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Abstract Background Access to sterile syringes is a proven means of reducing the transmission of human immunodeficiency virus (HIV), viral hepatitis, and bacterial infections among injection drug users. In many U.S. states and territories, drug paraphernalia and syringe prescription laws are barriers to syringe access for injection drug users (IDUs): pharmacists may be reluctant to sell syringes to suspected IDUs, and police may confiscate syringes or arrest IDUs who cannot demonstrate a "legitimate" medical need for the syringes they possess. These barriers can be addressed by physician prescription of syringes. This study evaluates physicians' willingness to prescribe syringes, using the theory of planned behavior to identify key behavioral influences. Methods We mailed a survey to a representative sample of physicians from the American Medical Association physician database. Non-responding physicians were then called, faxed, or re-sent the survey, up to four times. Results Twenty percent responded to the survey. Although less than 1 percent of respondents had ever prescribed syringes to a known injection drug user, more than 60% of respondents reported that they would be willing to do so. Physicians' willingness to prescribe syringes was best predicted by the belief that it was a feasible and effective intervention, but individual and peer attitudes were also significant. Conclusion This was the first nationwide survey of the physician willingness to prescribe syringes to IDUs. While the majority of respondents were willing to consider syringe prescription in their clinical practices, multiple challenges need to be addressed in order to improve physician knowledge and attitudes toward IDUs.

OBJECTIVES: We evaluated prevalence and intraprison incidence of HIV, hepatitis B virus, and hepatitis C virus infections among male prison inmates. METHODS: We observed intake prevalence for 4269 sentenced inmates at the Rhode Island Adult Correctional Institute between 1998 and 2000 and incidence among 446 continuously incarcerated inmates (incarcerated for 12 months or more). RESULTS: HIV, hepatitis B virus, and hepatitis C virus prevalences were 1.8%, 20.2%, and 23.1%, respectively. Infections were significantly associated with injection drug use (odds ratio = 10.1, 7.9, and 32.4). Incidence per 100 person-years was 0 for HIV, 2.7 for HBV, and 0.4 for HCV. CONCLUSIONS: High infection prevalence among inmates represents a significant community health issue. General disease prevention efforts must include prevention within correctional facilities. The high observed intraprison incidence of HBV underscores the need to vaccinate prison populations. [ABSTRACT FROM AUTHOR]

Injection drug users (IDUs) are a population at high risk for many diseases, including AIDS, and are clearly in need of medical and substance abuse treatment. Access to sterile syringes is critical for lowering the risk of transmission of HIV and other blood-borne pathogens among IDUs. Previously tried strategies include needle exchange programs and changing laws to allow the legal purchase and possession of syringes. An alternative strategy is to have physicians prescribe syringes to IDUs. To the best of our knowledge, this has previously been tried by only a few physicians in rare situations and never on a programmatic basis. This report describes the genesis of physician's syringe prescription in Rhode Island and some of the lessons learned to date. Because of the illicit nature of drug use, a tremendous amount of mistrust and fear on the part of IDUs often leads to poor interaction with the medical establishment. Prescription of syringes by a physician can serve as a tool for reaching out to a high-risk and often out-of-treatment population of drug users. It is a way for the health care community to tap into drug-using networks and bring those populations into a medical care system. [ABSTRACT FROM AUTHOR]

Background: Numerous studies have found higher rates of sexually transmitted infections (STIs) among military personnel than the general population, but the cumulative risk of acquiring STIs throughout an individual's military career has not been described., Methods: Using ICD-9 diagnosis codes, we analyzed the medical records of 100,005 individuals from all service branches, divided in equal cohorts (n = 6,667) between 1997 and 2011. As women receive frequent STI screening compared to men, these groups were analyzed separately. Incidence rates were calculated for pathogen-specific STIs along with syndromic diagnoses. Descriptive statistics were used to characterize the individuals within each accession year cohort; repeat infections were censored., Results: The total sample included 29,010 females and 70,995 males. The STI incidence rates (per 100 person-years) for women and men, respectively, were as follows: chlamydia (3.5 and 0.7), gonorrhea (1.1 and 0.4), HIV (0.04 and 0.07) and syphilis (0.14 and 0.15). During the study period, 22% of women and 3.3% of men received a pathogen-specific STI diagnosis; inclusion of syndromic diagnoses increased STI prevalence to 41% and 5.5%, respectively. In multivariate analyses, factors associated with etiologic and syndromic STIs among women included African American race, younger age and fewer years of education. In the overall sample, increasing number of years of service was associated with an increased likelihood of an STI diagnosis (p<0.001 for trend)., Conclusion: In this survey of military personnel, we found very high rates of STI acquisition throughout military service, especially among women, demonstrating that STI-related risk is significant and ongoing throughout military service. Lower STI incidence rates among men may represent under-diagnosis and demonstrate a need for enhancing male-directed screening and diagnostic interventions., Competing Interests: The authors have declared that no competing interests exist.

