Human Immunodeficiency Virus and Hepatitis C Virus Infection Testing Among Commercially Insured Persons Who Inject Drugs, United States, 2010-2017

The cascade of care for commercially-insured persons with opioid use disorder and comorbid HIV and HCV infections

BACKGROUND

Opioid use disorder (OUD) significantly impacts individual and public health and exacerbated further by concurrent infectious diseases. A syndemic approach is needed to address the intertwined OUD, HIV, and HCV epidemics, including the expanded use of medications for opioid use disorder (MOUD).

METHODS

To identify MOUD scale-up opportunities, we conducted a retrospective cohort study, representing commercially insured persons, and created the OUD care continuum, including HIV and HCV influences in adults (18-64 years) newly diagnosed with OUD in 2019 using Merative MarketSan data.

RESULTS

Among 124,467,633 individuals, the prevalence of OUD was 0.4 % (95 % CI: 0.36 %-0.46 %; N = 497,871), with 327,277 (65.7 %, 95 % CI: 65.60 %-65.87 %) newly diagnosed in 2019. Among these newly diagnosed individuals (54 % men, mean age 44±0.01), 53,568 (27.0 %, 95 % CI: 26.4 %-27.5 %) were prescribed MOUD, with retention rates at 1, 3, and 6 months being 89.0 % (95 % CI: 88.2 %-89.8 %), 66.0 % (95 % CI: 64.8 %-67.2 %), and 50.3 % (95 % CI: 48.3 %-51.6 %), respectively. Buprenorphine was the most prescribed MOUD (79.6 %, 95 % CI: 78.6 %-80.7 %), followed by XR-NTX (14.9 %, 95 % CI:14.0 %-15.8 %) and methadone (5.5 %, 95 % CI: 4.9 %-6.1 %). Six-month retention was highest for methadone (73.4 %, 95 % CI: 73.0 %-73.8 %), however, followed by buprenorphine (55.7 %, 95 % CI: 55.3 %-57.1 %) and substantially lower for XR-NTX (12.6 %, 95 % CI: 10.6 %-14.6 %). Screening for HIV and HCV was low among OUD enrollees (11.1 %, 14.4 %), slightly higher for MOUD initiators (18.0 %, 21.6 %). Being prescribed MOUD was correlated with HCV infection (AOR: 2.54; 95 % CI: 2.41-2.68), HCV/HIV coinfection (AOR: 1.89; 95 % CI: 1.41-2.53), and hospitalization for OUD-related services (AOR: 1.14; 95 % CI: 1.11-1.17), yet hospitalization for OUD-related services was positively correlated with XR-NTX (AOR: 2.72; 95 % CI: 2.56-2.85) prescription and negatively with methadone (AOR: 0.19; 95 % CI: 0.16-0.23) prescription. Having HIV was negatively correlated with being prescribed methadone (AOR: 0.33; 95 % CI: 0.13-0.86).

CONCLUSIONS

Substantial gaps in the OUD cascade persist, underscoring better implementation opportunities for MOUD prescription in hospital-based settings and expanding access to methadone beyond highly regulated sites given its low coverage yet high treatment retention.

Prevalence and associated risk factors of current hepatitis C infection among U.S. general population and injection drug users aged 20-59 years: NHANES 2009-2018

INTRODUCTION

The people who inject drugs (PWID) are attributed to high-risk groups for transmission of the Hepatitis C virus (HCV). This study assessed the prevalence and associated factors of current HCV infection (CHI) among U.S. general population and PWID of ages between 20 and 59 years old.

METHODS

This study utilized cross-sectional data from the 2009-2018 National Health and Nutrition Examination Survey, conducting separate analyses for the U.S. general population, including PWID and non-PWID, as well as specific analyses focusing solely on PWID. The analytical methods included the estimation of CHI prevalence, Rao-Scott chi-square test to compare CHI-positive and CHI-negative groups, and univariate and multivariable logistic regressions models to evaluate the associated risk factors of CHI.

RESULTS

The prevalence of CHI among general population and PWID were 1% and 19%, respectively. Compared to non-PWID, the odds of CHI were significantly higher among PWID (OR = 32.6, 95% CI = 17.7-60.3) in general population. Among PWID, male vs. female (OR = 2.6, 95% CI = 1.1-5.9), adults aged 40-59 vs. 20-39 years old (OR = 2.9, 95% CI = 1.2-7.3), Non-Hispanic Black vs. White (OR = 4.6, 95% CI = 1.5-13.6), with high school diploma or less educational attainment vs. above college degree (OR = 3.5, 95% CI = 1.4-9.2) showed higher odds of having CHI.

CONCLUSION

The prevalence of CHI was found to be higher among PWID especially those who were male, aged 40-59 years old, Non-Hispanic Black, and had lower educational attainment. Targeted intervention such as screening and awareness program among PWID population is recommended to reduce the burden of new HCV infections in the U.S.

Identification of factors associated with opioid-related and hepatitis C virus-related hospitalisations at the ZIP code area level in the USA: an ecological and modelling study

BACKGROUND

Opioid overdose and related diseases remain a growing public health crisis in the USA. Identifying sociostructural and other contextual factors associated with adverse health outcomes is needed to improve prediction models to inform policy and interventions. We aimed to identify high-risk communities for targeted delivery of screening and prevention interventions for opioid use disorder and hepatitis C virus (HCV).

