J Acquir Immune Defic Syndr Volume 70, Number 2, October 1, 2015
Letters to the Editor #University of North Carolina School of Medicine, Department of Obstetrics and Gynecology, Chapel Hill, NC
15.
REFERENCES 1. Forman D, de Martel C, Lacey CJ, et al. Global burden of human papillomavirus and related diseases. Vaccine. 2012;30(suppl 5): F12–F23. 2. Bosch FX, Manos MM, Munoz N, et al. Prevalence of human papillomavirus in cervical cancer: a worldwide perspective. International biological study on cervical cancer (IBSCC) Study Group. J Natl Cancer Inst. 1995;87:796–802. 3. Remmink AJ, Walboomers JM, Helmerhorst TJ, et al. The presence of persistent high-risk HPV genotypes in dysplastic cervical lesions is associated with progressive disease: natural history up to 36 months. Int J Cancer. 1995;61:306–311. 4. Steben M, Duarte-Franco E. Human papillomavirus infection: epidemiology and pathophysiology. Gynecol Oncol. 2007;107(2 suppl 1): S2–S5. 5. Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:12–19. 6. Ahdieh L, Munoz A, Vlahov D, et al. Cervical neoplasia and repeated positivity of human papillomavirus infection in human immunodeficiency virus-seropositive and -seronegative women. Am J Epidemiol. 2000;151:1148–1157. 7. de Sanjose S, Palefsky J. Cervical and anal HPV infections in HIV positive women and men. Virus Res. 2002;89:201–211. 8. Jamieson DJ, Duerr A, Burk R, et al. Characterization of genital human papillomavirus infection in women who have or who are at risk of having HIV infection. Am J Obstet Gynecol. 2002;186:21–27. 9. Minkoff H, Feldman J, DeHovitz J, et al. A longitudinal study of human papillomavirus carriage in human immunodeficiency virusinfected and human immunodeficiency virusuninfected women. Am J Obstet Gynecol. 1998;178:982–986. 10. Palefsky JM, Minkoff H, Kalish LA, et al. Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high-risk HIVnegative women. J Natl Cancer Inst. 1999; 91:226–236. 11. Strickler HD, Burk RD, Fazzari M, et al. Natural history and possible reactivation of human papillomavirus in human immunodeficiency virus-positive women. J Natl Cancer Inst. 2005;97:577–586. 12. Sun XW, Ellerbrock TV, Lungu O, et al. Human papillomavirus infection in human immunodeficiency virus-seropositive women. Obstet Gynecol. 1995;85:680–686. 13. Sun XW, Kuhn L, Ellerbrock TV, et al. Human papillomavirus infection in women infected with the human immunodeficiency virus. N Engl J Med. 1997;337:1343–1349. 14. Temmerman M, Tyndall MW, Kidula N, et al. Risk factors for human papillomavirus and
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16.
17.
18.
19.
20.
21.
22.
23.
24. 25.
26.
27.
28.
cervical precancerous lesions, and the role of concurrent HIV-1 infection. Int J Gynaecol Obstet. 1999;65:171–181. Minkoff H, Zhong Y, Burk RD, et al. Influence of adherent and effective antiretroviral therapy use on human papillomavirus infection and squamous intraepithelial lesions in human immunodeficiency virus-positive women. J Infect Dis. 2010;201:681–690. Adler DH, Kakinami L, Modisenyane T, et al. Increased regression and decreased incidence of human papillomavirus-related cervical lesions among HIV-infected women on HAART. AIDS. 2012;26:1645–1652. Heard I, Schmitz V, Costagliola D, et al. Early regression of cervical lesions in HIV-seropositive women receiving highly active antiretroviral therapy. AIDS. 1998;12:1459–1464. Heard I, Tassie JM, Kazatchkine MD, et al. Highly active antiretroviral therapy enhances regression of cervical intraepithelial neoplasia in HIV-seropositive women. AIDS. 2002;16: 1799–1802. Minkoff H, Ahdieh L, Massad LS, et al. The effect of highly active antiretroviral therapy on cervical cytologic changes associated with oncogenic HPV among HIV-infected women. AIDS. 2001;15:2157–2164. Batman G, Oliver AW, Zehbe I, et al. Lopinavir up-regulates expression of the antiviral protein ribonuclease L in human papillomavirus-positive cervical carcinoma cells. Antivir Ther. 2011;16:515–525. Zehbe I, Richard C, Lee KF, et al. Lopinavir shows greater specificity than zinc finger ejecting compounds as a potential treatment for human papillomavirus-related lesions. Antivir Res. 2011;91:161–166. Hampson INMI, Hampson L, Masinde M, et al. A Phase 1/2 trial of a self-applied, nonsurgical treatment for HPV related high grade cervical neoplasia. Paper presented at: oral presentation presented at 11th International Conference on Urban Health; March 5, 2014; Manchester, England. Bacon MC, von Wyl V, Alden C, et al. The women’s interagency HIV study: an observational cohort brings clinical sciences to the bench. Clin Diagn Lab Immunol. 2005;12:1013–1019. Kovacs A, Wasserman SS, Burns D, et al. Determinants of HIV-1 shedding in the genital tract of women. Lancet. 2001;358:1593–1601. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans (2009). A Review of Human Carcinogens. Part B: Biological Agents. Lyon, France: IARC. (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 100B). Chapter 6, Human papillomaviruses, pp. 255–313. Xue X, Kim MY, Castle PE, et al. A new method to address verification bias in studies of clinical screening tests: cervical cancer screening assays as an example. J Clin Epidemiol. 2014;67:343–353. D’Agostino RB Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17:2265–2281. Dumond JB, Yeh RF, Patterson KB, et al. Antiretroviral drug exposure in the female genital tract: implications for oral pre- and post-exposure prophylaxis. AIDS. 2007;21:1899–1907.
