redeemed CM earnings at any visit (“spenders”) were significantly more likely to produce stimulant-negative urine samples in the subsequent visit, compared to those who did not redeem (“savers”) 1.011* [1.005, 1.017], Z=3.43, p<0.001.
Conclusions
Findings support the economic concept of substitutability of CM purchases and explain trial outcomes as a function of frequency of CM purchases rather than frequency or accumulated total CM earnings. Promotion of frequent purchases in incentive-based programs should facilitate substitution for the perceived value of methamphetamine and improve abstinence outcomes.
doi:10.1037/a0032922
PMCID: PMC3940415  PMID: 24001246
Contingency Management; Behavioral Economics; Addiction
8.  Double-blind placebo-controlled evaluation of the PROMETA™ protocol for methamphetamine dependence 
Addiction (Abingdon, England)  2011;107(2):361-369.
Aims
To evaluate the efficacy and safety of the PROMETA™ Protocol for treating methamphetamine dependence.
Design
A double-blind, placebo-controlled 108-day study with random assignment to one of two study conditions: active medication with flumazenil (2 mg infusions on days 1, 2, 3, 22, 23), gabapentin (1200 mg to day 40) and hydroxazine (50 mg to day 10) versus placebo medication (with active hydroxazine only).
Setting
Three substance abuse treatment clinics: two in-patient, one out-patient.
Participants
Treatment-seeking, methamphetamine-dependent adults (n = 120).
Measurements
Primary outcome was percentage of urine samples testing negative for methamphetamine during the trial.
Findings
No statistically significant between-group differences were detected in urine drug test results, craving, treatment retention or adverse events.
Conclusions
The PROMETA protocol, consisting of flumazenil, gabapentin and hydroxyzine, appears to be no more effective than placebo in reducing methamphetamine use, retaining patients in treatment or reducing methamphetamine craving.
doi:10.1111/j.1360-0443.2011.03619.x
PMCID: PMC4122522  PMID: 22082089
Methamphetamine; pharmacotherapy; PROMETA protocol; substance abuse treatment
9.  Epidemiology, Sexual Risk Behavior, and HIV Prevention Practices of Men who Have Sex with Men Using GRINDR in Los Angeles, California 
Young men who have sex with men (YMSM) are at alarming risk for HIV acquisition, demonstrating the highest rates of incident infection of any age-risk group. GRINDR is a global positioning service-based social networking application popular with YMSM for sexual partnering. To assess the characteristics of YMSM who use GRINDR, we conducted a computer-assisted self-interview-based survey of 375 YMSM using GRINDR in metropolitan Los Angeles, recruited using the GRINDR platform. The median age was 25 (interquartile range, 22–27) years old, 42.4 % caucasian, 6.4 % African American, 33.6 % Latino, and 14.1 % Asian/Pacific Islander. Participants reported high rates of sexual partnering and unprotected anal intercourse (UAI). The majority (70 %) of those reporting unprotected anal intercourse reported low perception of HIV-acquisition risk. Of the participants, 83.1 % reported HIV testing within the past 12 months; 4.3 % had never been HIV tested. Of the participants, 4.5 % reported HIV-positive serostatus; 51.7 % indicated that they would be interested in participating in a future HIV prevention trial. Latinos were more likely than either caucasians or African Americans to endorse trial participation interest (odds ratio, 1.9; 95 % confidence interval [1.1–3.3]). HIV-positive test results were associated with increased number of anal sex partners in the past 3 months (adjusted odds ratio (AOR), 1.53 [0.97–2.40]), inconsistent inquiry about partners’ serostatus (AOR, 3.63 [1.37–9.64]), reporting the purpose for GRINDR use including “friendship” (AOR, 0.17 [0.03–1.06), and meeting a sexual partner in a bookstore in the past 3 months (AOR, 33.84 [0.99–1152]). Men recruited via GRINDR were high risk for HIV acquisition or transmission and interested in clinical trial participation, suggesting potential for this method to be used for recruitment of YMSM to HIV prevention trials.
doi:10.1007/s11524-012-9766-7
PMCID: PMC3732683  PMID: 22983721
Sexual risk behavior; HIV prevention; Education; Study recruitment
10.  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
11.  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
12.  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
13.  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)
14.  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
15.  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
16.  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
17.  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
18.  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
19.  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
20.  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
21.  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
22.  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
23.  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
24.  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
25.  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

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