METHODS

In this ecological and modelling study, we fit mixed-effects negative binomial regression models to identify factors associated with, and predict, opioid-related and HCV-related hospitalisations for ZIP code tabulation areas (ZCTAs) in South Carolina, USA. All individuals aged 18 years or older living in South Carolina from Jan 1, 2016, to Dec 31, 2021, were included. Data on opioid-related and HCV-related hospitalisations, as well as data on additional individual-level variables, were collected from medical claims records, which were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic and socioeconomic variables were obtained from the United States Census Bureau (American Community Survey, 2021) with additional structural health-care barrier data obtained from South Carolina's Center for Rural and Primary Health Care, and the American Hospital Directory.

FINDINGS

Between Jan 1, 2016, and Dec 31, 2021, 41 691 individuals were hospitalised for opioid misuse and 26 860 were hospitalised for HCV. There were a median of 80 (IQR 24-213) opioid-related hospitalisations and 61 (21-196) HCV-related hospitalisations per ZCTA. A standard deviation increase in ZCTA-level uninsured rate (relative risk 1·24 [95% CI 1·17-1·31]), poverty rate (1·24 [1·17-1·31]), mortality (1·18 [1·12-1·25]), and social vulnerability index (1·17 [1·10-1·24]) was significantly associated with increased combined opioid-related and HCV-related hospitalisation rates. A standard deviation increase in ZCTA-level income (0·79 [0·75-0·84]) and unemployment rate (0·87 [0·82-0·93]) was significantly associated with decreased combined opioid-related and HCV-related hospitalisations. Using 2016-20 hospitalisations as training data, our models predicted ZCTA-level opioid-related hospitalisations in 2021 with a median of 80·4% (IQR 66·8-91·1) accuracy and HCV-related hospitalisations in 2021 with a median of 75·2% (61·2-87·7) accuracy. Several underserved high-risk ZCTAs were identified for delivery of targeted interventions.

INTERPRETATION

Our results suggest that individuals from economically disadvantaged and medically under-resourced communities are more likely to have an opioid-related or HCV-related hospitalisation. In conjunction with hospitalisation forecasts, our results could be used to identify and prioritise high-risk, underserved communities for delivery of field-level interventions.

FUNDING

South Carolina Center for Rural and Primary Healthcare, National Institute on Drug Abuse, and National Library of Medicine.

Trends in Drug Spending of Oral Anticoagulants for Atrial Fibrillation, 2014-2021

INTRODUCTION

This study documents cost trends in oral anticoagulants (OAC) in patients with newly diagnosed atrial fibrillation.

METHODS

Using MarketScan databases, the mean annual patients' out-of-pocket costs, insurance payments, and the proportion of patients initiating OAC within 90 days from atrial fibrillation diagnosis were calculated from July 2014 to June 2021. Costs of OACs (apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin) and the payments by three insurance types (commercial payers, Medicare, and Medicaid) were calculated. Patients' out-of-pocket costs and insurance payments were adjusted to 2021 prices. Joinpoint regression models were used to test trends of outcomes and average annual percent changes (AAPC) were reported. Data analyses were performed in 2022-2023.

RESULTS

From July 2014 to June 2021, the mean annual out-of-pocket costs of any OAC increased for commercial insurance (AAPC 3.0%) and Medicare (AAPC 5.1%) but decreased for Medicaid (AAPC -3.3%). The mean annual insurance payments for any OAC significantly increased for all insurance groups (AAPC 13.1% [95% CI 11.3-15.0] for Medicare; AAPC 11.8% [95% CI 8.0-15.6] for commercial insurance; and AAPC 16.3% [95% CI 11.3-21.4] for Medicaid). The initiation of any OAC increased (AAPC 7.3% for commercial insurance; AAPC 10.2% for Medicare; AAPC 5.3% for Medicaid).

CONCLUSIONS

There was a substantial increase in the overall cost burden of OACs and OAC initiation rates in patients with newly diagnosed atrial fibrillation in 2014-2021; these findings provide insights into the current and anticipated impact of rising drug prices on patients' and payers' financial burden.

Health, harm reduction, and social service providers' perspectives on the appropriateness and feasibility of peer distribution of HIV self-test kits among people who use drugs

BACKGROUND

People who use drugs (PWUD) experience elevated HIV risk and numerous barriers to facility-based HIV testing. HIV self-testing (HIVST) could circumvent many of those barriers and is acceptable among PWUD, yet HIVST implementation for PWUD is limited. Service providers' perspectives on specific HIVST delivery strategies could help increase availability for PWUD.

METHODS

From April-November 2021, we interviewed 16 health, harm reduction, and social service providers working with PWUD in San Diego, CA. Interviews and rapid thematic analysis explored perspectives on HIVST's utility and appropriateness, as well as the feasibility of and anticipated challenges with specific HIVST delivery strategies, including peer or secondary distribution.