29. Pokorna J, Machala L, Rezacova P, et al. Current and novel inhibitors of HIV protease. Viruses. 2009;1:1209–1239.
Extreme Levels of Suicidality Among People Who Inject Drugs in Delhi, India: A Cause for Reflection for HIV Prevention Interventions To the Editors: The nexus between injecting drug use and HIV has emerged as an important public health priority in several major Indian cities. In Delhi, one of the worlds most heavily populated megacities, the HIV prevalence among people who inject drugs (PWID, who are predominantly male) is estimated to have risen from 10.0% in 2006 to 18.3% in 2010–11.1,2 Consequently, HIV prevention interventions have been implemented to mitigate HIV transmission risk in this population, including needle syringe exchange, opioid substitution therapy, peer education, and HIV testing and counseling. One core intermediate outcome sought by these interventions is the reduction of risky injecting and sexual practices. Interestingly, our recent study of PWID in Delhi documented an extremely high prevalence of the pastyear suicidal ideation (53%) and attempts (36%).3 These results are in line with findings from surveys of PWID elsewhere in the world, which have found lifetime prevalence of attempted suicide ranging between 17.0% and 47.0%,4–11 as compared with 2.7%– 4.6% in the general population (and 4.1% among the general population of The direct research costs were funded by Nossal Institute for Global Health, University of Melbourne. Some aspects of this Letter to the Editor were presented at the 28th World Congress of the International Association for Suicide Prevention, June 16–20, 2015, Montreal, Quebec, Canada. The authors have no conflicts of interest to disclose.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Acquir Immune Defic Syndr Volume 70, Number 2, October 1, 2015
India).12–16 In addition to this, we found that needle/syringe sharing and unprotected sex were very common and that suicidal thoughts were strongly associated with a significant increase in the likelihood of both needle/syringe sharing and unsafe sexual behaviors. Co-occurring suicidality and health risk behavior among men who have sex with men was also previously reported in JAIDS.17 We subsequently published additional analyses documenting an association between suicidality and male-to-male anal sex (which was almost exclusively unprotected) in this same community,18 and we examined the psychosocial risk factors for suicidal thoughts and attempts, which were depressive and anxiety symptom severity, homelessness, strained family and marital relationships, poor physical health, chronicity of addiction, recent experiences of physical violence, and a history of being forced or coerced into sex.19 These findings coalesce to advance 2 important issues that necessitate further comment and enquiry. First, there are significant challenges for HIV prevention and other public health interventions that seek to reduce risky behaviors in communities where there is a high degree of ambivalence about living. The reasons why many PWID engage in behaviors that put themselves and others at risk of HIV and other infections are multifaceted and extend beyond rational decisions based on knowledge about risks and the provision of resources such as new needles/syringes and condoms. The high level of suicidality observed among PWID in Delhi and its correlation with increased injecting and sexual risk behaviors impedes the program logic that improved knowledge, and access to resources will result in positive behavior change. To put it plainly, when someone is ambivalent about preserving their life today, they are less likely to be concerned about a disease they may or may not acquire in the future, a disease that they may or may not pass on to someone else, and that may or may not kill them before something else does (including themselves). In fact, there are theoretical and epidemiological grounds to suspect that a suicidal state may even encourage behavior that is known to be self-injurious.20,21
Furthermore, having a suicidal state of mind would make it very challenging for PWID to summon the sustained focus required to overcome the microenvironmental and macroenvironmental influences that in varying ways support and shape health risk behaviors, as has been aptly documented by Strathdee et al.22 This is relevant to the emerging literature on psychosocial syndemics, where co-occurring social and physical conditions interact in a mutually reinforcing way to enhance vulnerability to diseases.23 The epidemic of suicidality among PWID in Delhi would likely interact with the broader syndemic of psychosocial vulnerabilities in this subpopulation (eg, psychological distress, homelessness, chronicity of addiction, poor physical health, strained family and marital relationships, and experiences of physical violence) to increase susceptibility to HIV and other infectious diseases. Second, the HIV prevention interventions are vital and necessary but nevertheless in some ways bypass the arguably more urgent needs of this extremely vulnerable and marginalized subpopulation, many of whom are contemplating and/or attempting to kill themselves. A query is raised as to whether suicide prevention and all the health and social responses that this may entail should be considered an immediate priority in this community, just as much as HIV prevention, at least in the eyes of PWID themselves. To respond to HIV transmission risk in isolation raises an uncomfortable but inevitable question; is our main priority the concern that at-risk populations like PWID can act as a bridge for HIV transmission to the general community rather than the welfare of PWID themselves? This scenario exemplifies the broader issue that our public health agendas do not always match neatly with the immediate health and social needs of at-risk subpopulations who are targeted by the ensuing interventions. Further thought should be given to incorporating a holistic approach to addressing the broader suicide risk factors that compete with, or impede, the objectives of our HIV prevention interventions. With respect to PWID in Delhi, and potentially elsewhere in the world,
