Dynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15: a modelling study

The Future of HIV: Challenges in meeting the 2030 Ending the HIV Epidemic in the U.S. (EHE) reduction goal

Objectives

To predict the burden of HIV in the United States (US) nationally and by region, transmission type, and race/ethnicity through 2030.

Methods

Using publicly available data from the CDC NCHHSTP AtlasPlus dashboard, we generated 11-year prospective forecasts of incident HIV diagnoses nationally and by region (South, non-South), race/ethnicity (White, Hispanic/Latino, Black/African American), and transmission type (Injection-Drug Use, Male-to-Male Sexual Contact (MMSC), and Heterosexual Contact (HSC)). We employed weighted (W) and unweighted (UW) n-sub-epidemic ensemble models, calibrated using 12 years of historical data (2008-2019), and forecasted trends for 2020-2030. We compared results to identify persistent, concerning trends across models.

Results

We projected substantial decreases in incident HIV diagnoses nationally (W: 27.9%, UW: 21.9%), and in the South (W:18.0%, UW: 9.2%) and non-South (W: 21.2%, UW: 19.5%) from 2019 to 2030. However, concerning non-decreasing trends were observed nationally in key sub-populations during this period: Hispanic/Latino persons (W: 1.4%, UW: 2.6%), Hispanic/Latino MMSC (W: 9.0%, UW: 9.9%), people who inject drugs (PWID) (W: 25.6%, UW: 9.2%), and White PWID (W: 3.5%, UW: 44.9%). The rising trends among Hispanic/Latino MMSC and overall PWID were consistent across the South and non-South regions.

Conclusions

Although the forecasted national-level decrease in the number of incident HIV diagnoses is encouraging, the US is unlikely to achieve the Ending the HIV Epidemic in the U.S. goal of a 90% reduction in HIV incidence by 2030. Additionally, the observed increases among specific subpopulations highlight the importance of a targeted and equitable approach to effectively combat HIV in the US.

ASAP: A pharmacy-level intervention to increase nonprescription syringe sales to reduce bloodborne illnesses

BACKGROUND

Pharmacy syringe sales are effective structural interventions to reduce bloodborne illnesses in populations, and are legal in all but two states. Yet evidence indicates reduced syringe sales in recent years. This study was designed as a feasibility test of an intervention to promote syringe sales by pharmacies in Arizona.

METHODS

A four-month pilot among three Arizona pharmacies measured feasibility and acceptability through monthly surveys to 18 enrolled pharmacy staff members.

RESULTS

Pharmacy staff reported increased ease of dispensing syringes across the study. Rankings of syringe dispensing as 'easiest' among 6 measured pharmacy practices increased from 38.9 % at baseline to 50.1 % post intervention module training, and to 83.3 % at pilot conclusion. The majority (72.2 %) of pharmacy staff agreed that intervention materials were easy to use. Over 70 % indicated that the intervention was influential in their "being more open to selling syringes without a prescription to someone who might use them for illicit drug use," and 61.1 % reported that in the future, they were highly likely to dispense syringes to customers who would use them to inject drugs. A vast majority (92 %) reported being likely to dispense subsidized naloxone if available to their pharmacy at no cost.

CONCLUSIONS

An education-based intervention was found to be feasible and acceptable to pharmacy staff and had an observed impact on perceptions of ease and likelihood of dispensing syringes without a prescription to people who may use them to inject drugs.

Testing and Treatment Interventions in Community Settings Key to Controlling a Recent Human Immunodeficiency Virus Outbreak Among People Who Inject Drugs in Glasgow: A Modeling Study

BACKGROUND

A human immunodeficiency virus (HIV) outbreak was identified among people who inject drugs (PWID) in Glasgow in 2015, with >150 diagnoses by the end of 2019. The outbreak response involved scaling up HIV testing and improving HIV treatment initiation and retention.

METHODS

We parameterized and calibrated a dynamic, deterministic model of HIV transmission among PWID in Glasgow to epidemiological data. We use this model to evaluate HIV testing and treatment interventions. We present results in terms of relative changes in HIV prevalence, incidence, and cases averted.

RESULTS

If the improvements in both testing and treatment had not occurred, we predict that HIV prevalence would have reached 17.8% (95% credible interval [CrI], 14.1%-22.6%) by the beginning of 2020, compared to 5.9% (95% CrI, 4.7%-7.4%) with the improvements. If the improvements had been made on detection of the outbreak in 2015, we predict that peak incidence would have been 26.2% (95% CrI, 8.8%-49.3%) lower and 62.7% (95% CrI, 43.6%-76.6%) of the outbreak cases could have been averted. The outbreak could have been avoided if the improvements had already been in place.

CONCLUSIONS

Our modeling suggests that the HIV testing and treatment interventions successfully brought the HIV outbreak in Glasgow under control by the beginning of 2020.

Decentralized HIV testing: comparing peer and mail-based distribution strategies to improve the reach of HIV self-testing among people who use drugs in Florida

INTRODUCTION

People who use drugs (PWUD) are at increased risk for HIV infection. HIV self-testing (HIVST) is a promising method for identifying new infections, but optimal distribution strategies remain understudied.

METHODS

To characterize PWUD by HIVST distribution strategy (peers vs. mail), we examined data from July 2022 to June 2023 collected from a real-world HIVST program led by the non-profit, Florida Harm Reduction Collective. We used descriptive statistics and Poisson regressions with robust error variance to compare those who received HIVST through peers or via mail by socio-demographics, Ending the HIV Epidemic (EHE) county designation, and HIV testing experience.

RESULTS

Among 728 participants, 78% received HIVST from peers, 47% identified as cisgender female, 48% as heterosexual, and 45% as non-White; 66% resided in an EHE county, and 55% had no HIV testing experience. Compared to those who received an HIV self-test from peers, those who received tests via mail were less likely to be cisgender male (vs. cisgender female; prevalence ratio [PR] = 0.59, 95% confidence interval [CI]: 0.43, 0.81), non-Hispanic Black (vs. non-Hispanic White; PR = 0.57, 95% CI: 0.36, 0.89) or from EHE counties (vs. non-EHE counties; PR = 0.33, 95% CI: 0.25, 0.44). Those who received tests via mail were also more likely to identify their sexual orientation as "Other/Undisclosed" (vs. straight/heterosexual; PR = 2.00, 95% CI: 1.51, 2.66).

CONCLUSION

Our findings support the role of community-based HIVST distribution strategies in increasing HIV testing coverage among PWUD. Additional research could help inform the equitable reach of HIVST.

Comparing harm reduction and overdose response services between community-based and public health department syringe service programmes using a national cross-sectional survey

Background

Syringe services programmes (SSPs) are an evidence-based strategy to reduce infectious diseases and deliver overdose prevention interventions for people who use drugs. They face regulatory, administrative, and funding barriers that limit their implementation in the US, though the federal government recently began providing funding to support these efforts. In this study we aim to understand whether the organisational characteristics of SSPs are associated with the provision of syringe and other overdose response strategies.

Methods

We examine four outcomes using the National Survey of Syringe Services Programs (NSSSP) (N = 472): syringe distribution, naloxone distribution, fentanyl test strip (FTS) availability, and buprenorphine implementation. These outcomes are assessed across three organizational categories of SSPs-those operated by public health departments (DPH), community-based organizations (CBOs) with government funding, and CBOs without government funding-while adjusting for community-level confounders.

Findings

The proportion of SSPs by organizational category was 36% DPH, 42% CBOs with government funding, and 22% CBOs without government funding. Adjusting for community-level differences, we found that CBO SSPs with government funding had significantly higher provision of all four syringe and overdose response services as compared to DPH SSPs and across three of the four services as compared to CBO SSPs without government funding. CBO SSPs without government funding still had significantly higher provision of three of the four services as compared to programmes maintained by the DPH.

Interpretation

CBO SSPs have strong potential to expand overdose response services nationally, particularly if provided with sustained and adequate funding. Communities should aim to provide funding that does not hinder SSP innovation so they can remain flexible in responding to local needs.

Funding

This study was supported by Arnold Ventures (20-05172).

