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1.  Risk factors for recent non-fatal overdose among HIV-infected Russians who inject drugs 
AIDS care  2014;26(8):1013-1018.
Overdoses and HIV infection are common among Russians who inject drugs, yet risk factors have not been studied. We analyzed baseline data of 294 participants with 30 day injection drug use from an HIV secondary prevention trial for persons reporting “heavy” alcohol use (NIAAA risky drinking definition) and risky sex in the past 6 months. The outcome was any self-reported overdose in the previous 3 months. We examined demographic, HIV-related, criminal justice, mental health, substance use and injection risk factors. Participants’ characteristics included median age 29 years, 117/294 (40%) female, and median CD4 cell count 345/μl. Over three quarters 223/294 (76%) reported a history of overdose; 47/294 (16%) reported overdose in the past 3 months. Past month injection frequency (AOR 4.77, 95%CI: 1.63-14.0 highest vs. lowest quartile; AOR 3.58, 95%CI: 1.20-10.69 second highest vs. lowest quartile) and anti-retroviral therapy at time of interview (AOR 3.96 95%CI: 1.33-11.83) were associated with 3-month overdose. Nonfatal overdose among HIV-infected Russians who inject drugs is common. Risk factors include injection frequency and anti-retroviral therapy, which warrant further study. Overdose prevention efforts are needed among HIV-infected Russians who inject drugs.
doi:10.1080/09540121.2013.871218
PMCID: PMC4040021  PMID: 24382133
Overdose; Russia; injection drug use; anti-retroviral therapy; HIV
2.  How Accurate Are Blood (or Breath) Tests for Identifying Self-Reported Heavy Drinking Among People with Alcohol Dependence? 
Aims
Managing patients with alcohol dependence includes assessment for heavy drinking, typically by asking patients. Some recommend biomarkers to detect heavy drinking but evidence of accuracy is limited.
Methods
Among people with dependence, we assessed the performance of disialo-carbohydrate-deficient transferrin (%dCDT, ≥1.7%), gamma-glutamyltransferase (GGT, ≥66 U/l), either %dCDT or GGT positive, and breath alcohol (> 0) for identifying 3 self-reported heavy drinking levels: any heavy drinking (≥4 drinks/day or >7 drinks/week for women, ≥5 drinks/day or >14 drinks/week for men), recurrent (≥5 drinks/day on ≥5 days) and persistent heavy drinking (≥5 drinks/day on ≥7 consecutive days). Subjects (n = 402) with dependence and current heavy drinking were referred to primary care and assessed 6 months later with biomarkers and validated self-reported calendar method assessment of past 30-day alcohol use.
Results
The self-reported prevalence of any, recurrent and persistent heavy drinking was 54, 34 and 17%. Sensitivity of %dCDT for detecting any, recurrent and persistent self-reported heavy drinking was 41, 53 and 66%. Specificity was 96, 90 and 84%, respectively. %dCDT had higher sensitivity than GGT and breath test for each alcohol use level but was not adequately sensitive to detect heavy drinking (missing 34–59% of the cases). Either %dCDT or GGT positive improved sensitivity but not to satisfactory levels, and specificity decreased. Neither a breath test nor GGT was sufficiently sensitive (both tests missed 70–80% of cases).
Conclusions
Although biomarkers may provide some useful information, their sensitivity is low the incremental value over self-report in clinical settings is questionable.
doi:10.1093/alcalc/agu016
PMCID: PMC4060735  PMID: 24740846
3.  Depressive Symptoms and Antiretroviral Therapy (ART) Initiation Among HIV-infected Russian Drinkers 
AIDS and behavior  2014;18(6):1085-1093.
The impact of depressive symptoms on ART initiation among Russian HIV-infected heavy drinkers enrolled in a secondary HIV prevention trial (HERMITAGE) was examined. We assessed 133 participants eligible for ART initiation (i.e., CD4 count <350 cells/μl) who were not on ART at baseline. Depressive symptom severity and ART use were measured at baseline, 6- and 12-months. Association between depressive symptoms and subsequent ART initiation was evaluated using GEE logistic regression adjusting for gender, past ART use, injection drug use and heavy drinking. Depressive symptom severity was not significantly associated with lower odds of initiating ART. Cognitive depression symptoms were not statistically significant (global p=0.05); however, those with the highest level of severity had an AOR of 0.25 (95% CI: 0.09–0.71) for delayed ART initiation. Although the effect of depression severity was not significant, findings suggest a potential role of cognitive depression symptoms in decisions to initiate ART in this population.
doi:10.1007/s10461-013-0674-y
PMCID: PMC4020947  PMID: 24337725
HIV; Antiretroviral Therapy (ART); depressive symptoms; Russia
4.  Inflammatory cytokines and mortality in a cohort of HIV-infected adults with alcohol problems 
AIDS (London, England)  2014;28(7):1059-1064.
Background:
HIV infection leads to chronic inflammation and alterations in levels of inflammatory cytokines. The association between cytokine levels and mortality in HIV-infection is not fully understood.
Methods:
We analyzed data from a cohort of HIV-infected adults with alcohol problems who were recruited in 2001-2003, and were prospectively followed until 2010 for mortality using the National Death Index.