Background: The effects of at-risk drinking on HIV infection remain controversial. We investigated the impact of self-reported alcohol consumption on surrogate markers of HIV progression among individuals initiated on highly active antiretroviral therapy (HAART)., Methods: We analyzed individuals who were surveyed on alcohol use within a year of HAART initiation between 2006 and 2014. At-risk drinking was defined as consumption of at least 3 or 4 drinks/d, or 7 and 14 drinks/wk among women and men, respectively. We performed time-updated generalized estimating equation logistic regression to determine the effect of at-risk drinking on virologic failure (VF) and mixed-effects linear regression on CD4 count reconstitution, controlling for potential confounders., Results: Of 801 individuals initiated on HAART, 752 individuals with alcohol survey data were included in the analysis. Of these, 45% (n = 336) met criteria for at-risk drinking at HAART initiation on at least 1 survey. The rates of VF were 4.30 per 100 person-years (95% CI [2.86, 6.21]) for at-risk drinkers and 2.45 per 100 person-years (95% CI [1.57, 3.65]) for individuals without at-risk drinking. At-risk drinking was not significantly associated with VF (OR 1.73, 95% CI [0.92, 3.25]) (p = 0.087) or CD4 reconstitution (CD4 increase 11.4; 95% CI [-19.8, 42.7]) in univariate analyses; however, in our multivariate model, a statistically significant relationship between VF and at-risk drinking was observed (OR 2.28, 95% CI [ 1.01, 5.15])., Conclusions: We found a high proportion of at-risk drinking in our military cohort, which was predictive of VF in multivariate analysis. Given alcohol's effect on myriad HIV and non-HIV outcomes, interventions to decrease the prevalence of at-risk drinking among HIV-infected individuals are warranted., (Copyright © 2016 by the Research Society on Alcoholism.)

Background: Sexually transmitted infections have historically been burdensome in military populations. We describe the seroprevalence and seroincidence of vaccine-preventable human papillomavirus (VP-HPV) subtypes in a sample of 200 servicemen, along with the seroprevalence and seroincidence of herpes simplex virus (HSV-1/2) and syphilis in a sample of 200 men and 200 women., Methods: Sera from 200 men, along with associated demographic data, were obtained and tested for HPV serotypes at service entry and 10 years later. Similarly, 200 active-duty men and 200 active-duty women were tested for HSV-1/2 at entry to service and 4 years later., Results: The baseline prevalence of VP-HPV subtypes was 14.5%, and cumulative seroincidence of new infection was 34% over a 10-year period (n = 68). Of these, 63% (n = 43) represented HPV-6, HPV-11, or both; 18% of new infections were either HPV-16 or HPV-18, and 19% (n = 13) were a mixture of all 4 strains. At entry to military service, 33.5% of men were seropositive for HSV-1 and 1.5% were positive for HSV-2; seroincidence was 3.4 and 1.1 per 100 person-years, respectively. Among women, 39% were seropositive for HSV-1 and 4.0% for HSV-2; seroincidence was 5.5 and 3.3 per 100 person-years, respectively. There were 2 prevalent and 3 incident cases of syphilis., Conclusions: Sexually transmitted infections in military populations are highly prevalent, incident, and epidemiologically distinct. Our data show the rates of HPV and HSV-1/2 acquisition that are higher than those seen in the general public, again highlighting the need for continued preventive efforts. Consideration of universal HPV vaccination among men is warranted.

This study sought to assess the rate of hepatitis C virus (HCV) infection and associated risk factors in young adults 18-28 years of age who were incarcerated in the Rhode Island Department of Corrections. The majority of participants reported injection drug use and engaged in high-risk behaviors such as needle sharing. Despite having these risk factors and believing themselves to be at risk, the majority of youths reported no prior HCV testing. Correctional facilities present a unique opportunity to detect HCV infection and provide risk reduction education to young adults, the population with the highest rates of new infections in the US. Seventy-two incarcerated individuals with a history of drug use were approached to participate in the study; 68 completed the screening and interview. The rate of HCV infection among adults <30 years of age and incarcerated at the Rhode Island Department of Corrections in 2011 was high (24%). In 1998, the rate of HCV among inmates <30 years of age at the same facility was only 11.4%. These data follow the same increase in HCV infection rates among young adults observed in non-incarcerated young adults across the nation. HCV is the leading cause of liver failure and hepatocellular carcinoma in the US. Despite a decline and leveling in HCV incidence nationwide, alarming increases in HCV rates among adolescents and young adults have been reported during the period between the years 1992 and 2005. This disquieting epidemic is attributable to injection drug use amongst young adults.

Background: The Veterans Aging Cohort Study (VACS) index is a weighted combination of age and 8 clinical variables. It has been well correlated with all-cause mortality among HIV-infected patients. The US Military HIV Natural History Study (NHS) cohort provides a different validation population profile, being younger and healthier. A significant portion of the US HIV population is similarly composed; so, evaluation of the VACS index in this population is of great interest., Methods: NHS subjects have medical history and laboratory data collected at 6-month visits. We performed an external validation of the VACS index in the NHS evaluating correlation, discrimination, and calibration for all-cause mortality after highly active antiretroviral therapy initiation (HI). We then tested whether combining longitudinal VACS index values at different time points improves prediction of mortality., Results: The VACS index at 1 year after HI was well correlated with all-cause mortality (Harrell c statistic 0.78), provided good discrimination (log-rank P < 0.05), and was marginally well calibrated using Brier score. Accounting for VACS index at HI and 6 months after HI significantly improved a standard model, including only the VACS index at 1 year after HI (net reclassification improvement = 25.2%, 95% CI: 10.9% to 48.9%)., Conclusions: The VACS index was well correlated and provided good discrimination with respect to all-cause mortality among highly active antiretroviral therapy initiating subjects in the NHS. Moderate overprediction of mortality in this young, healthy population suggests minor recalibration that could improve fit among similar patients. Considering VACS index at HI and 6 months improved outcome prediction and allowed earlier risk assessment.

