Increases in Acute Hepatitis C Virus Infection Related to a Growing Opioid Epidemic and Associated Injection Drug Use, United States, 2004 to 2014

How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders?

BACKGROUND

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown.

METHODS

Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share").

RESULTS

The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only.

CONCLUSIONS

Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.

Supporting direct acting antiviral medication adherence and treatment completion in a sample of predominantly rural veterans with hepatitis C and substance use disorders

BACKGROUND

Clinic-based interventions are needed to promote successful direct acting antiviral (DAA) treatment for chronic hepatitis C virus (HCV) infection in patients with substance use disorders (SUDs) among rural Veterans.

METHODS

We implemented a clinic-based intervention which used motivational interviewing (MI) techniques to promote medication adherence and treatment completion with 12 weeks of DAA treatment among rural Veterans with chronic HCV and SUDs. Patients received an MI session with a licensed psychologist at baseline and at each two-week follow-up visit during DAA treatment. Patients received $25 per study visit completed. Patients were to attend a laboratory visit 12 weeks after treatment completion to assess for sustained virologic response (SVR).

RESULTS

Of the 20 participants who enrolled, 75% (n = 15) completed the planned 12-week course of treatment. Average adherence by pill count was 92% (SD = 3%). Overall SVR was 95% (19/20).

CONCLUSIONS

We demonstrated that a clinic-based intervention which incorporated frequent follow up visits and MI techniques was feasible and acceptable to a sample of predominantly rural Veterans with chronic HCV and SUDs.

CLINICAL TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT02823457) on July 1, 2016. https://clinicaltrials.gov .

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.

CDC's New Hepatitis C Virus Testing Recommendations for Perinatally Exposed Infants and Children: A Step Towards Hepatitis C Elimination

New U.S. Centers for Disease Control and Prevention (CDC) guidelines for hepatitis C virus (HCV) testing of perinatally exposed infants and children released in 2023 recommend a nucleic acid test (NAT) for detection of HCV ribonucleic acid (i.e., NAT for HCV RNA) at 2-6 months of age to facilitate early identification and linkage to care for children with perinatally acquired HCV infection. Untreated hepatitis C can lead to cirrhosis, liver cancer, and premature death and is caused by HCV, a blood-borne virus transmitted most often among adults through injection drug use in the United States. Perinatal exposure from a birth parent with HCV infection is the most frequent mode of HCV transmission among infants and children. New HCV infections have been increasing since 2010, with the highest rates of infection among people aged 20-39 years, leading to an increasing prevalence of HCV infection during pregnancy. In 2020, the CDC recommended one-time HCV screening for all adults aged 18 years and older and for all pregnant persons during each pregnancy. Detecting HCV infection during pregnancy is key for the identification of pregnant persons, linkage to care for postpartum treatment, and identification of infants with perinatal exposure for HCV testing. It was previously recommended that children who were exposed to HCV during pregnancy receive an antibody to HCV (anti-HCV) test at 18 months of age; however, most children were lost to follow-up before testing occurred, leaving children with perinatal infection undiagnosed. The new strategy of testing perinatally exposed children at age 2-6 months was found to be cost-effective in increasing the identification of infants who might develop chronic hepatitis C. This report describes the current perinatal HCV testing recommendations and how they advance national hepatitis C elimination efforts by improving the health of pregnant and postpartum people and their children.

Adherence to Hepatitis C Treatment Among Underserved Patients With Substance Use Disorder in a Pharmacist-led Treatment Model

BackgroundTreatment with medications for opioid use disorder (MOUD) may improve hepatitis C virus (HCV) treatment outcomes by providing additional contact with health care professionals to support patient engagement. Objective: We describe a pharmacist-led HCV treatment model and assessed the effect of MOUD on adherence to direct-acting antivirals (DAAs) in an underserved patient population. Methods: This was a retrospective cohort study of adults (age≥18 years) treated for HCV infection with DAAs at a Federally Qualified Health Center in Portland, Oregon, between March 1, 2019, and March 16, 2020. Patients were followed to 12 weeks to assess adherence to DAAs by MOUD status. Results: Among 59 eligible patients, 16 (27%) were prescribed MOUD. Baseline characteristics were similar between patients who did and did not receive MOUD. Adherence to DAAs was overall high and not significantly different between the groups (median: 98.5% vs median: 100%; P = .06). Five patients missed at least one dose due to an adverse drug effect and two of these patients discontinued HCV therapy due to these effects. Conclusion: Adherence to HCV therapy was nearly 100% among underserved patients in a pharmacist-led HCV treatment model and did not differ by MOUD engagement.

Leveraging opportunities for treatment/user simplicity (LOTUS): Navigating the current treatment landscape for achieving hepatitis C virus elimination among persons who inject drugs

All-oral, direct-acting antivirals can cure hepatitis C virus (HCV) in almost all infected individuals; yet, many individuals with chronic HCV are not treated, and the incidence of acute HCV is increasing in some countries, including the United States. Strains on healthcare resources during the COVID-19 pandemic negatively impacted the progress toward the World Health Organization goal to eliminate HCV by 2030, especially among persons who inject drugs (PWID). Here, we present a holistic conceptual framework termed LOTUS (Leveraging Opportunities for Treatment/User Simplicity), designed to integrate the current HCV practice landscape and invigorate HCV treatment programs in the setting of endemic COVID-19: (A) treatment as prevention (especially among PWID), (B) recognition that HCV cure may be achieved with variable adherence with evidence supporting some forgiveness for missed doses, (C) treatment of all persons with active HCV infection (viremic), regardless of acuity, (D) minimal monitoring (MinMon) during treatment, and (E) rapid test and treat (TnT). The objective of this article is to review the current literature supporting each LOTUS petal; identify remaining gaps in knowledge or data; define the remaining barriers facing healthcare providers; and review evidence-based strategies for overcoming key barriers.

Virologic Response and Reinfection Following HCV Treatment among Hospitalized People Who Inject Drugs: Follow-Up Data from the OPPORTUNI-C Trial

Treatment of hepatitis C among people who inject drugs (PWID) may be complicated by loss to follow-up and reinfection. We aimed to evaluate sustained virologic response (SVR) and reinfection, and to validate complete pharmacy dispensation as a proxy for cure among PWID enrolled in a trial of opportunistic HCV treatment. Data were obtained by reviewing the electronic patient files and supplemented by outreach HCV RNA testing. Reinfection was defined based on clinical, behavioral, and virological data. Intention to treat SVR ≥ 4 within 2 years after enrolment was accomplished by 59 of 98 (60% [95% CI 50-70]) during intervention conditions (opportunistic treatment) and by 57 of 102 (56% [95% CI 46-66]) during control conditions (outpatient treatment). The time to end of treatment response (ETR) or SVR ≥ 4 was shorter among intervention participants (HR 1.55 [1.08-2.22]; p = 0.016). Of participants with complete dispensation, 132 of 145 (91%) achieved ETR or SVR > 4 (OR 12.7 [95% CI 4.3-37.8]; p < 0.001). Four cases of reinfection were identified (incidence 3.8/100 PY [95% CI 1.0-9.7]). Although SVR was similar, the time to virologic cure was shorter among intervention participants. Complete dispensation is a valid correlate for cure among individuals at risk of loss to follow-up. Reinfection following successful treatment remains a concern.