The main independent variables were inflammatory biomarkers [IL-6, IL-10, TNF-alpha, C-reactive protein (CRP), Serum Amyloid A, Monocyte Chemotactic Protein-1 and Cystatin-C], measured at baseline in peripheral blood and categorized as high (defined as being in the highest quartile) vs. low. A secondary analysis was conducted using inflammatory burden score, defined as the number of biomarkers in the highest quartile (0,1,2 or ≥3). Cox models were used to assess the association between both biomarker levels and inflammatory burden with mortality adjusting for potential confounders.
Results:
Four hundred HIV-infected patients were included (74.8% male, mean age 42 years, 50% HCV-infected). As of 31st December 2009, 85 patients had died. In individual multivariable analyses for each biomarker, high levels of IL-6 and CRP were significantly associated with mortality [HR=2.49 (1.69-5.12), p<0.01] and [HR=1.87 (1.11-3.15), p=0.02], respectively. There was also a significant association between inflammatory burden score and mortality [HR=2.18 (1.29; 3.66) for ≥3 vs. 0, p=0.04]. In the fully adjusted multivariable analysis high levels of IL-6 remained independently associated with mortality [HR=2.57 (1.58-4.82), p<0.01].
Conclusions:
High IL-6 levels and inflammatory burden score were associated with mortality in a cohort of HIV-infected adults with alcohol problems.
doi:10.1097/QAD.0000000000000184
PMCID: PMC4105144  PMID: 24401638
IL-6; mortality; cytokines; HIV; alcohol
5.  Associations of Sex Trafficking History with Recent Sexual Risk among HIV-Infected FSWs in India 
AIDS and behavior  2014;18(3):555-561.
History of forced or coerced sex work entry and/or sex work entry prior to age 18 (i.e., sex trafficking) relate to early HIV risk; whether such risk persists is unclear. The current study assessed associations of reported sex trafficking histories and recent sexual risk among adult HIV-infected female sex workers (FSWs; n = 211) in Mumbai, India. Approximately one-half reported entering sex work prior to age 18 (50.2 %) or being forced or coerced into sex work (41.7 %). Past 90-day unprotected transactional sex was more prevalent among FSWs entering as minors than those entering as adults (AOR 2.06); in contrast, being forced or coerced into sex work related to reduction in such risk for HIV transmission (AOR 0.45). Histories of each form of sex trafficking may relate differently to later HIV risk. Intervention with HIV-infected FSWs entering sex work as minors should be prioritized based on potential elevated risk of HIV transmission.
doi:10.1007/s10461-013-0564-3
PMCID: PMC4111225  PMID: 23955657
Female sex workers; HIV-infected; Trafficking; India
6.  CD8+ T-Cells Count in Acute Myocardial Infarction in HIV Disease in a Predominantly Male Cohort 
BioMed Research International  2015;2015:246870.
Human Immunodeficiency Virus- (HIV-) infected persons have a higher risk for acute myocardial infarction (AMI) than HIV-uninfected persons. Earlier studies suggest that HIV viral load, CD4+ T-cell count, and antiretroviral therapy are associated with cardiovascular disease (CVD) risk. Whether CD8+ T-cell count is associated with CVD risk is not clear. We investigated the association between CD8+ T-cell count and incident AMI in a cohort of 73,398 people (of which 97.3% were men) enrolled in the U.S. Veterans Aging Cohort Study-Virtual Cohort (VACS-VC). Compared to uninfected people, HIV-infected people with high baseline CD8+ T-cell counts (>1065 cells/mm3) had increased AMI risk (adjusted HR = 1.82, P < 0.001, 95% CI: 1.46 to 2.28). There was evidence that the effect of CD8+ T-cell tertiles on AMI risk differed by CD4+ T-cell level: compared to uninfected people, HIV-infected people with CD4+ T-cell counts ≥200 cells/mm3 had increased AMI risk with high CD8+ T-cell count, while those with CD4+ T-cell counts <200 cells/mm3 had increased AMI risk with low CD8+ T-cell count. CD8+ T-cell counts may add additional AMI risk stratification information beyond that provided by CD4+ T-cell counts alone.
doi:10.1155/2015/246870
PMCID: PMC4320893  PMID: 25688354
7.  Association of Recent Incarceration with Traumatic Injury, Substance Use Related Health Consequences, and Health Care Utilization 
Journal of addiction medicine  2014;8(1):66-72.
Objective
The higher risk of death among recently released inmates relative to the general population may be due to the higher prevalence of substance dependence among inmates or an independent effect of incarceration. We explored the effects of recent incarceration on health outcomes that may be intermediate markers for mortality.
Methods
Longitudinal multivariable regression analysis were conducted on interview data (baseline, 3, 6, and 12 month follow-up) from alcohol and/or drug dependent individuals (n=553) participating in a randomized clinical trial to test the effectiveness of chronic disease management for substance dependence in primary care. The main independent variable was recent incarceration (spending ≥1 night in jail or prison in the past 3 months). The three main outcomes of this study were: any traumatic injury; substance use-related health consequences; and health care utilization defined as hospitalization (excluding addiction treatment or detoxification) and/or emergency department visit.