Background: Prior studies have suggested that HAART initiation may vary by race/ethnicity. Utilizing the U.S. military healthcare system, which minimizes confounding from healthcare access, we analyzed whether timing of HAART initiation and the appropriate initiation of primary prophylaxis among those at high risk for pneumocystis pneumonia (PCP) varies by race/ethnicity., Methods: Participants in the U.S. Military HIV Natural History Study from 1998-2009 who had not initiated HAART before 1998 and who, based on DHHS guidelines, had a definite indication for HAART (CD4 <200, AIDS event or severe symptoms; Group A), an indication to consider HAART (including CD4 <350; Group B) or electively started HAART (CD4 >350; Group C) were analyzed for factors associated with HAART initiation. In a secondary analysis, participants were also evaluated for factors associated with starting primary PCP prophylaxis within four months of a CD4 count <200 cells/mm3. Multiple logistic regression was used to compare those who started vs. delayed therapy; comparisons were expressed as odds ratios (OR)., Results: 1262 participants were evaluated in the analysis of HAART initiation (A = 208, B = 637, C = 479 [62 participants were evaluated in both Groups A and B]; 94% male, 46% African American, 40% Caucasian). Race/ethnicity was not associated with HAART initiation in Groups A or B. In Group C, African American race/ethnicity was associated with lower odds of initiating HAART (OR 0.49, p = 0.04). Race and ethnicity were also not associated with the initiation of primary PCP prophylaxis among the 408 participants who were at risk., Conclusions: No disparities in the initiation of HAART or primary PCP prophylaxis according to race/ethnicity were seen among those with an indication for therapy. Among those electively initiating HAART at the highest CD4 cell counts, African American race/ethnicity was associated with decreased odds of starting. This suggests that free healthcare can potentially overcome some of the observed disparities in HIV care, but that unmeasured factors may contribute to differences in elective care decisions.

In its 15th year, the Global Emerging Infections Surveillance and Response System (GEIS) continued to make significant contributions to global public health and emerging infectious disease surveillance worldwide. As a division of the US Department of Defense's Armed Forces Health Surveillance Center since 2008, GEIS coordinated a network of surveillance and response activities through collaborations with 33 partners in 76 countries. The GEIS was involved in 73 outbreak responses in fiscal year 2011. Significant laboratory capacity-building initiatives were undertaken with 53 foreign health, agriculture and/or defense ministries, as well as with other US government entities and international institutions, including support for numerous national influenza centers. Equally important, a variety of epidemiologic training endeavors reached over 4,500 individuals in 96 countries. Collectively, these activities enhanced the ability of partner countries and the US military to make decisions about biological threats and design programs to protect global public health as well as global health security.

Multi-drug resistant Neisseria gonorrhoeae (GC) threatens the successful treatment of gonorrhea. This report presents preliminary findings with regard to the prevalence of laboratory-confirmed GC and the extent of drug-resistance among sample populations in five countries. Between October 2010 and January 2013, 1,694 subjects (54% male; 45% female; 1% unknown) were enrolled and screened for the presence of laboratory-confirmed GC in the United States, Djibouti, Ghana, Kenya, and Peru. Overall, 108 (6%) of enrolled subjects tested positive for GC. Antimicrobial susceptibility testing results were available for 66 GC isolates. Resistance to at least three antibiotics was observed at each overseas site. All isolates tested in Ghana (n=6) were resistant to ciprofloxacin, penicillin, and tetracycline. In Djibouti, preliminary results suggested resistance to penicillin, tetracycline, ciprofloxacin, cefepime, and ceftriaxone. The small sample size and missing data prevent comparative analysis and limit the generalizability of these preliminary findings.

Vaccination against human papillomavirus (HPV) is recommended to prevent cervical cancer among women. Vaccinating men against human papillomavirus (HPV) can prevent penile, anal, and oral cancers, anogenital warts, and the transmission of HPV to their sexual partners. This study characterized HPV acquisition among male military members by evaluating both seroprevalence at entry into service and seroincidence of HPV infection after ten years of service. At entry, 29 of 200 (14.5%) male service members were positive for HPV serotypes 6, 11, 16, or 18. Of 199 initially seronegative for at least one of the four HPV serotypes, 68 (34.2%) seroconverted to one or more serotypes at ten years; more than one-third of these were seropositive for oncogenic HPV serotypes. This estimate of HPV seroprevalence among male military accessions is higher than that reported among U.S. civilian males. Vaccination to prevent genital warts and cancers resulting from HPV infection may decrease health care system burdens. Further analyses are warranted to understand the potential costs and benefits of a policy to vaccinate male service members.

Due to shared routes of infection, HIV-infected persons are frequently coinfected with other sexually transmitted infections (STIs). Studies have demonstrated the bidirectional relationships between HIV and several STIs, including herpes simplex virus-2 (HSV-2), hepatitis B and C viruses, human papilloma virus, syphilis, gonorrhea, chlamydia, and trichomonas. HIV-1 may affect the clinical presentation, treatment outcome, and progression of STIs, such as syphilis, HSV-2, and hepatitis B and C viruses. Likewise, the presence of an STI may increase both genital and plasma HIV-1 RNA levels, enhancing the transmissibility of HIV-1, with important public health implications. Regarding the effect of STIs on HIV-1 progression, the most studied interrelationship has been with HIV-1/HSV-2 coinfection, with recent studies showing that antiherpetic medications slow the time to CD4 <200 cells/µL and antiretroviral therapy among coinfected patients. The impact of other chronic STIs (hepatitis B and C) on HIV-1 progression requires further study, but some studies have shown increased mortality rates. Treatable, nonchronic STIs (i.e., syphilis, gonorrhea, chlamydia, and trichomonas) typically have no or transient impacts on plasma HIV RNA levels that resolve with antimicrobial therapy; no long-term effects on outcomes have been shown. Future studies are advocated to continue investigating the complex interplay between HIV-1 and other STIs.