Liver Transplantation from Brain-Dead Donors with Hepatitis B or C in South Korea: A 2014-2020 Korean Organ Transplantation Registry Data Analysis

BACKGROUND According to the current guidelines for liver transplantation (LT) of brain-dead donors with hepatitis B or C virus (HBV or HCV) in Korea, grafts from hepatitis B surface antigen (HBsAg)(+) or HCV antibody (anti-HCV)(+) donors must be transplanted only to HBsAg(+) or anti-HCV(+) recipients, respectively. We aimed to determine the current status and outcomes of brain-dead donor LT with HBV or HCV in Korea. MATERIAL AND METHODS This retrospective observational study included all LTs from brain-dead donors in the Korean Organ Transplantation Registry between April 2014 and December 2020. According to donor hepatitis status, 24 HBV(+), 1 HCV(+), and 1010 HBV(-)/HCV(-) donors were included. RESULTS Baseline/final model for end-stage liver disease score (MELD) for HBV(+), HCV(+), and HBV(-)/HCV(-) were 22.4±9.3/27.8±7.8, 16/11, and 33.0±15.4/35.5±7.1, respectively. MELD score of HBV (+) were lower than those of HBV(-)/HCV(-) (P<0.01). Five-year graft and patient survival rates of HBV(+) and HBV(-)/HCV(-) recipients were 81.7%/85.6%, and 76.6%/76.7%, respectively (P=0.73 and P=0.038). One-year graft and patient survival rates of HCV (+) graft recipients were both 100%. CONCLUSIONS No differences in graft and patient survival rates between HBV(+) and HBV(-)/HCV(-) groups were observed. Although accumulating the results of transplants from HBV (+) or HCV(+) grafts to HBV(-) or HCV(-) recipients is not possible owing to domestic regulations, Korea should conditionally permit transplantations from HBV(+) or HCV(+) grafts to HBV(-) or HCV(-) recipients by considering the risks and benefits based on foreign studies. Thereafter, we can accumulate the data from Korea and analyze the outcomes.

United States Provider Experiences with Telemedicine for Hepatitis C Treatment: A Nationwide Survey

Background

Hepatitis C virus (HCV) elimination requires treatment access expansion, especially for underserved populations. Telehealth has the potential to improve HCV treatment access, although data are limited on its incorporation into standard clinical practice.

Methods

We conducted a cross-sectional, e-mail survey of 598 US HCV treatment providers who had valid email addresses and 1) were located in urban areas and had written ≥20 prescriptions for HCV treatment to US Medicare beneficiaries in 2019-20 or 2) were located in non-urban areas and wrote any HCV prescriptions in 2019-20. Through email, we notified providers of a self-administered electronic 28-item survey of clinical strategies and attitudes about telemedicine for HCV.

Results

We received 86 responses (14% response rate), of which 75 used telemedicine for HCV in 2022. Of those 75, 24% were gastroenterologists/hepatologists, 23% general medicine, 17% infectious diseases, and 32% non-physicians. Most (82%) referred patients to commercial laboratories, and 85% had medications delivered directly to patients. Overwhelmingly, respondents (92%) felt that telehealth increases healthcare access, and 76% reported that it promotes or is neutral for treatment completion. Factors believed to be "extremely" or "very" important for telehealth use included patient access to technology (86%); patients' internet access (74%); laboratory access (76%); reimbursement for video visits (74%) and audio-only visits (66%). Non-physician licensing and liability statutes were rated "extremely" or "very" important by 43% and 44%, respectively.

Conclusions

Providers felt that telehealth increases HCV treatment access. Major limitations were technological requirements, reimbursement, and access to ancillary services. These findings support the importance of digital equity and literacy to achieve HCV elimination goals.

Opioid and other drug use and drug-related mortality as indicators of Hepatitis C and Human Immunodeficiency Virus in Oklahoma

OBJECTIVES

Outbreaks of injection drug use (IDU)-associated infections have become major public health concerns in the era of the opioid epidemic. This study aimed to (1) identify county-level characteristics associated with acute HCV infection and newly diagnosed IDU-associated HIV in Oklahoma and (2) develop a vulnerability index using these metrics.

METHODS

This study employs a county-level ecological design to examine those diagnosed with acute or chronic HCV or newly diagnosed IDU-associated HIV. Poisson regression was used to estimate the association between indicators and the number of new infections in each county. Primary outcomes were acute HCV and newly diagnosed IDU-associated HIV. A sensitivity analysis included all HCV (acute and chronic) cases. Three models were run using variations of these outcomes. Stepwise backward Poisson regression predicted new infection rates and 95% confidence intervals for each county from the final multivariable model, which served as the metric for vulnerability scores.

RESULTS

Predictors for HIV-IDU cases and acute HCV cases differed. The percentage of the county population aged 18-24 years with less than a high school education and population density were predictive of new HIV-IDU cases, whereas the percentage of the population that was male, white, Pacific Islander, two or more races, and people aged 18-24 years with less than a high school education were predictors of acute HCV infection. Counties with the highest predicted rates of HIV-IDU tended to be located in central Oklahoma and have higher population density than the counties with the highest predicted rates of acute HCV infection.

CONCLUSIONS

There is high variability in county-level factors predictive of new IDU-associated HIV infection and acute HCV infection, suggesting that different public health interventions need to be tailored to these two case populations.

Hepatitis C Cascade of Care in a Multidisciplinary Substance Use Bridge Clinic Model in Tennessee

Many barriers prevent individuals with substance use disorders from receiving hepatitis C virus (HCV) treatment. This study describes 96 patients with active HCV treated in an opioid use disorder bridge clinic model. Of 33 patients who initiated treatment, 25 patients completed treatment, and 13 patients achieved sustained virologic response.

Prompt access to outpatient care post-incarceration among adults with a history of substance use: Predisposing, enabling, and need-based factors

INTRODUCTION

As expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage.

METHODS

In this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18-64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release.

RESULTS

The size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7-15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48-2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use.

CONCLUSIONS

Conditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.

