Brief intervention to increase emergency department uptake of combined rapid human immunodeficiency virus and hepatitis C screening among a drug misusing population

Interventions to enhance testing, linkage to care, and treatment initiation for hepatitis C virus infection: a systematic review and meta-analysis

BACKGROUND

Despite the goal set by WHO to eliminate hepatitis C virus (HCV) as a public health threat, uptake of HCV testing and treatment remains low. To achieve this target, evidence-based interventions are needed to address the barriers to care for people with, or at risk of, HCV infection. We aimed to assess the efficacy of interventions to improve HCV antibody testing, HCV RNA testing, linkage to HCV care, and treatment initiation.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE (PubMed), Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and PsycINFO without language restrictions for reports published between database inception and July 21, 2020, assessing the following primary outcomes: HCV antibody testing; HCV RNA testing; linkage to HCV care; and direct-acting antiviral treatment initiation. We also searched key conference abstracts. We included randomised and non-randomised studies assessing non-pharmaceutical interventions that included a comparator or control group. Studies were excluded if they enrolled only paediatric populations (aged <18 years) or if they conducted the intervention in a different health-care setting to that of the control or comparator. Authors were contacted to clarify study details and to obtain additional population-level data. Data were extracted from the records identified into a pre-piloted and standardised data extraction form and a random-effects meta-analysis was used to pool the effects of the interventions on study outcomes. This study is registered in PROSPERO, CRD42020178035.

FINDINGS

Of 15 342 unique records identified, 142 were included, which reported on 148 unique studies (47 randomised controlled trials and 101 non-randomised studies). Medical chart reminders, provider education, and point-of-care antibody testing significantly improved at least three study outcomes compared with a comparator or control. Interventions that simplified HCV testing, including dried blood spot testing, point-of-care antibody testing, reflex RNA testing, and opt-out screening, significantly improved testing outcomes compared with a comparator or control. Enhanced patient and provider support through patient education, provider care coordination, and provider education also significantly improved testing outcomes compared with a comparator or control. Integrated care and patient navigation or care coordination significantly improved linkage to care and the uptake of direct-acting antiviral treatment compared with a comparator or control.

INTERPRETATION

Several interventions to improve HCV care that address several key barriers to HCV care were identified. New models of HCV care must be designed and implemented to address the barriers faced by the population of interest. Further high-quality research, including rigorously designed randomised studies, is still needed in key populations.

FUNDING

None.

Partnering With State Health Departments to Address Injection-Related Infections During the Opioid Epidemic: Experience at a Safety Net Hospital

Massachusetts is one of the epicenters of the opioid epidemic and has been severely impacted by injection-related viral and bacterial infections. A recent increase in newly diagnosed human immunodeficiency virus (HIV) infections among persons who inject drugs in the state highlights the urgent need to address and bridge the overlapping epidemics of opioid use disorder (OUD) and injection-related infections. Building on an established relationship between the Massachusetts Department of Public Health and Boston Medical Center, the Infectious Diseases section has contributed to the development and implementation of a cohesive response involving ambulatory, inpatient, emergency department, and community-based services. We describe this comprehensive approach including the rapid delivery of antimicrobials for the prevention and treatment of HIV, sexually transmitted diseases, systemic infections such as endocarditis, bone and joint infections, as well as curative therapy for chronic hepatitis C virus in a manner that is accessible to patients on the addiction-recovery continuum. We also provide an overview of programs that provide access to medications for OUD, harm reduction services including overdose education, and distribution of naloxone. Finally, we outline lessons learned to inform initiatives in other settings.

Care Facilitation Advances Movement Along the Hepatitis C Care Continuum for Persons With Human Immunodeficiency Virus, Hepatitis C, and Substance Use: A Randomized Clinical Trial (CTN-0064)

Background

Direct-acting antivirals can cure hepatitis C virus (HCV). Persons with HCV/HIV and living with substance use are disadvantaged in benefiting from advances in HCV treatment.

Methods

In this randomized controlled trial, participants with HCV/HIV were randomized between February 2016 and January 2017 to either care facilitation or control. Twelve-month follow-up assessments were completed in January 2018.

Care facilitation group participants received motivation and strengths-based case management addressing retrieval of HCV viral load results, engagement in HCV/HIV care, and medication adherence. Control group participants received referral to HCV evaluation and an offer of assistance in making care appointments. Primary outcome was number of steps achieved along a series of 8 clinical steps (eg, receiving HCV results, initiating treatment, sustained virologic response [SVR]) of the HCV/HIV care continuum over 12 months postrandomization.