Objectives: To investigate the epidemiology and risk factors of gonorrhoea (GC) or chlamydia (CT) coinfection in an HIV-positive US military cohort, focusing on the time after participants' knowledge of HIV diagnosis., Methods: The authors analysed data from 4461 participants enrolled in the U.S. Military Natural History Study cohort for GC or CT infection ≥6 months after their HIV-positive test., Results: During a mean follow-up of 7.08 years, 482 (11%) participants acquired a GC or CT infection. Of these, 283 (6%) acquired a GC infection, 278 (6%) acquired a CT infection and 123 (3%) had multiple GC or CT infections during follow-up. Risk of GC or CT infection was significantly greater in those younger, male, African-American and with a history of GC or CT infection., Conclusions: Frequent GC and CT diagnoses observed among members of this HIV-positive cohort indicate substantial ongoing risk behaviours that raise concerns for HIV transmission and underscore the need for continued screening to help identify and treat these sexually transmitted infections in this population.

Background: Although highly active antiretroviral therapy (HAART) has improved HIV survival, some patients receiving therapy are still dying. This analysis was conducted to identify factors associated with increased risk of post-HAART mortality., Methods: We evaluated baseline (prior to HAART initiation) clinical, demographic and laboratory factors (including CD4+ count and HIV RNA level) for associations with subsequent mortality in 1,600 patients who began HAART in a prospective observational cohort of HIV-infected U.S. military personnel., Results: Cumulative mortality was 5%, 10% and 18% at 4, 8 and 12 years post-HAART. Mortality was highest (6.23 deaths/100 person-years [PY]) in those with ≤ 50 CD4+ cells/mm3 before HAART initiation, and became progressively lower as CD4+ counts increased (0.70/100 PY with ≥ 500 CD4+ cells/mm3). In multivariate analysis, factors significantly (p < 0.05) associated with post-HAART mortality included: increasing age among those ≥ 40 years (Hazard ratio [HR] = 1.32 per 5 year increase), clinical AIDS events before HAART (HR = 1.93), ≤ 50 CD4+ cells/mm3 (vs. CD4+ ≥ 500, HR = 2.97), greater HIV RNA level (HR = 1.36 per one log10 increase), hepatitis C antibody or chronic hepatitis B (HR = 1.96), and HIV diagnosis before 1996 (HR = 2.44). Baseline CD4+ = 51-200 cells (HR = 1.74, p = 0.06), and hemoglobin < 12 gm/dL for women or < 13.5 for men (HR = 1.36, p = 0.07) were borderline significant., Conclusions: Although treatment has improved HIV survival, defining those at greatest risk for death after HAART initiation, including demographic, clinical and laboratory correlates of poorer prognoses, can help identify a subset of patients for whom more intensive monitoring, counseling, and care interventions may improve clinical outcomes and post-HAART survival.

Changes in serologic status in human immunodeficiency virus (HIV)/hepatitis B virus (HBV) co-infected individuals with either isolated anti-HBc or resolved HBV infection have been reported, but the frequency of clinically meaningful long-term serologic changes is not well-defined. This study therefore, examined longitudinal serologic status for hepatitis B surface antigen (HBsAg)-negative HIV/HBV co-infected participants in a large cohort. Among 5,222 cohort participants, 347 (7%) were initially isolated anti-HBc positive, and 1,073 (21%) had resolved HBV infection (concurrently reactive for anti-HBc and anti-HBs). Thirty-three (10%) of the 347 participants with isolated anti-HBc were later positive for HBsAg at least once, compared with 3 (0.3%) of those with resolved HBV (P < 0.001). A total of 14 participants became persistently positive for HBsAg and were thus classified as having late-onset chronic HBV infection at a median of 3.7 years after initial HBV diagnosis. For those initially with HBsAg-negative HIV/HBV co-infection, the rate of late-onset chronic HBV infection was 1.39/1,000 person-years. Those with late-onset chronic HBV infection experienced significant decreases in CD4 cell counts (P = 0.002) with a mean of 132 cells/µl at the time of late-onset chronic HBV infection, but no factor distinguished those who were positive for HBsAg only once from those that developed late-onset chronic HBV infection. Over a median of 2.9 years following late-onset chronic HBV infection, 3 of 14 subsequently lost HBsAg. The occurrence of late-onset chronic HBV infection in HBsAg negative HIV/HBV co-infected adults appears to be one important, albeit rare, clinical event seen almost exclusively in those with isolated anti-HBc and low CD4 cell count., (Copyright © 2011 Wiley-Liss, Inc.)

Background: Sterile syringe access is a critical component of HIV prevention programs. Although retail pharmacies provide convenient outlets for syringe access, injection drug users (IDUs) may encounter barriers to syringe purchase even where purchase without a prescription is legal. We sought to obtain an objective measure of syringe access in Tijuana, Mexico, where IDUs report being denied or overcharged for syringes at pharmacies., Methods: Trained "mystery shoppers" attempted to buy a 1 cc insulin syringe according to a predetermined script at all retail pharmacies in three Tijuana neighborhoods. The same pharmacies were surveyed by telephone regarding their syringe sales policies. Data on purchase attempts were analyzed using basic statistics to obtain an objective measure of syringe access and compared with data on stated sales policies to ascertain consistency., Results: Only 46 (28.4%) of 162 syringe purchase attempts were successful. Leading reasons for unsuccessful attempts were being told that the pharmacy didn't sell syringes (35.3%), there were no syringes in stock (31.0%), or a prescription was required (20.7%). Of 136 pharmacies also surveyed by telephone, a majority (88.2%) reported selling syringes but only one-third (32.5%) had a successful mystery shopper purchase; the majority of unsuccessful purchases were attributed to being told the pharmacy didn't sell syringes. There was similar discordance regarding prescription policies: 74 pharmacies said in the telephone survey that they did not require a prescription for syringes, yet 10 of these pharmacies asked the mystery shopper for a prescription., Conclusions: IDUs in Tijuana have limited access to syringes through retail pharmacies and policies and practices regarding syringe sales are inconsistent. Reasons for these restrictive and inconsistent practices must be identified and addressed to expand syringe access, reduce syringe sharing and prevent HIV transmission.