Results
Recent incarceration was not significantly associated with traumatic injury (adjusted odds ratio (AOR=0.98, 95%CI 0.65–1.49) or health care utilization (AOR=0.88, 95%CI: 0.64–1.20). However, recent incarceration was associated with higher odds for substance use-related health consequences (AOR=1.42, 95% CI: 1.02–1.98).
Conclusions
Among people with alcohol and/or drug dependence, recent incarceration was significantly associated with substance use-related health consequences but not injury or health care utilization after adjustment for covariates. These findings suggest that substance use related health consequences may be part of the explanation for the increased risk of death faced by former inmates.
doi:10.1097/ADM.0000000000000009
PMCID: PMC3962184  PMID: 24365804
Incarceration; substance dependence; trauma; health care utilization
8.  Does experiencing homelessness affect women’s motivation to change alcohol or drug use?? 
Background and Objectives
Homeless women are at high risk of drug and alcohol dependence and may receive less opportunity for treatment. Our objective was to examine the association between experiencing homelessness and motivation to change drug or alcohol use.
Methods
Women (n=154) participants in a study of substance dependence at an urban medical center (69 with some homeless days in the last 90 days; 85 continuously housed at baseline) completed 6 items rating motivation to change alcohol or drug use (i.e., importance, readiness, and confidence) at baseline and in 3, 6, and 12-month follow up interviews. Unadjusted, and longitudinal analyses controlling for covariates (e.g., demographics, insurance status, substance use consequences, mental health status, and participation in treatment), were conducted.
Results
There were no significant differences between women experiencing homeless days versus continuously housed women in the odds of reporting high motivation to change alcohol or drug use, either in unadjusted baseline analyses or longitudinal analyses adjusted for covariates. Covariates that were significantly associated with high importance, readiness or confidence to change behavior were higher life time consequences of substance use, and participation in 12-step programs.
Discussion and Conclusions
The findings suggest that clinicians should not make assumptions that homeless women have low motivation to change their substance use.
Scientific Significance and Future Directions
The same opportunities for addiction treatment should be offered to homeless as to housed women.
doi:10.1111/j.1521-0391.2013.12066.x
PMCID: PMC3857556  PMID: 24313245
Women; Homelessness; Motivation to Change; Alcohol Dependence; Drug Dependence
9.  No Detectable Association Between Frequency of Marijuana Use and Health or Healthcare Utilization Among Primary Care Patients Who Screen Positive for Drug Use 
ABSTRACT
BACKGROUND
Marijuana is the most commonly used illicit drug, yet its impact on health and healthcare utilization has not been studied extensively.
METHODS
To assess the cross-sectional association between frequency of marijuana use and healthcare utilization (emergency department and hospitalization) and health (comorbidity, health status), we studied patients in an urban primary care clinic who reported any recent (past 3-month) drug use (marijuana, opioids, cocaine, others) on screening. Frequency of marijuana use in the past 3 months was the main independent variable [daily/ almost daily, less than daily and no use (reference group)]. Outcomes assessed were past 3-month emergency department or hospital utilization, the presence of medical comorbidity (Charlson index ≥ 1), and health status with the EuroQol. We used separate multivariable regression models adjusting for age, sex, tobacco and other substance use.
RESULTS
All 589 participants reported recent drug use: marijuana 84 % (29 % daily, 55 % less than daily), cocaine 25 %, opioid 23 %, other drugs 8 %; 58 % reported exclusive marijuana use. Frequency of marijuana use was not significantly associated with emergency department use {adjusted odds ratio [AOR] 0.67, [95 % confidence interval (CI) 0.36, 1.24] for daily; AOR 0.69 [95 % CI 0.40,1.18] for less than daily versus no use}, hospitalization [AOR 0.79 (95 % CI 0.35, 1.81) for daily; AOR 1.23 (95 % CI 0.63, 2.40) for less than daily versus no use], any comorbidity [AOR 0.62, (95 % CI 0.33, 1.18) for daily; AOR 0.67 (95 % CI 0.38, 1.17) for less than daily versus no use] or health status (adjusted mean EuroQol 69.1, 67.8 and 68.0 for daily, less than daily and none, respectively, global p = 0.78).
CONCLUSIONS
Among adults in primary care who screen positive for any recent illicit or non-medical prescription drug use, we were unable to detect an association between frequency of marijuana use and health, emergency department use, or hospital utilization.
doi:10.1007/s11606-013-2605-z
PMCID: PMC3889953  PMID: 24048656
marijuana; primary care; health status; health service utilization
10.  Chronic Hepatitis C Virus Infection is Associated with All-Cause and Liver-Related Mortality in a Cohort of HIV-Infected Patients with Alcohol Problems 
Addiction (Abingdon, England)  2013;109(1):62-70.
Aims
To assess the association between hepatitis C virus (HCV) infection and overall and liver-related death in human immunodeficiency virus (HIV)-infected patients with alcohol problems.
Design
We analyzed data from a cohort of HIV-infected adults with current or past alcohol problems enrolled between 2001 and 2003, searching for causes of death until 2010 using the National Death Index.