Impact of the COVID-19 Pandemic on HIV Test Uptake Among People Who Inject Drugs in the Context of an HIV Outbreak

Glasgow, Scotland's largest city, has been experiencing an HIV outbreak among people who inject drugs (PWID) since 2015. A key focus of the public health response has been to increase HIV testing among those at risk of infection. Our aim was to assess the impact of COVID-19 on HIV testing among PWID in Glasgow. HIV test uptake in the last 12 months was quantified among: (1) PWID recruited in six Needle Exchange Surveillance Initiative (NESI) surveys (n = 6110); linked laboratory data for (2) people prescribed opioid agonist therapy (OAT) (n = 14,527) and (3) people hospitalised for an injecting-related hospital admission (IRHA) (n = 12,621) across four time periods: pre-outbreak (2010-2014); early-outbreak (2015-2016); ongoing-outbreak (2017-2019); and COVID-19 (2020-June 21). From the pre to ongoing period, HIV testing increased: the highest among people recruited in NESI (from 28% to 56%) and on OAT (from 17% to 54%) while the lowest was among people with an IRHA (from 15% to 42%). From the ongoing to the COVID-19 period, HIV testing decreased markedly among people prescribed OAT, from 54% to 37% (aOR 0.50, 95% CI 0.48-0.53), but increased marginally among people with an IRHA from 42% to 47% (aOR 1.19, 95% CI 1.08-1.31). In conclusion, progress in increasing testing in response to the HIV outbreak has been eroded by COVID-19. Adoption of a linked data approach could be warranted in other settings to inform efforts to eliminate HIV transmission.

Human antimicrobial peptide inactivation mechanism of enveloped viruses

HYPOTHESIS

Enveloped viruses are pivotal in causing various illnesses, including influenza and COVID-19. The antimicrobial peptide LL-37, a critical part of the human innate immune system, exhibits potential as an antiviral agent capable of thwarting these viral threats. Its mode of action involves versatile and non-specific interactions that culminate in dismantling the viral envelope, ultimately rendering the viruses inert. However, the exact mechanism of action is not yet understood.

EXPERIMENTS

Here, the mechanism of LL-37 triggered changes in the structure and function of an enveloped virus is investigated. The bacteriophage "Phi6" is used as a surrogate for pathogenic enveloped viruses. Small angle X-ray and neutron scattering combined with light scattering techniques demonstrate that LL-37 actively integrates into the virus's lipid envelope.

FINDINGS

LL-37 addition to Phi6 leads to curvature modification in the lipid bilayer, ultimately separating the envelope from the nucleocapsid. Additional biological assays confirm the loss of virus infectivity in the presence of LL-37, which coincides with the structural transformations. The results provide a fundamental understanding of the structure-activity relationship related to enveloped viruses. The knowledge of peptide-virus interactions can guide the design of future peptide-based antiviral drugs and therapies.

Come back when you're infected: pharmacy access to sterile syringes in an Arizona Secret Shopper Study, 2023

BACKGROUND

Pharmacies are critical healthcare partners in community efforts to eliminate bloodborne illnesses. Pharmacy sale of sterile syringes is central to this effort.

METHODS

A mixed methods "secret shopper" syringe purchase study was conducted in the fall of 2022 with 38 community pharmacies in Maricopa and Pima Counties, Arizona. Pharmacies were geomapped to within 2 miles of areas identified as having a potentially high volume of illicit drug commerce. Daytime venue sampling was used whereby separate investigators with lived/living drug use experience attempted to purchase syringes without a prescription. Investigator response when prompted for purchase rationale was "to protect myself from HIV and hepatitis C." A 24-item instrument measured sales outcome, pharmacy staff interaction (hostile/neutral/friendly), and the buyer's subjective experience.

RESULTS

Only 24.6% (n = 28) of 114 purchase attempts across the 38 pharmacies resulted in syringe sale. Less than one quarter (21.1%) of pharmacies always sold, while 44.7% never sold. Independent and food store pharmacies tended not to sell syringes. There emerged distinct pharmacy staff interactions characterized by body language, customer query, normalization or othering response, response to purchase request and closure. Pharmacy discretion and pharmacy policy not to sell syringes without a prescription limited sterile syringe access. Investigators reported frequent and adverse emotional impact due to pharmacy staff negative and stigmatizing interactions.

CONCLUSIONS

Pharmacies miss opportunities to advance efforts to eliminate bloodborne infections by stringent no-sale policy and discretion about syringe sale. State regulatory policy facilitating pharmacy syringe sales, limiting pharmacist discretion for syringe sales, and targeting pharmacy-staff level education may help advance the achievement of public health goals to eliminate bloodborne infections in Arizona.

Use of Syringe Service Programs in Rural vs Urban Maine: A Harm-Reduction Study

Introduction

Syringe service programs (SSPs) reduce HIV and viral hepatitis transmission, as well as the prevalence of improperly disposed needles and needle stick injuries among first responders. Infections associated with injection drug use are rising in rural areas, including Maine, leading to concerns that SSP services are difficult to access for rural residents.

Methods

A cross-sectional survey of 101 participants hospitalized with infections associated with injection drug use at 4 hospitals in Maine was collected over a 15-month period. Descriptive analyses were performed. Statistical analyses were completed using Fisher's exact tests, Pearson's chi-squared tests, and Student's t tests.

Results

Of 101 participants, 66 (65%) lived in urban areas, and 35 (35%) lived rurally. Participants living in rural areas reported less SSP use in the past 3 months (76% urban vs 43% rural). Rural participants also had a higher prevalence of injecting buprenorphine than urban participants (6% urban vs 12% rural). Rural participants were also more likely to obtain needles from pharmacies than urban participants (40% urban vs 71% rural).

Discussion

SSP programs are underrepresented and accessed less in rural areas of Maine. Rural populations of people who inject drugs have unique health characteristics and syringe-use practices.

Conclusions

These findings highlight the need to develop rural SSP programs that address the unique needs of rural populations.

Willingness to use and distribute HIV self-testing kits among people who inject drugs in the San Diego-Tijuana border region

BACKGROUND

HIV self-testing (HIVST) could increase HIV testing access among people who inject drugs (PWID), and secondary distribution (i.e., peer-delivery) of HIVST kits in PWID social networks could further expand coverage. We assessed willingness to use and distribute HIVST kits among PWID in the San Diego-Tijuana border region.

METHODS

From 2020 to 2021, HIV-negative PWID in San Diego, USA, and Tijuana, Mexico, completed surveys and provided data on individual (N = 539) and social network (N = 366) characteristics. We used modified Poisson regression to examine the effects of individual and social network characteristics on willingness to use and distribute HIVST kits.

RESULTS

Most participants were willing to use (81%) and distribute (81%) HIVST kits. At the individual level, prior HIV testing was positively associated with willingness to use (adjusted prevalence ratio [aPR] = 1.24, 95% confidence interval [CI] 1.10-1.40) and distribute (aPR = 1.27, 95% CI 1.12-1.43) HIVST kits, while perceiving oneself to be at higher HIV risk than others was negatively associated with willingness to use HIVST kits (aPR = 0.83, 95% CI 0.74-0.93). At the network level, willingness to distribute HIVST kits was positively associated with network size (aPR = 1.04 per member, 95% CI 1.01-1.08) and greater proportions of one's network encouraging them to use drugs (aPR = 1.29, 95% CI 1.16-1.44) and having a history of homelessness (aPR = 1.51, 95% CI 1.31-1.74) or detention/arrest (aPR = 1.57, 95% CI 1.36-1.82), and negatively associated with a greater proportion of one's network including "very close" persons (aPR = 0.80, 95% CI 0.69-0.94).

CONCLUSIONS

We found high potential for HIVST kits and their secondary distribution to increase HIV testing among PWID who face the greatest barriers to facility-based testing.

O-Know Opioid Knowledge Test: Development and Psychometric Testing in a Community Setting

Given the various sources and consequences of opioid use disorder (OUD) stigma, the mechanisms by which stigma occurs becomes more important. Educational deficits regarding OUD as a disease and treatment influence OUD stigma. The purpose of the study was to develop, pilot test and psychometrically evaluate the Opioid-Knowledge (O-Know) test in a community setting. A social media strategy was used to recruit 294 participants, in 2019, from a midwestern region experiencing an HIV epidemic, stemming from opioid and injection drug use. The Factor analysis used a tetrachoric correlation matrix, with principal axis factor extraction and Promax rotation. Horn's parallel analysis supported the factorial validity of a two-factor model representing OUD as a Disease (Cronbach's alpha = .57) and OUD Treatment and Recovery (Cronbach's alpha = .62). The reliability estimates were deemed adequate given the intended group-level uses for the instrument. Convergent construct validity was partially supported via the OUD Treatment and Recovery factor's negative correlation with personal opioid stigmatization (B = -.29, p =.001). OUD research must produce measures that convert observations to empirical generalizations. The psychometric analysis of the O-Know scale demonstrated progress in reducing measurement error to facilitate that conversion.