We analyzed HIV viral load (VL) and CD4 count changes, and antibody responses following MMR vaccination of individuals in the U.S. Military HIV Natural History Study cohort. Cases receiving at least one dose of MMR vaccine after HIV diagnosis were matched 1:2 to HIV-positive controls not receiving the vaccine. Baseline was defined as time of vaccination for cases and indexed and matched to the time post-HIV diagnosis for controls. Changes in CD4 count and VL at 6, 12, 18 and 24 months were compared between cases and controls using a general linear model. Available sera from cases were tested for MMR seropositivity at baseline and post-vaccination at 6, 12, 18, and 24 months. Overall mean CD4 count change from baseline through 24 months was 20 (±23) cells/μL greater for cases than controls (p=0.39). Similar non-significant changes in CD4 cell count were seen in the subset of those not on HAART at baseline. VL changes were small and similar between groups (mean differential change -0.04 (±0.18) log(10) copies/mL; p=0.84). Of 21 vaccinated participants with baseline serologic testing, 14 (67%) were reactive to measles, 19 (91%) to mumps, and 20 (95%) to rubella. Three (43%) of 7 participants nonreactive to measles developed measles IgG; for mumps, 1 (50%) of 2 developed mumps IgG; for rubella, 1 (100%) developed rubella IgG. MMR vaccination did not result in detrimental immunologic or virologic changes through 24 months post-vaccination., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

We examined the use of Kratom (Mitragyna sp.), a dietary supplement with mu-opioid agonist activity, by members of a cybercommunity who self-treat chronic pain with opioid analgesics from Internet pharmacies. Within one year, an increase in the number of mentions on Drugbuyers.com, a Web site that facilitates the online purchase of opioid analgesics, suggested that members began managing opioid withdrawal with Kratom. This study demonstrates the rapidity with which information on psychoactive substances disseminates through online communities and suggests that online surveillance may be important to the generation of effective opioid analgesic abuse prevention strategies.

Background: Adherence interventions for HAART can impact challenging populations, such as active substance users. Community-based modified directly observed therapy (MDOT) is a promising approach that needs to be critically evaluated., Methods: This study was a randomized clinical trial. HIV seropositive substance users were randomized to either standard of care (SOC) or MDOT, stratified by HAART experience. All participants were placed on a once-daily regimen and were met by an outreach worker for all 7 days during the first 3 months. We used an intent-to-treat analysis to evaluate differences in viral load suppression [> 2 log drop in plasma viral load (PVL) or PVL < 50] and changes in PVL and CD4 cell count from baseline to 3 months., Results: A total of 87 participants were enrolled (43 in SOC, 44 in MDOT), Using repeated measures logistic regression, MDOT participants were more likely to achieve PVL suppression (odds ratio, 2.16; 95% confidence interval, 1.0-4.7), driven primarily by those HAART experienced (odds ratio, 2.88; 95% confidence interval, 1.2-7.0). A significant treatment effect was also found in CD4 cell count change (P < 0.05). No differences were found by arm in undetectable PVL., Conclusion: This study provides evidence that MDOT is an effective strategy to reduce viral load and increase CD4 cell counts in HAART experienced substance users. MDOT should be included in the spectrum of options to enhance adherence in this population.

Naloxone, the standard treatment for heroin overdose, is a safe and effective prescription drug commonly administered by emergency room physicians or first responders acting under standing orders of physicians. High rates of overdose deaths and widely accepted evidence that witnesses of heroin overdose are often unwilling or unable to call 9-1-1 has led to interventions in several US cities and abroad in which drug users are instructed in overdose rescue techniques and provided a "take-home" dose of naloxone. Under current Food and Drug Administration (FDA) regulations, such interventions require physician involvement. As part of a larger study to evaluate the knowledge and attitudes of doctors towards providing drug treatment and harm reduction services to injection drug users (IDUs), we investigated physician knowledge and willingness to prescribe naloxone. Less than one in four of the respondents in our sample reported having heard of naloxone prescription as an intervention to prevent opiate overdose, and the majority reported that they would never consider prescribing the agent and explaining its application to a patient. Factors predicting a favorable attitude towards prescribing naloxone included fewer negative perceptions of IDUs, assigning less importance to peer and community pressure not to treat IDUs, and increased confidence in ability to provide meaningful treatment to IDUs. Our data suggest that steps to promote naloxone distribution programs should include physician education about evidence-based harm minimization schemes, broader support for such initiatives by professional organizations, and policy reform to alleviate medicolegal concerns associated with naloxone prescription. FDA re-classification of naloxone for over-the-counter sales and promotion of nasal-delivery mechanism for this agent should be explored.