Results

Three hundred eighty-one individuals were screened and 113 randomized. Median age was 51 years; 58.4% of participants were male and 72.6% were Black/African American. Median HIV-1 viral load was 27 209 copies/mL, with 69% having a detectable viral load. Mean number of steps completed was statistically significantly higher in the intervention group vs controls (2.44 vs 1.68 steps; χ ² [1] = 7.36, P = .0067). Men in the intervention group completed a statistically significantly higher number of steps than controls. Eleven participants achieved SVR with no difference by treatment group.

Conclusions

The care facilitation intervention increased progress along the HCV/HIV care continuum, as observed for men and not women. Study findings also highlight continued challenges to achieve individual-patient SVR and population-level HCV elimination.

Clinical Trials Registration

NCT02641158.

Impact of routine opt-out HIV/HCV screening on testing uptake at a syringe services program: An interrupted time series analysis

Background:

Hepatitis C (HCV) is the most common infectious disease among people who inject drugs (PWID). Engaging PWID in harm reduction services, such as syringe service programs (SSPs), is critical to reduce HCV and HIV transmission. Additionally, testing for HIV and HCV among PWID is important to improve diagnosis and linkage to care. On March 1, 2018, Florida’s only legal SSP implemented bundled opt-out HIV/HCV testing at enrollment. We aimed to examine the differences in HIV/HCV testing uptake before and after the implementation of the opt-out testing policy.

Methods:

Multivariable logistic regression was used to assess predictors of accepting HIV/HCV tests, controlling for opt-in and opt-out policy. Monthly estimates of the percent of participants accepting an HIV test, HCV test, or both were generated. Interrupted Time Series (ITS) analysis evaluated the immediate policy impact on level of uptake and trend in uptake over time for bundled HIV/HCV testing before and after the opt-out testing policy.

Results:

The total study period was 37 months between December 2016–January 2020 with 512 SSP participants 15 months prior and 547 SSP participants 22 months after implementation of bundled HIV/HCV opt-out testing. Significant predictors of accepting both HIV/HCV tests were cocaine injection (aOR = 2.36), self-reported HIV positive status (aOR = 0.39) and self-reported HCV positive status (aOR = 0.27). Based on the ITS results, there was a significant increase in uptake of HIV/HCV testing by 42.4% (95% CI: 26.2%–58.5%, p < 0.001) immediately after the policy change to opt-out testing.

Conclusion:

Bundled opt-out HIV/HCV testing substantially increased the percentage of SSP clients who received HIV and HCV rapid tests at enrollment into the program, and the effect remained stable across the 22 months post opt-out testing policy. Future investigation must assess PWID-level perspective of testing preferences and examine whether this testing approach improves HIV/HCV detection among PWID previously unaware of their status.

Developing an Accident and Emergency HIV Testing Program in Belize City: Recommendations from Key Stakeholders

With the ultimate goal of developing an accident and emergency (A&E) department HIV testing program in Belize City, Belize, we sought input from key stakeholders on program components and potential facilitators and barriers to HIV testing in emergency care. We conducted semistructured interviews among 4 key stakeholder groups at Karl Heusner Memorial Hospital Authority (KHMHA) in Belize City: (1) 20 A&E patients, (2) 5 A&E physicians, (3) 5 A&E nurses, and (4) 5 KHMHA administrators. We performed a qualitative content analysis of the interview transcripts and isolated important themes. Major themes included: (1) Patient selection: patients preferred to test all A&E patients. All other stakeholder groups preferred testing specific patient groups. (2) Training: Specific training should be completed for staff. (3) Confidentiality: integral for testing. (4) Facilitators and barriers: facilitators included respectful relationships, privacy, resources, coordination, and education. Barriers included stigmatization, patient willingness, inadequate resources, privacy, and testing biases.

Comparison of a video to a pictorial brochure in improving HIV/AIDS and HIV testing knowledge and increasing HIV testing motivation and behavioral skills among adult emergency department patients

OBJECTIVES

We sought to determine if a pictorial brochure improves HIV/AIDS and HIV testing knowledge and increases HIV testing motivation and behavioral skills as well as a video among adult emergency department patients, regardless of language spoken and health literacy level.