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
adopting socioculturally tailored strategies to tackle the drivers of suicidality in this subpopulation could represent an opportunity to holistically enhance HIV prevention interventions and further mitigate some of the drivers of health risk behaviors. There are several potential approaches to integrating suicide prevention within HIV prevention interventions. Initially, HIV prevention interventions could work with their staff and clients to develop greater awareness of the high risk of suicide in this community and to adopt some basic suicide prevention skills. This could be complemented by developing and implementing a brief acute suicide risk assessment/screening tool that could identify those clients at greatest risk and could also facilitate counseling regarding the links between suicidality and health risk behaviors. To make a more substantial change, there is a real need to create innovative interventions that specifically attempt to address the psychosocial syndemic production of risk (including suicide, HIV, chronicity of addiction, and other risks) in this community by moving towards a model of social recovery that targets basic psychosocial needs. Ideally, this ought to include access to safe and affordable housing options; vocational/educational opportunities that give a sense of purpose and allow PWID to make a meaningful social and familial contribution; interventions aimed at reducing streetbased violence and discrimination toward PWID; and initiatives aimed at strengthening or rebuilding familial connections. If we start to better meld the different needs and priorities at play in innovative ways, we may just find out that HIV prevention interventions are all the stronger for it in the longer term.
Gregory Armstrong, PhD* Luke Samson, BA† *Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia †The Society for Service to Urban Poverty (SHARAN), Delhi, India www.jaids.com |
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Letters to the Editor
REFERENCES 1. National AIDS Control Organisation. HIV Sentinel Surveillance and HIV Estimation, 2006. Delhi, India: National AIDS Control Organisation; 2006. 2. National AIDS Control Organisation. HIV Sentinel Surveillance 2010–11: A Technical Brief. India: Department of AIDS Control, Government of India; 2012. 3. Armstrong G, Jorm AF, Samson L, et al. Association of depression, anxiety, and suicidal ideation with high-risk behaviors among men who inject drugs in Delhi, India. J Acquir Immune Defic Syndr. 2013;64:502–510. 4. Darke S, Ross J, Williamson A, et al. Patterns and correlates of attempted suicide by heroin users over a 3-year period: findings from the Australian treatment outcome study. Drug Alcohol Depend. 2007;87:146–152. 5. Ravndal E, Vaglum P. Overdoses and suicide attempts: different relations to psychopathology and substance abuse? A 5-year prospective study of drug abusers. Eur Addict Res. 1999;5:63–70. 6. Johnsson E, Fridell M. Suicide attempts in a cohort of drug abusers: a 5-year follow-up study. Acta Psychiatr Scand. 1997;96:362–366. 7. Darke S, Ross J. The relationship between suicide and heroin overdose among methadone maintenance patients in Sydney, Australia. Addiction. 2001;96:1443–1453. 8. Murphy SL, Rounsaville BJ, Eyre S, et al. Suicide attempts in treated opiate addicts. Compr Psychiatry. 1983;24:79–89. 9. Rossow I, Lauritzen G. Balancing on the edge of death: suicide attempts and life-threatening overdoses among drug addicts. Addiction. 1999;94:209–219. 10. Backmund M, Meyer K, Schutz C, et al. Factors associated with suicide attempts among injection drug users. Subst Use Misuse. 2011;46:1553–1559. 11. Havens JR, Sherman SG, Sapun M, et al. Prevalence and correlates of suicidal ideation among young injection vs. noninjection drug users. Subst Use Misuse. 2006;41:245–254. 12. Nock MK, Borges G, Bromet EJ, et al. Crossnational prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192:98–105. 13. Pirkis J, Burgess P, Dunt D. Suicidal ideation and suicide attempts among Australian adults. Crisis. 2000;21:16–25. 14. Bronisch T, Wittchen HU. Suicidal ideation and suicide attempts: comorbidity with depression, anxiety disorders, and substance abuse disorder. Eur Arch Psychiatry Clin Neurosci. 1994;244:93–98. 15. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617–626. 16. Nock MK, Borges G, Ono Y. Suicide: Global Perspectives from the WHO World Mental Health Surveys. New York, NY: Cambridge University Press; 2012. 17. Carrico AW, Neilands TB, Johnson MO. Suicidal ideation is associated with HIV transmission risk in men who have sex with men. J Acquir Immune Defic Syndr. 2010;54: e3–e4.
