ANNOTATION (Freudenreich & Cohen)

The Findings: 2473 patients who were screened for recruitment into a study at 12 US community-based substance use treatment programs self-reported HIV- and HCV-positive status of 3.6% and 30.6%, respectively. About 50% of patients reported having been tested for HIV more than a year ago; for HCV, about 40% of patients were tested more than a year ago. For HIV, 20% had never been tested. Members of high-risk groups were more likely to have been tested recently and frequently and be aware of their serostatus.

Strength and Weaknesses: While this was a large sample, the study was not a random sample of substance use treatment centres but sites participating in a multi-site trial. This study was not designed to comprehensively assess who gets screened for HIV/HCV and obstacles to screening and care linkage. It was based on self-report which might not show good concordance with actual serostatus. Since this was only a screening for study participation, a limited number of variables were collected (e.g., no information regarding type and severity of substance use).

Relevance: Substance use treatment sites provide an important opportunity for bundled HIV/HCV testing and also for linkage to treatment. In this study, a significant minority of patients had not been tested for HIV, and the majority had not been tested recently. This is a missed opportunity. HIV (and HCV) screening combined with linkage to treatment should be an important part of what substance use programs routinely offer to every patient. C-L psychiatrists in such settings should look at the admissions to such programs and devise workflows that make HIV/HCV screening a routine part of care.

ANNOTATION (Freudenreich & Cohen)

The Findings: Using data from two Danish cohorts (one cohort of HIV patients from 8 clinical centres throughout Denmark and matched controls from Copenhagen) as well as mortality data from the country’s national registries, the authors showed that patients with HIV who never smoked had a risk for myocardial infarction (MI) that was comparable to a background risk (i.e., the risk for the people of Copenhagen). However, past and current smokers had an increased MI risk (relative risk of 1.78 and 2.83, respectively). The so-called population-attributable fraction (PAF) of ever smoking was very high for HIV patients (72% compared to 24% for the Copenhagen population).

Strength and Weaknesses: This was a large cohort study that took advantage of well-run and established nationwide registries in a Scandinavian country. Still, the Copenhagen control population might not be comparable to the communities that made up the HIV cohort. There might also be other variables (e.g., different rates of illicit drug use) that were not measured and that could account for some differences between the HIV and the Copenhagen population with regards to MI pathogenesis.

Relevance: Smoking is a very significant contributor to MI in HIV patients and smoking cessation must be a major health goal for HIV patients. While other factors might also play a role in the pathogenesis of MI in HIV patients (e.g., drug toxicity), the calculated PAF in this study suggests that smoking cessation would prevent 3/4 of MIs. Psychiatrists might be particularly suited to assist their HIV colleagues in implementing smoking cessation programs in HIV clinics, including the use of effective medications such as varenicline. All too often, varenicline is under-utilized because of psychiatric side effect concerns that could be managed with careful education and monitoring.