Responding to the HIV Health Literacy Needs of Clients in Substance Use Treatment: The Role of Universal PrEP Education in HIV Health and Prevention

Health literacy, particularly HIV health literacy, is a key social determinant of health and can be significantly improved through targeted health education. This paper explores the often-overlooked potential of pre-exposure prophylaxis (PrEP) education as a powerful tool to enhance HIV health literacy among people with substance use disorders (PWSUD), a population notably susceptible to HIV. Given the syndemic interplay of substance use disorders (SUDs) and HIV, health professionals, especially substance use counselors, are uniquely positioned to bolster HIV health literacy and positively influence health outcomes. This article offers a brief introduction to PrEP, delineates potential barriers and facilitators to its use and education, and proposes strategies for effective PrEP education, implementation, and adherence. By equipping substance use counselors with essential knowledge and skills, we aim to encourage and promote the integration of PrEP education into substance use treatment. The overarching objective is to empower counselors to proactively engage in HIV prevention efforts, thereby fulfilling pressing health literacy needs and contributing to improved health outcomes among PWSUD.

Variation in HIV Transmission Behaviors Among People Who Use Drugs in Rural US Communities

Importance

People who use drugs (PWUD) continue to be at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within various rural communities is poorly understood.

Objective

To examine the association of characteristics of rural PWUD with HIV transmission behaviors.

Design, Setting, and Participants

In this cross-sectional study, surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin) were collected January 2018 through March 2020 and analyzed August through December 2022. A chain-referral sampling strategy identified convenience sample seeds who referred others who used drugs. Rural PWUD who reported any past 30-day injection drug use or noninjection opioid use "to get high" were included.

Exposures

Individual characteristics, including age, race, gender identity, sexual orientation, partnership status, drug of choice, and location, were collected.

Main Outcomes and Measures

Past 30-day frequency of behaviors associated with HIV transmission, including drug injection, syringe sharing, opposite- and same-gender partners, transactional sex, and condomless sex, was assessed.

Results

Of 3048 rural PWUD (mean [SD] age, 36.1 [10.3] years; 225 American Indian [7.4%], 96 Black [3.2%], and 2576 White [84.5%] among 3045 with responses; and 1737 men [57.0%] among 3046 with responses), most participants were heterosexual (1771 individuals [86.8%] among 2040 with responses) and single (1974 individuals [68.6%] among 2879 with responses). Opioids and stimulants were reported as drug of choice by 1636 individuals (53.9%) and 1258 individuals (41.5%), respectively, among 3033 individuals with responses. Most participants reported recent injection (2587 of 3046 individuals [84.9%] with responses) and condomless sex (1406 of 1757 individuals [80.0%] with responses), among whom 904 of 1391 individuals (65.0%) with responses indicated that it occurred with people who inject drugs. Syringe sharing (1016 of 2433 individuals [41.8%] with responses) and transactional sex (230 of 1799 individuals [12.8%] with responses) were reported less frequently. All characteristics and behaviors, except the number of men partners reported by women, varied significantly across locations (eg, mean [SD] age ranged from 34.5 [10.0] years in Wisconsin to 39.7 [11.0] years in Illinois; P < .001). In multivariable modeling, younger age (adjusted odds ratio [aOR] for ages 15-33 vs ≥34 years, 1.36; 95% CI, 1.08-1.72) and being single (aOR, 1.37; 95% CI, 1.08-1.74) were associated with recent injection; younger age (aOR, 1.49; 95% CI, 1.20-1.85) and bisexual orientation (aOR vs heterosexual orientation, 2.27; 95% CI, 1.60-3.23) with syringe sharing; gender identity as a woman (aOR vs gender identity as a man, 1.46; 95% CI, 1.01-2.12), bisexual orientation (aOR vs heterosexual orientation, 2.59; 95% CI, 1.67-4.03), and being single (aOR, 1.71; 95% CI, 1.15-2.55) with transactional sex; and bisexual orientation (aOR vs heterosexual orientation, 1.60; 95% CI, 1.04-2.46) and stimulants as the drug of choice (aOR vs opioids, 1.45; 95 CI, 1.09-1.93) with condomless sex with someone who injects drugs.

Conclusions and Relevance

This study found that behaviors associated with HIV transmission were common and varied across communities. These findings suggest that interventions to reduce HIV risk among rural PWUD may need to be tailored to locally relevant factors.

A Dynamic Spatial Factor Model to Describe the Opioid Syndemic in Ohio

BACKGROUND

The opioid epidemic has been ongoing for over 20 years in the United States. As opioid misuse has shifted increasingly toward injection of illicitly produced opioids, it has been associated with HIV and hepatitis C transmission. These epidemics interact to form the opioid syndemic.

METHODS

We obtain annual county-level counts of opioid overdose deaths, treatment admissions for opioid misuse, and newly diagnosed cases of acute and chronic hepatitis C and newly diagnosed HIV from 2014 to 2019. Aligned with the conceptual framework of syndemics, we develop a dynamic spatial factor model to describe the opioid syndemic for counties in Ohio and estimate the complex synergies between each of the epidemics.

RESULTS

We estimate three latent factors characterizing variation of the syndemic across space and time. The first factor reflects overall burden and is greatest in southern Ohio. The second factor describes harms and is greatest in urban counties. The third factor highlights counties with higher than expected hepatitis C rates and lower than expected HIV rates, which suggests elevated localized risk for future HIV outbreaks.

CONCLUSIONS

Through the estimation of dynamic spatial factors, we are able to estimate the complex dependencies and characterize the synergy across outcomes that underlie the syndemic. The latent factors summarize shared variation across multiple spatial time series and provide new insights into the relationships between the epidemics within the syndemic. Our framework provides a coherent approach for synthesizing complex interactions and estimating underlying sources of variation that can be applied to other syndemics.

Study protocol for an efficacy trial of the "PrEP for Health" intervention to increase HIV PrEP use among people who inject drugs

BACKGROUND

HIV incidence has recently increased among people who inject drugs (PWID) across the United States, with outbreaks occurring in states with long-standing syringe service programs (SSPs) including Massachusetts (MA). Antiretroviral pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy recommended for PWID, but uptake in this marginalized population is extraordinarily low.

METHODS

We describe the design and procedures for a National Institute on Drug Abuse (NIDA)-funded (R01) randomized controlled trial (RCT) testing the efficacy of "PrEP for Health," a multicomponent behavioral intervention to increase PrEP uptake, adherence, and persistence among HIV-negative PWID attending SSPs in two areas of the U.S. Northeast that are heavily affected by injection-related HIV transmission. Participants are equally randomized to receive the "PrEP for Health" intervention (involving individually tailored HIV and PrEP education, motivational interviewing, problem-solving skills and planning, and ongoing navigation support) or an enhanced standard of care (eSOC) control condition involving a brief educational video on the utility of PrEP for HIV prevention. Co-primary outcomes are PrEP uptake (using medical/pharmacy records) and adherence (using tenofovir quantification in hair samples); a secondary outcome is PrEP persistence (using medical/pharmacy records) over 12 months. Major assessments occur at baseline, 1-, 3-, 6-, and 12-month follow-up visits. Planned analyses will examine intervention efficacy, specific hypothesized conceptual mediators of the intervention effect (e.g., self-perceived HIV risk; PrEP knowledge, interest in use, motivation, and behavioral skills) and epidemiologically linked moderators (e.g., age; gender; condomless vaginal or anal sex).

DISCUSSION

Findings from our extensive preliminary research with the study population revealed that a multicomponent, theory-based intervention targeting PrEP knowledge, motivation, self-efficacy, behavioral skills, and structural barriers to PrEP access is urgently needed for PWID who are at risk of HIV acquisition. We also learned that SSPs represent a highly acceptable service setting for delivering such interventions. In this study, we are evaluating the efficacy of the "PrEP for Health" intervention. If efficacious, findings from our implementation evaluation could help guide its dissemination to diverse SSPs and possibly other community-based settings accessed by this population.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT04430257, registered June 12, 2020.

Syringe Services Programs to Reduce Intravenous Disease Transmission in Substance Use Disorders

Syringe services programs (SSPs) are evidence-based programs. SSPs are integral in preventing bloodborne diseases while increasing access to care and reducing drug overdose deaths. SSPs are often the only source of health care for people who use drugs. Several states in the United States support and offer community-based SPPs; however, US prisons do not offer such programs to those incarcerated. Nurses are bridging the gap in support of SSPs and are being backed by organizations such as the American Nurses Association and the Association of Nurses in AIDS Care.