METHODS

ED patients were stratified by primary language spoken (English or Spanish) and health literacy level (lower or higher) and randomly assigned to watch the study video or review the content-matched pictorial brochure. HIV/AIDS and HIV testing knowledge, motivation for HIV testing, and behavioral skills for HIV testing were assessed using study instruments before and after watching the video or reviewing the pictorial brochure.

RESULTS

Of the 712 English- and 655 Spanish-speaking ED patients, HIV/AIDS and HIV testing knowledge improved more among participants in the video than the pictorial brochure arm (∆ 0.43; 95% confidence interval [CI]: 0.07, 0.79). This improvement was more pronounced among those with lower (∆ 0.60; 95% CI: 0.06, 1.13) than higher health literacy (∆ 0.27; 95% CI: -0.22, 0.76). HIV testing motivation was high before the intervention and did not increase differentially between arms. Confidence in recognizing when to be tested for HIV was slightly greater in the video than pictorial brochure arm (∆ 0.15; 95% CI: 0.01, 0.28), but did not differ by language spoken or health literacy level.

CONCLUSIONS

A video improved HIV/AIDS and HIV testing knowledge slightly more than a pictorial brochure. Other considerations (eg, patient volume, staffing, space, and video access) should guide EDs on how best to provide information about HIV testing to ED patients.

A need for implementation science to optimise the use of evidence-based interventions in HIV care: A systematic literature review

To improve health outcomes in people living with HIV, adoption of evidence-based interventions (EBIs) using effective and transferable implementation strategies to optimise the delivery of healthcare is needed. ViiV Healthcare's Positive Pathways initiative was established to support the UNAIDS 90-90-90 goals. A compendium of EBIs was developed to address gaps within the HIV care continuum, yet it was unknown whether efforts existed to adapt and implement these EBIs across diverse clinical contexts. Therefore, this review sought to report on the use of implementation science in adapting HIV continuum of care EBIs. A systematic literature review was undertaken to summarise the evaluation of implementation and effectiveness outcomes, and report on the use of implementation science in HIV care. Ten databases were reviewed to identify studies (time-period: 2013-2018; geographic scope: United States, United Kingdom, France, Germany, Italy, Spain, Canada, Australia and Europe; English only publications). Studies were included if they reported on people living with HIV or those at risk of acquiring HIV and used interventions consistent with the EBIs. A broad range of study designs and methods were searched, including hybrid designs. Overall, 118 publications covering 225 interventions consistent with the EBIs were identified. These interventions were evaluated on implementation (N = 183), effectiveness (N = 81), or both outcomes (N = 39). High variability in the methodological approaches was observed. Implementation outcomes were frequently evaluated but use of theoretical frameworks was limited (N = 13). Evaluations undertaken to assess effectiveness were inconsistent, resulting in a range of measures. This review revealed extensive reporting on implementation science as defined using evaluation outcomes. However, high variability was observed in how implementation outcomes and effectiveness were defined, quantified, and reported. A more specific and consistent approach to conducting and reporting on implementation science in HIV could facilitate achievement of UNAIDS 90-90-90 targets.

Lack of efficacy in a randomised trial of a brief intervention to reduce drug use and increase drug treatment services utilisation among adult emergency department patients over a 12-month period

OBJECTIVES

Assess the 12-month efficacy of a brief intervention (BI) on reducing drug use and increasing drug treatment services utilisation among adult emergency department (ED) patients.

METHODS

This randomised, controlled trial enrolled 18-64-year-old ED patients needing a drug use intervention. Treatment arm participants received a tailored BI while control arm participants only completed the study questionnaires. Self-reported past 3-month drug use and engagement in drug treatment services were compared by study arm at 3-month intervals over 1 year. Multiple imputations were performed to overcome loss-to-follow-up.

RESULTS

Of the 1030 participants, follow-up completion ranged 55%-64% over the four follow-ups. At 12 months, the two study arms were similar in regards to mean: (1) proportion reporting any drug use (treatment: 67.1% (61.6 to 72.6), control: 74.4% (69.4 to 79.4)); (2) drug use frequency on a five-point scale (treatment: 3.7 (3.3 to 4.2), control: 4.6 (4.0 to 5.2)); (3) total days of drug use (treatment: 28.3 (23.2 to 33.4), control: 33.4 (28.5 to 38.2)); (4) most number of times drugs used/day (treatment: 4.6 (3.6 to 5.5), control: 6.1 (4.8 to 7.3)) and (5) typical number of times drugs used/day (treatment: 3.3 (2.5 to 4.1), control: 5.1 (3.9 to 6.2)). Utilisation of drug treatment services also was similar by study arm. In multivariable regression analyses, patients who were homeless or had higher drug use at baseline continued to have greater drug use in follow-up.

