HIV Psychiatry

Annotated Abstracts of Journal Articles
2015, 2nd Quarter

HIV Psychiatry

Annotations by Oliver Freudenreich, MD, FAPM and Mary Ann Cohen, MD, FAPM
June 2015

  1. Self-reported HIV and HCV screening rates and serostatus among substance abuse treatment patients
  2. Myocardial infarction among Danish HIV-infected individuals: population-attributable fractions associated with smoking

Also of interest:

  • Rich JD, Adashi EY: Ideological anachronism involving needle and syringe exchange programs: lessons from the Indiana HIV outbreak
    JAMA 2015; 314(1):23-24Earlier this year, the governor of Indiana declared a state of public health emergency to combat the largest-ever HIV outbreak in his state, resulting from needle sharing by people who were injecting opiates. This declaration allowed him to temporarily override state law and implement a needle exchange program. Needle exchange programs have been shown to be an effective strategy to prevent HIV infections in patients with injection drug use but face ideological headwind. This viewpoint in JAMA provides some background about policies regarding needle exchange programs and lessons learned from the Indiana outbreak, including the importance of a functioning public health system.
  • New York State Department of Health AIDS Institute: UPDATE: Antiretroviral Therapy, Section III: When to Initiate ART
    June 2015New York State’s antiretroviral guideline has been updated to reflect recent research findings, including preliminary results from the Strategic Timing of AntiRetroviral Treatment (START) trial, a major randomized trial that is being conducted at 215 sites in 35 countries to determine the best time to initiate ART for HIV.
    Interim results by the study’s DSMB suggest that early treatment when the CD4 count is still normal, as opposed to delaying ART initiation until the CD4 count is below 350 cells/mm3, reduces by half the risk of death or serious illness (press release). Accordingly, the guideline now recommends that “All patients with confirmed HIV infection should be offered ART, regardless of CD4 count.” Initiation of ART at the earliest time prevents not only mortality and morbidity but also HIV transmission.



PUBLICATION #1 — HIV Psychiatry
Self-reported HIV and HCV screening rates and serostatus among substance abuse treatment patients

Hernandez D, Feaster DJ, Gooden L, et al
AIDS Behav 2015 May 8 [Epub ahead of print]

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.


Substance users are at increased risk for HIV and HCV infection. Still, many substance use treatment programs (SUTP) fail to offer HIV/HCV testing. The present secondary analysis of screening data from a multi-site randomized trial of rapid HIV testing examines self-reported HIV/HCV testing patterns and serostatus of 2473 SUTP patients in 12 community-based sites that had not previously offered on-site testing. Results indicate that most respondents screened for the randomized trial tested more than a year prior to intake for HIV (52 %) and HCV (38 %). Prevalence rates were 3.6 and 30 % for HIV and HCV, respectively. The majority of participants that were HIV (52.2 %) and HCV-positive (40.5 %) reported having been diagnosed within the last 1-5 years. Multivariable logistic regression showed that members of high-risk groups were more likely to have tested. Bundled HIV/HCV testing and linkage to care issues are recommended for expanding testing in community-based SUTP settings.

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PUBLICATION #2 — HIV Psychiatry
Myocardial infarction among Danish HIV-infected individuals: population-attributable fractions associated with smoking

Rasmussen LD, Helleberg M, May MT, et al
Clin Infect Dis 2015; 60(9):1415-23

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.


Background: Human immunodeficiency virus-infected individuals have increased risk of myocardial infarction (MI); however, the contribution from smoking and potentiating effects of HIV are controversial.

Methods: From the Danish HIV Cohort Study and the Copenhagen General Population Study, we identified 3251 HIV-infected individuals and 13 004 population controls matched on age and gender. Data on MI were obtained from the National Hospital Registry and the National Registry of Causes of Death. We calculated adjusted incidence rate ratios (aIRR) for risk of MI and population-attributable fractions (PAF) of MI associated with smoking.

Results: In never smokers, HIV was not associated with an increased risk of MI (aIRR, 1.01; 95% confidence interval [CI], .41-2.54). In previous and current smokers, HIV was associated with a substantially increased risk of MI (aIRR, 1.78; 95% CI, .75-4.24 and aIRR, 2.83; 95% CI, 1.71-4.70). The PAF associated with ever smoking (previous or current) was 72% (95% CI, 55%-82%) for HIV-infected individuals and 24% (95% CI, 3%-40%) for population controls. If all current smokers stopped smoking, 42% (95% CI, 21%-57%) and 21% (95% CI, 12%-28%) of all MIs could potentially be avoided in these 2 populations.

Conclusions: Smoking is associated with a higher risk of MI in the HIV-infected population than in the general population. Approximately 3 of 4 MIs among HIV-infected individuals are associated with ever smoking compared with only 1 of 4 MIs among population controls. Smoking cessation could potentially prevent more than 40% of MIs among HIV-infected individuals, and smoking cessation should be a primary focus in modern HIV care.


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