Not all clusters are equal: dynamics of molecular HIV-1 clusters in a statewide Rhode Island epidemic

OBJECTIVES

Molecular epidemiology is a powerful tool to characterize HIV epidemics and prioritize public health interventions. Typically, HIV clusters are assumed to have uniform patterns over time. We hypothesized that assessment of cluster evolution would reveal distinct cluster behavior, possibly improving molecular epidemic characterization, towards disrupting HIV transmission.

DESIGN

Retrospective cohort.

METHODS

Annual phylogenies were inferred by cumulative aggregation of all available HIV-1 pol sequences of individuals with HIV-1 in Rhode Island (RI) between 1990 and 2020, representing a statewide epidemic. Molecular clusters were detected in annual phylogenies by strict and relaxed cluster definition criteria, and the impact of annual newly-diagnosed HIV-1 cases to the structure of individual clusters was examined over time.

RESULTS

Of 2153 individuals, 31% (strict criteria) - 47% (relaxed criteria) clustered. Longitudinal tracking of individual clusters identified three cluster types: normal, semi-normal and abnormal. Normal clusters (83-87% of all identified clusters) showed predicted growing/plateauing dynamics, with approximately three-fold higher growth rates in large (15-18%) vs. small (∼5%) clusters. Semi-normal clusters (1-2% of all clusters) temporarily fluctuated in size and composition. Abnormal clusters (11-16% of all clusters) demonstrated collapses and re-arrangements over time. Borderline values of cluster-defining parameters explained dynamics of non-normal clusters.

CONCLUSIONS

Comprehensive tracing of molecular HIV clusters over time in a statewide epidemic identified distinct cluster types, likely missed in cross-sectional analyses, demonstrating that not all clusters are equal. This knowledge challenges current perceptions of consistent cluster behavior over time and could improve molecular surveillance of local HIV epidemics to better inform public health strategies.

Patient and Provider Perspectives on a Novel, Low-Threshold HIV PrEP Program for People Who Inject Drugs Experiencing Homelessness

BACKGROUND

HIV outbreaks among people who inject drugs (PWID) and experience homelessness are increasing across the USA. Despite high levels of need, multilevel barriers to accessing antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention persist for this population. The Boston Health Care for the Homeless Program (BHCHP) initiated a low-threshold, outreach-based program to support engagement in PrEP services among PWID experiencing homelessness.

METHODS

To inform dissemination efforts, we explored patient and provider perspectives on key program components. From March to December 2020, we conducted semi-structured qualitative interviews with current and former BHCHP PrEP program participants and prescribers, patient navigators, and outreach workers (i.e., providers). Thematic analysis explored perspectives on key program components.

RESULTS

Participants (n = 21) and providers (n = 11) identified the following five key components of BHCHP's PrEP program that they perceived to be particularly helpful for supporting patient engagement in PrEP services: (1) community-driven PrEP education; (2) low-threshold, accessible programming including same-day PrEP prescribing; (3) tailored prescribing supports (e.g., on-site pharmacy, short-term prescriptions, medication storage); (4) intensive outreach and navigation; and (5) trusting, respectful patient-provider relationships.

DISCUSSION

Findings suggest that more patient-centered services formed the basis of BHCHP's innovative, successful PrEP program. While contextual challenges including competing public health emergencies and homeless encampment "sweeps" necessitate ongoing programmatic adaptations, lessons from BHCHP's PrEP program can inform PrEP delivery in a range of community-based settings serving this population, including syringe service programs and shelters.

Environmental Uncertainty and Substance Use Disorders: A Behavior Analytic Perspective

Substance use disorder (SUD) and drug overdose deaths represent major economic, health, and safety issues in the United States. The psychology of uncertainty provides a mechanism for understanding, reducing, and controlling the damage from substance misuse. Illicit drugs (such as heroin or cocaine) are uncertain in their availability, quality, and acquisition (the time and effort required to obtain them) compared with nondrug-related alternatives (such as consumable goods, hobbies, or paychecks). Furthermore, the severity and likelihood of negative outcomes associated with drug use likewise are uncertain. Such uncertainties worsen substance use outcomes. The current review conveys what is known about the impact of uncertainty on substance use: laboratory investigations of uncertain time and effort required to obtain a substance and uncertain drug quality show uncertainty exacerbates harm. Furthermore, uncertain negative outcomes are not likely to deter substance use in individuals with a SUD. Finally, several policy implications include access to agonist medications; creating a safer drug supply; access to clean syringes/needles, naloxone, and safe-injection sites; and ending incarceration for substance use.

Factors Associated with Exchange Sex Among Cisgender Persons Who Inject Drugs: Women and MSM-23 U.S. Cities, 2018

Persons who inject drugs (PWID) and exchange sex face disproportionate HIV rates. We assessed prevalence of exchange sex (receiving money/drugs for sex from ≥ 1 male partner(s) during the past year) among cisgender PWID, separately for women and men with a history of sex with men (MSM). We examined factors associated with exchange sex, including sociodemographic characteristics, sexual and drug use behaviors, and healthcare access/utilization. Over one-third of the 4657 participants reported exchange sex (women: 36.2%; MSM: 34.8%). Women who exchanged sex (WES) were significantly more likely to test HIV-positive than other women. Men who exchanged sex with men (MESM) showed a similar trend. WES and MESM shared many characteristics, including being uninsured, experiencing recent homelessness, condomless sex, polydrug use, and receptive/distributive needle sharing. These findings highlight a need to strengthen prevention interventions and address structural determinants of HIV for WES and MESM, particularly PWID who exchange sex.

Application of machine learning algorithms for localized syringe services program policy implementation - Florida, 2017

BACKGROUND

People who inject drugs (PWID) are at an amplified vulnerability for experiencing a multitude of harms related to their substance use, including viral (e.g. HIV, Hepatitis C) and bacterial infections (e.g. endocarditis). Implementation of evidence-based interventions, such as syringe services programs (SSPs), remains imperative, particularly in locations at an increased risk of HIV outbreaks. This study aims to identify communities in Florida that are high-priority locations for SSP implementation by examining state-level data related to the substance use and overdose crises.

METHODS

State-level surveillance data were aggregated at the ZIP Code Tabulation Area (ZCTA) (n = 983) for 2017. We used confirmed cases of acute HCV infection as a proxy of injection drug use. Least Absolute Selection and Shrinkage Operator (LASSO) regression was used to develop a machine learning model to identify significant indicators of acute HCV infection and high-priority areas for SSP implementation due to their increased vulnerability to an HIV outbreak.

RESULTS

The final model retained three variables of importance: (1) the number of drug-associated skin and soft tissue infection hospitalizations, (2) the number of chronic HCV infections in people aged 18-39, and 3) the number of drug-associated endocarditis hospitalizations. High-priority SSP implementation locations were identified in both urban and rural communities outside of current Ending the HIV Epidemic counties.

CONCLUSION

SSPs are long researched, safe, and effective evidence-based programs that offer a variety of services that reduce disease transmission and assist with combating the overdose crisis. Opportunities to increase services in needed regions across the state now exist in Florida as supported by the expansion of the Infectious Disease Elimination Act of 2019. This study provides details where potential areas of concern may be and highlights regions where future evidence-based harm reduction programs, such as SSPs, would be useful to reduce opioid overdoses and disease transmission among PWID.Key messagesThe rate of acute HCV in Florida in 2017 was 1.9 per 100,000, nearly twice the national average.Serious injection related infections among PWID are significant indicators of acute HCV infection.High-priority SSP implementation locations in Florida were identified in both urban and rural communities, including those outside of current Ending the HIV Epidemic counties.

SOPHIE: Viral outbreak investigation and transmission history reconstruction in a joint phylogenetic and network theory framework

Genomic epidemiology is now widely used for viral outbreak investigations. Still, this methodology faces many challenges. First, few methods account for intra-host viral diversity. Second, maximum parsimony principle continues to be employed for phylogenetic inference of transmission histories, even though maximum likelihood or Bayesian models are usually more consistent. Third, many methods utilize case-specific data, such as sampling times or infection exposure intervals. This impedes study of persistent infections in vulnerable groups, where such information has a limited use. Finally, most methods implicitly assume that transmission events are independent, although common source outbreaks violate this assumption. We propose a maximum likelihood framework, SOPHIE, based on the integration of phylogenetic and random graph models. It infers transmission networks from viral phylogenies and expected properties of inter-host social networks modeled as random graphs with given expected degree distributions. SOPHIE is scalable, accounts for intra-host diversity, and accurately infers transmissions without case-specific epidemiological data.