Background: The incarceration rate has increased 239% in the United States over the past 2 decades. This increase in incarceration has been fueled by the movement towards a criminal, rather than medical, response to the problem of drug dependence. For women in particular, incarceration and drug use are interdependent epidemics. Given that incarceration is common among drug-dependent persons, infectious diseases--including hepatitis B virus (HBV) and hepatitis C virus (HCV) infection--are prevalent among incarcerated persons. We sought to determine the incidence of HBV and HCV infection among recidivist women prisoners., Methods: From 1996 through 1997, excess from serum samples collected during HIV testing of female admittees to a state Department of Corrections facility were tested for HBV and HCV. Multiple samples obtained from women incarcerated multiple times during the study period were compared for incidence., Results: Baseline prevalences of markers of HBV and HCV were 36% and 34%, respectively. Incidence rates for HBV and HCV infection among reincarcerated women were 12.2 and 18.2 per 100 person-years, respectively. The majority of the time spent between serial intakes was not spent in the correctional facility; thus, incident infections likely occurred in the community., Conclusions: Incidences of HBV and HCV infection among reincarcerated women were high. Prisons and jails can be efficient locations for the diagnosis, treatment, and prevention of hepatitis B and C through programs such as testing, counseling, education, vaccination, and linkage to medical and drug treatment services.

In 2003, the Centers for Disease Control and Prevention issued recommendations to screen all inmates with a history of injection drug use or other risk factors for hepatitis C. We compared self-reported risk factors for hepatitis C with serostatus from inmates in the Rhode Island Department of Corrections. Of the male inmates who were hepatitis C positive, 66% did not report injection drug use. Risk-based testing underestimates the hepatitis C virus (HCV) prevalence in correctional settings and limits the opportunity to diagnose and prevent hepatitis C infection.

Directly observed therapy, which has been successful in the treatment of tuberculosis, is being adapted for the treatment of HIV to decrease long-term morbidity and mortality. We describe the experiences of 69 HIV-infected individuals who were enrolled in a community-based modified directly observed therapy (MDOT) program. Participants were referred by their primary care physicians based on nonadherence to antiretroviral therapy, and/or active substance use. A near-peer outreach worker initially delivered medications to participants 5 to 7 days per week, with visits subsequently tapered to 1 to 3 days per week after 3 or more months. Questionnaires were completed and laboratory values were obtained at baseline, 1 month, and every 3 months after enrollment. At enrollment, 96% of participants had a history of substance use, 71% had a history of incarceration, and 93% were experienced with highly active antiretroviral therapy (HAART). At the time of their 6-month assessment visit, 31 of 69 participants were receiving observed therapy visits. The median baseline plasma viral load (PVL) was 4.8 log, and the median individual change in PVL from baseline to 6 months among participants receiving MDOT was a decrease of 2.7 log. Reasons why participants were not receiving visits included medication holidays, hospitalization or assisted living, incarceration, discontinuation of program involvement, and death. These results support that MDOT should be included in the spectrum of options available to enhance adherence to HAART among patients who are unsuccessful with self-administration of their medications.

Highly active antiretroviral therapy (HAART) can dramatically decrease human immunodeficiency virus (HIV) load in plasma, increase CD4+ cell counts, and prolong life for HIV-seropositive persons. However, the need for optimal adherence has been recognized. We implemented a pilot community-based program of directly observed therapy (DOT) with HAART among persons with substance use disorders and a history of failure of HAART. A near-peer outreach worker initially delivered and observed once-daily HAART doses on up to 7 days per week. Many participants tapered the frequency of visits. Participants were assessed by a brief questionnaire and determination of their CD4+ cell count and plasma HIV load. Twenty-five HIV-seropositive persons were enrolled and followed-up for a mean of 6.6 months (standard deviation, 3.9 months). We found that once-daily dosing of HAART by DOT is feasible in this population; in addition to observation of the majority of doses, most participants achieved virus suppression and felt favorably about the intervention. Tapering the intensity of visits with maximum flexibility was necessary to enhance the acceptability of the program to participants.

Background: Hepatitis B continues to be a substantial problem in the United States despite the existence of a safe and effective vaccine. Vaccination programs for inmates could reach many high-risk individuals but little is known about U.S. inmates' willingness to accept hepatitis B virus (HBV) vaccination while incarcerated. The goal of this study was to assess inmates' knowledge about hepatitis B and their willingness to accept hepatitis B vaccination while incarcerated., Methods: We interviewed 153 male and female inmates at the Rhode Island Department of Corrections (RIDOC) using a voluntary, anonymous survey., Results: Ninety-three percent of inmates said they would agree to receive the hepatitis B vaccine while incarcerated. More than half of the 30% who reported having risk factors for hepatitis B did not consider themselves to be at risk for hepatitis B and almost half (44%) of all inmates were not aware that hepatitis B can be transmitted through unprotected sex., Conclusion: Hepatitis B vaccination programs in correctional settings are a public health priority and would be well received by the target population. Such programs would help protect the health of incarcerated persons and the communities to which they return.

Injection drug users (IDUs) are at increased risk for many health problems, including acquisition of human immunodeficiency virus (HIV) and hepatitis B and C. These risks are compounded by barriers in obtaining legal, sterile syringes and in accessing necessary medical care. In 1999, we established the first-ever syringe prescription program in Providence, Rhode Island, to provide legal access to sterile syringes, reduce HIV risk behaviors, and encourage entry into medical care. Physicians provided free medical care, counseling, disease testing, vaccination, community referrals, and prescriptions for sterile syringes for patients who were not ready to stop injecting. We recruited 327 actively injecting people. Enrolled participants had limited stable contact with the health care system at baseline; 45% were homeless, 59% were uninsured, and 63% did not have a primary care physician. Many reported high-risk injection behaviors such as sharing syringes (43% in the last 30 days), reusing syringes (median of eight times), and obtaining syringes from unreliable sources (80%). This program demonstrates the feasibility, acceptability, and unique features of syringe prescription for IDUs. The fact that drug use is acknowledged allows an open and frank discussion of risk behaviors and other issues often not disclosed to physicians. The syringe prescription program in Providence represents a promising and innovative approach to disease prevention and treatment for IDUs.