Setting and participants
Participants were HIV-infected adults with current or past alcohol problems, recruited in Boston, MA from HIV clinics at two hospitals, homeless shelters, drug treatment programs, subject referrals, flyers, and another cohort study with comparable recruitment sites.
Measurements
The primary and secondary outcomes were all-cause and liver-related mortality, respectively. The main independent variable was HCV RNA status (positive vs. negative). Mortality rates and Kaplan-Meier survival curves were calculated by HCV status for both overall and liver-related mortality. Cox proportional hazards models were used to assess the association between HCV infection and overall and liver-related death, adjusting for alcohol and drug use over time.
Findings
397 adults (50% HCV-infected) were included. As of December 31, 2009, 83 cohort participants had died (60 HCV-infected, 23 HCV-uninfected; log rank test p<0.001), and 26 of those deaths were liver-related (21 HCV-infected, 5 HCV-uninfected; log rank test p<0.001). All-cause and liver-related mortality rates were 4.68 and 1.64 deaths per 100 person-years for HCV-infected patients and 1.65 and 0.36 per 100 person-years for those without HCV, respectively. In the fully adjusted Cox model, HCV infection was associated with both overall [HR 2.55 (95%CI:1.50–4.33), p<0.01], and liver-related mortality [HR 3.24 (95%CI:1.18–8.94), p=0.02].
Conclusion
Hepatitis C virus infection is independently associated with all-cause and liver-related mortality in human immunodeficiency virus-infected patients with alcohol problems, even when accounting for alcohol and other drug use.
doi:10.1111/add.12367
PMCID: PMC3947001  PMID: 24112091
12.  Is cannabis use associated with HIV drug and sex risk behaviors among Russian HIV-infected risky drinkers? 
Drug and alcohol dependence  2013;132(0):74-80.
Background
While cannabis use has been associated with increased HIV drug and sex risk behaviors, its impact on risk behaviors among HIV-infected individuals has not yet been established.
Methods
This study examined data from Russian HIV-infected risky drinkers enrolled in a randomized controlled trial of a behavioral intervention. The primary independent variable was cannabis use (current [past 30 days use], recent past [use but not in past 30 days] vs. no past year use). Primary outcomes were needle sharing and number of unprotected sexual episodes. Secondary outcomes were drug injection, number of injections, and multiple sex partners. Longitudinal regression analyses controlled for age, gender, marital status, education, CD4 count, ART use, risky alcohol use, other drug use, depressive symptoms and randomization group.
Results
Cannabis use was common with 20% current and 26% recent past use at baseline. In longitudinal analyses current, but not recent past, cannabis consumption was significantly associated with needle sharing (AOR 2.23 current vs. none, 95% CI: 1.46, 3.36), drug injection (AOR 3.05 current vs. none, 95% CI: 2.06, 4.53) and number of injections (adjusted IRR 1.50 current vs. none, 95% CI: 1.19, 1.89). Current and recent past cannabis use were significantly associated with multiple sex partners but not with number of unprotected sex episodes.
Conclusion
Cannabis use was associated with drug and sex risk behaviors among Russian HIV-infected risky drinkers. Inquiry about cannabis use among HIV-infected patients may reveal a patient group at higher risk for sex and drug use behaviors that lead to HIV transmission.
doi:10.1016/j.drugalcdep.2013.01.009
PMCID: PMC3726566  PMID: 23410616
Cannabis use; HIV; sex risk behavior; drug risk behavior; Russia
13.  Impact of lifetime alcohol use on liver fibrosis in a population of HIV-infected patients with and without hepatitis C coinfection 
Background
The effect of alcohol on liver disease in HIV infection has not been well characterized.
Methods
We performed a cross-sectional multivariable analysis of the association between lifetime alcohol use and liver fibrosis in a longitudinal cohort of HIV-infected patients with alcohol problems. Liver fibrosis was estimated with two non-invasive indices, “FIB-4”, which includes platelets, liver enzymes, and age; and “APRI”, which includes platelets and liver enzymes. FIB-4<1.45 and APRI<0.5 defined absence of liver fibrosis. FIB-4>3.25 and APRI>1.5 defined advanced liver fibrosis. The main independent variable was lifetime alcohol consumption (<150 kg, 150–600kg, >600 kg).
Results
Subjects (n=308) were 73% male, mean age 43 years, 49% with hepatitis C virus (HCV) infection, 60% on antiretroviral therapy, 49% with an HIV RNA load<1000 copies/mL, and 18.7% with a CD4 count<200 cells/mm3. Forty-five percent had lifetime alcohol consumption >600 kg, 32.7% 150–600 kg, and 22.3% <150 kg; 33% had current heavy alcohol use, and 69% had >9 years of heavy episodic drinking. Sixty-one percent had absence of liver fibrosis and 10% had advanced liver fibrosis based on FIB-4. In logistic regression analyses controlling for age, gender, HCV infection, and CD4 count, no association was detected between lifetime alcohol consumption and absence of liver fibrosis (FIB-4<1.45) [adjusted odds ratio (AOR)=1.12 (95%CI:0.25–2.52) for 150–600 kg versus <150 kg; AOR=1.11 (95%CI:0.52–2.36) for >600 kg vs. <150 kg; global p=0.95]. Additionally, no association was detected between lifetime alcohol use and advanced liver fibrosis (FIB-4>3.25). Results were similar using APRI, and among those with and without HCV infection.