Nurse Practitioner-Led Integrated Rapid Access to HIV Prevention for People Who Inject Drugs (iRaPID): Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

The ongoing volatile opioid epidemic remains a significant public health concern, alongside continued outbreaks of HIV and hepatitis C virus among people who inject drugs. The limited access to and scale-up of medications for opioid use disorder (MOUD) among people who inject drugs, coupled with multilevel barriers to pre-exposure prophylaxis (PrEP) uptake, makes it imperative to integrate evidence-based risk reduction and HIV prevention strategies in innovative ways. To address this need, we developed an integrated rapid access to HIV prevention program for people who inject drugs (iRaPID) that incorporates same-day PrEP and MOUD for this population.

OBJECTIVE

The primary objective of this pilot study is to assess the feasibility and acceptability of the program and evaluate its preliminary efficacy on PrEP and MOUD uptake for a future randomized controlled trial (RCT). We also aim to explore information on the implementation of the program in a real-world setting using a type I hybrid implementation trial design.

METHODS

Using a type I hybrid implementation trial design, we are pilot testing the nurse practitioner-led iRaPID program while exploring information on its implementation in a real-world setting. Specifically, we will assess the feasibility and acceptability of the iRaPID program and evaluate its preliminary efficacy on PrEP and MOUD uptake in a pilot RCT. The enrolled 50 people who inject drugs will be randomized (1:1) to either iRaPID or treatment as usual (TAU). Behavioral assessments will occur at baseline, and at 1, 3, and 6 months. Additionally, we will conduct a process evaluation of the delivery and implementation of the iRaPID program to collect information for future implementation.

RESULTS

Recruitment began in July 2021 and was completed in August 2022. Data collection is planned through February 2023. The Institutional Review Boards at Yale University and the University of Connecticut approved this study (2000028740).

CONCLUSIONS

This prospective pilot study will test a nurse practitioner-led, integrated HIV prevention program that incorporates same-day PrEP and MOUD for people who inject drugs. This low-threshold protocol delivers integrated prevention via one-stop shopping under the direction of nurse practitioners. iRaPID seeks to overcome barriers to delayed PrEP and MOUD initiation, which is crucial for people who inject drugs who have had minimal access to evidence-based prevention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04531670; https://clinicaltrials.gov/ct2/show/NCT04531670.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42585.

Surveillance for endemic infectious disease outbreaks: Adaptive sampling using profile likelihood estimation

Outbreaks of an endemic infectious disease can occur when the disease is introduced into a highly susceptible subpopulation or when the disease enters a network of connected individuals. For example, significant HIV outbreaks among people who inject drugs have occurred in at least half a dozen US states in recent years. This motivates the current study: how can limited testing resources be allocated across geographic regions to rapidly detect outbreaks of an endemic infectious disease? We develop an adaptive sampling algorithm that uses profile likelihood to estimate the distribution of the number of positive tests that would occur for each location in a future time period if that location were sampled. Sampling is performed in the location with the highest estimated probability of triggering an outbreak alarm in the next time period. The alarm function is determined by a semiparametric likelihood ratio test. We compare the profile likelihood sampling (PLS) method numerically to uniform random sampling (URS) and Thompson sampling (TS). TS was worse than URS when the outbreak occurred in a location with lower initial prevalence than other locations. PLS had lower time to outbreak detection than TS in some but not all scenarios, but was always better than URS even when the outbreak occurred in a location with a lower initial prevalence than other locations. PLS provides an effective and reliable method for rapidly detecting endemic disease outbreaks that is robust to this uncertainty.

The impact of syringe services program closure on the risk of rebound HIV outbreaks among people who inject drugs: a modeling study

OBJECTIVE

Despite their effectiveness in preventing the transmission of HIV among people who inject drugs (PWID), syringe services programs (SSPs) in many settings are hampered by social and political opposition. We aimed to estimate the impact of closure and temporary interruption of SSP on the HIV epidemic in a rural United States setting.

METHODS

Using an agent-based model (ABM) calibrated to observed surveillance data, we simulated HIV risk behaviors and transmission in adult populations who inject and do not inject drugs in Scott County, Indiana. We projected HIV incidence and prevalence between 2020 and 2025 for scenarios with permanent closure, delayed closure (one additional renewal for 24 months before closure), and temporary closure (lasting 12 months) of an SSP in comparison to persistent SSP operation.

RESULTS

With sustained SSP operation, we projected an incidence rate of 0.15 per 100 person-years among the overall population (95% simulation interval: 0.06-0.28). Permanently closing the SSP would cause an average of 58.4% increase in the overall incidence rate during 2021-2025, resulting in a higher prevalence of 60.8% (50.9-70.6%) (18.7% increase) among PWID by 2025. A delayed closure would increase the incidence rate by 38.9%. A temporary closure would cause 12 (35.3%) more infections during 2020-2021.

CONCLUSION

Our analysis suggests that temporary interruption and permanent closure of existing SSPs operating in rural United States may lead to 'rebound' HIV outbreaks among PWID. To reach and sustain HIV epidemic control, it will be necessary to maintain existing and implement new SSPs in combination with other prevention interventions.

Estimating the HIV Effective Reproduction Number in the United States and Evaluating HIV Elimination Strategies

CONTEXT

The reproduction number is a fundamental epidemiologic concept used to assess the potential spread of infectious diseases and whether they can be eliminated.

OBJECTIVE

We estimated the 2017 United States HIV effective reproduction number, Re, the average number of secondary infections from an infected person in a partially infected population. We analyzed the potential effects on Re of interventions aimed at improving patient flow rates along different stages of the HIV care continuum. We also examined these effects by individual transmission groups.

DESIGN

We used the HIV Optimization and Prevention Economics (HOPE) model, a compartmental model of disease progression and transmission, and the next-generation matrix method to estimate Re. We then projected the impact of changes in HIV continuum-of-care interventions on the continuum-of-care flow rates and the estimated Re in 2020.

SETTING

United States.

PARTICIPANTS

The HOPE model simulated the sexually active US population and persons who inject drugs, aged 13 to 64 years, which was stratified into 195 subpopulations by transmission group, sex, race/ethnicity, age, male circumcision status, and HIV risk level.

MAIN OUTCOME MEASURES

The estimated value of Re in 2017 and changes in Re in 2020 from interventions affecting the continuum-of-care flow rates.

RESULTS

Our estimated HIV Re in 2017 was 0.92 [0.82, 0.94] (base case [min, max across calibration sets]). Among the interventions considered, the most effective way to reduce Re substantially below 1.0 in 2020 was to maintain viral suppression among those receiving HIV treatment. The greatest impact on Re resulted from changing the flow rates for men who have sex with men (MSM).

CONCLUSIONS

Our results suggest that current prevention and treatment efforts may not be sufficient to move the country toward HIV elimination. Reducing Re to substantially below 1.0 may be achieved by an ongoing focus on early diagnosis, linkage to care, and sustained viral suppression especially for MSM.

Characterizing opioid-involved overdose risk in local communities: An opioid overdose vulnerability assessment across Indiana, 2017

The objective of this initiative was to conduct a comprehensive opioid overdose vulnerability assessment in Indiana and evaluate spatial accessibility to opioid use disorder treatment, harm reduction services, and opioid response programs. We compiled 2017 county-level (n = 92) data on opioid-related and socioeconomic indicators from publicly available state and federal sources. First, we assessed the spatial distribution of opioid-related indicators in a geographic information system (GIS). Next, we used a novel regression-weighted ranking approach with mean standardized covariates and an opioid-involved overdose mortality outcome to calculate county-level vulnerability scores. Finally, we examined accessibility to opioid use disorder treatment services and opioid response programs at the census tract-level (n = 1511) using two-step floating catchment area analysis. Opioid-related emergency department visit rate, opioid-related arrest rate, chronic hepatitis C virus infection rate, opioid prescription rate, unemployment rate, and percent of female-led households were independently and positively associated with opioid-involved overdose mortality (p < 0.05). We identified high-risk counties across the rural-urban continuum and primarily in east central Indiana. We found that only one of the 19 most vulnerable counties was in the top quintile for treatment services and had naloxone provider accessibility in all of its census tracts. Findings from our vulnerability assessment provide local-level context and evidence to support and inform future public health policies and targeted interventions in Indiana in areas with high opioid overdose vulnerability and low service accessibility. Our approach can be replicated in other state and local public health jurisdictions to assess opioid-involved public health vulnerabilities.

Plasma virome and the risk of blood-borne infection in persons with substance use disorder

There is an urgent need for innovative methods to reduce transmission of bloodborne pathogens like HIV and HCV among people who inject drugs (PWID). We investigate if PWID who acquire non-pathogenic bloodborne viruses like anelloviruses and pegiviruses might be at greater risk of acquiring a bloodborne pathogen. PWID who later acquire HCV accumulate more non-pathogenic viruses in plasma than matched controls who do not acquire HCV infection. Additionally, phylogenetic analysis of those non-pathogenic virus sequences reveals drug use networks. Here we find first in Baltimore and confirm in San Francisco that the accumulation of non-pathogenic viruses in PWID is a harbinger for subsequent acquisition of pathogenic viruses, knowledge that may guide the prioritization of the public health resources to combat HIV and HCV.

