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ABSTRACTTourette syndrome (TS) affects about 0.5% of the population worldwide, but only sparse and conflicting data exist on TS prevalence among minority samples. Here we used VISITTS (a survey preceded by a short video showing tic phenomenology) and community outreach to provide estimates of tic disorder prevalence in African Americans. Community health workers (CHWs) left flyers at households in a predominantly minority neighborhood and approached people at a community health fair. Of 606 such contacts, 222 individuals agreed to discuss the study. Of these, 70% enrolled, of whom 82% identified as Black and 64% female. The VISITTS was well received. Lifetime prevalence of TS or another chronic tic disorder (TS/CTD) was 3.2%, and 31% endorsed any lifetime simple tic. The number of enrolled Black participants is remarkable compared to earlier TS studies, allowing one of the first prevalence estimates in this population (TS 2.3%, TS/CTD 3.9%). Tic disorders were endorsed only by Black respondents, though the small White sample precluded statistical comparison. Women had higher rates than men of TS (M:F = 0:1) and of any lifetime simple tic (M:F = 0.85), differing significantly from the expected 4:1 ratio (p= .009 and p < .001, respectively). For TS/CTD the ratio was 1.2:1 (p > .15). We conclude that VISITTS is a feasible tic screening tool in a minority population, that CHW community outreach increases enrollment of Black participants, that TS/CTD is no less common in this population, and that tics were as common in female as in male respondents.

•Reductions in depressive symptoms are followed by reductions in pain and opioid use.•Reductions in depressive symptoms are followed by anxiety symptoms.•Treating depression may potentially reduce other co-occurring conditions.•Causal inference methods with observational data may highlight treatment benefits.•RCTs testing depression treatment should examine effects on a range of outcomes.

We aimed to investigate the impact of reducing drinking in patients with unhealthy alcohol use on improvement of chronic pain interference, substance use, and psychiatric symptoms. We analyzed longitudinal data from 2003 to 2015 in the Veterans Aging Cohort Study, a prospective, multisite observational study of US veterans, by emulating a hypothetical randomized trial (a target trial). Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT) questionnaire, and outcome conditions were assessed via validated survey items. Individuals were followed from the first time their AUDIT score was ≥ 8 (baseline), a threshold consistent with unhealthy alcohol use. We compared individuals who reduced drinking (AUDIT < 8) at the next follow‐up visit with individuals who did not (AUDIT ≥ 8). We fit separate logistic regression models to estimate odds ratios for improvement of each condition 2 years postbaseline among individuals who had that condition at baseline: moderate or severe pain interference symptoms, tobacco smoking, cannabis use, cocaine use, depressive symptoms, and anxiety symptoms. Inverse probability weighting was used to account for potential selection bias and confounding. Adjusted 2‐year odds ratios (95% confidence intervals) for associations between reducing drinking and improvement or resolution of each condition were as follows: 1.49 (0.91, 2.42) for pain interference symptoms, 1.57 (0.93, 2.63) for tobacco smoking, 1.65 (0.92, 2.95) for cannabis use, 1.83 (1.03, 3.27) for cocaine use, 1.11 (0.64, 1.92) for depressive symptoms, and 1.33 (0.80, 2.22) for anxiety symptoms. We found some evidence for improvement of pain interference symptoms and substance use after reducing drinking among US veterans with unhealthy alcohol use, but confidence intervals were wide. Among ~1500 US Veterans who reported unhealthy alcohol use, (scoring 8+ on the ‘AUDIT’ questionnaire) we compared whose who reduced (score of <8) and did not reduce (score of 8+) their drinking after ~1 year. We compared the two groups for improvement of co‐occurring conditions another year later. We found some evidence for greater improvement of pain interference symptoms and greater discontinuation of co‐occurring substance use (i.e. smoking, cocaine, and cannabis) after reducing drinking compared with not reducing drinking.

HIV care providers often serve as the specialist and the primary care point-of-contact for persons living with HIV (PLWH) and unhealthy alcohol use. The purpose of the present qualitative study was to understand HIV care provider perceptions and approaches to managing unhealthy alcohol use in HIV primary care settings. Using a semi-structured interview guide, in-depth interviews were conducted among 14 HIV care providers (5 medical doctors, 5 nurse practitioners/physician assistants, 2 medical assistants, 2 clinical administrative staff) in private and public HIV clinics, across urban and rural areas of Florida. Interviews were coded using a grounded theory approach with inter-rater consensus. Six themes were identified. In summary, providers reported (1) inconsistent assessment of alcohol consumption, as well as (2) varying levels of confidence in self-report of alcohol use which may be affected by patient provider rapport and trust. While providers (3) acknowledge potential negative impacts of alcohol use on health outcomes and HIV treatment, providers reported (4) inconsistent recommendations regarding alcohol use among their patients. Lastly, providers reported (5) limited resources for patients with unhealthy alcohol use and (6) low confidence in their ability to help patients reduce use. Results from our study suggest salient differences in provider approaches to the assessment and management of unhealthy alcohol use in HIV primary care settings. Implementation of care for unhealthy alcohol use in these settings may be facilitated through use of clinically useful, validated alcohol use assessments and use of evidence-based recommendations of alcohol use/non-use among PLWH. Training in brief intervention techniques for alcohol reduction may increase provider confidence and support in the management of unhealthy alcohol use among PLWH.

