System models that seem effective include use of multidisciplinar

System models that seem effective include use of multidisciplinary academic or community-based partnerships that incorporate physicians with training in addiction and hepatology, as well as nurses, outreach workers, and research coordinators. Reinfection with HCV remains an issue for many patients, with ongoing risk behaviors leading caregivers to withhold treatment. Rates of reinfection with HCV reported in the literature vary, but rates as high as 5.27 cases/100 person-years have been reported in incarcerated subjects[58] and 5.4 cases/100 person-years in active IDUs

in the community.[59] There is some evidence that engagement in liver care and treatment reduces risk behaviors, and there may be an immunologic component of protection against reinfection as well.[60] Management of individual patients with substance abuse remains a significant barrier to HCV treatment, despite evidence that such treatment improves SVR rates among IDUs treated for HCV infection and improves the likelihood of receiving HIV care as well.[61] Psychiatric diagnoses are common among those with HIV- and liver-related coinfections. At Johns Hopkins, 54% of patients presenting for medical evaluation had an Axis

1 psychiatric diagnosis, including major depression (20%), adjustment disorder (18%), cognitive Pritelivir impairment (18%), and substance abuse (74%). The presence of untreated mental disorders has a significant effect on the probability of overall survival.[62] There has been significant growth in research efforts associated with liver disease and HIV. One has to look no further than the increasing prominence given to liver-related topics at international meetings such as the Conference on Retroviruses and Opportunistic Infections, which has significantly increased the proportion of time and space devoted to this subject between 2008 and 2013. The support provided by the NIH to HIV & Liver Disease 2012 by three

Stem Cells inhibitor institutes (the NIAID, the NIAAA, and the NIDA) also speaks to the importance given to this subject area by key funders of research. The strategic plans from several NIH institutes currently include specific mention of liver disease as a research topic of interest. Moving forward, there is a growing interest in the association of HIV with aging, including adaptations in liver physiology that occur in older HIV-infected individuals. The use of data and samples from large cohorts and repositories remain a key focus of NIH, including the ACTG, Women’s Interagency HIV Study, Multicenter AIDS Cohort Study, AIDS Link to the Intravenous Experience, and others. The key barrier to research in this field is the global limitations of the funding environment within the NIH.

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