Hepatitis C Exposure Diagnosis and Testing in Infants Born to Hepatitis C Virus-infected Mothers

BACKGROUND

There has been a 5-fold increase in the number of cases of hepatitis C virus (HCV) infection among pregnant women, which is potentially associated with the increase in opioid use.

METHODS

This study was a retrospective review of infants born at a tertiary urban hospital in New Jersey, from January 1, 2011 to January 1, 2021, who were born to mothers with a prenatal diagnosis of HCV.

RESULTS

Of the 142 mothers with a prenatal diagnosis of HCV, 114 (80%) infants had a diagnosis of HCV exposure in the electronic health records. Of the HCV-exposed infants with follow-up data at 24 months of age, 52 (46%) were tested, with 34 of 52 (65%) receiving adequate testing. Infants documented as HCV exposed were more likely to be born to a mother with nonopioid drug use in pregnancy (P = 0.01) and have a higher birth weight (P = 0.03). Of tested infants, those with a higher number of well-child pediatrician visits (P = 0.01) were more likely to receive adequate testing. Trends showed more polymerase chain reaction testing than antibody testing for those who were inadequately tested.

CONCLUSIONS

A significant proportion of infants born to HCV-infected mothers were either not identified at birth (20%) or did not receive adequate testing on follow-up (35%). Further work needs to be done to improve documentation of HCV exposure at birth and follow-up testing to avoid missing congenitally acquired HCV.

How do people who use opioids express their qualities and capacities? An assessment of attitudes, behaviors, and opportunities

People who nonmedically use drugs (PWUD) face intricate social issues that suppress self-actualization, communal integration, and overall health and wellness. "Strengths-based" approaches, an under-used pedagogy and practice in addiction medicine, underscore the significance of identifying and recognizing the inherent and acquired skills, attributes, and capacities of PWUD. A strengths-based approach engenders client affirmation and improves their capacity to reduce drug use-related harms by leveraging existing capabilities. Exploring this paradigm, we conducted and analyzed interviews with 46 PWUD who were clients at syringe services programs in New York City and rural southern Illinois, two areas with elevated rates of opioid-related morbidity and mortality, to assess respondents' perceived strengths. We located two primary thematic modalities in which strengths-based ethos is expressed: individuals (1) being and advocate and resource for harm reduction knowledge and practices and (2) engaging in acts of continuous self-actualization. These dynamics demonstrate PWUD strengths populating and manifesting in complex ways that both affirm and challenge humanist and biomedical notions of individual agency, as PWUD refract enacted, anticipated, and perceived stigmas. In conclusion, programs that blend evidence-based, systems-level interventions on drug use stigma and disenfranchisement with meso and micro-level strengths-based interventions that affirm and leverage personal identity, decision-making capacity, and endemic knowledge may help disrupt health promotion cleavages among PWUD.

Estimated Number of Injection-Involved Overdose Deaths in US States From 2000 to 2020: Secondary Analysis of Surveillance Data

BACKGROUND

In the United States, both drug overdose mortality and injection-involved drug overdose mortality have increased nationally over the past 25 years. Despite documented geographic differences in overdose mortality and substances implicated in overdose mortality trends, injection-involved overdose mortality has not been summarized at a subnational level.

OBJECTIVE

We aimed to estimate the annual number of injection-involved overdose deaths in each US state from 2000 to 2020.

METHODS

We conducted a stratified analysis that used data from drug treatment admissions (Treatment Episodes Data Set-Admissions; TEDS-A) and the National Vital Statistics System (NVSS) to estimate state-specific percentages of reported drug overdose deaths that were injection-involved from 2000 to 2020. TEDS-A collects data on the route of administration and the type of substance used upon treatment admission. We used these data to calculate the percentage of reported injections for each drug type by demographic group (race or ethnicity, sex, and age group), year, and state. Additionally, using NVSS mortality data, the annual number of overdose deaths involving selected drug types was identified by the following specific multiple-cause-of-death codes: heroin or synthetic opioids other than methadone (T40.1, T40.4), natural or semisynthetic opioids and methadone (T40.2, T40.3), cocaine (T40.5), psychostimulants with abuse potential (T43.6), sedatives (T42.3, T42.4), and others (T36-T59.0). We used the probabilities of injection with the annual number of overdose deaths, by year, primary substance, and demographic groups to estimate the number of overdose deaths that were injection-involved.

RESULTS

In 2020, there were 91,071 overdose deaths among adults recorded in the United States, and 93.1% (84,753/91,071) occurred in the 46 jurisdictions that reported data to TEDS-A. Slightly less than half (38,253/84,753, 45.1%; 95% CI 41.1%-49.8%) of those overdose deaths were estimated to be injection-involved, translating to 38,253 (95% CI 34,839-42,181) injection-involved overdose deaths in 2020. There was large variation among states in the estimated injection-involved overdose death rate (median 14.72, range 5.45-31.77 per 100,000 people). The national injection-involved overdose death rate increased by 323% (95% CI 255%-391%) from 2010 (3.78, 95% CI 3.33-4.31) to 2020 (15.97, 95% CI 14.55-17.61). States in which the estimated injection-involved overdose death rate increased faster than the national average were disproportionately concentrated in the Northeast region.

CONCLUSIONS

Although overdose mortality and injection-involved overdose mortality have increased dramatically across the country, these trends have been more pronounced in some regions. A better understanding of state-level trends in injection-involved mortality can inform the prioritization of public health strategies that aim to reduce overdose mortality and prevent downstream consequences of injection drug use.

Understanding healthcare engagement for people who inject drugs

People who inject drugs (PWID) are at an increased risk of multimorbid mental health and chronic diseases, which are frequently underdiagnosed and under-treated due to systemic barriers and ongoing substance use. Healthcare engagement is essential to address these conditions and prevent excess morbidity and mortality. The goal of this study was to understand how PWID engage in care for their chronic health conditions and substance use treatment given the known historic and pervasive barriers. We conducted 24 semistructured qualitative interviews informed by the Behavioral Model for Vulnerable Populations between July-September 2019. Participants were sampled across a range of comorbidities, including co-occurring mental health disorders. Thematic analysis was conducted to explore experiences of healthcare engagement for multimorbid chronic diseases, mental health, and treatment for substance use disorder. Mean age for participants was 58 years; 63% reported male sex and 83% reported Black race. Interviews yielded themes regarding healthcare access and wraparound services, positive patient-provider relationships, service integration for substance use treatment and mental health, healthcare needs alignment, medication of opioid use disorder stigma, and acceptance of healthcare. Taken together, participants described how these themes enabled healthcare engagement. Engagement in care is crucial to support health and recovery. Clinical implications include the importance of strengthening patient-provider relationships, encouraging integration of medical and mental health services, and counseling on substance use treatment options in a non- stigmatizing manner. Additionally, policy to reimburse wrap-around support for substance use recovery can improve care engagement and outcomes related to chronic diseases, mental health, and substance use among PWID. No Patient or Public Contribution: While we acknowledge and thank ALIVE participants for their time for data collection and sharing their perspectives, no ALIVE participants, other people who use drugs, and service users were involved in data collection, analysis or interpretation of data, or in preparation of the manuscript.