RESULTS

Participants viewed HIV as a significant threat to PWUD health and confirmed the presence of numerous barriers to local facility-based HIV testing. Participants viewed HIVST as a promising and potentially empowering solution. Based on community familiarity with secondary distribution of harm reduction supplies (i.e., naloxone) and information, participants viewed secondary distribution of HIVST kits as an appropriate and feasible strategy for increasing the reach of HIVST, but also described potential barriers (e.g., engaging socially disconnected individuals, ensuring linkages to services following HIVST) and provided suggestions for alternative HIVST kit delivery models (e.g., harm reduction vending machines).

CONCLUSIONS

Service providers viewed secondary distribution of HIVST kits among PWUD as promising, appropriate, and feasible, yet specialized efforts may be needed to reach the most marginalized individuals and ensure consistent provision of educational information and referral supports that maximize the impact of this approach.

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.

Rationale, evidence, and steps for implementation of medication for opioid use disorder treatment programs in HIV primary care settings

As the opioid crisis continues to escalate, the management of patients with opioid use disorder has crossed over to the care of patients with chronic infectious diseases, specifically HIV, HBV, and HCV, typically managed in the primary care setting. Consensus guidelines recommend testing for HIV and hepatitis in persons who inject drugs at least annually, but high-risk sexual activity may put other patients at risk as well. Significant barriers to robust care of these patient populations include low rates of HIV and hepatitis testing, limited access to methadone treatment programs, lack of widespread knowledge of how to prescribe office-based opioid treatment, and ongoing stigma surrounding prescribing of HIV treatment and prophylaxis medications. Clinical pharmacists across ambulatory, infectious diseases, and opioid stewardship specialties have the opportunity to play a key role in the implementation and support of harm reduction and medication for opioid use disorder services in the outpatient setting. The goal of this article is to discuss the rationale and evidence for these services and provide a framework for implementation.

HIV and HCV testing at clinical encounters among people who inject drugs, 2013-2018-Opportunities for increased testing and prevention

People who inject drugs (PWID) with unsafe injection practices have substantial risk for HIV and hepatitis C virus (HCV) infections. We describe frequency of, and factors associated with, HIV and HCV testing during clinical encounters with PWID. Inpatient and Emergency Department clinical encounters at an Atlanta hospital were abstracted from medical records spanning January 2013-December 2018. We estimated frequency of HIV and HCV testing during injection drug use (IDU)-related encounters among PWID without previous diagnoses. We assessed associations between patient factors and testing using generalized estimating equations models. HIV testing occurred in 39.3% and HCV testing occurred in 17.1% of eligible IDU-related encounters. Testing was more likely in IDU-related encounters during 2017-2018 than in encounters during 2013-2014; (HIV, AOR = 2.14, 95% CI, 1.32-3.49, p < .01). Testing was less likely among Black/African American patients compared to White patients (adjusted odds ratio [AOR]: HIV, AOR = 0.48, 95% confidence interval [CI], 0.33-0.72, p < .01); HCV, AOR = 0.41, 95% CI, 0.24-0.70, p < .01). This difference may be attributable to recent testing among Black patients in non-IDU related encounters. HIV and HCV testing improved over time; however, missed opportunities for testing still existed. Strategies should aim to improve equitable HIV and HCV testing among PWID.

A study protocol for Project I-Test: a cluster randomized controlled trial of a practice coaching intervention to increase HIV testing in substance use treatment programs

BACKGROUND

People with substance use disorders are vulnerable to acquiring HIV. Testing is fundamental to diagnosis, treatment, and prevention; however, in the past decade, there has been a decline in the number of substance use disorder (SUD) treatment programs offering on-site HIV testing. Fewer than half of SUDs in the USA offer on-site HIV testing. In addition, nearly a quarter of newly diagnosed cases have AIDS at the time of diagnosis. Lack of testing is one of the main reasons that annual HIV incidences have remained constant over time. Integration of HIV testing with testing for HCV, an infection prevalent among persons vulnerable to HIV infection, and in settings where they receive health services, including opioid treatment programs (OTPs), is of great public health importance.

METHODS/DESIGN

In this 3-arm cluster-RCT of opioid use disorders treatment programs, we test the effect of two evidence-based "practice coaching" (PC) interventions on the provision and sustained implementation of on-site HIV testing, on-site HIV/HCV testing, and linkage to care. Using the National Survey of Substance Abuse Treatment Services data available from SAMHSA, 51 sites are randomly assigned to one of the three conditions: practice coach facilitated structured conversations around implementing change, with provision of resources and documents to support the implementation of (1) HIV testing only, or (2) HIV/HCV testing, and (3) a control condition that provides a package with information only. We collect quantitative (e.g., HIV and HCV testing at 6-month-long intervals) and qualitative site data near the time of randomization, and again approximately 7-12 months after randomization.

DISCUSSION

Innovative and comprehensive approaches that facilitate and promote the adoption and sustainability of HIV and HCV testing in opioid treatment programs are important for addressing and reducing HIV and HCV infection rates. This study is one of the first to test organizational approaches (practice coaching) to increase HIV and HIV/HCV testing and linkage to care among individuals receiving treatment for opioid use disorder. The study may provide valuable insight and knowledge on the multiple levels of intervention that, if integrated, may better position OTPs to improve and sustain testing practices and improve population health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03135886. Registered on 2 May 2017.