CONCLUSIONS

Among adult ED patients requiring a drug use intervention, this BI did not decrease drug use or increase drug treatment services utilisation over a 12-month period more than the control condition.

TRIAL REGISTRATION NUMBER

NCT01124591; Pre-trial.

Sexual HIV risk behavior outcomes of brief interventions for drug use in an inner-city emergency department: Secondary outcomes from a randomized controlled trial

BACKGROUND

Drug use is an established risk factor for HIV. Brief Interventions (BIs) targeting reductions in both drug use and HIV risk behaviors may help curtail these related epidemics. The present study evaluates the impact of BIs for drug use and HIV risk reduction on sexual HIV risk behaviors among a primarily marijuana-using sample during a 12-month post-intervention follow-up period.

METHODS

We conducted a randomized controlled trial of 780 adult patients in an Emergency Department (ED) with past 3-month drug use (primarily non-injecting). This study used a 3 × 2 factorial design (3 ED-based conditions: computer-delivered brief intervention [Computer BI], therapist-delivered, computer-guided BI [Therapist BI], or enhanced usual care (EUC-ED) for drug-using adults; 2 follow-up conditions at 3 months: booster or control). This analysis examines the outcomes of the BIs on sexual HIV risk behaviors at 3-, 6-, and 12-months.

RESULTS

Compared to the enhanced usual care control, the combined Therapist BI with booster resulted in significant reductions in scores on the sexual risk subscale of the HIV Risk Taking Behaviour Scale over 12-months, when controlling for baseline sexual risk, gender, and drug dependency status. The baseline interventions alone, booster alone, and Computer BI plus booster did not differ from the comparison group (EUC plus control).

CONCLUSIONS

A therapist-delivered BI for drug use and HIV risk behaviors, combined with a follow-up therapist-delivered booster, shows promise for reducing sexual HIV risk behaviors among a primarily marijuana using, non-injecting sample.

Survey of programmatic experiences and challenges in delivery of hepatitis B and C testing in low- and middle-income countries

Background

There have been few reports on programmatic experience of viral hepatitis testing and treatment in resource-limited settings. To inform the development of the 2017 World Health Organization (WHO) viral hepatitis testing guidance and in particular the feasibility of proposed recommendations, we undertook a survey across a range of organisations engaged with hepatitis testing in low- and middle-income countries (LMICs). Our objective was to describe current hepatitis B and C testing practices across a range of settings in different countries, as well as key barriers or challenges encountered and proposed solutions to promote testing scale-up.

Methods

Hepatitis testing programmes in predominantly LMICs were identified from the WHO Global Hepatitis Programme contacts database and through WHO regional offices, and invited to participate. The survey comprised a six-part structured questionnaire: general programme information, description of hepatitis testing, treatment and care services, budget and funding, data on programme outcomes, and perceptions on key barriers encountered and strategies to address these.

Results

We interviewed 22 viral hepatitis testing programmes from 19 different countries. Nine were from the African region; 6 from the Western Pacific; 4 from South-East Asia; and 3 from Eastern Europe. All but four of the programmes were based in LMICs, and 10 (45.5%) were supported by non-governmental or international organizations. All but two programmes undertook targeted testing of specific affected populations such as people living with HIV, people who inject drugs, sex workers, health care workers, and pregnant women. Only two programmes focussed on routine testing in the general population. The majority of programmes were testing in hospital-based or other health facilities, particularly HIV clinics, and community-based testing was limited. Nucleic acid testing (NAT) for confirmation of HCV and HBV viraemia was available in only 30% and 18% of programmes, respectively. Around a third of programmes required some patient co-payment for diagnosis. The most commonly identified challenges in scale-up of hepatitis testing were: limited community awareness about viral hepatitis; lack of facilities or services for hepatitis testing; no access to low cost treatment, particularly for HCV; absence of national guidance and policies; no dedicated budget for hepatitis; and lack of trained health care and laboratory workers.

Conclusions

At this early stage in the global scale-up of testing for viral hepatitis, there is a wide variation in testing practices and approaches across different programmes. There remains limited access to NAT to confirm viraemia, and patient self-payment for testing and treatment is common. There was consensus from implementing organizations that scale-up of testing will require increased community awareness, health care worker training, development of national strategies and guidelines, and improved access to low cost NAT virological testing.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2767-0) contains supplementary material, which is available to authorized users.

