Age-Related Differences in Past or Present Hepatitis C Virus Infection Among People Who Inject Drugs: National Human Immunodeficiency Virus Behavioral Surveillance, 8 US Cities, 2015

Modeling the impact of the COVID-19 pandemic on achieving HCV elimination amongst young and unstably housed people who inject drugs in San Francisco

BACKGROUND

Young adult (18-30 years) people who inject drugs (PWID) face high hepatitis C virus (HCV) prevalence. In San Francisco, where >60% of PWID lack stable housing, barriers hinder HCV treatment access. We assessed progress towards the World Health Organization's (WHO) HCV elimination goal of an 80% reduction in incidence over 2015-2030, focusing on young (YPWID) and unstably housed PWID in San Francisco.

METHODS

We developed a dynamic HCV transmission model among PWID, parameterized and calibrated using bio-behavioural survey datasets from San Francisco. This included 2018 estimates for the antibody-prevalence among PWID (77%) and care cascade estimates for HCV for YPWID (72% aware of their status and 33% ever initiating treatment). Based on programmatic data, we assumed a 53.8% reduction in testing and 40.7% decrease in treatment from 2020 due to the COVID-19 pandemic, which partially rebounded from April 2021 with testing rates then being 31.1% lower than pre-pandemic rates and treatment numbers being 19.5% lower. We simulated different scenarios of how services changed after the pandemic to project whether elimination goals would be met.

RESULTS

Continuing post-pandemic rates of testing and treatment, the model projects an 83.3% (95% credibility interval [95% CrI]:60.6-96.9%) decrease in incidence among PWID over 2015-2030 to 1.5/100pyrs (95% CrI:0.3-4.4) in 2030. The probability of achieving the elimination goal by 2030 is 62.0%. Among YPWID and unstably housed PWID, the probability of achieving the elimination goal by 2030 is 54.8 and 67.6%, respectively. Importantly, further increasing testing and treatment rates to pre-pandemic levels by 2025 only results in a small increase in the probability (67.5%) of the elimination goal being achieved among all PWID by 2030, while increased coverage of medication for opioid use disorder among YPWID and/or housing interventions results in the probability of achieving elimination increasing to over 75%.

CONCLUSION

The COVID-19 pandemic impeded progress toward achieving HCV elimination. Our findings indicate that existing partial rebounds in HCV testing and treatment may achieve the elimination goal by 2030, with an additional scale-up of interventions aimed at YPWID or unstably housed PWID ensuring San Francisco is likely to achieve elimination by 2030.

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.

HCV prevalence and phylogenetic characteristics in a cross-sectional, community study of young people who inject drugs in New York City: Opportunity for and threats to HCV elimination

Background and Aims

In the United States, the opioid epidemic has led many young people who use opioids to initiate injection drug use, putting them at risk for hepatitis C virus (HCV) infection. However, community surveys to monitor HCV prevalence among young people who inject drugs (YPWID) are rare.

Methods

As part of Staying Safe (Ssafe), a trial to evaluate an HCV-prevention intervention, a community-recruited sample of 439 young people who use opioids (ages 18-30) in New York City (NYC) were screened from 2018 to 2021. Screening procedures included a brief verbal questionnaire, a visual check for injection marks, onsite urine drug testing, rapid HCV antibody (Ab) testing, and dried blood spot (DBS) collection. DBS specimens were sent to a laboratory for HCV RNA testing and phylogenetic analysis to identify genetic linkages among HCV RNA-positive specimens. Multivariable logistic regression was used to assess associations between HCV status (Ab and RNA) and demographics and drug use patterns.

Results

Among the 330 participants who reported injecting drugs (past 6 months), 33% (n = 110) tested HCV Ab-positive, 58% of whom (n = 64) had HCV RNA-positive DBS specimens, indicating active infection. In multivariable analysis, visible injection marks (AOR = 3.02; p < 0.001), older age (AOR = 1.38; p < 0.05), and female gender (AOR = 1.69; p = 0.052) were associated with HCV Ab-positive status. Visible injection marks were also associated with HCV RNA-positive status (AOR = 5.24; p < 0.01). Twenty-five percent of RNA-positive specimens (14/57) were genetically linked.