Lung Protective Ventilation during Pregnancy: An Observational Cohort Study

Objectives  We sought to describe characteristics of mechanically ventilated pregnant patients, evaluate utilization of low-tidal-volume ventilation (LTVV) and high-tidal-volume ventilation (HTVV) by trimester, and describe maternal and fetal outcomes by ventilation strategy. Study Design  This is a retrospective cohort study of pregnant women with mechanical ventilation for greater than 24 hours between July 2012 and August 2020 at a tertiary care academic medical center. We defined LTVV as average daily tidal volume 8 mL/kg of less of predicted body weight, and HTVV as greater than 8 mL/kg. We examined demographic characteristics, maternal and fetal characteristics, and outcomes by ventilation strategy. Results  We identified 52 ventilated pregnant women, 43 had LTVV, and 9 had HTVV. Acute respiratory distress syndrome occurred in 73% ( N  = 38) of patients, and infection was a common indication for ventilation ( N  = 33, 63%). Patients had LTVV more often than HTVV in all trimesters. Obstetric complications occurred frequently, 21% ( N  = 11) experienced preeclampsia or eclampsia, and among 43 patients with available delivery data, 60% delivered preterm ( N  = 26) and 16% had fetal demise ( N  = 7). Conclusion  LTVV was utilized more often than HTVV among pregnant women in all trimesters. There was a high prevalence of maternal and fetal morbidity and fetal mortality among our cohort. Key Points Our center utilized low tidal more often than high-tidal-volume ventilation during all trimesters of pregnancy.Prone positioning can be performed at advanced gestations.Infection is a common cause of antepartum ventilation.

Barriers and Facilitators to Harm Reduction for Opioid Use Disorder: A Qualitative Study of People With Lived Experience

STUDY OBJECTIVE

Although an increasing number of emergency departments (ED) offer opioid agonist treatment, naloxone, and other harm reduction measures, little is known about patient perspectives on harm reduction practices delivered in the ED. The objective of this study was to identify patient-focused barriers and facilitators to harm reduction strategies in the ED.

METHODS

We conducted semistructured interviews with a convenience sample of individuals in Massachusetts diagnosed with opioid use disorder. We developed an interview guide, and interviews were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. After initial interviews and coding, we triangulated the results among a focus group of 4 individuals with lived experience.

RESULTS

We interviewed 25 participants with opioid use disorder, 6 recruited from 1 ED and 19 recruited from opioid agonist treatment clinics. Key themes included accessibility of harm reduction supplies, lack of self-care resulting from withdrawal and hopelessness, the impact of stigma on the likelihood of using harm reduction practices, habit and knowledge, as well as the need for user-centered harm reduction interventions.

CONCLUSION

In this study, people with lived experience discussed the characteristics and need for user-centered harm reduction strategies in the ED that centered on reducing stigma, treatment of withdrawal, and availability of harm reduction materials.

An Analysis of Social Determinants of Health and Their Implications for Hepatitis C Virus Treatment in People Who Inject Drugs: The Case of Baltimore

Background

Sixty-eight percent of the nearly 3.5 million people living with hepatitis C virus (HCV) in the United States are people who inject drugs (PWID). Despite effective treatments, uptake remains low in PWID. We examined the social determinants of health (SDoH) that affect the HCV care cascade.

Methods

We conducted a secondary analysis of data from 720 PWID in a cluster-randomized trial. We recruited PWID from 12 drug-affected areas in Baltimore. Inclusion criteria were injection in the prior month or needle sharing in the past 6 months. Intake data consisted of a survey and HCV testing. Focusing on SDoH, we analyzed self-report of (1) awareness of HCV infection (in those with active or previously cured HCV) and (2) prior HCV treatment (in the aware subgroup). We used descriptive statistics and logistic regression for statistical analyses.

Results

The 342 participants were majority male and Black with a median age of 52 years. Women were more likely to be aware of their status but less likely to be treated. Having a primary care provider and HIV-positive status were associated with increased awareness and treatment. Unhoused people had 51% lower odds of HCV treatment. People who reported that other PWID had shared their HCV status with them had 2.3-fold higher odds of awareness of their own status.

Conclusions

Further study of gender disparities in HCV treatment access is needed. Increased social support was associated with higher odds of HCV treatment, suggesting an area for future interventions. Strategies to identify and address SDoH are needed to end HCV.

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.

Staff-Facilitated Telemedicine Care Delivery for Treatment of Hepatitis C Infection among People Who Inject Drugs

BACKGROUND

Telemedicine offers the opportunity to provide clinical services remotely, thereby bridging geographic distances for people engaged in the medical system. Following the COVID-19 pandemic, the widespread adoption of telemedicine in clinical practices has persisted, highlighting its continued relevance for post-pandemic healthcare. Little is known about telemedicine use among people from socially marginalized groups.

METHODS

The No One Waits (NOW) Study is a single-arm clinical trial measuring the acceptability, feasibility, and safety of an urban point-of-diagnosis hepatitis C (HCV) treatment initiation model delivered in a non-clinical community setting. Participants enrolled in the NOW Study are recruited via street outreach targeting people experiencing homelessness and injecting drugs. Throughout the NOW Study, clinical care is delivered through a novel staff-facilitated telemedicine model that not only addresses geographic and transportation barriers, but also technology and medical mistrust, barriers often unique to this population. While clinicians provide high-quality specialty practice-based care via telemedicine, on-site staff provide technical support, aid in communication and rapport, and review the clinicians' instructions and next steps with participants following the visits. Research questionnaires collect information on participants' experience with and perceptions of telemedicine (a) prior to treatment initiation and (b) at treatment completion.

DISCUSSION

For people from socially marginalized groups with HCV infection, creative person-centered care approaches are necessary to diagnose, treat, and cure HCV. Although non-clinical, community-based staff-facilitated telemedicine requires additional resources compared to standard-of-care telemedicine, it could expand the reach and offer a valuable entrance into technology-delivered care for socially marginalized groups.

TRIAL REGISTRATION

NCT03987503.