Improving HIV and HCV Testing in Substance Use Disorder Programs (SUDs) That Provide Medications for Opiate Use Disorder (MOUD): Role of Addressing Barriers and Implementing Universal and Site-Specific Approaches

Introduction. National strategies to end the HIV epidemic and eliminate hepatitis c (HCV) through a syndemic approach require improvements in testing for HIV and HCV. Given the intersection of the opioid crisis with HIV and HCV acquisition, substance use disorder (SUD) treatment centers providing medications for opiate use disorder (MOUD) provide a critical opportunity to expand testing. Rates of testing in MOUD clinics have been suboptimal. Method. We employed the Nominal Group Technique (NGT), Ishikawa cause and effect diagrams, and individualized Quality Improvement (QI) efforts at two SUD clinics (SUD A and B) in Connecticut (CT) as part of an HRSA-funded grant focused on improving HCV cure in persons with HIV/HCV coinfection. Baseline and longitudinal data were collected on rates of HIV and HCV testing and positivity as well as linkage to treatment. Results. Between April 1, 2019, and May 31, 2021, for SUD A and B respectively, HIV testing increased from 13% to 90% and 33% to 83%; HCV testing increased from 4% to 90% and 30% to 82%, with few reported cases of HIV/HCV coinfection. HCV testing revealed new and prior diagnoses at both sites, with subsequent referrals for treatment. Qualitative assessments identified best practices which included the institution of formal policies and procedures, streamlining of testing logistics, designation of a site champion, and broadening relevant education to staff and clients. Conclusion. Strategic assessment of barriers and facilitators to HIV and HCV testing at MOUD clinics can lead to improved testing and referral rates that are key to improving the cascade of care for both diseases.

Hepatitis C Virus Testing and Care Cascade Among Transgender and Gender Diverse Individuals

INTRODUCTION

Hepatitis C virus (HCV) prevalence among transgender and gender-diverse individuals ranges from 1.8% to 15.7% versus 1% in the general population. Previous HCV studies inclusive of transgender and gender-diverse individuals primarily rely on convenience-based sampling methods or are geographically restricted. The purpose of this study is to compare the prevalence of HCV diagnoses, testing, and care engagement between transgender and gender-diverse and cisgender individuals.

METHODS

Using Optum's de-identified Clinformatics® Data Mart Database, in 2022, the unadjusted prevalence of HCV testing among all adults and people who inject drugs from January 2001 to December 2019 was measured. Multivariable logistic regression was used to compare the adjusted odds of HCV diagnoses and care engagement by gender subgroup.

RESULTS

The overall unadjusted frequency of HCV diagnoses among transgender and gender-diverse individuals was approximately 3 times that of cisgender individuals (1.06% vs 0.38%, p<0.001), including among people who inject drugs (6.36% vs 2.36%, p=0.007). Compared with cisgender women, transfeminine/nonbinary individuals had over 5 times the adjusted odds of a HCV diagnosis and approximately 3.5 times the odds of being tested for HCV. In addition, compared with cisgender women, transfeminine/nonbinary individuals had significantly increased odds of having a HCV‒related procedure (e.g., abdominal ultrasounds, liver biopsies, Fibroscans). Cisgender men had significantly increased odds of receiving HCV medication compared with cisgender women.

CONCLUSIONS

Although testing was higher among transgender and gender-diverse individuals, the higher overall frequency of HCV diagnoses among transgender and gender-diverse than among cisgender individuals signals persistent health disparities. Interventions are warranted to prevent HCV and increase ongoing testing and treatment uptake among transgender and gender-diverse populations.

Missed opportunities for prevention: prevalence and incidence of human immunodeficiency virus and hepatitis C virus diagnoses among a cohort of individuals discharged from an urban hospital with injection drug-related diagnoses, 2012-2019

PURPOSE

Risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections has increased due to the ongoing opioid epidemic and unsafe injection practices. We estimated the prevalence and incidence of HIV and HCV diagnoses among people who inject drugs from hospital-based clinical encounters.

METHODS

We linked clinical encounters at an Atlanta hospital during 2012-2018 with state HIV and HCV surveillance records to examine the prevalence of infections at discharge and incidence of infections post clinical encounter.

RESULTS

At discharge, 32.9% and 28.6% of patients with injection drug use-related clinical encounters had an HIV or HCV diagnosis, respectively. HIV and HCV diagnoses at the time of discharge were mostly among 40-64 years old patients, males, and Black/African Americans. Post clinical encounter, 3.8% of patients were later diagnosed with HIV, and 16.5% were later diagnosed with HCV, translating to incidence rates of 9.3 per 1000 person-years and 41.5 per 1000 person-years, respectively. The majority of HIV and HCV diagnoses post clinical encounter occurred among Black/African Americans and males. Of patients with HIV and HCV diagnoses post clinical encounter, 27.3% and 11.9% had been tested during their clinical encounter, respectively.

CONCLUSIONS

Targeted interventions for HIV/HCV prevention, screening, diagnosis, and linkage to treatment are needed to reduce the incidence of new infections among people who inject drugs.

The role of community pharmacies in the HIV and HCV care continuum

Introduction

In 2019, there were over 1.1 million people living with human immunodeficiency virus (HIV) and 2.4 million people living with hepatitis C virus (HCV) in the United States. One in seven (14%) are unaware of their HIV infection and almost half of all HCV infections are undiagnosed. People with unstable housing are disproportionately affected by HIV and HCV. The present study will evaluate interventions by community pharmacists that may reduce HIV and HCV transmission and promote linkage to care.