Conclusion

The relatively low prevalence of active infection suggests the potential impact of treatment-as-prevention in reducing HCV prevalence among YPWID. Targeted community serosurveys could help identify actively infected YPWID for treatment, thereby reducing HCV incidence and future transmissions.

Hepatitis C virus infection and co-infection with HIV among persons who inject drugs in 10 U.S. cities-National HIV Behavioral Surveillance, 2018

BACKGROUND

Characterizing acute and chronic hepatitis C virus (HCV) infection and HIV/HCV co-infection among persons who inject drugs (PWID) can inform elimination efforts.

METHODS

During 2018 National HIV Behavioral Surveillance in 10 U.S. metropolitan statistical areas (MSAs), PWID were recruited using respondent-driven sampling and offered a survey, HIV testing, and HCV antibody and RNA testing. We examined prevalence and associated characteristics of HCV infection and HIV/HCV co-infection. Associations were assessed using log-linked Poisson regression models with robust standard errors accounting for clustering by recruitment chain and adjusting for MSA and network size.

RESULTS

Overall, 44.2% had current HCV infection (RNA detected), with 3.9% classified as acute infection (HCV antibody non-reactive/RNA detected) and 40.3% as chronic (HCV antibody reactive/RNA detected). Four percent had HIV/HCV co-infection. Current HCV infection was significantly higher among PWID who were male, White, injected >1 time/day, shared syringes in past year, and shared injection equipment in past year. PWID who were transgender, injecting >5 years, and most often injected speedball (heroin and cocaine together) or stimulants alone were more likely to have HIV/HCV co-infection. Among PWID who never previously had HCV infection, 9.9% had acute HCV infection. Among PWID who started injecting ≤5 years ago, 41.5% had already acquired HCV infection.

CONCLUSIONS

Acute and chronic HCV infections were substantial among a sample of PWID in 10 U.S. MSAs. Accessibility to HCV RNA testing, promoting safer practices, and intervening early with harm reduction programs for recent injection initiates will be critical to disease elimination efforts for PWID.

Seroprevalence and risk factors associated with hepatitis C: a cross-sectional study of persons who inject drugs in Puerto Rico, 2018

BACKGROUND

People Who Inject Drugs (PWID) are at a higher risk of acquiring bloodborne infections. We aimed to estimate the seroprevalence of the Hepatitis C Virus (HCV) in PWID and identify correlates and risk factors using data from the Puerto Rico National HIV Behavioral Surveillance System, PWID cycle 5, conducted in 2018.

METHODS

A total of 502 San Juan Metropolitan Statistical Area participants were recruited through the Respondent Driven Sampling method. Sociodemographic, health-related, and behavioral characteristics were assessed. Testing for HCV antibodies was completed after the face-to-face survey. Descriptive and logistic regression analyses were performed.

RESULTS

Overall seroprevalence of HCV was 76.5% (95% CI: 70.8-81.4%). A significantly (p < 0.05) higher HCV seroprevalence was observed among PWID with the following characteristics: heterosexuals (78.5%), high school graduates (81.3%), tested for sexually transmitted infections (STI) in the past 12 months (86.1%), frequent speedball injection (79.4%), and knowing the HCV serostatus of the last sharing partner (95.4%). Adjusted logistic regression models showed that having completed high school and reported STI testing in the past 12 months were significantly associated with HCV infection (OR_a = 2.23; 95% CI: 1.06-4.69; OR_a = 2.14; 95% CI: 1.06-4.30, respectively).

CONCLUSIONS

We report a high seroprevalence of HCV infection in PWID. Social health disparities and potential missed opportunities validate the continuing call for local action for public health and prevention strategies.

Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics

Importance

US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown.

Objective

To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids.

Design, Setting, and Participants

In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort.

Main Outcomes and Measures

Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs).

Results

The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000.

Conclusions and Relevance

This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.