Six women with substance abuse and poor adherence histories received daily antiretroviral directly observed therapy (DOT). Cervicovaginal lavage (CVL) and plasma HIV-1-RNA levels were measured at baseline, 1 month, 3 months, and 6 months. All subjects had undetectable (below 2.6 log10 copies/ml) CVL HIV-1-RNA levels by 3 months and undetectable plasma HIV-1-RNA levels by 6 months. The mean CD4 cell increase was 76 cells/mm3. DOT appears effective and may reduce infectiousness in this high-risk population.

Background: Drug use, particularly among women, is a public health issue given its health effects and its impact on HIV transmission. Becoming HIV seropositive could lead to differing patterns of drug use over time. HIV infection may decrease drug use due to an increased access to health services. Alternatively, increased drug use may occur due to depression associated with being HIV infected, leading to despair, hopelessness, and a lack of motivation to become drug free., Methods: We evaluated the potential association between HIV serostatus and drug use among a cohort of 1310 women who were part of a multicenter collaborative study on the natural history of HIV infection. Eight hundred seventy-one HIV-seropositive women and 439 HIV-seronegative women were enrolled at four sites (New York, Providence, Baltimore, and Detroit). We defined drug use as any heroin or cocaine use reported at the baseline visit (enrollment)., Results: Drug use was found to decrease during earlier visits (months 1-24) and remained stable at 20% thereafter (months 30-84). No significant differences in change of drug use were noted by HIV serostatus, using generalized estimating equation-based logistic regression analyses., Conclusions: HIV-seropositive status did not affect drug use patterns over time within our population of high-risk women.

Objective: To examine pharmacists' attitudes and obstacles to syringe sales to IDUs without prescriptions in Rhode Island, around the time that such sales became legal in the state., Design: Self-administered written survey., Setting: Rhode Island., Participants: 400 randomly selected pharmacist members of the Rhode Island Pharmacists Association., Main Outcome Measures: Responses to survey items., Results: Of the 400 pharmacists contacted, 131 (33%) completed and returned the survey; of these, 101 (77%) were pharmacists who worked in stores that provided direct nonprescription syringe sales to the public. The majority of these 101 pharmacists were willing to sell syringes to a suspected IDU without a prescription (65%), favored providing free sharps containers for disposal (68%), and supported providing pamphlets on safer injection practices (88%). Willingness to sell syringes to IDUs without a prescription was significantly correlated with various beliefs about possible consequences of sales., Conclusion: The high level of support for nonprescription syringe sales to IDUs is promising. The correlation between the willingness to sell syringes to IDUs without a prescription and various beliefs suggests that future educational interventions might encourage pharmacists to sell syringes to this population without a prescription to decrease HIV and hepatitis transmission.

Audio computer assisted self-interview (ACASI) has been shown to elicit significantly higher reports of sensitive HIV risk behaviors compared with interviewer-administered questionnaires (IAQ). Injection drug users were randomized to either ACASI (n = 556) or IAQ (n = 586) in order to evaluate reporting differences. A significant interaction was found between mode of administration (ACASI/IAQ) and HIV status. HIV-seropositive respondents on ACASI compared with IAQ were less likely to report condom use (odds ratio [OR] = .42, p < .01) and condom use frequency (OR = .28, p < .002), compared with HIV-seronegative respondents. Based on ACASI results, HIV-seropositive individuals engaged in fewer preventive behaviors than suggested by IAQ. These findings support the validity of ACASI as an important mode of data collection in reducing socially desirable responding, especially among HIV-seropositive subjects.

Injection drug users (IDUs) are a population at high risk for many diseases, including AIDS, and are clearly in need of medical and substance abuse treatment. Access to sterile syringes is critical for lowering the risk of transmission of HIV and other blood-borne pathogens among IDUs. Previously tried strategies include needle exchange programs and changing laws to allow the legal purchase and possession of syringes. An alternative strategy is to have physicians prescribe syringes to IDUs. To the best of our knowledge, this has previously been tried by only a few physicians in rare situations and never on a programmatic basis. This report describes the genesis of physician's syringe prescription in Rhode Island and some of the lessons learned to date. Because of the illicit nature of drug use, a tremendous amount of mistrust and fear on the part of IDUs often leads to poor interaction with the medical establishment. Prescription of syringes by a physician can serve as a tool for reaching out to a high-risk and often out-of-treatment population of drug users. It is a way for the health care community to tap into drug-using networks and bring those populations into a medical care system.

A 37-year-old man coinfected with HIV-1 and human T-lymphotropic virus type II presumably through injection drug use had a high CD4+ count and low HIV viral load without anti-retroviral therapy for over six years. As an HIV long-term non-progressor, his case supports the hypothesis that coinfection with HTLV-II does not adversely affect the course of HIV disease.