Methods

This study was conducted in an independent community pharmacy in Spokane, Washington. Eligible study participants were walk-in patients of the pharmacy, over the age of 18, and experiencing homelessness. Pharmacy patients were excluded if they had a history of HIV or HCV diagnosis, received a screening for HIV or HCV in the last six months or were unable to give informed consent. The intervention included administration of HIV and HCV point-of-care testing (POCT) using a blood sample, risk determination interview, comprehensive HIV and HCV education, and personalized post-test and risk mitigation counseling followed by referral to partnering health clinics.

Results

Fifty participants were included in the final data analysis. Twenty-two participants (44%) had a reactive HCV POCT, and one participant had a reactive HIV POCT. Of the 94% of participants who reported illicit drug use, 74% reported injection drug use. Seventy-six percent (n = 38) qualified for PrEP. Pharmacist referrals were made for 28 participants and 71% were confirmed to have established care.

Conclusion

Individuals experiencing homelessness are at an increased risk for acquiring HIV and HCV due to risky sexual behaviors and substance misuse. PrEP is underutilized in the U.S. and pharmacist involvement in the HIV and HCV care continuum may have a significant impact in improving linkage and retention in care of difficult to treat populations.

Economic Impact of Universal Hepatitis C Virus Testing for Middle-Aged Adults Who Inject Drugs

INTRODUCTION

The objective of this study was to estimate the economic impact of providing universal hepatitis C virus testing in commercially insured middle-aged persons who inject drugs in the U.S.

METHODS

This study developed a dynamic 10-year economic model to project the clinical and economic outcomes associated with hepatitis C virus testing among middle-aged adult persons who inject drugs, from a payer's perspective. Costs related to hepatitis C virus testing, direct-acting antiviral, and liver-related outcomes between the (1) current hepatitis C virus testing rate (i.e., 8%) and (2) universal hepatitis C virus testing rate (i.e., 100%) were compared. Among patients testing positive, 21% of those without cirrhosis and 48% of those with cirrhosis were assumed to initiate direct-acting antivirals. Sensitivity analyses were performed to identify variables (e.g., direct-acting antiviral drug costs, hepatitis C virus testing costs, direct-acting antiviral treatment rate) influencing this study's conclusion.

RESULTS

The model predicts that during the 10-year period, universal hepatitis C virus testing will cost an additional $242 per person who injects drugs to the payers' healthcare budgets compared with the current scenario. Sensitivity analyses showed values ranging from $1,656 additional costs to $1,085 cost savings across all varied parameters and scenarios. A total of 80% of the current direct-acting antiviral costs indicated that cost savings will be $383 per person who injects drugs.

CONCLUSIONS

Universal hepatitis C virus testing among persons who inject drugs would not achieve cost savings within 10 years, with the cost of direct-acting antivirals contributing the most to the spending. To promote universal hepatitis C virus testing among persons who inject drugs, decreasing direct-acting antiviral costs and sustainable funding streams for hepatitis C virus testing should be considered.

Investigating the sociodemographic and behavioural factors associated with hepatitis C virus testing amongst people who inject drugs in England, Wales and Northern Ireland: A quantitative cross-sectional analysis

BACKGROUND

Hepatitis C virus (HCV) transmission in the UK is driven by injecting drug use. We explore HCV testing uptake amongst people who inject drugs (PWID) in England, Wales and Northern Ireland, and identify factors associated with i) ever having an HCV test amongst people who have ever injected drugs, and ii) recently having an HCV test (within the current or previous year) amongst people who currently inject drugs (reported injecting drugs within the last year).

METHODS

We analysed data from the 2019 'Unlinked Anonymous Monitoring Survey' of PWID, using logistic regression.

RESULTS

Of 3,127 PWID, 2,065 reported injecting drugs within the last year. Most (86.7%) PWID had a lifetime history of HCV testing. In multivariable analysis, higher odds of ever testing were associated with: female sex (aOR=1.54; 95%CI 1.11-2.14), injecting duration ≥3 years (aOR=2.94; 95%CI 2.13-4.05), ever receiving used needles/syringes (aOR=1.74; 95%CI 1.29-2.36), ever being on opioid agonist treatment (aOR=2.91; 95%CI 2.01-4.21), ever being imprisoned (aOR=1.86; 95%CI 1.40-2.48) and ever being homeless (aOR=1.54; 95%CI 1.14-2.07). Amongst PWID who had injected drugs within the last year, 49.9% had recently undertaken an HCV test. After adjustment, factors associated with higher odds of undertaking a recent HCV test included: injecting crack in the last year (aOR=1.29; 95%CI 1.03-1.61), experiencing a non-fatal overdose in the last year (aOR=1.39; 95%CI 1.05-1.85), ever being on opioid agonist treatment (aOR=1.48; 95%CI 0.97-2.25), receiving HCV information in the last year (aOR=1.99; 95%CI 1.49-2.65) and using a healthcare service in the last year (aOR=1.80; 95%CI 1.21-2.67).