Spread of bloodborne infections, such as HCV and HIV, is a problem, particularly amongst people who inject drugs (PWID). Here, the authors describe and then confirm in observational PWID cohorts that those with more non-pathogenic viruses in plasma were more likely later to acquire HCV than PWID who had fewer of these non-pathogenic viruses.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.

Interdisciplinary HIV Sentinel Case Review: Identifying Practices to Prevent Outbreaks in Philadelphia

INTRODUCTION

The Ending the HIV Epidemic in the U.S. initiative considers cluster and outbreak response essential. This article describes the design, implementation, and early findings of a Philadelphia-based project to systematically assess sentinel cases among priority populations for improving public health infrastructure and preventing future outbreaks.

METHODS

Sentinel HIV cases (i.e., early-stage or acute infection or molecular cluster cases) were identified among priority populations (Black and Hispanic/Latino men who have sex with men, youth aged 18-24 years, and transgender people who have sex with men). Chart abstraction and structured interview data were reviewed to determine themes and service gaps and to identify, prioritize, and implement recommendations. Interdisciplinary review teams included individuals with lived experience, frontline staff, and local agency leadership.

RESULTS

Data were collected during July 2019-December 2020 and analyzed for 53 of 126 sentinel cases of HIV diagnosed since July 1, 2018. The majority were men who have sex with men (79.3%), those aged 18-24 years (67.9%), and non-Hispanic Black (67.9%). More than half received sexually transmitted infection and HIV testing ≤3 years preceding HIV diagnosis (56.6% and 54.7%, respectively), had a healthcare visit within 12 months before diagnosis (64.2%), and had no evidence of pre-exposure prophylaxis awareness (58.5%). Project recommendations effectuated actions to improve pre-exposure prophylaxis provision, integrate sexually transmitted infection and HIV testing, and educate primary care providers.

CONCLUSIONS

HIV sentinel case review is a model for health departments to rapidly respond to recent transmission, identify missed HIV prevention opportunities, strengthen community partnerships, and implement programmatic and policy changes. Such efforts may prevent outbreaks and inform longer-term strategies.

Politicized disease surveillance: A theoretical lens for understanding sociopolitical influence on the monitoring of disease epidemics

Sociopolitical forces commonly influence the collection, analysis, dissemination, and general perceptions of epidemiological information. Yet few theoretical lenses provide insight into the mechanisms through which such influence occurs. In this article, I draw and expand upon empirical findings to propose a novel theoretical lens, politicized disease surveillance, which I define as extreme or undue sociopolitical influence on public health surveillance systems or processes in ways that impact disease incidences and prevalences, or estimates or perceptions thereof. This lens foregrounds disease incidence and prevalence as objects of contestation and policy influence and articulates how certain facets of sociopolitical forces shape disease incidences and prevalences-especially amid an epidemic-through one or more channels: (1) the diagnostic construct; (2) screening tools, procedures, or systems; or (3) the behaviors of individuals who are living with or at risk for a certain disease. I provide several contemporary illustrations of politicized disease surveillance and discuss its theoretical and practical implications.

Could the 2010 HIV outbreak in Athens, Greece have been prevented? A mathematical modeling study

INTRODUCTION

In 2009 and 2010, Athens, Greece experienced a hepatitis C virus (HCV) and a Human Immunodeficiency Virus (HIV) outbreak among People Who Inject Drugs (PWID), respectively. The HCV outbreak was not detected, while that of HIV was identified in 2011. The integrated HIV-interventions, launched in early 2012, managed to reduce directly the HIV incidence and indirectly the HCV incidence. This study aims to assess what would have been the course of the HIV outbreak and its associated economic consequences if the 2009 HCV outbreak had been detected and integrated interventions had been initiated 1- or 2-years earlier.

METHODS

The model was calibrated to reproduce the observed HIV epidemiological and clinical parameters among PWID of Athens, Greece. We examined the effect of the 1- or 2-years earlier detection scenarios, the 1-year later detection, the non-detection scenario, and compared them to the status quo scenario.

RESULTS

Cumulative HIV cases, under the status-quo scenario during 2009-2019, were 1360 (90% Credible intervals: 290, 2470). If the HCV outbreak had been detected 1- or 2- years earlier, with immediate initiation of integrated interventions, 740 and 1110 HIV cases could be averted by 2019, respectively. Regarding the costs, if there was an efficient notification system to detect the HCV outbreak 1 or 2 years earlier, 35.2-53.2 million euros could be saved compared to the status quo by 2019.

CONCLUSIONS

If the HCV outbreak had been detected and promptly addressed, the HIV outbreak would have been prevented and 35.2-53.2 million euros could have been saved.

Incorporating metadata in HIV transmission network reconstruction: A machine learning feasibility assessment

HIV molecular epidemiology estimates the transmission patterns from clustering genetically similar viruses. The process involves connecting genetically similar genotyped viral sequences in the network implying epidemiological transmissions. This technique relies on genotype data which is collected only from HIV diagnosed and in-care populations and leaves many persons with HIV (PWH) who have no access to consistent care out of the tracking process. We use machine learning algorithms to learn the non-linear correlation patterns between patient metadata and transmissions between HIV-positive cases. This enables us to expand the transmission network reconstruction beyond the molecular network. We employed multiple commonly used supervised classification algorithms to analyze the San Diego Primary Infection Resource Consortium (PIRC) cohort dataset, consisting of genotypes and nearly 80 additional non-genetic features. First, we trained classification models to determine genetically unrelated individuals from related ones. Our results show that random forest and decision tree achieved over 80% in accuracy, precision, recall, and F1-score by only using a subset of meta-features including age, birth sex, sexual orientation, race, transmission category, estimated date of infection, and first viral load date besides genetic data. Additionally, both algorithms achieved approximately 80% sensitivity and specificity. The Area Under Curve (AUC) is reported 97% and 94% for random forest and decision tree classifiers respectively. Next, we extended the models to identify clusters of similar viral sequences. Support vector machine demonstrated one order of magnitude improvement in accuracy of assigning the sequences to the correct cluster compared to dummy uniform random classifier. These results confirm that metadata carries important information about the dynamics of HIV transmission as embedded in transmission clusters. Hence, novel computational approaches are needed to apply the non-trivial knowledge collected from inter-individual genetic information to metadata from PWH in order to expand the estimated transmissions. We note that feature extraction alone will not be effective in identifying patterns of transmission and will result in random clustering of the data, but its utilization in conjunction with genetic data and the right algorithm can contribute to the expansion of the reconstructed network beyond individuals with genetic data.

Longitudinal typing of molecular HIV clusters in a statewide epidemic

BACKGROUND

HIV molecular epidemiology is increasingly integrated into public health prevention. We conducted cluster typing to enhance characterization of a densely sampled statewide epidemic towards informing public health.

METHODS

We identified HIV clusters, categorized them into types, and evaluated their dynamics between 2004 and 2019 in Rhode Island. We grouped sequences by diagnosis year, assessed cluster changes between paired phylogenies, t0 and t1, representing adjacent years and categorized clusters as stable (cluster in t0 phylogeny = cluster in t1 phylogeny) or unstable (cluster in t0 ≠ cluster in t1). Unstable clusters were further categorized as emerging (t1 phylogeny only) or growing (larger in t1 phylogeny). We determined proportions of each cluster type, of individuals in each cluster type, and of newly diagnosed individuals in each cluster type, and assessed trends over time.

RESULTS

A total of 1727 individuals with available HIV-1 subtype B pol sequences were diagnosed in Rhode Island by 2019. Over time, stable clusters and individuals in them dominated the epidemic, increasing over time, with reciprocally decreasing unstable clusters and individuals in them. Conversely, proportions of newly diagnosed individuals in unstable clusters significantly increased. Within unstable clusters, proportions of emerging clusters and of individuals in them declined; whereas proportions of newly diagnosed individuals in growing clusters significantly increased over time.

CONCLUSION

Distinct molecular cluster types were identified in the Rhode Island epidemic. Cluster dynamics demonstrated increasing stable and decreasing unstable clusters driven by growing, rather than emerging clusters, suggesting consistent in-state transmission networks. Cluster typing could inform public health beyond conventional approaches and direct interventions.