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J Acquir Immune Defic Syndr Volume 70, Number 2, October 1, 2015 18. Armstrong G, Jorm AF, Samson L, et al. Male-to-male sex among men who inject drugs in Delhi, India: Overlapping HIV risk behaviours. Int J Drug Policy. 2015;26: 404–411. 19. Armstrong G, Jorm AF, Samson L, et al. Suicidal ideation and attempts among men who inject drugs in Delhi, India: psychological and social risk factors. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1367–1377. 20. Houck CD, Hadley W, Lescano CM, et al; Project Shield Study Group. Suicide attempt and sexual risk behavior: relationship among adolescents. Arch Suicide Res. 2008; 12:39–49. 21. Husky MM, Guignard R, Beck F, et al. Risk behaviors, suicidal ideation and suicide attempts in a nationally representative French sample. J Affect Disord. 2013;151: 1059–1065. 22. Strathdee SA, Hallett TB, Bobrova N, et al. HIV and risk environment for injecting drug users: the past, present, and future. Lancet. 2010;376:268–284. 23. Singer M, Clair S. Syndemics and public health: reconceptualizing disease in biosocial context. Med Anthropol Q. 2003;17: 423–441.
Nutritional Support to HIV Patients Starting ART To the Editors: We welcome the systematic review1 on nutrition assessment, counseling, and support interventions among people with HIV/AIDS. The review emphasizes the need for wellconducted trials to inform policy makers but also mentions the ethical challenges of designing studies with unsupplemented control groups, and the possible role of duration and timing of supplementation. The authors searched literature databases from January 1995 to May 2014. Of 4 randomized food intervention trials identified, only 1 had an unsupplemented control group, and the report from that study does not seem to have been peer reviewed and published (KEMRI, 2012). The authors have no funding or conflicts of interest to disclose. All authors have been involved in intervention trials testing food products developed by Nutriset.
In fact, another 2 randomized nutrition intervention trials could have been included if the authors had also searched databases of registered trials. The ARTFood trial, published in May 2014,2 randomized 282 HIV-infected Ethiopian patients [with body mass index (BMI) .17 kg/m2] to lipidbased nutrient supplements (LNS) with either whey or soy protein, for the first 3 months of antiretroviral therapy (ART) or the subsequent 3 months. As such, it was possible to have an unsupplemented comparison group over the first 3 months, but also, although with limited power, to explore the effect of early versus late supplementation. In addition, patients with BMI between 16 and 17 kg/m2 were randomized to receive LNS in the first 3 months of ART to support comparison of whey and soy. Those with BMI below 16 kg/m2 were excluded and referred to standard care of severe malnutrition. The primary outcome was accumulation of lean body mass, measured using the deuterium dilution technique, as well as grip strength and physical activity. After 3 months, those receiving LNS had increased weight by 2.05 kg in addition to the 0.87 kg weight gain among those receiving only ART. Of the 2.05 kg effect on weight, 0.90 kg was lean mass. Those only on ART had no increase in lean mass at all. The effect on lean mass was accompanied by an increase in grip strength, but not in physical activity. Interestingly, LNS with whey was associated with a marginally significant increase in CD4 count (25 cells/mL; 95% confidence interval: −2 to 53), and significant increments in CD3 and CD8. We found it justified to have an unsupplemented (delayed supplementation) control group for patients with a BMI above 17 kg/m2, not least because mortality during commencement of ART in Ethiopia is low but also because it is plausible that supplementation may be more beneficial when given with some delay. First, until inflammation has faded, the nutrients provided may not be absorbed and metabolized effectively to result in regain of muscles and organs, and recovery of immune and other body
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Letters to the Editor #University of North Carolina School of Medicine, Department of Obstetrics and Gynecology, Chapel Hill, NC
15.