CONCLUSION

Results suggest that PWID who have experienced homelessness and incarceration - amongst the most vulnerable and marginalised in the PWID population - are engaging with HCV testing, but overall there remain missed testing opportunities. Recent initiates to injecting have highest HCV infection risk but lower odds of testing, and peer-education may help target this group.

Behavioral Risk Factors for HIV Infection in Hospitalized Persons Who Co-use Stimulants and Opioids

We investigated the association of 90-day opioid and stimulant co-use and HIV risk behaviors in a cross-sectional analysis of hospitalized HIV-negative people who inject drugs (PWID). We compared those injecting opioids alone to two sub-groups who co-used opioids with (1) cocaine, (2) amphetamine-type stimulants (ATS), on sex and injection drug risk behaviors assessed via the Risk Assessment Battery (RAB), where a higher score indicates a higher risk. Of 197 participants who injected opioids, 53% co-used cocaine only, 5% co-used ATS only, 18% co-used both cocaine and ATS, 24% co-used neither stimulant. PWID who injected opioids alone had a mean RAB drug risk score of 5.98 points and sex risk score of 2.16 points. Compared to PWID who injected opioids alone, PWID who co-used stimulants had higher mean drug risk RAB scores: cocaine, b = 2.84 points [95% confidence interval (CI) 1.01; 4.67]; ATS, b = 3.43 points (95% CI 1.29; 5.57). Compared to PWID who injected opioids alone, cocaine co-use was associated with higher sex RAB scores b = 1.06 points (95% CI 0.32; 1.79). Overall, we found a significant association between stimulant co-use and higher HIV sex and drug risk scores.

The association of Medicare Part D prior authorization for buprenorphine-naloxone with adherence to opioid use disorder treatment guidelines in the United States

AIMS

To assess differences in the quality of opioid use disorder (OUD) treatment received by Medicare beneficiaries enrolled in health plans that used prior authorization (PA) for buprenorphine-naloxone compared with those enrolled in plans that did not use PA.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional observational study, United States. Continuously enrolled beneficiaries (71 294) with an OUD who filled at least one prescription for buprenorphine-naloxone between March 2012 and July 2017.

MEASUREMENTS

Percentage of patients tested for hepatis B, hepatis C, HIV and liver functioning; percentage of patients with urine drug screens and number of urine drug screens; continuous use of buprenorphine-naloxone for at least 180 days; co-use of benzodiazepines; number of outpatient visits with and without an OUD diagnosis.

FINDINGS

PA was significantly associated with a lower likelihood of testing for hepatitis B [-3.5, 95% confidence interval (CI) = -4.4, -2.7] and C (-5.9, 95% CI = -6.9, -4.9), but the findings were inconclusive as to whether or not there was a difference in HIV (-1.1, 95% CI = -2.5, 0.4) or liver function testing (1.3, 95% CI = -0.1, 2.7). PA was associated with a lower likelihood of urine drug screening (-25.5, 95% CI = -26.8, -24.1) and with fewer drug screens (-2.5, 95% CI = -3.0, -2.1). Findings were inconclusive as to whether or not there was a difference in continuous use of buprenorphine-naloxone (0.3, 95% CI = -1.2, 1.8). PA was associated with fewer outpatient visits (-2.1, 95% CI = -3.0, -1.2) and fewer outpatient visits with an OUD diagnosis (-1.7, 95% CI = -2.1, -1.3). PA was associated with a lower likelihood of filling benzodiazepine prescriptions before and after buprenorphine-naloxone induction (-28.9, 95% CI = -29.6, -28.3) but a greater likelihood of only using benzodiazepines after buprenorphine-naloxone induction (10.6, 95% CI = 9.3, 11.8).

CONCLUSIONS

US Medicare patients subject to prior authorization for buprenorphine-naloxone are not more likely to receive high-quality treatment for opioid use disorder than patients not subject to prior authorization.

Cascade of Hepatitis C Virus Care Among Patients With Substance Use Disorders

INTRODUCTION

Hepatitis C virus testing is recommended for people at high risk for infection, including those with substance use disorders. Little is known about the cascade of hepatitis C virus care (including testing, diagnosis, and treatments) among patients with substance use disorders in real-world clinical practice. This study aims to characterize the hepatitis C virus cascade of care and identify the factors associated with hepatitis C virus testing and diagnosis among Florida Medicaid beneficiaries with substance use disorders.

METHODS

A retrospective cohort analysis of Florida Medicaid data (2013-2018) was conducted in 2020 for patients aged 18-64 years with newly diagnosed substance use disorders (year 2012 was used to ascertain 1-year previous enrollment). A generalized estimating equation identified the factors associated with hepatitis C virus testing; a multivariable logistic model identified the factors associated with hepatitis C virus diagnosis.

RESULTS

Of the 156,770 patients with substance use disorders, 18% were tested for hepatitis C virus at least once. Among the tested patients, 8% had hepatitis C virus diagnoses. Among the 2,177 patients having a hepatitis C virus diagnosis, 11% initiated hepatitis C virus treatments, and 96% of them completed the hepatitis C virus treatments. Factors associated with being less likely to receive hepatitis C virus testing included being male (AOR=0.73, 95% CI=0.71, 0.75) and White (AOR=0.85, 95% CI=0.83, 0.87), whereas individuals who were male (AOR=1.49, 95% CI=1.35, 1.66) and White (AOR=2.71, 95% CI=2.38, 3.08) were more likely to be diagnosed with hepatitis C virus. The odds of receiving hepatitis C virus testing significantly increased annually (AOR=1.06, 95% CI=1.05, 1.07).