Hepatitis C antibody prevalence and behavioral correlates in people who inject drugs attending harm reduction services in Lisbon, Portugal

The hepatitis C virus (HCV) infection is an important public health problem, affecting millions of people worldwide. People who inject drugs (PWID) are at increased risk of HCV infection due to, among other factors, widespread unsafe injecting practices, such as sharing of infected equipment or unprotected sexual practices. In Portugal, there is a lack of data regarding the proportion of infected persons through injecting drug use. This study aimed to evaluate the anti-HCV prevalence and behavioral correlates of infection in PWID attending harm reduction services in the Metropolitan Area of Lisbon, Portugal. A cross-sectional study with a purposive sample of PWID was undertaken between March 2018 and March 2020. Participants were recruited through the harm-reduction services of a nongovernmental organization. A rapid diagnostic test for anti-HCV screening was performed. Data on drug consumption history and current practices, past HCV testing, care and treatment history, and knowledge regarding hepatitis C were also collected through a questionnaire applied by trained inquirers. A total of 176 PWID participated in this study. An overall prevalence of 70.5% of anti-HCV positive in this population was found. Those with an anti-HCV positive testing result tended to start consuming at a younger age and have a higher consumption of benzodiazepines in the last 30 days. Sharing needles and other injecting material is a frequent risk behavior among this group. Also, they are more likely to have attended an opioid agonist treatment and to have undertaken previous hepatitis C and HIV tests in the past. This study represents an important effort to better understand the HCV prevalence and behavioral correlates of infection among PWID in Portugal, as well as to better estimate those in need of HCV treatment.

Hepatitis C antibody prevalence, correlates and barriers to care among people who inject drugs in Central California

Hepatitis C (HCV) infection among people who inject drugs (PWID) is a major public health concern. We examined correlates of HCV antibody (anti-HCV) seropositivity and characteristics of prior HCV testing and treatment among PWID in Fresno, California, which has among the highest prevalence of injection drug use (IDU) in the United States. We surveyed 494 peer-recruited PWID (≥18 years of age) in 2016 about their experiences with HCV testing and treatment, and conducted HCV and HIV antibody testing for all participants. Bivariate analyses and multivariable logistic regressions were used to identify correlates of anti-HCV seropositivity. A majority (65%) tested positive for anti-HCV, with 32% of those being unaware of their HCV status. Anti-HCV seroprevalence was independently and positively associated with older age (AOR = 1.11 per year, 95% CI = 1.06, 1.17), years injecting (AOR = 1.08 per year, 95% CI = 1.03, 1.13), distributive syringe sharing (AOR = 2.76, 95% CI = 1.29, 5.94), having syringes confiscated by police (AOR = 2.65, 95% CI = 1.22, 5.74), ever trading sex (AOR = 3.51, 95% CI = 1.40, 8.81) and negatively associated with being Black/African American (non-Hispanic) (AOR = 0.06, 95% CI = 0.01, 0.47). Prior HCV testing was associated with older age, ever getting syringes from a syringe services program, and having interactions with police. For those aware of their anti-HCV seropositivity, only 11% had initiated treatment; reasons for not seeing a physician regarding diagnosis included not feeling sick (23%), currently using drugs/alcohol (19%) and not knowing where to go for HCV medical care (19%). Our findings highlight the importance of expanding community-based access to sterile syringes alongside HCV testing and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking testing and treatment.

Healthcare coverage and service access for low-income adults with substance use disorders

INTRODUCTION

Although health coverage facilitates service access to adults in the general population, uncertainty exists over the extent to which this relationship extends to low-income adults with substance use disorders.

METHODS

The health status and service use patterns of low-income adults with substance use disorders who had continuous, discontinuous, and no past year health coverage were compared using data from the 2015-2019 National Survey on Drug Use and Health (NSDUH). The NSDUH is a nationally representative survey of the civilian non-institutionalized population.

RESULTS

In the weighted sample (unweighted n = 9243), approximately 65.66% of low-income adults with substance use disorders had continuous coverage, 17.03% had discontinuous coverage, and 17.31% had no insurance coverage during the past year. Although few group differences were observed in self-reported health status, the uninsured group compared to the discontinously and continuously covered groups, respectively, was less likely to report a past year substance use treatment visit (11.03% vs. 14.83% vs. 15.61%), an outpatient care visit (53.39% vs. 71.27% vs. 79.04%), an emergency department visit (33.33% vs. 45.76% vs. 45.57%), or an inpatient admission (9.24% vs. 15.11% vs. 15.58%).