Conclusions
In this cohort of HIV-infected patients with alcohol problems, we found no significant association between lifetime alcohol consumption and absence of liver fibrosis or the presence of advanced liver fibrosis, suggesting that alcohol may be less important than other known factors that promote liver fibrosis in this population.
doi:10.1111/acer.12129
PMCID: PMC3758457  PMID: 23647488
alcohol; HIV; Hepatitis C virus; liver fibrosis
14.  Interleukin-6 Is Associated with Noninvasive Markers of Liver Fibrosis in HIV-Infected Patients with Alcohol Problems 
AIDS Research and Human Retroviruses  2013;29(8):1110-1116.
Abstract
Both HIV and hepatitis C virus (HCV) cause chronic inflammation and alterations in serum inflammatory cytokines. The impact of inflammatory cytokines on liver fibrosis is not well understood. We studied the association between interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α and liver fibrosis in HIV-infected patients with current or past alcohol problems (CAGE ≥2 or physician investigator diagnosis). Liver fibrosis was estimated with FIB-4 (FIB-4 <1.45 defined the absence of liver fibrosis and FIB-4 >3.25 defined advanced fibrosis). Logistic regression was used to assess the association between cytokines and fibrosis, adjusting for age, sex, CD4, HIV RNA, current antiretroviral therapy, body mass index, and HCV. Secondary analyses explored whether the association between HCV and liver fibrosis was mediated by these cytokines. Participants (n=308) were all HIV-infected; 73% were male with a mean age of 42 years; half had detectable HCV-RNA, 60.7% had an absence of liver fibrosis, and 10.1% had advanced fibrosis. In models that adjusted for each cytokine separately, higher levels of IL-6 were significantly associated with an absence of fibrosis [adjusted OR (95% CI): 0.43 (0.19, 0.98), p=0.05] and were borderline significant for advanced fibrosis [adjusted OR (95% CI): 8.16 (0.96, 69.54), p=0.055]. In the final model, only higher levels of IL-6 remained significantly associated with advanced liver fibrosis [adjusted OR (95% CI): 11.78 (1.17, 118.19), p=0.036]. Adjustment for inflammatory cytokines attenuated the adjusted OR for the association between HCV and fibrosis in the case of IL-6 [for the absence of fibrosis from 0.32 (0.17, 0.57) p<0.01 to 0.47 (0.23, 0.96) p=0.04; and for advanced fibrosis from 7.22 (2.01, 25.96) p<0.01 to 6.62 (1.20, 36.62) p=0.03], suggesting IL-6 may be a partial mediator of the association between HCV and liver fibrosis. IL-6 was strongly and significantly associated with liver fibrosis in a cohort of HIV-infected patients with alcohol problems. IL-6 may be a useful predictive marker for liver fibrosis for HIV-infected patients.
doi:10.1089/aid.2012.0348
PMCID: PMC3715787  PMID: 23601055
15.  Punitive policing and associated substance use risks among HIV-positive people in Russia who inject drugs 
Introduction
Drug law enforcement is part of the HIV risk environment among people who inject drugs (PWID). Punitive policing practices such as extrajudicial arrests for needle possession and police planting of drugs have been described anecdotally in Russia, but these experiences and their associations with risky drug behaviours have not been quantified. This study aims to quantify the burden of extrajudicial police arrests among a cohort of HIV-positive PWID in Russia and to explore its links to drug-related health outcomes.
Methods
In a cross-sectional study of 582 HIV-positive people with lifetime injection drug use (IDU) in St. Petersburg, Russia, we estimated the prevalence of self-reported extrajudicial police arrests. We used multiple logistic regression to evaluate associations between arrests and the following outcomes: overdose, recent IDU and receptive needle sharing.
Findings
This cohort's mean age was 29.8 years, 60.8% were male; 75.3% reported non-fatal drug overdose, 50.3% recent IDU and 47.3% receptive needle sharing. Extrajudicial arrests were reported by more than half (60.5%, 95% confidence interval [CI]: 56.5–64.5) and were associated with higher odds of non-fatal drug overdose (AOR 1.52, 95% CI: 1.02–2.25) but not with recent IDU (AOR 1.17, arrests were associated with receptive needle sharing (AOR 1.84, 95% CI: 1.09–3.09).
Conclusions
Extrajudicial police arrests were common among this cohort of Russian HIV-positive PWID and associated with non-fatal overdose and, among those with recent IDU, receptive needle sharing. As a part of the HIV risk environment of PWIDs, these practices might contribute to HIV transmission and overdose mortality. Further research is needed to relate these findings to the operational environment of law enforcement and to better understand how police interventions among PWIDs can improve the HIV risk environment.
doi:10.7448/IAS.17.1.19043
PMCID: PMC4093768  PMID: 25014321
human rights; police involvement; PLHA; injection drug use; key populations; Russian Federation
16.  Low Vitamin D Status of Patients in Methadone Maintenance Treatment 
Journal of addiction medicine  2009;3(3):134-138.