REFERENCES 1. Forman D, de Martel C, Lacey CJ, et al. Global burden of human papillomavirus and related diseases. Vaccine. 2012;30(suppl 5): F12–F23. 2. Bosch FX, Manos MM, Munoz N, et al. Prevalence of human papillomavirus in cervical cancer: a worldwide perspective. International biological study on cervical cancer (IBSCC) Study Group. J Natl Cancer Inst. 1995;87:796–802. 3. Remmink AJ, Walboomers JM, Helmerhorst TJ, et al. The presence of persistent high-risk HPV genotypes in dysplastic cervical lesions is associated with progressive disease: natural history up to 36 months. Int J Cancer. 1995;61:306–311. 4. Steben M, Duarte-Franco E. Human papillomavirus infection: epidemiology and pathophysiology. Gynecol Oncol. 2007;107(2 suppl 1): S2–S5. 5. Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:12–19. 6. Ahdieh L, Munoz A, Vlahov D, et al. Cervical neoplasia and repeated positivity of human papillomavirus infection in human immunodeficiency virus-seropositive and -seronegative women. Am J Epidemiol. 2000;151:1148–1157. 7. de Sanjose S, Palefsky J. Cervical and anal HPV infections in HIV positive women and men. Virus Res. 2002;89:201–211. 8. Jamieson DJ, Duerr A, Burk R, et al. Characterization of genital human papillomavirus infection in women who have or who are at risk of having HIV infection. Am J Obstet Gynecol. 2002;186:21–27. 9. Minkoff H, Feldman J, DeHovitz J, et al. A longitudinal study of human papillomavirus carriage in human immunodeficiency virusinfected and human immunodeficiency virusuninfected women. Am J Obstet Gynecol. 1998;178:982–986. 10. Palefsky JM, Minkoff H, Kalish LA, et al. Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high-risk HIVnegative women. J Natl Cancer Inst. 1999; 91:226–236. 11. Strickler HD, Burk RD, Fazzari M, et al. Natural history and possible reactivation of human papillomavirus in human immunodeficiency virus-positive women. J Natl Cancer Inst. 2005;97:577–586. 12. Sun XW, Ellerbrock TV, Lungu O, et al. Human papillomavirus infection in human immunodeficiency virus-seropositive women. Obstet Gynecol. 1995;85:680–686. 13. Sun XW, Kuhn L, Ellerbrock TV, et al. Human papillomavirus infection in women infected with the human immunodeficiency virus. N Engl J Med. 1997;337:1343–1349. 14. Temmerman M, Tyndall MW, Kidula N, et al. Risk factors for human papillomavirus and
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16.
17.
18.
19.
20.
21.
22.
23.
24. 25.
26.
27.
28.
cervical precancerous lesions, and the role of concurrent HIV-1 infection. Int J Gynaecol Obstet. 1999;65:171–181. Minkoff H, Zhong Y, Burk RD, et al. Influence of adherent and effective antiretroviral therapy use on human papillomavirus infection and squamous intraepithelial lesions in human immunodeficiency virus-positive women. J Infect Dis. 2010;201:681–690. Adler DH, Kakinami L, Modisenyane T, et al. Increased regression and decreased incidence of human papillomavirus-related cervical lesions among HIV-infected women on HAART. AIDS. 2012;26:1645–1652. Heard I, Schmitz V, Costagliola D, et al. Early regression of cervical lesions in HIV-seropositive women receiving highly active antiretroviral therapy. AIDS. 1998;12:1459–1464. Heard I, Tassie JM, Kazatchkine MD, et al. Highly active antiretroviral therapy enhances regression of cervical intraepithelial neoplasia in HIV-seropositive women. AIDS. 2002;16: 1799–1802. Minkoff H, Ahdieh L, Massad LS, et al. The effect of highly active antiretroviral therapy on cervical cytologic changes associated with oncogenic HPV among HIV-infected women. AIDS. 2001;15:2157–2164. Batman G, Oliver AW, Zehbe I, et al. Lopinavir up-regulates expression of the antiviral protein ribonuclease L in human papillomavirus-positive cervical carcinoma cells. Antivir Ther. 2011;16:515–525. Zehbe I, Richard C, Lee KF, et al. Lopinavir shows greater specificity than zinc finger ejecting compounds as a potential treatment for human papillomavirus-related lesions. Antivir Res. 2011;91:161–166. Hampson INMI, Hampson L, Masinde M, et al. A Phase 1/2 trial of a self-applied, nonsurgical treatment for HPV related high grade cervical neoplasia. Paper presented at: oral presentation presented at 11th International Conference on Urban Health; March 5, 2014; Manchester, England. Bacon MC, von Wyl V, Alden C, et al. The women’s interagency HIV study: an observational cohort brings clinical sciences to the bench. Clin Diagn Lab Immunol. 2005;12:1013–1019. Kovacs A, Wasserman SS, Burns D, et al. Determinants of HIV-1 shedding in the genital tract of women. Lancet. 2001;358:1593–1601. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans (2009). A Review of Human Carcinogens. Part B: Biological Agents. Lyon, France: IARC. (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 100B). Chapter 6, Human papillomaviruses, pp. 255–313. Xue X, Kim MY, Castle PE, et al. A new method to address verification bias in studies of clinical screening tests: cervical cancer screening assays as an example. J Clin Epidemiol. 2014;67:343–353. D’Agostino RB Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17:2265–2281. Dumond JB, Yeh RF, Patterson KB, et al. Antiretroviral drug exposure in the female genital tract: implications for oral pre- and post-exposure prophylaxis. AIDS. 2007;21:1899–1907.