CONCLUSIONS

Although the cross sectional design limits causal inferences, the correlations between lacking health insurance and low rates of substance use treatment and healthcare use raise the possibility that increasing healthcare coverage might increase access to substance use treatment and other needed healthcare services for low-income adults with substance use disorders.

Hepatitis C mortality trends in San Francisco: can we reach elimination targets?

PURPOSE

Hepatitis C virus (HCV) is the most common blood-borne infection in the United States, and a leading cause of liver disease, transplant, and mortality. CDC HCV elimination goals include reducing HCV-related mortality by 65% (from 2015) by 2030.

METHODS

We used vital registry data (CDC WONDER) to estimate overall and demographic-specific HCV-related mortality from 1999 to 2019 in San Francisco and then used an exponential model to project progress toward HCV elimination. Local trends were compared to state and national trends.

RESULTS

Between 1999 and 2019, there were 1819 HCV-related deaths in San Francisco, representing an overall age-adjusted mortality rate of 9.4 (95% CI 9.0, 9.9) per 100,000 population. The age-adjusted HCV-related mortality rates were significantly higher among males (13.7), persons aged 55 years and older (28.0), Black and/or African Americans (32.2) compared to other racial groups, and Hispanic/Latinos (11.6) compared to non-Hispanic and/or Latinos. Overall and in most subgroups, mortality rates were lowest between 2015 and 2019. Since 2015, San Francisco observed a significantly larger reduction in agbe-adjusted HCV-related mortality than California or the U.S. Projected age-adjusted HCV-related mortality rates for San Francisco for 2020 and 2030 were 4.7 (95% CI 3.5, 6.2) and 1.1 (95% CI 0.7, 1.8), respectively.

CONCLUSIONS

Based on trends between 2015 and 2019, San Francisco, California, and the U.S. are projected to achieve 65% reduction in HCV-mortality at or before 2030. Based on current trends, San Francisco is projected to achieve this goal earlier.

Long-term Infective Endocarditis Mortality Associated With Injection Opioid Use in the United States: A Modeling Study

BACKGROUND

The expansion of the US opioid epidemic has led to significant increases in infections, such as infective endocarditis (IE), which is tied to injection behaviors. We aimed to estimate the population-level IE mortality rate among people who inject opioids and compare the risk of IE death against the risks of death from other causes.

METHODS

We developed a microsimulation model of the natural history of injection opioid use. We defined injection behavior profiles by both injection frequency and injection techniques. We accounted for competing risks of death and populated the model with primary and published data. We modeled cohorts of 1 million individuals with different injection behavior profiles until age 60 years. We combined model-generated estimates with published data to project the total expected number of IE deaths in the United States by 2030.

RESULTS

The probabilities of death from IE by age 60 years for 20-, 30-, and 40-year-old men with high-frequency use with higher infection risk techniques compared to lower risk techniques for IE were 53.8% versus 3.7%, 51.4% versus 3.1%, and 44.5% versus 2.2%, respectively. The predicted population-level attributable fraction of 10-year mortality from IE among all risk groups was 20%. We estimated that approximately 257 800 people are expected to die from IE by 2030.

CONCLUSIONS

The expected burden of IE among people who inject opioids in the United States is large. Adopting a harm reduction approach, including through expansion of syringe service programs, to address injection behaviors could have a major impact on decreasing the mortality rate associated with the opioid epidemic.

HIV Infection and Depression Among Opiate Users in a US Epicenter of the Opioid Epidemic

Using a mobile research facility, we enrolled 141 opioid users from a neighborhood of Philadelphia, an urban epicenter of the opioid epidemic. Nearly all (95.6%) met DSM-5 criteria for severe opioid use disorder. The prevalence of HIV infection (8.5%) was more than seven times that found in the general population of the city. Eight of the HIV-positive participants (67.0%) reported receiving antiretroviral treatment but almost all of them had unsuppressed virus (87.5%). The majority of participants (57.4%) reported symptoms consistent with major depressive disorder. Severe economic distress (60.3%) and homelessness were common (57%). Polysubstance use was nearly universal, 72.1% had experienced multiple overdoses and prior medication for opioid use disorder (MOUD) treatment episodes (79.9%), but few currently engaged in addiction care. The prevalence, multiplicity and severity of chronic health and socioeconomic problems highlight consequences of the current opioid epidemic and underscore the urgent need to develop integrated models of treatment.