Aim
To examine the prevalence and risk factors of low vitamin D status (vitamin D deficiency or insufficiency) among patients in a methadone maintenance treatment (MMT) program.
Design
Cross-sectional study of subjects recruited from an MMT program in a higher latitude (Boston, MA).
Measurements
Standardized survey and medical record review were used to assess patient characteristics. Serum was tested to determine vitamin D deficiency (25-hydroxyvitamin D <20 ng/mL) and insufficiency (25-hydroxyvitamin D between 20 and 30 ng/mL). Multivariable analyses were used to assess risk factors associated with vitamin D deficiency.
Findings
Low vitamin D status was found in 52% of the subjects (48 of 93), deficiency in 36%, and insufficiency in an additional 16%. Older age (OR = 3.47; 95% CI 1.31–9.22) and black or Hispanic race/ethnicity (OR 3.34; 95% CI 1.30–8.58) were significantly associated with higher risk of vitamin D deficiency.
Conclusion
Low vitamin D status was present in a majority of patients recruited from an MMT program. This raises the question as to whether this is a generalizable phenomenon and whether these patients are at higher risk of complications of low vitamin D status including bone pain, periodontal disease, osteomalacia, and cardiovascular disease.
doi:10.1097/ADM.0b013e31819b736d
PMCID: PMC4059827  PMID: 21769009
methadone maintenance; vitamin D; drug dependence; medical complications
17.  Pain is Associated with Heroin Use over Time in HIV-Infected Russian Drinkers 
Addiction (Abingdon, England)  2013;108(10):1779-1787.
Aims
This study evaluated whether pain was associated with increased risk of using heroin, stimulants or cannabis among HIV-infected drinkers in Russia.
Design
Secondary analysis of longitudinal data from the HERMITAGE study, a behavioral randomized controlled trial, with data collected at baseline, 6 month and 12 month visits.
Setting
Recruitment occurred at HIV and addiction treatment sites in St. Petersburg, Russian Federation.
Participants
Six-hundred and ninety-nine HIV-infected adult drinkers.
Measurements
The primary outcome was past month illicit drug use; secondary outcomes examined each drug (heroin, stimulants and cannabis) separately. The main predictor was pain that at least moderately interfered with daily living. General estimating equations (GEE) logistic regression models were used to evaluate the association between pain and subsequent illicit drug use adjusting for potential confounders.
Findings
Participants reporting pain appeared to have higher odds of using illicit drugs, although the results did not reach statistical significance (adjusted Odds Ratio [OR]=1.32; 95% CI: 0.99, 1.76, p=0.06). There was a significant association between pain and heroin use (OR=1.54; 95% CI: 1.11 to 2.15, p=0.01) but not other drugs (OR=0.75; 95% CI: 0.40 to 1.40, p=0.35 for stimulants and OR=0.70; 95% CI: 0.45 to 1.07, p=0.09 for cannabis).
Conclusions
HIV-infected Russian drinkers who reported pain were more likely to use heroin over time. Pain may be an unrecognized risk factor for persistent heroin use with implications for HIV transmission in Russia.
doi:10.1111/add.12274
PMCID: PMC4012755  PMID: 23773361
Pain; HIV; substance use; heroin
18.  Associations between Partner Violence Perpetration and History of STI among HIV-infected Substance Using Men in Russia 
AIDS care  2012;25(5):646-651.
Studies document a significant association between victimization from intimate partner violence (IPV) and sexually transmitted infections (STI) and HIV among substance using women in Russia and elsewhere, but no study has examined IPV perpetration and STI among Russian men or HIV-infected men in Eastern Europe. This study was designed to assess the association between lifetime history of IPV perpetration and STI (lifetime and current) among substance using HIV-infected men in Russia. Cross-sectional analyses were conducted with baseline data from 415 male participants enrolled in a randomized HIV intervention clinical trial [the HERMITAGE Study]. Participants were HIV-infected men reporting recent heavy alcohol use and unprotected sex in St. Petersburg, Russia. Baseline surveys assessed demographics, IPV perpetration, risk behaviors, and STI history. Current STI was assessed via blood testing for syphilis and urine testing for gonorrhea, Chlamydia and trichomonas. Multiple logistic regression analyses were used to assess the association between history of IPV with lifetime and current STI. Participants were aged 20–57 years. Almost half of participants (46%) reported a history of IPV perpetration; 81% reported past 30-day binge alcohol use, and 43% reported past 30-day injection drug use. Past and current STI was 41% and 12%, respectively. Men reporting a history of IPV perpetration had significantly higher odds of reporting ever having an STI (AOR=1.6, 95% CI=1.1, 2.4) but lower odds of testing positive for a current STI (AOR=0.50, 95% CI=0.26, 0.96). These findings demonstrate that a history of male IPV perpetration is common in HIV-infected Russian men and associated with a history of STI. Programmatic work toward IPV prevention is needed in Russia and may be beneficial in mitigating STIs, but more research is needed to understand how and why the association between IPV and STI changes over time in this population.
doi:10.1080/09540121.2012.722188
PMCID: PMC3582729  PMID: 22971088
19.  Chronic Care Management for Dependence on Alcohol and Other Drugs: The AHEAD Randomized Trial 
Importance
People with substance dependence have health consequences, high healthcare utilization and frequent comorbidity but often receive poor quality care overall and for dependence. Chronic care management has been proposed as an approach to improve care and outcomes.