Interventions to optimise the care continuum for chronic viral hepatitis: a systematic review and meta-analyses

BACKGROUND

Advances in therapy for hepatitis B virus (HBV) and hepatitis C virus (HCV) have ushered in a new era in chronic hepatitis treatment. To maximise the effectiveness of these medicines, individuals must be engaged and retained in care. We analysed operational interventions to enhance chronic viral hepatitis testing, linkage to care, treatment uptake, adherence, and viral suppression or cure.

METHODS

We did a systematic review of operational interventions, and did meta-analyses for sufficiently comparable data. We searched PubMed, Embase, WHO library, International Clinical Trials Registry Platform, PsycINFO, and CINAHL for randomised controlled trials and controlled non-randomised studies that examined operational interventions along the chronic viral hepatitis care continuum, published in English up to Dec 31, 2014. We included non-pharmaceutical intervention studies with primary or secondary outcomes of testing, linkage to care, treatment uptake, treatment adherence, treatment completion, treatment outcome, or viral endpoints. We excluded dissertations and studies of children only. Data were extracted by two independent reviewers, with disagreements resolved by a third reviewer. Studies were assessed for bias. Data from similar interventions were pooled and quality of evidence was assessed using GRADE. This study was registered in PROSPERO (42014015094).

FINDINGS

We identified 7583 unduplicated studies, and included 56 studies that reported outcomes along the care continuum (41 for HCV and 18 for HBV). All studies except one were from high-income countries. Lay health worker HBV test promotion interventions increased HBV testing rates (relative risk [RR] 2·68, 95% CI 1·82-3·93). Clinician reminders to prompt HCV testing during clinical visits increased HCV testing rates (3·70, 1·81-7·57). Nurse-led educational interventions improved HCV treatment completion (1·14, 1·05-1·23) and cure (odds ratio [OR] 1·93, 95% CI 1·44-2·59). Coordinated mental health, substance misuse, and hepatitis treatment services increased HCV treatment uptake (OR 3·03, 1·24-7·37), adherence (RR 1·22, 1·05-1·41), and cure (RR 1·21, 1·07-1·38) compared with usual care.

INTERPRETATION

Several simple, inexpensive operational interventions can substantially improve engagement and retention along the chronic viral hepatitis care continuum. Further operational research to inform scale-up of hepatitis services is needed in low-income and middle-income countries.

FUNDING

World Health Organization and US Fulbright Program.

Knowledge translation studies in paediatric emergency medicine: A systematic review of the literature

AIM

Systematic review of knowledge translation studies focused on paediatric emergency care to describe and assess the interventions used in emergency department settings.

METHODS

Electronic databases were searched for knowledge translation studies conducted in the emergency department that included the care of children. Two researchers independently reviewed the studies.

RESULTS

From 1305 publications identified, 15 studies of varied design were included. Four were cluster-controlled trials, two patient-level randomised controlled trials, two interrupted time series, one descriptive study and six before and after intervention studies. Knowledge translation interventions were predominantly aimed at the treating clinician, with some targeting the organisation. Studies assessed effectiveness of interventions over 6-12 months in before and after studies, and 3-28 months in cluster or patient level controlled trials. Changes in clinical practice were variable, with studies on single disease and single treatments in a single site showing greater improvement.

CONCLUSIONS

Evidence for effective methods to translate knowledge into practice in paediatric emergency medicine is fairly limited. More optimal study designs with more explicit descriptions of interventions are needed to facilitate other groups to effectively apply these procedures in their own setting.

Patient choice in opt-in, active choice, and opt-out HIV screening: randomized clinical trial

STUDY QUESTION

What is the effect of default test offers--opt-in, opt-out, and active choice--on the likelihood of acceptance of an HIV test among patients receiving care in an emergency department?

METHODS

This was a randomized clinical trial conducted in the emergency department of an urban teaching hospital and regional trauma center. Patients aged 13-64 years were randomized to opt-in, opt-out, and active choice HIV test offers. The primary outcome was HIV test acceptance percentage. The Denver Risk Score was used to categorize patients as being at low, intermediate, or high risk of HIV infection.