CONCLUSIONS

Future studies are warranted to investigate the barriers to access hepatitis C virus testing and treatment among Florida Medicaid beneficiaries with substance use disorders, especially for White male individuals.

Screening at a Federally Qualified Health Center in the Midwest for Hepatitis C Among People Who Inject Drugs, 2019-2020

Introduction

Hepatitis C virus (HCV) infection is a public health epidemic. People who inject drugs (PWID) are at high risk for transmitting and contracting HCV. The objective of this study was to assess the effectiveness of a multifaceted intervention at a federally qualified health center in the US Midwest to improve HCV screening rates among PWID.

Methods

A prospective quality improvement initiative was conducted to increase the proportion of PWID screened for HCV. Inclusion criteria consisted of being seen by a primary care provider from April 16, 2019, through February 28, 2020, being aged 18 years or older, and confirmation of intravenous drug use. PWID status was confirmed by reviewing electronic health records. The multifaceted intervention consisted of educational sessions for the health care team and workflow changes. We analyzed the proportion of patients screened preintervention and postintervention by using χ² tests.

Results

Of 742 patients who met the inclusion criteria, the proportion of PWID screened preintervention was 59.6% (n = 329) and the proportion of PWID screened postintervention was 65.1% (n = 283), increasing the screening rate by 5.5 percentage points. A χ² test of homogeneity indicated a significant relationship between the preintervention and postintervention periods, and screening outcomes (P < .001).

Conclusion

This multifaceted intervention to increase HCV screening resulted in a modest increase in the proportion of PWID screened. Consistent and health care system–wide screening approaches are needed to optimize the potential of HCV treatment and cure options now available.

Key Elements on the Pathway to HCV Elimination: Lessons Learned From the AASLD HCV Special Interest Group 2020

With a decade left to reach the ambitious goals for viral hepatitis elimination set out by the World Health Organization, many challenges remain. Despite the remarkable improvements in therapy for hepatitis C virus (HCV) infection, most people living with the infection remain undiagnosed, and only a fraction have received curative therapy. Accordingly, the 2020 HCV Special Interest Group symposium at the annual American Association for the Study of Liver Diseases Liver Meeting examined policies and strategies for the scale-up of HCV testing and expanded access to HCV care and treatment outside the specialty setting, including primary care and drug treatment and settings for care of persons who inject drugs and other marginalized populations at risk for HCV infection. The importance of these paradigms in elimination efforts, including micro-elimination strategies, was explored, and the session also included discussion of hepatitis C vaccine development and other strategies to reduce mortality through the use of organs from HCV-infected organ donors for HCV-negative recipients. In this review, the key concepts raised at this important symposium are summarized.

Progress toward closing gaps in the hepatitis C virus cascade of care for people who inject drugs in San Francisco

Background

People who inject drugs (PWID) are disproportionately affected by hepatitis C virus (HCV). Data tracking the engagement of PWID in the continuum of HCV care are needed to assess the reach, target the response, and gauge impact of HCV elimination efforts.

Methods

We analyzed data from the National HIV Behavioral Surveillance (NHBS) surveys of PWID recruited via respondent driven sampling (RDS) in San Francisco in 2018. We calculated the number and proportion who self-reported ever: (1) tested for HCV, (2) tested positive for HCV antibody, (3) diagnosed with HCV, (4) received HCV treatment, (5) and attained sustained viral response (SVR). To assess temporal changes, we compared 2018 estimates to those from the 2015 NHBS sample.

Results

Of 456 PWID interviewed in 2018, 88% had previously been tested for HCV, 63% tested antibody positive, and 50% were diagnosed with HCV infection. Of those diagnosed, 42% received treatment. Eighty-one percent of those who received treatment attained SVR. In 2015 a similar proportion of PWID were tested and received an HCV diagnosis, compared to 2018. However, HCV treatment was more prevalent in the 2018 sample (19% vs. 42%, P-value 0.01). Adjusted analysis of 2018 survey data showed having no health insurance (APR 1.6, P-value 0.01) and having no usual source of health care (APR 1.5, P-value 0.01) were significantly associated with untreated HCV prevalence.

Conclusion

While findings indicate an improvement in HCV treatment uptake among PWID in San Francisco, more than half of PWID diagnosed with HCV infection had not received HCV treatment in 2018. Policies and interventions to increase coverage are necessary, particularly among PWID who are uninsured and outside of regular care.

The Changing Epidemiology of Hepatitis C Virus Infection in the United States During the Years 2010 to 2018

Hepatitis C virus (HCV) infection remains an important cause of morbidity and mortality throughout the world, leading to serious health problems among those who are chronically infected. Since 1992, the Centers for Disease Control and Prevention has been collecting data on the incidence of HCV infection in the United States. In 2018, more than 50 000 individuals were estimated to have acute HCV infection.The most recently reported data on the prevalence of infection indicate that approximately 2.4 million people are living with hepatitis C in the United States. Transmission of HCV occurs predominantly through sharing contaminated equipment for injecting drugs.Two major events have had a significant impact on the incidence and prevalence of hepatitis C in the past few decades: the US opioid crisis and the discovery of curative treatments for HCV infection. To better understand the impact of these events, we examine reported trends in the incidence and prevalence of infection.

