Monthly Archives: August 2016

How to minimize HIV risk

Even from a research standpoint, definitions across various studies lack consistency, according to Elizabeth Bowen, an assistant professor in the University at Buffalo School of Social Work, whose new study published in the Journal of HIV/AIDS & Social Work suggests how understanding housing histories and the multiple dimensions of homelessness can help better identify who might be at greater risk of transmitting or contracting HIV.

“The homeless population can’t be painted with a broad brush because there will be people within that group who have more stability than others,” she said.

“This study came of wanting to break down what it means to be homeless and linking that with HIV risk behaviors.”

Bowen’s research looked specifically at residents of single-room occupancy (SRO) housing in Chicago, a group that illustrates the difficulty of assigning a unified definition of homelessness.

Bowen says there is a subset of the SRO group that considers themselves homeless, even though they have a place to live, because of uncertainly derived from factors that include concerns about rent increases and an inability to continue to afford even minimal housing such as an SRO.

“That’s one end of the spectrum,” says Bowen. “It’s a transient population that’s bouncing into and out of SRO buildings and other locations, such as staying in overnight shelters or on the street. But on the other end is the long-term resident, who may have been stably housed for 20 years.”

When thinking about how to help minimize HIV risk, Bowen says it’s important to target the right people.

“The long-term residents might need help in other areas, but the research suggests they’re not engaging in the same risky behaviors, such as drug use or having multiple sexual partners, as the residents who had been homeless more recently or who still considered themselves to be homeless.”

This information is critical to social workers trying to identify who might be most in need of help.

“We talk a lot in social work about harm reduction,” says Bowen, who was a social worker in Chicago before her career in research and higher education. “It is apparent to me that there is a sub-population of SRO residents who might need those harm-reduction services — and it wouldn’t have to be a major intervention. It might be a matter of brief screening and counseling.”

But Bowen also points out that this type of research underscores the need for affordable housing in U.S. cities.

SROs are basic, low-rent units, often constituting buildings that developers can easily, and with increasing frequency, convert into more profitable structures.

“Even while we were collecting data for this study, we saw some of these buildings closing,” she says. “This limited option is getting increasingly scarce.”

Bowen says the link between health and housing goes beyond HIV to include many chronic long-term health issues, both physical and mental.

SROs might be affordable, but the rent for this type of housing still represents a large percentage of a resident’s income, which is often exclusively Supplemental Security Income.

“There’s very little money left over for food, health care and other essentials,” says Bowen. “There needs to be not only more high-quality affordable housing options, but more subsidized housing so people are not spending more than half of their fixed monthly income on a place to live.”

Prompt coordinated treatment are needed for TB and HIV Patient

People with HIV or diabetes, who are taking immune-suppressing medications, or who smoke or abuse drugs, are at higher risk for developing TB disease once infected.

Patients often are diagnosed with HIV and TB at the same time. In 2003, when the previous TB guidelines were developed, patients with HIV usually did not start their anti-retroviral therapy (ART) until after TB treatment was completed, unless the immunosuppression from HIV-infection progressed. Recommendations for timing of initiation of ART have since changed.

“Data from numerous trials have made it very clear that patients with HIV should begin treatment with anti-retroviral therapy (ART) during TB treatment, and not wait until after TB therapy is completed,” said Payam Nahid, M.D., M.P.H., lead author of the guidelines and professor of medicine at the University of California, San Francisco School of Medicine. “Research shows that all patients with TB and HIV should receive treatment for both conditions, with HIV treatment beginning within 8 to 12 weeks of the start of TB therapy. Some patients may need HIV treatment even sooner.”

Dr. Nahid notes that ART may need to be delayed especially in HIV-infected patients with TB meningitis; in these patients, very early initiation of ART (within two weeks of the start of TB treatment) has been associated with increased risk of death. Nonetheless, ART should be initiated as early as possible during TB treatment. If patients do not receive ART during treatment of TB, the new guidelines recommend that TB treatment should be extended to eight months or longer, to reduce risk of relapse.

TB is a bacterial infection that is spread through the air and most often attacks the lungs. Drug-susceptible TB bacteria can be killed by the medications normally used to treat TB disease. After two decades of steady declines, the number of new U.S. TB cases rose slightly in 2015 to 9,563, according to provisional data released by CDC. It is one of the world’s deadliest diseases: in 2014, it is estimated that 9.6 million people worldwide fell newly ill with TB, and 1.5 million died.

The new guidelines recommend comprehensive care of all patients with TB disease (known as case management), including the use of directly observed therapy (DOT), which improves treatment success. In DOT, a health care provider watches the patient swallow each dose of medication during the six-month course of therapy. To be consistent with the principles of patient-centered care, the guidelines recommend that decisions regarding the use of DOT be made in partnership with the patient. DOT should be provided by trained health care workers in the doctor’s office, clinic, or the patient’s home, place of employment, school or other site convenient for the patient. For all TB patients, case management is essential to ensure treatment is effective, the guidelines note.

“Case management, including DOT and patient education and counseling, is vital to reducing the risk of non-adherence to treatment, and consequently the risks of TB relapse, drug-resistance and other illnesses,” said Philip LoBue, MD, director of the Division of Tuberculosis Elimination (DTBE) at CDC in Atlanta. “We now have clear evidence to show that the benefits of case management are real.”

Although the guidelines focus on drug-susceptible TB, following the recommendations can help stem the growing problem of acquired drug resistance, researchers note. This includes recommendations related to avoiding highly intermittent therapies, and using case management strategies such as DOT.

Because rapid killing of the TB bacteria reduces the risk of death and the spread of the disease, the guidelines note that TB treatment (currently a combination of four medications) should begin as soon as the patient is suspected of having active TB disease, even before test results confirm the diagnosis. They also recommend therapy be given daily, rather than intermittently.

At a Glance

  • Patients diagnosed with HIV and tuberculosis (TB) should receive prompt, coordinated treatment for both conditions, recommend new ATS/CDC/IDSA guidelines on the treatment of drug-susceptible TB disease.
  • Using case management strategies, including directly observed therapy (DOT), in caring for patients with TB disease reduces the risk of treatment failure and development of drug resistance.
  • Rather than waiting for test results, treatment should begin as soon as TB disease is suspected, and daily therapy is best to reduce risk of relapse and drug resistance.
  • In 2014, more than 9 million people worldwide developed active TB, including more than 9,000 in the United States.