STUDY ANSWER AND LIMITATIONS

38.0% (611/1607) of patients in the opt-in testing group accepted an HIV test, compared with 51.3% (815/1628) in the active choice arm (difference 13.3%, 95% confidence interval 9.8% to 16.7%) and 65.9% (1031/1565) in the opt-out arm (difference 27.9%, 24.4% to 31.3%). Compared with active choice testing, opt-out testing led to a 14.6 (11.1 to 18.1) percentage point increase in test acceptance. Patients identified as being at intermediate and high risk were more likely to accept testing than were those at low risk in all arms (difference 6.4% (3.4% to 9.3%) for intermediate and 8.3% (3.3% to 13.4%) for high risk). The opt-out effect was significantly smaller among those reporting high risk behaviors, but the active choice effect did not significantly vary by level of reported risk behavior. Patients consented to inclusion in the study after being offered an HIV test, and inclusion varied slightly by treatment assignment. The study took place at a single county hospital in a city that is somewhat unique with respect to HIV testing; although the test acceptance percentages themselves might vary, a different pattern for opt-in versus active choice versus opt-out test schemes would not be expected.

WHAT THIS PAPER ADDS

Active choice is a distinct test regimen, with test acceptance patterns that may best approximate patients' true preferences. Opt-out regimens can substantially increase HIV testing, and opt-in schemes may reduce testing, compared with active choice testing.

FUNDING, COMPETING INTERESTS, DATA SHARING

This study was supported by grant NIA 1RC4AG039078 from the National Institute on Aging. The full dataset is available from the corresponding author. Consent for data sharing was not obtained, but the data are anonymized and risk of identification is low.Trial registration Clinical trials NCT01377857.

Aplicação do instrumento Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): uma revisão integrativa

RESUMO Objetivo Objetivou-se sistematizar o conhecimento e a aprendizagem de como é a aplicação do instrumento Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Método Revisão integrativa, realizada entre maio e julho do ano de 2014, nas bases de dados Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Medical Literature Analysis and Retrieval System Online (Medline), PubMed e Scientific Electronic Library Online (SciELO), assim como no sistema de busca do Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Foram selecionados 26 artigos. Resultados: O ASSIST concentrou-se no auxílio da identificação e classificação do uso de substância psicoativa, tendo se revelado importante no rastreamento do envolvimento com o álcool e outras drogas, e efetivo no nível primário à saúde. Conclusão: Confirmou-se como instrumento a ser usado na Atenção à Saúde.

Evaluation of a brief intervention to reduce the negative consequences of drug misuse among adult emergency department patients

OBJECTIVES

Determine if a brief intervention (BI) reduces the negative consequences of drug use/misuse among adult emergency department (ED) patients, and identify patients more likely to benefit from the BI.

METHODS

This randomized, controlled trial enrolled 1026 18-64 year-old ED patients whose drug misuse indicated a needed for a BI. Differences in total Inventory of Drug Use Consequences (InDUC) scores between the treatment (BI) and control arms (no BI) were assessed every 90 days over a one-year period. Regression models were constructed to identify demographic and clinical factors associated with greater reductions in total InDUC scores.

RESULTS

Although total InDUC scores decreased for both the treatment and control arms, there were no differences in scores between the treatment and the control arms at baseline at each follow-up. In the regression analyses, participants who were not using drugs or received drug treatment in the past 90 days generally had lower InDUC scores at each follow-up.

CONCLUSIONS

Although negative consequences decreased in both study arms over time, receiving a BI did not lead to a greater reduction in the negative consequences of drug misuse than not receiving a BI. Of importance in the design of future ED drug misuse interventions, participants who were successful in stopping their drug misuse or receiving drug treatment did show fewer negative consequences of drug use/misuse.

Factors Influencing Uptake of Rapid HIV and Hepatitis C Screening Among Drug Misusing Adult Emergency Department Patients: Implications for Future HIV/HCV Screening Interventions

In this randomized, controlled trial among 957 English- or Spanish-speaking drug misusing adult emergency department (ED) patients, we determined if a tailored brief intervention (BI) increased uptake of rapid HIV/HCV screening, and identified factors associated with greater screening uptake. Rapid HIV/HCV screening uptake was greater in the control than the BI arm (45 vs. 38 %; p < 0.04). Screening uptake depended on elapsed study time and which research staff member offered testing. In the control arm, uptake was lowest for those spending <30 or ≥90 min in the study. In the BI arm, screening uptake generally increased over time. Tailored BI content specifically addressing participant HIV/HCV knowledge, HIV/HCV risk behaviors, or need for HIV/HCV screening was not associated with greater screening uptake. These study findings suggested factors that should be considered when designing future ED-based screening initiatives, such as elapsed study time, who offers testing, and the content of interventions.