Barriers to Hepatitis C Treatment and Interest in Telemedicine-Based Care Among Clients of a Syringe Access Program

Background

Sharing equipment for injection drug use is the most common mode of hepatitis C virus (HCV) transmission in the United States, yet people who inject drugs (PWID) historically have low rates of HCV treatment. New strategies are needed to expand access to HCV treatment among PWID. Co-locating HCV treatment at syringe access programs (SAPs) reduces barriers to treatment, and telemedicine-based treatment programs could expand access further.

Methods

To evaluate interest in a co-localized or telemedicine-based program at an SAP in Denver, Colorado, we surveyed 171 SAP clients to understand barriers to HCV treatment and comfort with various appointment modalities.

Results

Eighty-nine of the surveyed SAP clients (52%), 50 of whom had not completed treatment, reported current or prior HCV infection. The most commonly cited reasons for not seeking HCV treatment were ongoing drug use, logistic barriers, and medical system barriers. Eighty-eight percent of clients with HCV reported that they would be more likely to get treatment if they were able to do so at the SAP, and the rate was higher among people who reported reluctance to seek medical care in general (98% vs 77%, P = .011). In-person appointments were preferred, though 77% of respondents were comfortable with a video appointment. However, only 60% of SAP clients reported having access to a phone, and fewer (48%) had access to video capability.

Conclusions

These findings suggest that telemedicine-based treatment at an SAP could improve access to HCV treatment, but successful implementation would require attention to barriers impacting clients' ability to participate in telemedicine appointments.

Wiidookaage'Win: A Community-Based Qualitative Approach to Developing a Facebook Group Intervention for Native Women to Support Recovery From Opioid Use

PURPOSE

To develop a culturally-tailored American Indian/Alaska Native (AI/AN) women's Facebook group supporting opioid recovery as an adjunct to medication.

DESIGN

Community-based, qualitative approach.

SETTING

Minnesota, U.S.

PARTICIPANTS

AI/AN women in opioid recovery, interested parties, and a Community Advisory Committee (CAC) of AI/AN women with lived experience, health care providers, and community members.

INTERVENTION

We developed evidence-based content focusing on stress/trauma and substance use, mindfulness, responding to triggers, and supportive community resources. Additional content centered on AI/AN culture was also selected.

METHOD

Interviews were conducted by two women, then transcribed and coded using content analysis with NVivo software. Results were presented to CAC for further content refinement.

RESULTS

CAC members (n = 10) guided study methods, intervention development, and dissemination activities. 14 AI/AN women (mean age 36.4 years; mean 6.7 months opioid abstinence) and 12 interested parties (7 men, 5 women) were receptive to an AI/AN gender-specific Facebook group, preferring content with AI/AN people and/or text resonating with AI/AN culture (e.g., Native traditions, family, personal stories, historical trauma). Recommendations included (1) protect confidentiality, (2) retain positivity, (3) incorporate resources and exercises to build coping skills, and (4) moderators should be authentic and relatable to build trust.

CONCLUSIONS

Our approach provides a model for developing culturally tailored, appealing and effective social media interventions to support AI/AN women in recovery from opioid use disorder.

Confirming Eight-Factor Structure of the Substance Use Motives Measure in a Sample of US College Students

The 2020 National Survey on Drug Use indicates nearly three quarters of individuals ages 18-25 have used substances in the past year. Research suggests individuals who use substances to cope with negative mood states are typically more substance-involved, report more psychological distress, and have a more extensive treatment history. Additionally, the high rate of polysubstance use among substance using adults in the U.S. highlights the need for broadband measures that can adequately capture use, consequences, and motivations for use of multiple substances. However, most measures assessing motives for use are typically substance specific. Recently, Biolcati and Passini (2019) developed a brief, but comprehensive model of broad substance use motives (i.e., Substance Use Motives Measure, SUMM) based on well-established motives questionnaires (e.g., DMQ-R, MMQ). They found support for their proposed eight-factor model in an online sample of Italian citizens (ages 18-60). No studies to date have examined the psychometric properties of the SUMM with an English-speaking or US college student sample. The current study evaluates the factor structure of the SUMM in a sample of 143 college students (74.8% female, 77.6% White, and 94.4% non-Hispanic/Latinx) at a large, southeastern university in the United States. Results of a confirmatory factor analysis showed support for the previously identified eight-factor structure for the SUMM, with acceptable model fit and internal consistency of each factor found. Findings support using the SUMM as a broad measure of substance use motives, but more research is needed to assess measurement invariance across different groups and to evaluate external, concurrent, and convergent validity using other well-established measures of substance use motives, severity, and psychiatric symptomatology.

Characterizing Opioid Withdrawal Experiences and Consequences Among a Community Sample of People Who Use Opioids

BACKGROUND

Opioid withdrawal symptoms are a highly salient and consequential health condition experienced by people who use opioids (PWUO). This study utilized qualitative interviews to explore opioid withdrawal experiences and consequences among PWUO in Los Angeles County, USA.

METHODS

Semi-structured qualitative interviews were conducted with 22 PWUO (aged 27-63 years) between May 2021 and May 2022. Participants self-reported opioid and injection drug use in the last 30 days. We employed an inductive thematic approach to systematically code and synthesize textual interview data.

RESULTS

Participants experienced withdrawal symptoms frequently, with many going to great lengths to avoid them. Withdrawal pain was described as incapacitating and interfered with PWUO's ability to sustain regular employment and ensure stable housing. Avoiding withdrawal was described as influential in driving decisions to continue using opioids. Mechanisms for managing withdrawal included using other substances to the point of sedation. PWUO who transitioned from heroin to fentanyl use revealed more frequent, painful, and faster onset of withdrawal symptoms. Adverse withdrawal experiences and fear of precipitated withdrawal from buprenorphine were barriers to treatment initiation and continuation.

CONCLUSION

Withdrawal symptoms among PWUO increase health risk. Improved strategies to treat opioid withdrawal are urgently needed. Solutions such as safe supply and intentional opioid withdrawal interventions (educational trainings, withdrawal comfort kits) are needed to improve withdrawal management and reduce opioid-related harm.

Association of spatial proximity to fixed-site syringe services programs with HCV serostatus and injection equipment sharing practices among people who inject drugs in rural New England, United States

BACKGROUND

Hepatitis C virus (HCV) disproportionately affects rural communities, where health services are geographically dispersed. It remains unknown whether proximity to a syringe services program (SSP) is associated with HCV infection among rural people who inject drugs (PWID).