29. Pokorna J, Machala L, Rezacova P, et al. Current and novel inhibitors of HIV protease. Viruses. 2009;1:1209–1239.
Extreme Levels of Suicidality Among People Who Inject Drugs in Delhi, India: A Cause for Reflection for HIV Prevention Interventions To the Editors: The nexus between injecting drug use and HIV has emerged as an important public health priority in several major Indian cities. In Delhi, one of the worlds most heavily populated megacities, the HIV prevalence among people who inject drugs (PWID, who are predominantly male) is estimated to have risen from 10.0% in 2006 to 18.3% in 2010–11.1,2 Consequently, HIV prevention interventions have been implemented to mitigate HIV transmission risk in this population, including needle syringe exchange, opioid substitution therapy, peer education, and HIV testing and counseling. One core intermediate outcome sought by these interventions is the reduction of risky injecting and sexual practices. Interestingly, our recent study of PWID in Delhi documented an extremely high prevalence of the pastyear suicidal ideation (53%) and attempts (36%).3 These results are in line with findings from surveys of PWID elsewhere in the world, which have found lifetime prevalence of attempted suicide ranging between 17.0% and 47.0%,4–11 as compared with 2.7%– 4.6% in the general population (and 4.1% among the general population of The direct research costs were funded by Nossal Institute for Global Health, University of Melbourne. Some aspects of this Letter to the Editor were presented at the 28th World Congress of the International Association for Suicide Prevention, June 16–20, 2015, Montreal, Quebec, Canada. The authors have no conflicts of interest to disclose.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Acquir Immune Defic Syndr Volume 70, Number 2, October 1, 2015
India).12–16 In addition to this, we found that needle/syringe sharing and unprotected sex were very common and that suicidal thoughts were strongly associated with a significant increase in the likelihood of both needle/syringe sharing and unsafe sexual behaviors. Co-occurring suicidality and health risk behavior among men who have sex with men was also previously reported in JAIDS.17 We subsequently published additional analyses documenting an association between suicidality and male-to-male anal sex (which was almost exclusively unprotected) in this same community,18 and we examined the psychosocial risk factors for suicidal thoughts and attempts, which were depressive and anxiety symptom severity, homelessness, strained family and marital relationships, poor physical health, chronicity of addiction, recent experiences of physical violence, and a history of being forced or coerced into sex.19 These findings coalesce to advance 2 important issues that necessitate further comment and enquiry. First, there are significant challenges for HIV prevention and other public health interventions that seek to reduce risky behaviors in communities where there is a high degree of ambivalence about living. The reasons why many PWID engage in behaviors that put themselves and others at risk of HIV and other infections are multifaceted and extend beyond rational decisions based on knowledge about risks and the provision of resources such as new needles/syringes and condoms. The high level of suicidality observed among PWID in Delhi and its correlation with increased injecting and sexual risk behaviors impedes the program logic that improved knowledge, and access to resources will result in positive behavior change. To put it plainly, when someone is ambivalent about preserving their life today, they are less likely to be concerned about a disease they may or may not acquire in the future, a disease that they may or may not pass on to someone else, and that may or may not kill them before something else does (including themselves). In fact, there are theoretical and epidemiological grounds to suspect that a suicidal state may even encourage behavior that is known to be self-injurious.20,21
Furthermore, having a suicidal state of mind would make it very challenging for PWID to summon the sustained focus required to overcome the microenvironmental and macroenvironmental influences that in varying ways support and shape health risk behaviors, as has been aptly documented by Strathdee et al.22 This is relevant to the emerging literature on psychosocial syndemics, where co-occurring social and physical conditions interact in a mutually reinforcing way to enhance vulnerability to diseases.23 The epidemic of suicidality among PWID in Delhi would likely interact with the broader syndemic of psychosocial vulnerabilities in this subpopulation (eg, psychological distress, homelessness, chronicity of addiction, poor physical health, strained family and marital relationships, and experiences of physical violence) to increase susceptibility to HIV and other infectious diseases. Second, the HIV prevention interventions are vital and necessary but nevertheless in some ways bypass the arguably more urgent needs of this extremely vulnerable and marginalized subpopulation, many of whom are contemplating and/or attempting to kill themselves. A query is raised as to whether suicide prevention and all the health and social responses that this may entail should be considered an immediate priority in this community, just as much as HIV prevention, at least in the eyes of PWID themselves. To respond to HIV transmission risk in isolation raises an uncomfortable but inevitable question; is our main priority the concern that at-risk populations like PWID can act as a bridge for HIV transmission to the general community rather than the welfare of PWID themselves? This scenario exemplifies the broader issue that our public health agendas do not always match neatly with the immediate health and social needs of at-risk subpopulations who are targeted by the ensuing interventions. Further thought should be given to incorporating a holistic approach to addressing the broader suicide risk factors that compete with, or impede, the objectives of our HIV prevention interventions. With respect to PWID in Delhi, and potentially elsewhere in the world,