A Systematic Review and Meta-Analysis of Studies Evaluating the Effect of Medication Treatment for Opioid Use Disorder on Infectious Disease Outcomes

The opioid epidemic has fueled infectious disease epidemics. We determined the impact of medications for opioid use disorder (MOUD) on treatment outcomes of opioid use disorder (OUD)-associated infectious diseases: antiretroviral therapy (ART) adherence, human immunodeficiency virus (HIV) viral suppression, hepatitis C virus (HCV) sustained virologic response, HCV reinfection, new hepatitis B virus infections, and infectious endocarditis-related outcomes. Manuscripts reporting on these infectious disease outcomes in adults with OUD receiving MOUD compared with those with OUD "not" receiving MOUD were included. Initial search yielded 8169 papers; 9 were included in the final review. The meta-analysis revealed that MOUD was associated with greater ART adherence (odds ratio [OR] = 1.55; 95% confidence interval [CI] = 1.12-2.15) and HIV viral suppression (OR = 2.19; 95% CI = 1.88-2.56). One study suggested a positive association between MOUD and HCV sustained virologic response. There is significant support for integrating MOUD with HIV treatment to improve viral suppression among persons with HIV (PWH) and OUD. Treatment of OUD among PWH should be a priority to combat the opioid and HIV epidemics.

A qualitative study of injection and sexual risk behavior among unstably housed people who inject drugs in the context of an HIV outbreak in Northeast Massachusetts, 2018

BACKGROUND

To investigate the underlying causes of a sudden increase in HIV among people who inject drugs (PWID) and initiate an appropriate response to the outbreak, we engaged in in-depth qualitative interviews with members of the PWID community in Lawrence and Lowell, Massachusetts.

METHODS

We interviewed 34 PWID who were currently or recently unstably housed, then transcribed interviews and coded transcripts, grouping codes into categories from which we identified key themes.

RESULTS

Participants described a heightened threat of overdose prompting PWID to inject together, increasing opportunities for sharing injection equipment. There were misunderstandings about safe injection practices to prevent HIV transmission and a low threshold for injection-related risk taking. Stigma regarding HIV prevented conversations about HIV status. Less thought was given to sexual risks than injection-related risks for HIV transmission.

CONCLUSIONS

We found multiple facilitators of HIV transmission. Additional HIV education and prevention interventions focusing on both injection and sexual risk practices would benefit this population, in addition to structural interventions such as increased access and availability of syringe service programs.

Methodological approaches for the prediction of opioid use-related epidemics in the United States: a narrative review and cross-disciplinary call to action

The opioid crisis in the United States has been defined by waves of drug- and locality-specific Opioid use-Related Epidemics (OREs) of overdose and bloodborne infections, among a range of health harms. The ability to identify localities at risk of such OREs, and better yet, to predict which ones will experience them, holds the potential to mitigate further morbidity and mortality. This narrative review was conducted to identify and describe quantitative approaches aimed at the "risk assessment," "detection" or "prediction" of OREs in the United States. We implemented a PubMed search composed of the: (1) objective (eg, prediction), (2) epidemiologic outcome (eg, outbreak), (3) underlying cause (ie, opioid use), (4) health outcome (eg, overdose, HIV), (5) location (ie, US). In total, 46 studies were included, and the following information extracted: discipline, objective, health outcome, drug/substance type, geographic region/unit of analysis, and data sources. Studies identified relied on clinical, epidemiological, behavioral and drug markets surveillance and applied a range of methods including statistical regression, geospatial analyses, dynamic modeling, phylogenetic analyses and machine learning. Studies for the prediction of overdose mortality at national/state/county and zip code level are rapidly emerging. Geospatial methods are increasingly used to identify hotspots of opioid use and overdose. In the context of infectious disease OREs, routine genetic sequencing of patient samples to identify growing transmission clusters via phylogenetic methods could increase early detection capacity. A coordinated implementation of multiple, complementary approaches would increase our ability to successfully anticipate outbreak risk and respond preemptively. We present a multi-disciplinary framework for the prediction of OREs in the US and reflect on challenges research teams will face in implementing such strategies along with good practices.

Evaluation of the scale-up of HIV testing among people who inject drugs in Scotland in the context of an ongoing HIV outbreak

BACKGROUND

A large outbreak of HIV among people who inject drugs (PWID) has been ongoing in Glasgow city centre (GCC), Scotland since early 2015. The outbreak is associated with high levels of homelessness, cocaine injecting and injecting in public places. A key component of the public health response was the scale-up of HIV testing in a range of services engaged with PWID. Our aims were to: 1) evaluate the extent of and change in HIV testing over the course of the outbreak and 2) examine factors associated with reporting an HIV test.

METHODS

Self-report of an HIV test in the last 12 months was collected for 15,081 PWID interviewed in six national cross-sectional bio-behavioural surveys during 2008-2018. Multi-variate logistic regression was undertaken to determine trends in HIV testing by region of recruitment (GCC; rest of Glasgow; other Scottish city centres (SCC); and rest of Scotland) and outbreak period (pre: 2008-14; early: 2015-16; ongoing: 2017-18).

RESULTS

HIV testing increased across all regions and was most pronounced in GCC comparing the ongoing (67%) to the pre-outbreak period (33%) (aOR=4.68, 95% CI 3.23 to 6.77, p<0.001). However, compared to other SCCs pre-outbreak (with 46% reporting testing), those recruited in GCC had a lower odds of HIV testing early outbreak (aOR=0.37, 95% CI 0.27 to 0.54, p<0.001) and more modest increased odds in the ongoing outbreak period (aOR=1.41, 95% CI 0.97 to 2.05, p=0.069). Among PWID recruited in the whole of Glasgow in the ongoing phase, reporting an HIV test was associated with injecting cocaine or in public places (aOR=2.20, 95% CI 1.53 to 3.17, p<0.001), receipt of methadone (aOR=1.48, 95% CI 1.01 to 2.17, p=0.042) and incarceration in the last year (aOR=1.72, 95% CI 1.18 to 2.51, p=0.004).

CONCLUSIONS

Relatively low levels of HIV testing pre- and early-outbreak likely hindered efforts to control the spread of infection among PWID in Glasgow. Uptake has since increased with expansion of testing across multiple settings, particularly among those at high risk of infection. Further effort is needed to ensure the vast majority of PWID are regularly tested, not just in the epicentre of the outbreak but in other areas with low population prevalence of infection.

Are spatial models advantageous for predicting county-level HIV epidemiology across the United States?

Predicting human immunodeficiency virus (HIV) epidemiology is vital for achieving public health milestones. Incorporating spatial dependence when data varies by region can often provide better prediction results, at the cost of computational efficiency. However, with the growing number of covariates available that capture the data variability, the benefit of a spatial model could be less crucial. We investigate this conjecture by considering both non-spatial and spatial models for county-level HIV prediction over the US. Due to many counties with zero HIV incidences, we utilize a two-part model, with one part estimating the probability of positive HIV rates and the other estimating HIV rates of counties not classified as zero. Based on our data, the compound of logistic regression and a generalized estimating equation outperforms the candidate models in making predictions. The results suggest that considering spatial correlation for our data is not necessarily advantageous when the purpose is making predictions.

Interplay Between Geography and HIV Transmission Clusters in Los Angeles County

BACKGROUND

Clusters of HIV diagnoses in time and space and clusters of genetically linked cases can both serve as alerts for directing prevention and treatment activities. We assessed the interplay between geography and transmission across the Los Angeles County (LAC) HIV genetic transmission network.

METHODS

Deidentified surveillance data reported for 8186 people with HIV residing in LAC from 2010 through 2016 were used to construct a transmission network using HIV-TRACE. We explored geographic assortativity, the tendency for people to link within the same geographic region; concordant time-space pairs, the proportion of genetically linked pairs from the same geographic region and diagnosis year; and Jaccard coefficient, the overlap between geographical and genetic clusters.

RESULTS

Geography was assortative in the genetic transmission network but less so than either race/ethnicity or transmission risk. Only 18% of individuals were diagnosed in the same year and location as a genetically linked partner. Jaccard analysis revealed that cis-men and younger age at diagnosis had more overlap between genetic clusters and geography; the inverse association was observed for trans-women and Blacks/African Americans.

CONCLUSIONS

Within an urban setting with endemic HIV, genetic clustering may serve as a better indicator than time-space clustering to understand HIV transmission patterns and guide public health action.

Shifting the paradigm: physician-authorized, student-led efforts to provide harm reduction services amidst legislative opposition

Background

For over 30 years, syringe services programs (SSPs) have served as an efficacious intervention for the prevention of HIV and Hepatitis C transmission among persons who use drugs. Despite a strong body of evidence for the effectiveness of SSPs as a preventative public health measure, numerous local and state governments in the United States continue to resist the establishment of new SSPs and aggressively pursue the closure of those already in operation.