Sex Differences in Substance Use Among Adult Emergency Department Patients: Prevalence, Severity, and Need for Intervention

BACKGROUND

Substance use is prevalent among emergency department (ED) patients, and sex has been implicated as an important factor in the etiology, pathophysiology, sequelae, and treatment of substance use disorders. However, additional information is needed about the epidemiology of substance use as it relates to sex among ED patients.

OBJECTIVES

This study examined sex differences in the prevalence and severity of self-reported tobacco, alcohol, and drug use among adult ED patients.

METHODS

A random sample of English- or Spanish-speaking, non-critically ill or injured, 18- to 64-year-old patients was approached at two urban EDs and asked to self-report their lifetime and past 3-month tobacco, alcohol, and drug use. Participants completed the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) using an audio computer-assisted self-interview. Participants were categorized by their substance severity (ASSIST score) and need for a brief or more intensive intervention per World Health Organization recommendations. Substance misuse prevalence, frequency, severity, and need for interventions were compared between sexes by substance category. Multivariable logistic regression models were used to examine the association between sexes and the need for intervention after adjusting for sociodemographic characteristics.

RESULTS

Of the 6,432 participants in the study, the median age was 37 years (interquartile range = 26 to 48 years), and 56.6% were female. Overall, lifetime, and past 3-month use was higher for men across all substances (tobacco, alcohol, and drugs). Among those reporting past 3-month use, the frequency of use was similar between sexes for tobacco and all drugs, but men reported more frequent alcohol use. Men had higher mean ASSIST scores compared to women, 30.3 (standard error [SE] ± 0.8) vs. 21.1 (SE ± 0.5); mean difference 9.2 (95% confidence interval [CI] = 7.4 to 10.9). The need for any intervention (brief or intensive) was similar between sexes for tobacco and drugs. After sociodemographic factors were adjusted for, women were less likely than men to need any intervention for alcohol (odds ratio [OR] = 0.6; 95% CI = 0.4 to 0.8), but not other substances: tobacco (OR = 0.9; 95% CI = 0.6 to 1.3), marijuana (OR = 0.8; 95% CI = 0.6 to 1.1), or other drugs (OR = 1.1; 95% CI = 0.7 to 1.7).

CONCLUSIONS

Although men have a higher overall prevalence of substance use, the frequency and severity of use were similar for men and women for most substances. After other characteristics were adjusted for, sex appears associated with the need for interventions for alcohol, but not tobacco, marijuana, or other drugs.

Short-term Efficacy of a Brief Intervention to Reduce Drug Misuse and Increase Drug Treatment Utilization Among Adult Emergency Department Patients

OBJECTIVES

Although brief interventions (BIs) have shown some success for smoking cessation and alcohol misuse, it is not known if they can be applied in the emergency department (ED) to drug use and misuse. The objectives of this investigation were to assess the 3-month efficacy of a BI to reduce drug use and misuse, increase drug treatment services utilization among adult ED patients, and identify subgroups more likely to benefit from the BI.

METHODS

This randomized, controlled trial enrolled 18- to 64-year-old English- or Spanish-speaking patients from two urban, academic EDs whose responses to the Alcohol, Smoking, and Substance Involvement Screening Test indicated a need for a brief or intensive intervention. Treatment participants received a tailored BI, while control participants only completed the study questionnaires. At the 3-month follow-up, each participant's past 3-month drug use and misuse and treatment utilization were compared to his or her baseline enrollment data. Regression modeling was used to identify subgroups of patients (per demographic and clinical factors) more likely to stop or reduce their drug use or misuse or engage in drug treatment by the 3-month follow-up assessment.

RESULTS

Of the 1,030 participants, the median age was 30 years (interquartile range = 24 to 42 years), and 46% were female; 57% were white/non-Hispanic, 24.9% were black/non-Hispanic, and 15% were Hispanic. The most commonly misused drugs were marijuana, prescription opioids, cocaine/crack, and benzodiazepines. Although at follow-up the proportions of participants reporting any past 3-month drug misuse had decreased in both study arms (control 84% vs. treatment 78%), the decreases were similar between the two study arms (Δ-6.3%; 95% confidence interval [CI] = -13.0% to 0.0). In addition, at follow-up there were no differences between study arms in those who were currently receiving drug treatment (Δ1.8; 95% CI = -3.5 to 6.8), who had received treatment during the past 3 months (Δ-2.0; 95% CI = -6.5 to 2.4), or who at least contacted a treatment program (Δ 1.7; 95% CI = -2.4 to 6.1). Those whose baseline screening indicated the need for a brief instead of a more intensive intervention, and those currently engaged in drug treatment at the 3-month follow-up, were generally more likely to stop or decrease their drug use/misuse.