Objectives: To review issues related to discarded syringes in the community and to describe community-based programs for the safe disposal of used needles and syringes., Methods: We used the medical literature and chain referral to identify community-based syringe disposal programs other than syringe exchange programs (SEPs). We held a workshop in June 1996 involving staff from disposal programs; manufacturers of syringes, sharps containers, and other disposal devices; solid waste companies; public health staff; and researchers., Results: Fifteen programs for the safe disposal of syringes were identified in the United States, Canada, and Australia. Of these, 12 primarily served persons with diabetes who use insulin, and 3 primarily served injection drug users (IDUs). The programs used three major strategies: puncture-resistant containers discarded in trash, community drop boxes, and sharps containers turned in for biohazard disposal at community sites, hospitals, or pharmacies. Participants in the workshop described key points in developing syringe disposal programs. Programs should involve pharmacists, physicians, waste disposal companies, public health departments, hospitals, diabetes educators, persons with diabetes who use insulin, and IDUs. For IDUs, criminal penalties for possession of syringes are a substantial deterrent to participation in community efforts to safely dispose of used syringes. The multiple and sometimes conflicting local, state, and federal laws and regulations concerning medical waste hinder development of multistate or national approaches to the safe disposal of syringes. More information is needed on community-based syringe disposal programs., Conclusion: Communities in the United States, Canada, and Australia have developed different approaches to achieve safe disposal of used syringes.

Before 1982, the authors performed 177 primary total hip arthroplasties using a single-sized, extensively porous-coated cobalt-chrome femoral prosthesis. The current status of 122 of these arthroplasties is known. Two femoral prostheses have been revised for late symptomatic loosening, 2 for stem fracture, and 1 for infection. From 1982 to 1984, 227 primary arthroplasties were performed using the same stem in multiple sizes. Of these cases, 171 are available for followup. One stem (0.6%) has been revised for symptomatic loosening. Large osteolytic femoral lesions (average size, 8.1 cm2) developed in 3 patients, associated with an unusually large amount of polyethylene wear of their acetabular components. These patients have been treated by exchange of the polyethylene liner within the porous-coated acetabular component and allografting of the osteolytic lesions. The femoral components were not exchanged because osteolysis had not eroded the integrity of the supporting bone-implant interface to a point where loosening occurred. Before 1987, 193 patients with loose femoral components were treated with revision total hip arthroplasty, also using an extensively porous-coated cobalt-chrome femoral stem of similar design. Ten (5.7%) patients have required rerevision of the femoral prosthesis. Six of these 10 rerevisions were performed because of symptomatic loosening. Ninety-three percent of the patients in the primary series had relief of their preoperative pain and have improved functional ability; 94.2% are satisfied with their results. In the revision series, 89.1% of the patients are free of pain and function better than preoperatively, and 89.6% are fully satisfied with their results.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1980 and 1986, ninety-three femoral revision arthroplasties without cement were performed on ninety-one patients who had symptomatic loosening of a stemmed femoral component of a total hip prosthesis. Eighty-one of these patients (eighty-three hips) were followed for at least five years (range, five to thirteen years; mean, nine years). Forty-three hips also had a revision of a cemented acetabular component with use of a hemispherical, porous-coated implant inserted without cement. The results are presented in a traditional manner in terms of implant survivorship, radiographic evaluation for stability of the implant, and standardized hip scores. Changes due to the treatment are presented as outcomes in terms of the physician's criteria for the success of the operation, the patient's criteria for the success of the operation, and the patient's economic status. No hips that needed additional operations were excluded, and we reported the outcome regardless of any interim operative procedures (including re-revisions). At the latest follow-up examination, nineteen (23 per cent) of the eighty-three hips had had an additional operation, including seventeen hips (20 per cent) for which re-revision had been necessary. In ten (12 per cent) of the eighty-three hips, the re-revision had involved an index implant. The rate of re-revision of the index femoral component was 10 per cent and the rate of mechanical loosening of that component was 11 per cent. The rate of re-revision of the index acetabular component was 7 per cent and the rate of mechanical loosening of that component was 11 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Fifteen years of clinical experience with porous-coated prostheses demonstrated the durability of this type of fixation. This experience was documented by clinical follow-up study of the 393 cases treated by the senior author before 1985. Only six of these femoral components have been revised: three for loosening, two for stem breakage, and one for infection. Thus, the revision rate for the porous-coated stems was 1.5%. Porous-coated acetabular components were used in 227 of the arthroplasties. Five of these porous-coated cups have been revised: four for malposition leading to dislocation and one for late loosening secondary to osteolysis. Thus, the revision rate for these porous-coated acetabular components was 2.2%. Twenty bipolar and 146 cemented acetabular components were used in the remaining 166 cases treated before 1985. Eleven (7.5%) of the cemented acetabular components were revised. Revisions of the porous-coated components were rare in the first ten postoperative years. The clinical data were supplemented with analysis of postmortem specimens from 15 patients. Mechanical testing of the femoral specimens showed the relative micromotion at the porous surface to be exceptionally small (less than 40 microns). Seven of these postmortem retrievals involved cases with unilateral arthroplasties. In these cases, the contralateral normal femur also was removed, and a prosthesis identical to that in the in vivo implanted side was inserted to simulate the immediate postoperative condition. Dual-energy X-ray absorptiometry (DEXA) of the seven paired femora demonstrated that bone remodeling can be expected to produce a 5%-52% loss of periprosthetic bone mineral content, with the greatest loss occurring in the more osteoporotic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors present their results for cementless femoral revision arthroplasty using extensively porous coated implants. Patients have been prospectively followed for 5 to 11 years (mean 7.4 years). The revision rate was 5.7%, and the radiographic loosening rate was 1.1%, to give a mechanical failure rate of only 6.9%. As a result of the revision procedure, the pain level was improved for 89.1% of the patients, walking status was improved for 82.8% of the patients, and functional level was improved for 88.5% of the patients. These results compare very favorably with any reports on revision arthroplasty using cement with a similar length follow-up.