The Geography of Opioid Use Disorder: A Data Triangulation Approach

Opioid use disorder is complex and not easily quantified among US populations because there are no dedicated reporting systems in place. We review indicators of opioid use disorder available at the state and county (human immunodeficiency virus diagnoses among people who inject drugs, hepatitis C diagnosis in people <50 years, opioid overdose death rates, and opioid prescription rate). The interpretation of the ecological results and the visualization of indicators at the local level will provide actionable insights for clinicians and public health officials seeking to mitigate the consequences of opioid use disorder at the patient and community levels.

Soft Tissue, Bone, and Joint Infections in People Who Inject Drugs

Infections are a common complication among people who inject drugs (PWID). Skin and soft tissue infections (SSTI) as well as bone and joint infections comprise a significant source of morbidity and mortality among this population. The appropriate recognition and management of these infections are critical for providers, as is familiarity with harm-reduction strategies. This review provides an overview of the presentation and management of SSTI and bone and joint infections among PWID, as well as key prevention measures that providers can take.

Hepatitis C testing and treatment uptake among young people who use opioids in New York City: A cross-sectional study

Young people who use drugs have a rising hepatitis C (HCV) incidence in the United States, but they may face barriers to testing and treatment adoption due to stigma. We conducted a cross-sectional study of New York City residents aged 18-29 years who reported non-medical prescription opioid and/or heroin use in the past 30 days. Participants were recruited from the community between 2014-2016 via respondent-driven sampling. Participants completed an in-person structured survey that included questions about HCV testing and treatment and received HCV antibody testing. There were 539 respondents: 353 people who inject drugs (PWID) and 186 non-PWID. For PWID, median age was 25 years, 65% were male and 73% non-Hispanic White. For non-PWID, median age was 23 years, 73% were male and 39% non-Hispanic White. 20% of PWID and 54% of non-PWID had never been tested for HCV (P < .001). Years since first injection (aOR 1.16, CI: 1.02-1.32, P = .02) and history of substance use treatment (aOR 3.17, CI: 1.53-6.61, P = .02) were associated with prior testing among PWID. The seroprevalence of HCV among PWID was 25%, adjusted for sampling weights. Of the 75 who were aware of their HCV-positive status, 53% had received HCV-related medical care, and 28% had initiated treatment. HCV prevalence among young PWID is high, and many have never been tested. Injection experience and treatment engagement is associated with testing. Interventions to increase testing earlier in injection careers, and to improve linkage to HCV treatment, will be critical for young PWID.

Hepatocellular Carcinoma Surveillance in a Cohort of Chronic Hepatitis C Virus-Infected Patients with Cirrhosis

BACKGROUND

Six-monthly hepatocellular carcinoma (HCC) screening in cirrhotic patients has been recommended since 2011. HCC prognosis is associated with diagnosis at an early stage. We examined the prevalence and correlates of 6-monthly HCC surveillance in a cohort of HCV-infected cirrhotic patients.

METHODS

Data were obtained from the medical records of patients receiving care from four hospitals between January 2011 and December 2016. Frequencies and logistic regression were conducted.

RESULTS

Of 2,933 HCV-infected cirrhotic patients, most were ≥ 60 years old (68.5%), male (62.2%), White (65.8%), and had compensated cirrhosis (74.2%). The median follow-up period was 3.5 years. Among these patients, 10.9% were consistently screened 6 monthly and 21.4% were never screened. Patients with a longer history of cirrhosis (AOR = 0.86, 95% CI = 0.80-0.93) were less likely to be screened 6 monthly while decompensated cirrhotic patients (AOR = 1.39, 95% CI = 1.06-1.81) and cirrhotic patients between 18 and 44 years (AOR = 2.01, 95% CI = 1.07-3.74) were more likely to be screened 6 monthly compared to compensated cirrhotic patients and patients 60 years and older respectively. There were no significant differences by race, gender, or insurance type.