Objective
To determine whether chronic care management (CCM) for alcohol and other drug (AOD) dependence improves substance use outcomes compared to usual primary care.
Design, Setting, and Participants
The AHEAD study was a randomized trial in people with AOD dependence, not necessarily seeking treatment, at a Boston hospital-based primary care practice. Of the 655 eligible participants, 563 (86%) were randomized. Study participants were recruited from September 2006 to September 2008 from a free-standing residential detoxification unit (74%) and referrals from an urban teaching hospital and advertisements (26%). Participants were randomized to CCM (n=282) or no CCM (n=281).
Intervention
CCM included longitudinal care coordinated with a primary care clinician, motivational enhancement therapy, relapse prevention counseling, and on-site medical, addiction and psychiatric treatment, social work assistance and referrals (including mutual help). The no CCM group received a primary care appointment, and a list of treatment resources including a phone number to arrange counseling.
Main Outcome and Measure
The primary outcome was self-reported abstinence from opioids, stimulants or heavy drinking. Biomarkers were secondary outcomes. We employed longitudinal analyses for data from 3, 6 and 12 months (last interview January 21, 2010).
Results
Of 563 participants, 95% completed 12-month follow-up. Baseline characteristics of the study participants were similar across randomization groups, but differed significantly for race and depressive symptoms. There was no significant difference in abstinence from opioids, stimulants or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds ratio 0.84; 95% confidence interval (CI) 0.65–1.10; p=0.21). No significant differences were found for secondary outcomes: addiction severity, health-related quality of life or drug problems. No subgroup effects were found except among those with alcohol dependence in whom CCM was associated with fewer alcohol problems (mean 10 vs. 13, incidence rate ratio 0.85, 95% CI 0.72–1.00, p=0.048).
Conclusions and Relevance
Among persons with AOD dependence, CCM compared with a primary care appointment but no CCM did not increase self-reported abstinence over 12 months. Whether more intensive or longer duration CCM is effective would require further investigation.
doi:10.1001/jama.2013.277609
PMCID: PMC3902022  PMID: 24045740
20.  The Short Inventory of Problems—Modified for Drug Use (SIP-DU): Validity in a Primary Care Sample 
Primary care physicians can help drug-dependent patients mitigate adverse drug use consequences; instruments validated in primary care to measure these consequences would aid in this effort. This study evaluated the validity of the Short Inventory of Problems—Alcohol and Drugs modified for Drug Use (SIP-DU) among subjects recruited from a primary care clinic (n = 106). SIP-DU internal consistency was evaluated using Cronbach’s alphas, convergent validity by correlating the total SIP-DU score with the DAST-10, and construct validity by analyzing the factor structure. The SIP-DU demonstrated high internal consistency (Cronbach’s alpha for overall scale .95, subscales .72–.90) comparable with other SIP versions and correlated well with the DAST-10 (r = .70). Confirmatory factor analysis suggested an unacceptable fit of previously proposed factors; exploratory factor analyses suggested a single factor of drug use consequences. The SIP-DU offers primary care clinicians a valid and practical assessment tool for drug use consequences.
doi:10.1111/j.1521-0391.2012.00223.x
PMCID: PMC3889861  PMID: 22494228
21.  Predictors of Active Injection Drug Use in a Cohort of Patients Infected With Hepatitis C Virus 
American journal of public health  2012;103(1):105-111.
Objectives
We investigated potential risk factors for active injection drug use (IDU) in an inner-city cohort of patients infected with hepatitis C virus (HCV).
Methods
We used log-binomial regression to identify factors independently associated with active IDU during the first 3 years of follow-up for the 289 participants who reported ever having injected drugs at baseline.
Results
Overall, 142 (49.1%) of the 289 participants reported active IDU at some point during the follow-up period. In a multivariate model, being unemployed (prevalence ratio [PR] = 1.93; 95% confidence interval [CI] = 1.24, 3.03) and hazardous alcohol drinking (PR = 1.67; 95% CI = 1.34, 2.08) were associated with active IDU. Smoking was associated with IDU but this association was not statistically significant. Patients with all 3 of those factors were 3 times as likely to report IDU during follow-up as those with 0 or 1 factor (PR = 3.3; 95% CI = 2.2, 4.9). Neither HIV coinfection nor history of psychiatric disease was independently associated with active IDU.
Conclusions
Optimal treatment of persons with HCV infection will require attention to unemployment, alcohol use, and smoking in conjunction with IDU treatment and prevention.
doi:10.2105/AJPH.2012.300819
PMCID: PMC3518356  PMID: 23153145
22.  Nondisclosure of HIV Infection to Sex Partners and Alcohol’s Role: A Russian Experience 
AIDS and behavior  2013;17(1):390-398.