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
adopting socioculturally tailored strategies to tackle the drivers of suicidality in this subpopulation could represent an opportunity to holistically enhance HIV prevention interventions and further mitigate some of the drivers of health risk behaviors. There are several potential approaches to integrating suicide prevention within HIV prevention interventions. Initially, HIV prevention interventions could work with their staff and clients to develop greater awareness of the high risk of suicide in this community and to adopt some basic suicide prevention skills. This could be complemented by developing and implementing a brief acute suicide risk assessment/screening tool that could identify those clients at greatest risk and could also facilitate counseling regarding the links between suicidality and health risk behaviors. To make a more substantial change, there is a real need to create innovative interventions that specifically attempt to address the psychosocial syndemic production of risk (including suicide, HIV, chronicity of addiction, and other risks) in this community by moving towards a model of social recovery that targets basic psychosocial needs. Ideally, this ought to include access to safe and affordable housing options; vocational/educational opportunities that give a sense of purpose and allow PWID to make a meaningful social and familial contribution; interventions aimed at reducing streetbased violence and discrimination toward PWID; and initiatives aimed at strengthening or rebuilding familial connections. If we start to better meld the different needs and priorities at play in innovative ways, we may just find out that HIV prevention interventions are all the stronger for it in the longer term.
Gregory Armstrong, PhD* Luke Samson, BA† *Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia †The Society for Service to Urban Poverty (SHARAN), Delhi, India www.jaids.com |
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
REFERENCES 1. National AIDS Control Organisation. HIV Sentinel Surveillance and HIV Estimation, 2006. Delhi, India: National AIDS Control Organisation; 2006. 2. National AIDS Control Organisation. HIV Sentinel Surveillance 2010–11: A Technical Brief. India: Department of AIDS Control, Government of India; 2012. 3. Armstrong G, Jorm AF, Samson L, et al. Association of depression, anxiety, and suicidal ideation with high-risk behaviors among men who inject drugs in Delhi, India. J Acquir Immune Defic Syndr. 2013;64:502–510. 4. Darke S, Ross J, Williamson A, et al. Patterns and correlates of attempted suicide by heroin users over a 3-year period: findings from the Australian treatment outcome study. Drug Alcohol Depend. 2007;87:146–152. 5. Ravndal E, Vaglum P. Overdoses and suicide attempts: different relations to psychopathology and substance abuse? A 5-year prospective study of drug abusers. Eur Addict Res. 1999;5:63–70. 6. Johnsson E, Fridell M. Suicide attempts in a cohort of drug abusers: a 5-year follow-up study. Acta Psychiatr Scand. 1997;96:362–366. 7. Darke S, Ross J. The relationship between suicide and heroin overdose among methadone maintenance patients in Sydney, Australia. Addiction. 2001;96:1443–1453. 8. Murphy SL, Rounsaville BJ, Eyre S, et al. Suicide attempts in treated opiate addicts. Compr Psychiatry. 1983;24:79–89. 9. Rossow I, Lauritzen G. Balancing on the edge of death: suicide attempts and life-threatening overdoses among drug addicts. Addiction. 1999;94:209–219. 10. Backmund M, Meyer K, Schutz C, et al. Factors associated with suicide attempts among injection drug users. Subst Use Misuse. 2011;46:1553–1559. 11. Havens JR, Sherman SG, Sapun M, et al. Prevalence and correlates of suicidal ideation among young injection vs. noninjection drug users. Subst Use Misuse. 2006;41:245–254. 12. Nock MK, Borges G, Bromet EJ, et al. Crossnational prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192:98–105. 13. Pirkis J, Burgess P, Dunt D. Suicidal ideation and suicide attempts among Australian adults. Crisis. 2000;21:16–25. 14. Bronisch T, Wittchen HU. Suicidal ideation and suicide attempts: comorbidity with depression, anxiety disorders, and substance abuse disorder. Eur Arch Psychiatry Clin Neurosci. 1994;244:93–98. 15. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617–626. 16. Nock MK, Borges G, Ono Y. Suicide: Global Perspectives from the WHO World Mental Health Surveys. New York, NY: Cambridge University Press; 2012. 17. Carrico AW, Neilands TB, Johnson MO. Suicidal ideation is associated with HIV transmission risk in men who have sex with men. J Acquir Immune Defic Syndr. 2010;54: e3–e4.