Commentary

In Orange County, California, local officials have repeatedly mobilized in opposition of the establishment of syringe access – thereby hindering access to healthcare for thousands of predominantly unhoused individuals. The county was previously served by the Orange County Needle Exchange Program from 2016 until 2018 when a civil suit brought by the Orange County Board of Supervisors resulted in the closure of the program. For more than 2 years, persons who inject drugs in Orange County lacked reliable access to clean syringes, placing them at increased risk for contracting HIV and Hepatitis C. Here, we comment on the ongoing effort to restore syringe access in Orange County. This collaborative physician-directed endeavor has brought together students and community volunteers to provide vital harm reduction services to a remarkably underserved population. Since the reestablishment of syringe access in Orange County by the Harm Reduction Institute, new legal barriers have arisen including the passage of new municipal legislation banning the operation of syringe exchanges. We are well-equipped to overcome these obstacles. This work serves as an affirmation of assertions made by previous authors regarding the unique qualifications of medical & graduate students as effective harm reductionists.

Conclusion

Harm reduction services are vital to the health and well-being of people who use drugs. The provision of these services should not be impeded by legislative interference by municipal, county, or state governments.

The opioid crisis and HIV in the USA: deadly synergies

The opioid epidemic is one of the greatest public health problems that the USA faces. Opioid overdose death rates have increased steadily for more than a decade and doubled in 2013-17, as the highly potent synthetic opioid fentanyl entered the drug supply. Demographics of new HIV diagnoses among people who inject drugs are also changing, with more new HIV diagnoses occurring among White people, young people (aged 13-34 years), and people who reside outside large central metropolitan areas. Racial differences also exist in syringe sharing, which decreased among Black people and Hispanic people but remained unchanged among White people in 2005-15. Recent HIV outbreaks have occurred in rural areas of the USA, as well as among marginalised people in urban areas with robust HIV prevention and treatment services (eg, Seattle, WA). Multiple evidence-based interventions can effectively treat opioid use disorder and prevent HIV acquisition. However, considerable barriers exist precluding delivery of these solutions to many people who inject drugs. If the USA is serious about HIV prevention among this group, stigma must be eliminated, discriminatory policies must change, and comprehensive health care must be accessible to all. Finally, root causes of the opioid epidemic such as hopelessness need to be identified and addressed.

Call to action: how can the US Ending the HIV Epidemic initiative succeed?

With more than 1·2 million people living with HIV in the USA, a complex epidemic across the large and diverse country, and a fragmented health-care system marked by widening health disparities, the US HIV epidemic requires sustained scientific and public health attention. The epidemic has been stubbornly persistent; high incidence densities have been sustained over decades and the epidemic is increasingly concentrated among racial, ethnic, and sexual and gender minority communities. This fact remains true despite extraordinary scientific advances in prevention, treatment, and care-advances that have been led, to a substantial degree, by US-supported science and researchers. In this watershed year of 2021 and in the face of the COVID-19 pandemic, it is clear that the USA will not meet the stated goals of the National HIV/AIDS Strategy, particularly those goals relating to reductions in new infections, decreases in morbidity, and reductions in HIV stigma. The six papers in the Lancet Series on HIV in the USA have each examined the underlying causes of these challenges and laid out paths forward for an invigorated, sustained, and more equitable response to the US HIV epidemic than has been seen to date. The sciences of HIV surveillance, prevention, treatment, and implementation all suggest that the visionary goals of the Ending the HIV Epidemic initiative in the USA might be achievable. However, fundamental barriers and challenges need to be addressed and the research effort sustained if we are to succeed.

Between Emergency Department Visits: The Role of Harm Reduction Programs in Mitigating the Harms Associated With Injection Drug Use

Injection drug use is a major public health problem in the United States. Cocaine, heroin, and methamphetamine are the most commonly injected illicit drugs, whereas opioids are responsible for the majority of overdose fatalities. Although recent emergency department (ED) efforts have focused on expanding capacity for buprenorphine induction for opioid use disorder treatment, the injection of illicit drugs carries specific health risks that require acknowledgment and management, particularly for patients who decline substance use treatment. Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself. Harm-reduction strategies fundamental to emergency medicine include naloxone distribution for opioid overdose. This clinical Review Article examines the specific health complications of injection drug use and reviews the evidence base for 2 interventions effective in reducing morbidity and mortality related to drug injection, irrespective of the specific drug used, that are less well known and infrequently leveraged by emergency medicine clinicians: syringe service programs and supervised injection facilities. In accordance with the recommendations of health authorities such as the Centers for Disease Control and Prevention, emergency clinicians can promote the use of harm-reduction programs in the community to reduce viral transmission and other risks of injection drug use by providing patients with information about and referrals to these programs after injection drug use-related ED visits.

Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study

BACKGROUND

Syringe services programs (SSPs) are effective venues for delivering harm-reduction services to people who inject drugs (PWID). However, SSPs often face significant barriers to implementation, particularly in the absence of known human immunodeficiency virus (HIV) outbreaks.

METHODS

Using an agent-based model, we simulated HIV transmission in Scott County, Indiana, a rural county with a 1.7% prevalence of injection drug use. We compared outcomes arising in the absence of an SSP, in the presence of a pre-existing SSP, and with implementation of an SSP after the detection of an HIV outbreak among PWID over 5 years following the introduction of a single infection into the network.

RESULTS

In the absence of an SSP, the model predicted an average of 176 infections among PWID over 5 years or an incidence rate of 12.1/100 person-years. Proactive implementation averted 154 infections and decreased incidence by 90.3%. With reactive implementation beginning operations 10 months after the first infection, an SSP would prevent 107 infections and decrease incidence by 60.8%. Reductions in incidence were also observed among people who did not inject drugs.

CONCLUSIONS

Based on model predictions, proactive implementation of an SSP in Scott County had the potential to avert more HIV infections than reactive implementation after the detection of an outbreak. The predicted impact of reactive SSP implementation was highly dependent on timely implementation after detecting the earliest infections. Consequently, there is a need for expanded proactive SSP implementation in the context of enhanced monitoring of outbreak vulnerability in Scott County and similar rural contexts.

Principles of Harm Reduction for Young People Who Use Drugs

In summarizing the proceedings of a longitudinal meeting of experts on substance use disorders among adolescents and young adults, we review 2 principles of care related to harm reduction for young adults with substance use disorders. The first is that harm reduction services are critical to keeping young adults alive and healthy and can offer opportunities for future engagement in treatment. Such services therefore should be offered at every opportunity, regardless of an individual's interest or ability to minimize use of substances. The second is that all evidence-based harm reduction strategies available to older adults should be available to young adults and that whenever possible, harm reduction programs should be tailored to young adults and be developmentally appropriate.

'It's just basically a box full of disease'-navigating sterile syringe scarcity in a rural New England state

BACKGROUND AND AIMS

Injection drug use has increased in non-urban communities in the United States where sterile syringe access is limited. This study aimed to characterize how people who inject drugs in a predominantly rural state navigate syringe scarcity.

DESIGN

Qualitative study.

SETTING

New Hampshire (NH), USA. At the time of our study, syringe services programs were illegal in NH but pharmacies could sell ≤ 10 syringes without prescription.

PARTICIPANTS/CASES

Twenty people aged ≥ 18 years who injected at least once in the past 30 days were recruited through provider referral, street-based recruitment and snowball sampling.

MEASUREMENTS

Semi-structured interview guide. Verbatim transcripts were coded based on interview guide constructs and emergent themes. Analysis focused on pharmacy syringe access, unofficial syringe sources and related impacts on syringe sharing and reuse FINDINGS: Participants could identify no local pharmacies that sold syringes without prescription. Pharmacy purchase in neighboring counties, or across state lines, required private transportation and this, along with purchaser identification requirements, presented substantial access barriers. Interstate travel also exposed participants to vigilant policing of interstate highways and potential criminal justice involvement. Many participants thus resorted to informal syringe sources closer to home including purchasing syringes on the street, using discarded syringes, breaking into biohazard containers and constructing improvised syringes out of salvaged syringe parts, metals and plastics. Repeated re-use of syringes until they were no longer operational was common. Overall, syringe scarcity gave participants few options but to engage in syringe sharing and re-use, putting them at risk of serious injection-related infections.

CONCLUSIONS

Limited sterile syringe access contributes to an environment in which people who inject drugs report that they are less able to refrain from risky injection practices.