CONCLUSIONS

The BI employed in this study did not reduce drug use and misuse or increase treatment utilization more than the control condition over a 3-month period. Future research should help determine what role, if any, BIs should play in affecting drug use and misuse among ED patients.

A randomized controlled trial of the effects of a brief intervention to increase chlamydia and gonorrhea testing uptake among young adult female emergency department patients

OBJECTIVES

The objective of this study was to test the effect of a brief educational and counseling intervention on increasing the uptake of free testing for Chlamydia trachomatis (chlamydia) and Neisseria gonorrhea (gonorrhea) among young female emergency department (ED) patients. Women are particularly vulnerable to more serious consequences of these infections due to asymptomatic presentation. Increased testing is important to detect, treat, and halt the spread of these infections among asymptomatic women.

METHODS

This was a randomized controlled trial. Research assistants (RAs) approached female patients in two EDs. Eligible patients were between 18 and 35 years of age, who reported having sex with males, but were not attending the ED for either treatment of sexually transmitted infection (STI) or testing for possible STI exposure. Participants responded to survey questions about their lifetime and past 3-month substance use, number of recent sexual partners, condom use, and perception of risks for chlamydia and gonorrhea infections. Following the survey, the RAs randomized participants into study control or treatment arms. Each treatment arm participant received a brief educational/counseling intervention from the RA. The brief intervention focused on the woman's personal risks for chlamydia and gonorrhea and condoms attitudes and usage. As the primary outcome of this study, participants were offered free urine tests for chlamydia and gonorrhea infection postintervention or post-survey completion, depending on group assignment.

RESULTS

A total of 171 women completed the baseline assessment and were offered chlamydia and gonorrhea testing. The mean (±SD) age was 26 (±4.76) years, 18% were Hispanic, and 12% were Spanish-speaking only. The brief intervention that was offered to increase these women's awareness of their STI risk did not result in increased acceptance of testing; 48% in the brief intervention group accepted testing (95% confidence interval [CI] = 32% to 64%) versus 36% in the control group (95% CI = 19% to 53%). In a multivariable logistic regression, only self-identifying as being Hispanic was associated with greater willingness to be tested. Of the asymptomatic women tested (n = 71), five tested positive for chlamydia. This represents a positivity rate of 7%. There were no positive test results for gonorrhea. Women who reported high-risk factors for STI, such as younger age (≤25 years), having sex in the past 90 days without using condoms, identified substance use, or previous STI, were not more likely to accept the offer of chlamydia and gonorrhea testing.

CONCLUSIONS

The brief intervention used in this study did not increase the uptake of testing for chlamydia and gonorrhea infections in this sample, in comparison to receiving no intervention. Although Hispanic women were more likely to accept chlamydia and gonorrhea testing, it is concerning that those women who report STI risk factors were not more likely to accept the offer of chlamydia and gonorrhea testing. Future research should focus on the refinement of an intervention protocol to focus on prior STI and lack of condom use to increase the uptake of testing among this high-risk group.

Comparison of substance-use prevalence among Rhode Island and The Miriam Hospital Emergency Department patients to state and national general population prevalence estimates

OBJECTIVES

Compare the prevalence of recent alcohol, tobacco, and drug use among patients from two Rhode Island emergency departments (EDs) to Rhode Island state and United States national general population estimates between 2010 and 2012.

METHODS

Secondary analysis of ED patient data and the National Survey of Drug Use and Health.

RESULTS

Alcohol was the most commonly reported substance, and prevalence of its use was higher among ED patients than those in the national, but not the Rhode Island, general population. Drug use was higher among ED patients than in the state and national general population. For ED patients, tobacco and opioid use was highest among 26-34 year-olds, alcohol and marijuana highest among 18-25 years-olds, and cocaine highest among 35-49 years-olds.

CONCLUSION

Rhode Island Hospital and The Miriam Hospital ED patients report a greater prevalence of substance use than the national population and in many cases the state general population.