Acceptability and Effectiveness of Hepatitis C Care at Syringe Service Programs for People Who Inject Drugs in New York City

Introduction/Objectives: The incidence of hepatitis C (HCV) infection is rising among people who inject drugs (PWID). Even in the context of known HCV prevention and treatment strategies, some PWID remain unengaged in HCV care. This study aimed to identify and characterize experiences and perceptions of PWID regarding the acceptability and effectiveness of HCV testing and treatment at a local syringe service program (SSP). Methods: A total of 36 PWID participated in semi-structured interviews at an SSP in New York City. Interviews were audio-recorded, transcribed, and coded by three coders, following a constructivist grounded theory approach. Relevant themes were identified as they emerged from the data. Results: Interviews with PWID revealed three themes related to the impact of SSPs on HCV care: (1) non-stigmatizing SSP environments, (2) the role of SSPs in improving HCV knowledge, and (3) acceptability of SSPs as sites for HCV care among PWID. Discussion: This paper contributes to the ongoing understanding that SSPs provide a well-accepted source of HCV services for PWID. Participants believed that SSPs are accessible and effective sites for HCV care, and suggested that stigma among PWID continues to affect receipt of HCV care in traditional settings. Conclusions: Understanding attitudes and beliefs of PWID regarding the effectiveness of SSPs as sites for HCV care is crucial for the development of focused strategies to reduce HCV transmission, and to ultimately achieve HCV elimination. Given this, further research is warranted investigating how best to improve HCV care at harm reduction sites such as SSPs.

Utilizing public health data to geotarget hepatitis C virus elimination approaches in urban and rural Michigan

Using Michigan public health data, we assessed geographical access to specialist providers for hepatitis C virus (HCV) treatment in urban and rural areas in Michigan and explored correlates of HCV in these areas to help inform HCV elimination planning and resource allocations. We found higher HCV incidence in urban areas, lower treatment specialist access in rural areas, but few correlates of HCV across adult populations in both areas. State and local HCV elimination planning should include population-based screening among all adults and address geographical barriers to care.

Evaluation of Infectious Disease Test Ordering and Positivity Rates in Illicit Fentanyl Users

BACKGROUND

The emergence of illicit fentanyl use has resulted in considerable morbidity and mortality. Although illicit use of other opioids has been associated with transmission of viral and bacterial infections, limited data exist for the prevalence of infectious diseases among illicit fentanyl users. The purpose of this study was to assess the likelihood of infectious disease testing and infection prevalence among illicit fentanyl users.

METHODS

Results from urine drug screens (UDSs) performed from August 13, 2019, to October 16, 2019, were obtained from the laboratory information system with concurrent microbial testing. Patients were categorized based on UDS results, and illicit drug use was inferred from physician encounter notes in the electronic medical record.

RESULTS

Suspected illicit drugs users with fentanyl detected by UDS were more likely to be screened [odds ratio (OR): 1.7; 95% CI, 1.26-2.4] and test positive for hepatitis C virus (HCV) by immunoassay (OR: 5.89; 95% CI, 2.93-11.31) than patients without drugs detected. Patients with suspected illicit fentanyl use who were discharged from the emergency department (ED) were less likely to be tested for HCV than patients in outpatient settings (OR: 3.47; 95% CI, 1.05-10.4) and inpatient settings (OR: 17.43; 95% CI, 6.53-45.88). Patients with suspected illicit fentanyl use were more likely to have infected abscesses or wounds (OR: 5.12; 95% CI, 2.07-13.7) and Staphylococcus aureus infections (OR: 4.5; 95% CI, 1.59-12.28) than patients without drugs detected.

CONCLUSIONS

Patients with a positive UDS for fentanyl and suspected illicit use were more likely to test positive for HCV, were rarely screened for HCV in the ED, and had an increased risk of invasive S. aureus wound or abscess infection. These findings may represent considerable barriers to care for patients who use fentanyl illicitly.

Opioid Use Disorder and Associated Infectious Disease: The Role of the Laboratory in Addressing Health Disparities

BACKGROUND

Opioid use disorder, defined as a pattern of problematic opioid use leading to clinically significant impairment, has resulted in considerable morbidity and mortality throughout the world. This is due, at least in part, to the marginalized status of patients with opioid use disorder, limiting their access to appropriate laboratory testing, diagnosis, and treatment. Infections have long been associated with illicit drug use and contribute considerably to morbidity and mortality. However, barriers to testing and negative stigmas associated with opioid use disorder present unique challenges to infectious disease testing in this patient population.

CONTENT

This review addresses the associations between opioid use disorder and infectious organisms, highlighting the health disparities encountered by patients with opioid use disorder, and the important role of laboratory testing for diagnosing and managing these patients.

SUMMARY

Infections are among the most frequent and adverse complications among patients with opioid use disorder. As a result of health disparities and systemic biases, patients that misuse opioids are less likely to receive laboratory testing and treatment. However, laboratories play a crucial in identifying patients that use drugs illicitly and infections associated with illicit drug use.