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J Acquir Immune Defic Syndr Volume 70, Number 2, October 1, 2015 18. Armstrong G, Jorm AF, Samson L, et al. Male-to-male sex among men who inject drugs in Delhi, India: Overlapping HIV risk behaviours. Int J Drug Policy. 2015;26: 404–411. 19. Armstrong G, Jorm AF, Samson L, et al. Suicidal ideation and attempts among men who inject drugs in Delhi, India: psychological and social risk factors. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1367–1377. 20. Houck CD, Hadley W, Lescano CM, et al; Project Shield Study Group. Suicide attempt and sexual risk behavior: relationship among adolescents. Arch Suicide Res. 2008; 12:39–49. 21. Husky MM, Guignard R, Beck F, et al. Risk behaviors, suicidal ideation and suicide attempts in a nationally representative French sample. J Affect Disord. 2013;151: 1059–1065. 22. Strathdee SA, Hallett TB, Bobrova N, et al. HIV and risk environment for injecting drug users: the past, present, and future. Lancet. 2010;376:268–284. 23. Singer M, Clair S. Syndemics and public health: reconceptualizing disease in biosocial context. Med Anthropol Q. 2003;17: 423–441.
Nutritional Support to HIV Patients Starting ART To the Editors: We welcome the systematic review1 on nutrition assessment, counseling, and support interventions among people with HIV/AIDS. The review emphasizes the need for wellconducted trials to inform policy makers but also mentions the ethical challenges of designing studies with unsupplemented control groups, and the possible role of duration and timing of supplementation. The authors searched literature databases from January 1995 to May 2014. Of 4 randomized food intervention trials identified, only 1 had an unsupplemented control group, and the report from that study does not seem to have been peer reviewed and published (KEMRI, 2012). The authors have no funding or conflicts of interest to disclose. All authors have been involved in intervention trials testing food products developed by Nutriset.
In fact, another 2 randomized nutrition intervention trials could have been included if the authors had also searched databases of registered trials. The ARTFood trial, published in May 2014,2 randomized 282 HIV-infected Ethiopian patients [with body mass index (BMI) .17 kg/m2] to lipidbased nutrient supplements (LNS) with either whey or soy protein, for the first 3 months of antiretroviral therapy (ART) or the subsequent 3 months. As such, it was possible to have an unsupplemented comparison group over the first 3 months, but also, although with limited power, to explore the effect of early versus late supplementation. In addition, patients with BMI between 16 and 17 kg/m2 were randomized to receive LNS in the first 3 months of ART to support comparison of whey and soy. Those with BMI below 16 kg/m2 were excluded and referred to standard care of severe malnutrition. The primary outcome was accumulation of lean body mass, measured using the deuterium dilution technique, as well as grip strength and physical activity. After 3 months, those receiving LNS had increased weight by 2.05 kg in addition to the 0.87 kg weight gain among those receiving only ART. Of the 2.05 kg effect on weight, 0.90 kg was lean mass. Those only on ART had no increase in lean mass at all. The effect on lean mass was accompanied by an increase in grip strength, but not in physical activity. Interestingly, LNS with whey was associated with a marginally significant increase in CD4 count (25 cells/mL; 95% confidence interval: −2 to 53), and significant increments in CD3 and CD8. We found it justified to have an unsupplemented (delayed supplementation) control group for patients with a BMI above 17 kg/m2, not least because mortality during commencement of ART in Ethiopia is low but also because it is plausible that supplementation may be more beneficial when given with some delay. First, until inflammation has faded, the nutrients provided may not be absorbed and metabolized effectively to result in regain of muscles and organs, and recovery of immune and other body
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