METHODS

Data are from a cross-sectional sample of adults who reported injecting drugs in the past 30 days recruited from rural counties in New Hampshire, Vermont, and Massachusetts (2018-2019). We calculated the road network distance between each participant's address and the nearest fixed-site SSP, categorized as ≤ 1 mile, 1-3 miles, 3-10 miles, and > 10 miles. Staff performed HCV antibody tests and a survey assessed past 30-day injection equipment sharing practices: borrowing used syringes, borrowing other used injection equipment, and backloading. Mixed effects modified Poisson regression estimated prevalence ratios (aPR) and 95% confidence intervals (95% CI). Analyses were also stratified by means of transportation.

RESULTS

Among 330 PWID, 25% lived ≤ 1 mile of the nearest SSP, 17% lived 1-3 miles of an SSP, 12% lived 3-10 miles of an SSP, and 46% lived > 10 miles from an SSP. In multivariable models, compared to PWID who lived within 1 mile of an SSP, those who lived 3 to 10 miles away had a higher prevalence of HCV seropositivity (aPR: 1.25, 95% CI 1.06-1.46), borrowing other used injection equipment (aPR: 1.23, 95% CI 1.04-1.46), and backloading (aPR: 1.48, 95% CI 1.17-1.88). Similar results were observed for PWID living > 10 miles from an SSP: aPR [HCV]: 1.19, 95% CI 1.01-1.40; aPR [borrowing other used equipment]:1.45, 95% CI 1.29-1.63; and aPR [backloading]: 1.59, 95% CI 1.13-2.24. Associations between living 1 to 3 miles of an SSP and each outcome did not reach statistical significance. When stratified by means of transportation, associations between distance to SSP and each outcome (except borrowing other used injection equipment) were only observed among PWID who traveled by other means (versus traveled by automobile).

CONCLUSIONS

Among PWID in rural New England, living farther from a fixed-site SSP was associated with a higher prevalence of HCV seropositivity, borrowing other used injection equipment, and backloading, reinforcing the need to increase SSP accessibility in rural areas. Means of transportation may modify this relationship.

A Composite Score for Predicting Vertical Transmission of Hepatitis C: A Multicenter Study

BACKGROUND

Prevention of the vertical transmission of the hepatitis C virus (HCV) presents an obstetric challenge. There are no approved antiviral medications for the treatment or prevention of HCV for pregnant patients.

OBJECTIVE

We aimed to create a composite score to accurately identify a population of pregnant patients with HCV who have high potential for vertical transmission.

STUDY DESIGN

In a retrospective, multicenter cohort study, we identified pregnant patients with hepatitis C with linked data to their infants who have had HCV RNA or HCV antibody testing. Demographic data, including age and race/ethnicity, as well as clinical and laboratory data, including tobacco/alcohol use, infections, liver function tests, the HCV RNA titer, HCV antibody, HCV genotype, absolute lymphocyte count, and platelet count, were collected. Data were analyzed using logistic regression and receiver operating characteristics (ROCs) and internally validated using the forward selection bootstrap method.

RESULTS

We identified 157 pregnant patients and 163 corresponding infants. The median maternal delivery age was 29 (IQR: 25-33) years, and the majority (141, or 89.8%) were White. A high HCV RNA titer, high absolute lymphocyte count, and high platelet count were associated with vertical transmission. A high HCV RNA titer had an AUROC of 0.815 with sensitivity, specificity, a positive predictive value, and a negative predictive value of 100.0%, 59.1%, 17.6%, and 100.0%, respectively. A composite score combining the three risk factors had an AUROC of 0.902 (95% CI = 0.840-0.964) but with a risk of overfitting.

CONCLUSIONS

An HCV RNA titer alone or a composite score combining the risk factors for HCV vertical transmission can potentially identify a population of pregnant patients where the rate of vertical transmission is high, allowing for potential interventions during antepartum care.

Screening for hepatitis C as part of an opioid stewardship quality improvement initiative: Identifying infected patients and analyzing linkage to care

Screening patients with opioid use disorder (OUD) for HCV can potentially decrease morbidity and mortality if HCV-infected individuals are linked to care. We describe a quality improvement initiative focused on patients with OUD, incorporating an electronic health record decision-support tool for HCV screening across multiple health care venues, and examining the linkage to HCV care. Of 5829 patients with OUD, 4631 were tested for HCV (79.4%), (compared to a baseline of 8%) and 1614 (27.7%) tested positive. Two hundred and thirty patients had died at the study onset. Patients tested in the acute care and emergency department settings were more likely to test positive than those in the ambulatory setting (OR = 2.21 and 2.49, p < 0.001). Before patient outreach, 279 (18.2%) HCV-positive patients were linked to care. After patient outreach, 326 (23.0%) total patients were linked to care. Secondary end points included mortality and the number of patients who were HCV-positive who achieved a cure. The mortality rate in patients who were HCV-positive (12.2%) was higher than that in patients who were HCV-negative (7.4%) (OR = 1.72, p < 0.001) or untested patients (6.2%) (OR = 2.10, p<0.001). Of the 326 with successful linkage to care, 113 (34.7%) had a documented cure. An additional 55 (16.9%) patients had a possible cure, defined as direct acting antiviral ordered but no follow-up documented, known treatment in the absence of documented sustained viral response lab draw, or documentation of cure noted in outside medical records but unavailable laboratory results. A strategy utilizing electronic health record decision-support tools for testing patients with OUD for HCV was highly effective; however, linking patients with HCV to care was less successful.

Updates on syringe coverage and service uptake among needle and syringe programs in the United States, 2019-2020

BACKGROUND

As injection drug use has increased in the US, so too has the prevalence of receptive syringe sharing. Since the 1980s, Needle and Syringe Programs (NSPs) have been an important source of clean injection equipment and disposal of used syringes. This study reports national syringe coverage and examines the impact of program attributes on organizational-level service uptake, defined as number of syringes distributed per participant contact per year.

METHODS

In 2019 and 2020, we administered an annual cross-sectional survey to NSPs operating in the US (n = 260). A national estimate of coverage was calculated by dividing the total number of syringes distributed by the 2019 and 2020 population estimate of people who inject drugs (PWID). Frequency distributions and percentages were calculated for categorical variables (e.g., funding, census region, distribution policy/modality), and median and interquartile ranges (IQR) were calculated for continuous variables (e.g., participant contacts, syringes distributed). Bivariate and multivariable mixed effects logistic regression models were used to estimate the odds ratio associated with organizational characteristics on increasing service uptake at the NSP level.