CONCLUSION

The prevalence of consistent HCC surveillance remains low despite formalized recommendations. One in five patients was never surveilled. Patients with a longer history of cirrhosis were less likely to be surveilled consistently despite their greater HCC risk. Improving providers' knowledge about current HCC surveillance guidelines, educating patients about the benefits of consistent HCC surveillance, and systemic interventions like clinical reminders and standing HCC surveillance protocols can improve guideline-concordant surveillance in clinical practice.

Are we on the precipice of a new epidemic? Risk for hepatitis C among HIV-negative men-, trans women-, and trans men- who have sex with men in the United States

Emerging data from Europe have documented increases in diagnoses of acute hepatitis C virus (HCV) infection among HIV-negative men who have sex with men. We investigated risk factors for HCV and their correlates in the Together 5000 study, a U.S. national cohort study of HIV-negative men (n = 6089), transgender women (n = 40), and transgender men (n = 42) who have sex with men. We used bivariate and multivariable analyses to determine demographic and behavioral factors associated with high risk for acute HCV infection (using the HCV-MOSAIC risk indicator with a score ≥ 2.0). Mean HCV risk score was 1.38 (SD = 1.09) and 27.3% of participants had HCV risk scores ≥ 2.0. In multivariable modeling, being cisgender male (vs. not) was associated with having a lower HCV-MOSAIC risk score. Meanwhile, being white, having been incarcerated, prior use of HIV pre- or post-exposure prophylaxis, having ever been tested for HIV, and recent methamphetamine use were associated with high risk for HCV. More than one-in-four participants exceeded the threshold score for HCV risk. Those with high HCV-MOSAIC risk scores were more likely to have been in settings where they could be tested for acute HCV (i.e., HIV testing, PrEP care, PEP care, incarceration), suggesting opportunities to engage them in HCV screening, prevention, and treatment.

Identification and Management of Opioid Use Disorder in Primary Care: an Update

PURPOSE OF REVIEW

The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs.

RECENT FINDINGS

The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.

HCV incidence is associated with injecting partner age and HCV serostatus mixing in young adults who inject drugs in San Francisco

BACKGROUND

HCV incidence is increasing in the US, notably among younger people who inject drugs (PWID). In a cohort of young adult (age<30 years) PWID in San Francisco we examined whether 'injecting partner mixing' factors, i.e. age of partner and knowledge of their HCV serostatus, were associated with HCV transmission.

METHODS

In 448 susceptible PWID studied prospectively. All participants were asked to report characteristics and behaviors they engaged in with up to 3 injecting partners defined as "people whom you injected the most with" in the past month". These partnerships did not specify that drugs or injecting equipment was shared. HCV incidence was estimated by age of up to 3 injecting partners, categorized as: (i) all <30; (ii) mixed-age (<&≥30); and (iii) all ≥30 years and perceived knowledge of the HCV status of participants' injecting partners' HCV status. Interaction was evaluated between partnership age categories and perceived HCV status of partners.

RESULTS

Between 2006-2018, overall HCV incidence (/100 person years observation [pyo]) was 19.4 (95% CI: 16.4, 22.9). Incidence was highest in those with mixed-age partnerships: 28.5 (95% CI: 21.8, 37.1) and those whose partners were all <30 (23.9; 95% CI: 18.8, 30.4), and lowest if partners were ≥30 (7.5; 95% CI: 4.8, 11.8). In a multivariable analyses adjusting for age, sex (of index), injection frequency, and injection partnership 'monogamy', we found evidence for an interaction: the highest HCV incidence was seen in PWID whose partners were all <30 and who knew at least one of their partners was HCV-positive (58.9, 95% CI: 43.3, 80.0; p<0.01).

CONCLUSIONS

Younger injectors are more likely to acquire HCV from their similarly-aged peers, than older injecting partners. Protective seroadaptive behavior may contribute to reduce incidence. These findings can inform new HCV prevention approaches for young PWID needed to curb the HCV epidemic.