Nondisclosure of one’s HIV infection to sexual partners obviates safer sex negotiations and thus jeopardizes HIV transmission prevention. The role of alcohol use in the disclosure decision process is largely unexplored. This study assessed the association between alcohol use and recent nondisclosure of HIV serostatus to sex partners by HIV-infected risky drinkers in St. Petersburg, Russia. Approximately half (317/605; 52.4 %) reported not having disclosed their HIV serostatus to all partners since awareness of infection. Using three separate GEE logistic regression models, we found no significant association between alcohol dependence, risky alcohol use (past 30 days), or alcohol use at time of sex (past 30 days) with recent (past 3 months) nondisclosure (AOR [95 %CI] 0.81 [0.55, 1.20], 1.31 [0.79, 2.17], 0.75 [0.54, 1.05], respectively). Alcohol use at time of sex was associated with decreased odds of recent nondisclosure among seroconcordant partners and among casual partners. Factors associated with nondisclosure were relationship with a casual partner, a serodiscordant partner, multiple sex partners, awareness of HIV diagnosis less than 1 year, and a lifetime history of sexually transmitted disease. Nondisclosure of HIV status to sex partners is common among HIV-infected Russians, however alcohol does not appear to be a predictor of recent disclosure.
doi:10.1007/s10461-012-0216-z
PMCID: PMC3634358  PMID: 22677972
Nondisclosure; Disclosure; HIV; Russia; Alcohol
23.  Prevalence and Correlates of Non-Disclosure of HIV Serostatus to Sex partners among HIV-Infected Female Sex Workers and HIV-infected Male Clients of Female Sex Workers in India 
AIDS and behavior  2013;17(1):399-406.
This study examines non-disclosure of HIV serostatus to sex partners among HIV-infected adults involved with transactional sex in Mumbai, India. Surveys were conducted with HIV-infected female sex workers (n = 211) and infected male clients (n = 205) regarding HIV knowledge, awareness of sex partners’ HIV serostatus, alcohol use, transactional sex involvement post-HIV diagnosis and non-disclosure of HIV serostatus. Gender-stratified multiple logistic regression models were used for analysis. Non-disclosure of one’s serostatus to all sex partners was reported by almost three-fifths of females and two-fifths of males. Predictors of non-disclosure included lack of correct knowledge about HIV and no knowledge of sex partners’ HIV serostatus. Among females, recent alcohol consumption also predicted non-disclosure. Among males, 10 + paid sexual partners in the year following HIV diagnosis predicted non-disclosure. Secondary HIV prevention efforts in India require greater focus on HIV disclosure communication and integrated alcohol and sexual risk reduction.
doi:10.1007/s10461-012-0263-5
PMCID: PMC3634359  PMID: 22810892
HIV serostatus non-disclosure; Female sex workers; Male clients; Alcohol use; India
24.  EFFECT OF QUALITY CHRONIC DISEASE MANAGEMENT FOR ALCOHOL AND DRUG DEPENDENCE ON ADDICTION OUTCOMES 
We examinedthe effect ofthe quality of primary care-basedchronic disease management (CDM)for alcohol and/or other drug (AOD) dependenceonaddiction outcomes.We assessed qualityusing 1)avisit frequencybased measure and 2) a self-reported assessment measuring alignment with the chronic care model. The visit frequency based measure had no significant association with addiction outcomes. Theself-reported measure of care - when care was at a CDM clinic - was associated with lower drug addiction severity.The self-reported assessment of care from any healthcare source (CDM clinic or elsewhere)was associated with lower alcoholaddiction severity and abstinence.These findings suggest that high quality CDM for AOD dependence may improve addiction outcomes.Quality measuresbased upon alignment with the chronic care model may better capture features of effective CDM care than a visitfrequency measure.
doi:10.1016/j.jsat.2012.06.001
PMCID: PMC3507538  PMID: 22840687
25.  Aberrant drug-related behaviors: Unsystematic documentation does not identify prescription drug use disorder 
Pain medicine (Malden, Mass.)  2012;13(11):1436-1443.
Objective
No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD.
Design
A cross-sectional study of PC patients at an urban, academic medical center.
Subjects
264 English-speaking patients (ages 18–60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits.
Outcome Measures
Composite International Diagnostic Interview defined DSM-IV diagnoses of past-year PDUD and no disorder. EMRs were reviewed for 15 pre-specified ADRBs (e.g. early refill, stolen medications) in the year before and after study entry. Fisher’s exact test compared frequencies of each ADRB between participants with and without PDUD.
Results
61 participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only “appearing intoxicated or high” documented more frequently among participants with PDUD (n=10, 16%) vs. no disorder (n=8, 4%), p=0.002. The only common ADRB, “emergency visit for pain,” did not discriminate between those with and without the disorder (82% PDUD vs. 78% no disorder, p=0.6).
Conclusions
EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.
doi:10.1111/j.1526-4637.2012.01497.x
PMCID: PMC3501607  PMID: 23057631
Prescription drug use disorder; diagnosis; aberrant drug-related behaviors; primary care; chronic pain

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