RESULTS

From 2019 to 2020, the total number of participant contacts by NSPs increased from 871,976 to 898,891, and the number of syringes distributed increased from 92,648,529 to 113,071,748. The national coverage estimate increased from 29.5 (95 % CI = 15.0, 58.2) to 35.8 (95 % CI = 18.2, 70.6) syringes per PWID. Fifty-eight percent of NSPs increased service uptake in 2020 as compared to the previous year. NSPs that received government funding and NSPs that changed to a less restrictive syringe distribution policy were more likely to increase service uptake (aOR 1.80, 95 % CI = 1.01, 3.22 and aOR 3.33, 95 % CI = 1.11, 9.94, respectively). Syringe distribution modalities also diversified, with more NSPs reaching participants via backpacking/outreach, fixed site pop-ups, mobile delivery, mail-based delivery, leaving supplies out, and secondary distribution.

CONCLUSION

Both governmental investment in harm reduction programming and needs-based distribution of syringes increased service uptake and thus should be expanded and sustained to reduce harms associated with injection drug use.

Kidney Transplantation From Brain-Dead Donors With Hepatitis B or C in South Korea: A 2015 to 2020 Korean Organ Transplantation Registry Data Analysis

BACKGROUND

According to the current Center for Korean Network for Organ Sharing guidelines for kidney transplantation from brain-dead donors with hepatitis B or C infection, organs from hepatitis B surface antigen-positive (HbsAg+) or anti-hepatitis C virus-positive (HCV+) donors can only be transplanted into HBsAg+ or anti-HCV+ recipients. We aimed to confirm the status and the outcomes of kidney transplantation from brain-dead donors with hepatitis B or C virus in Korea.

METHODS

This retrospective study included all kidney transplantations from brain-dead donors in the Korean Organ Transplantation Registry database between January 2015 and June 2020, divided into 3 groups according to donor hepatitis status. Finally, kidney transplantations from 80 HBV+, 12 HCV+, and 2013 HBV-/HCV- donors were included.

RESULTS

No statistically significant differences were observed in the recipient characteristics and the transplant outcomes except the waiting time (HBV+ to HBV-/HCV-, P < .001; HCV+ to HBV-/HCV-, P = .10; HBV+ to HCV+P = .95). Five-year graft survival rates of the HBV+, HCV+, and HBV-/HCV- recipients were 95%, 83%, and 85%, respectively (HBV+ to HCV+, P = .22; HCV+ to HBV-/HCV-, P = .81; HBV+ to HBV-/HCV-, P = .02). Five-year patient survival rates of the HBV+, HCV+, and HBV-/HCV- recipients were 95%, 100%, and 76%, respectively (HBV+ to HCV+, P = .61; HCV+ to HBV-/HCV-, P = .13; HBV+ to HBV-/HCV-, P < .001).

CONCLUSION

HBV+/HCV+ brain-dead donor kidney transplantation outcomes were comparable to HBV-/HCV-. South Korea should consider conditionally permitting transplantation from HBV+ or HCV+ donors to HBV- or HCV- recipients to accumulate new data and conduct further studies.

Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

Hepatitis C infection seroprevalence in pregnant women worldwide: a systematic review and meta-analysis

Background

Monitoring progress towards the WHO global target to eliminate hepatitis C virus (HCV) infection by 2030, entails reliable prevalence estimates for HCV infection in different populations. Little is known about the global burden of HCV infection in pregnant women. Here, for the first time to our knowledge, we estimated the global and regional seroprevalence of HCV antibody (Ab) and determinants in pregnant women.

Methods

In this systematic review and meta-analysis study, we searched PubMed/MEDLINE, Web of Science, Embase, Scopus, and SciELO databases for peer-reviewed observational studies between January 1, 2000 and April 1, 2023, without language or geographical restrictions. Pooled global seroprevalence (and 95% confidence interval, CI) were estimated using random-effects meta-analysis and seroprevalences were categorised according to World Health Organization regions and subregions, publishing year, countries' income and human development index (HDI) levels. We used sensitivity analysis to assess the effect of four large sample size studies on pooled global prevalence through the "leave-one-out" method. We also investigated the association of potential risk factors with HCV seropositivity in pregnant women by subgroup and meta-regression analyses. The Protocol was registered in PROSPERO CRD42023423259.

Findings

We included 192 eligible studies (208 datasets), with data for 148,509,760 pregnant women from 53 countries. The global seroprevalence of HCV Ab in pregnant women was 1.80% (95% CI, 1.72-1.89%) and 3.29% (3.01-3.57%) in overall and sensitivity analyses, respectively. The seroprevalence was highest in the Eastern Mediterranean region (6.21%, 4.39-8.29%) and lowest in the Western Pacific region (0.75%, 0.38-1.22%). Subgroup analysis indicated that the seroprevalence of HCV Ab among pregnant women was significantly higher for those with opioid use disorder (51.94%, 95% CI: 37.32-66.39) and HIV infection (4.34%, 95% CI: 2.21-7.06%) than for the general population of pregnant women (1.08%, 95% CI: 1.02-1.15%), as confirmed by multivariable meta-regression (p < 0.001). A significant decreasing trend was observed with increasing human development index levels. Other important risk factors for HCV seropositivity included older age, lower educational levels, poly sexual activity, history of blood transfusion, hospitalization, surgery, abortion and sexual transmitted diseases, having scarification/tattoo or piercing, and testing hepatitis B positive.

Interpretation

This meta-analysis showed relatively high burden of exposure to HCV infection (2.2-5.3 million) in pregnant women globally. However, due to substantial heterogeneity between studies, our estimates might be different than the true seroprevalence. Our findings highlighted the need to expand HCV screening for women of reproductive age or during pregnancy, particularly in countries with high prevalence; as well as for more studies that assess safety of existing therapeutic drugs during pregnancy or potentially support development of drugs for pregnant women.

Funding

There was no funding source for this study.

Mobile service delivery in response to the opioid epidemic in Philadelphia

BACKGROUND

The harms of opioid use disorder (OUD) and HIV infection disproportionately impact marginalized populations, especially people experiencing homelessness and people who inject drugs (PWID). Mobile OUD service delivery models are emerging to increase access and reduce barriers to OUD care. While there is growing interest in these models, there is limited research about the services they provide, how they operate, and what barriers they face. We characterize the capacity, barriers, and sustainment of mobile OUD care services in a large city with a high incidence of OUD and HIV.

METHODS

From May to August 2022, we conducted semi-structured interviews with leadership from all seven mobile OUD care units (MOCU) providing a medication for OUD or other substance use disorder services in Philadelphia. We surveyed leaders about their unit's services, staffing, operating location, funding sources, and linkages to care. Leaders were asked to describe their clinical approach, treatment process, and the barriers and facilitators to their operations. Interview recordings were coded using rapid qualitative analysis.