The relationship between alcohol consumption and atherosclerosis has not been sufficiently examined among people living with HIV (PLWH). We analyzed data from PLWH in the Women's Interagency HIV Study (WIHS; n= 1,164) and the Multicenter AIDS Cohort Study (MACS; n= 387) with no history of cardiovascular disease (CVD). Repeated measures of intima‐media thickness of the right common carotid artery (CCA‐IMT) were assessed using B‐mode ultrasound from 2004 to 2013. Current alcohol consumption was collected at time of CCA‐IMT measurement and was categorized according to gender‐specific weekly limits. Group‐based trajectory models categorized participants into past 10‐year consumption patterns (1994 to 2004). Multivariate generalized estimating equations were conducted to assess the association of past and current alcohol use patterns on change in CCA‐IMT by cohort, controlling for age, race, cigarette and illicit drug use, probable depression, HIV RNA viral load, antiretroviral therapy exposure, and hepatitis C coinfection. Among the WIHS, past heavy alcohol consumption was associated with increased CCA‐IMT level over time (β = 8.08, CI 0.35, 15.8, p= 0.04), compared to abstinence. Among the MACS, compared to abstinence, all past consumption patterns were associated with increased CCA‐IMT over time (past low: β = 15.3, 95% CI 6.46, 24.2, p< 0.001; past moderate: β = 14.3, CI 1.36, 27.2, p= 0.03; past heavy: β = 21.8, CI 4.63, 38.9, p= 0.01). Current heavy consumption was associated with decreased CCA‐IMT among the WIHS (β = −11.4, 95% CI −20.2, −2.63, p= 0.01) and MACS (β = −15.4, 95% CI −30.7, −0.13, p= 0.04). No statistically significant time by consumption pattern effects were found. In both cohorts, 10‐year heavy consumption was associated with statistically significant increases in carotid artery thickness, compared to abstinence. Long‐term patterns of drinking at any level above abstinence were particularly significant for increases in IMT among men, with heavy consumption presenting with the greatest increase. Our results suggest a potentially different window of risk among past and current heavy drinkers. Further studies are needed to determine whether alcohol consumption level is associated with intermediate measures of atherosclerosis. Alcohol screening and interventions to reduce heavy consumption may benefit PLWH who are at risk of CVD. The relationship between alcohol consumption and atherosclerosis has not been sufficiently examined among people living with HIV (PLWH). We analyzed data from PLWH with no history of cardiovascular disease (CVD) using repeated measures of intima‐media thickness and alcohol consumption. Our results suggest a potentially different window of risk among past and current heavy drinkers. Alcohol screening and interventions to reduce heavy consumption may benefit PLWH who are at risk for CVD.

Objective: We sought to quantify the extent to which a depression screening instrument commonly used in primary care settings provides additional information regarding pain interference symptoms, anxiety, and substance use.Methods: Veterans Aging Cohort Study (VACS) data collected from 2003 through 2015 was used to calculate odds ratios (OR) for associations between positive depression screening result cutoffs and clustering conditions. We assessed the test performance characteristics (likelihood ratio value, positive predictive value, and the percentage of individuals correctly classified) of a positive Patient Health Questionnaire (PHQ-9 & PHQ-2) depression screen for the identification of pain interference symptoms, anxiety, and substance use.Results: A total 7731 participants were included in the analyses. The median age was 50 years. The PHQ-9 threshold of ≥20 was strongly associated with pain interference symptoms (OR 21.6, 95% CI 17.5-26.7) and anxiety (OR 72.1, 95% CI 52.8-99.0) and yielded likelihood ratio values of 7.5 for pain interference symptoms and 21.8 for anxiety and positive predictive values (PPV) of 84% and 95%, respectively. A PHQ-9 score of ≥10 still showed significant associations with pain interference symptoms (OR 6.1, 95% CI 5.4-6.9) and symptoms of anxiety (OR 11.3, 95% CI 9.7-13.1) and yet yielded lower likelihood ratio values (4.36 & 8.24, respectively). The PHQ-9 was less strongly associated with various forms of substance use.Conclusion: Depression screening provides substantial additional information regarding the likelihood of pain interference symptoms and anxiety and should trigger diagnostic assessments for these other conditions.

Introduction:Unhealthy alcohol use, smoking, and depressive symptoms are risk factors for cardiovascular disease (CVD). Little is known about the prevalence of their co-occurrence -termed a syndemic, or the synergistic effect of 2+ conditions on CVD risk in HIV-infected (HIV+) people. We investigated the association of this syndemic and future CVD events among HIV+ and uninfected people.Hypothesis:The syndemic (2+ conditions) of unhealthy drinking, smoking, and depressive symptoms will be common and associated with increased CVD risk. Among those with this syndemic, HIV+ people will have greater risk of CVD vs. uninfected people.Methods:We analyzed data from 4252 participants free of CVD at baseline in the Veterans Aging Cohort Study-8, a prospective, observational study of HIV+ and uninfected veterans followed from 2002-2014. We defined unhealthy alcohol use, smoking, and depressive symptoms using validated instruments. Baseline conditions were categorized as 0, 1, or 2+ (syndemic). ICD-9 codes identified incident CVD events (coronary heart disease, ischemic stroke, heart failure, peripheral artery disease). Covariates are presented in the Table.Results:Prevalence of the syndemic was 52% and 48% for HIV+ and uninfected veterans, respectively. There were 845 incident CVD events during the median follow-up of 10.1 years. The syndemic was associated with greater risk among HIV+ (2.13 times) and uninfected (1.78 times) veterans compared to uninfected with 0 conditions. Among those with the syndemic, risk was marginally higher (20%) among HIV+ vs. uninfected veterans (p=.047).Conclusions:Half of veterans had syndemic conditions that were associated with increased CVD risk. This risk increased modestly with 1 condition and sharply with 2+ conditions. Among those with the syndemic, risk may be higher among HIV+ vs. uninfected veterans. Future research should address the utility of linked screening and treatment of these syndemic conditions.