RESULTS

MOCUs are run by small, multidisciplinary teams, typically composed of a clinician, one or two case managers, and a peer recovery specialist or outreach worker. MOCUs provide a range of services, including medications for OUD, wound care, medical services, case management, and screening for infectious diseases. No units provide methadone, but all units provide naloxone, six write prescriptions for buprenorphine, and one unit dispenses buprenorphine. The most frequently reported barriers include practical challenges of working on a MOCU (e.g. lack of space, safety), lack of community support, and patients with substantial medical and psychosocial needs. Interviewees reported concerns about funding and specifically as it relates to providing their staff with adequate pay. The most frequently reported facilitators include positive relationships with the community, collaboration with other entities (e.g. local nonprofits, the police department, universities), and having non-clinical staff (e.g. outreach workers, peer recovery specialists) on the unit.

CONCLUSIONS

MOCUs provide life-saving services and engage marginalized individuals with OUD. These findings highlight the challenges and complexities of caring for PWID and demonstrate a need to strengthen collaborations between MOCU providers and the treatment system. Policymakers should consider programmatic funding for permanent mobile OUD care services.

Trends in Hepatitis C Virus and HIV Care Outcomes Among People With HIV in Georgia, United States, 2014-2019

OBJECTIVE

If untreated, hepatitis C virus (HCV) leads to poor health outcomes, including liver disease and death, particularly among people with HIV (PWH). We describe trends over time in incidence rates of HCV diagnoses among PWH in the state of Georgia.

METHODS

We constructed a retrospective cohort of PWH in Georgia by using matched HIV and HCV case surveillance data from people diagnosed with HCV infection from January 1, 2014, through December 31, 2019. We calculated annual incidence rates per 1000 person-years and estimated trends over time in HCV diagnoses among the cohort of PWH by demographic characteristics and HIV care outcomes using Poisson regression analysis, with α = .05 considered significant.

RESULTS

From 2014 through 2019, among 49 530 PWH in Georgia, 1945 (3.9%) were diagnosed with HCV infection. During this period, overall incidence per 1000 person-years of newly diagnosed HCV infection among PWH decreased from 8.7 to 4.5 (P for trend < .001). However, from 2014 through 2019, the annual incidence rates of PWH who were newly diagnosed with HCV infection increased from 4.6 to 7.1 (P for trend = .003) among people born from 1980 through 1989 and from 3.3 to 12.8 (P for trend < .001) among people born in 1990 or later.

CONCLUSION

Strategies are needed to increase prevention, diagnosis, and treatment of HIV/HCV coinfection, particularly among PWH born in 1980 and later. Routine linkage of state surveillance data can inform prioritization of PWH at highest risk of HCV infection.

CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children - United States, 2023

The elimination of hepatitis C is a national priority (https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf). During 2010-2021, hepatitis C virus (HCV) acute and chronic infections (hereinafter referred to as HCV infections) increased in the United States, consequences of which include cirrhosis, liver cancer, and death. Rates of acute infections more than tripled among reproductive-aged persons during this time (from 0.8 to 2.5 per 100,000 population among persons aged 20-29 years and from 0.6 to 3.5 among persons aged 30-39 years). Because acute HCV infection can lead to chronic infection, this has resulted in increasing rates of HCV infections during pregnancy. Approximately 6%-7% of perinatally exposed (i.e., exposed during pregnancy or delivery) infants and children will acquire HCV infection. Curative direct-acting antiviral therapy is approved by the Food and Drug Administration for persons aged ≥3 years. However, many perinatally infected children are not tested or linked to care. In 2020, because of continued increases in HCV infections in the United States, CDC released universal screening recommendations for adults, which included recommendations for screening for pregnant persons during each pregnancy (Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC recommendations for hepatitis C screening among adults-United States, 2020. MMWR Recomm Rep 2020;69[No. RR-2]:1-17). This report introduces four new CDC recommendations: 1) HCV testing of all perinatally exposed infants with a nucleic acid test (NAT) for detection of HCV RNA at age 2-6 months; 2) consultation with a health care provider with expertise in pediatric hepatitis C management for all infants and children with detectable HCV RNA; 3) perinatally exposed infants and children with an undetectable HCV RNA result at or after age 2 months do not require further follow-up unless clinically warranted; and 4) a NAT for HCV RNA is recommended for perinatally exposed infants and children aged 7-17 months who previously have not been tested, and a hepatitis C virus antibody (anti-HCV) test followed by a reflex NAT for HCV RNA (when anti-HCV is reactive) is recommended for perinatally exposed children aged ≥18 months who previously have not been tested. Proper identification of perinatally infected children, referral to care, and curative treatment are critical to achieving the goal of hepatitis C elimination.

Hepatitis C Virus Elimination in the United States: Challenges, Progress, and Future Steps

Hepatitis C virus (HCV) infection is a major public health challenge with a simple, highly efficacious, all-oral therapy (direct-acting antivirals) that can achieve cure. Owing to the ease of treatment, the World Health Organization outlined goals to eliminate HCV by the year 2030. However, unforeseen challenges have hampered progress, and few countries are on track to meet these goals. Significant disparities remain among priority populations because of barriers to care on the systemic, provider, and patient levels. In turn, many local, state, and national organizations have been persistent in tackling these barriers, the greatest of which is linkage to care. In 2023, the White House launched a multipronged national initiative to eliminate HCV infection. The resulting economic impact of the national HCV elimination program is estimated to yield a significant net cost savings of $18.1 billion within a 10-year period. This article addresses the barriers to HCV care in different priority populations and discusses innovative models of HCV care that have been introduced in the United States.

Field Testing the "Avoid the Needle" Intervention for Persons at Risk for Transitioning to Injecting Drug Use in Tallinn, Estonia and New York City, USA

This study aimed to field tested the "Avoid the Needle" (AtN) intervention to reduce transitions from non-injecting to injecting drug use in two different epidemiological settings. Respondent driven sampling was used to recruit current non-injecting drug users (NIDUs) in Tallinn, Estonia in 2018-19 and in New York City (NYC) in 2019-20. Both persons who had never injected and persons who had previously injected but not in the last 6 months were eligible; a structured interview was administered, a blood sample collected, and the intervention administered by trained interventionists. We recruited 19 non-injectors from Tallinn and 140 from NYC. Participants in Tallinn were younger and had begun using drugs at earlier ages than participants in NYC. The primary drugs used in Tallinn were amphetamine, fentanyl, and opioid analgesics, while in NYC they were heroin, cocaine, speedball, and fentanyl. Six-month follow-up data were obtained from 95% of participants in Tallinn. The study was interrupted by COVID-19 lockdown in NYC, but follow-up data were obtained from 59% of participants. There were minimal transitions to injecting: 1/18 in Tallinn and 0/83 in NYC. There were significant declines in the frequencies of using readily injectable drugs (fentanyl, amphetamine, heroin, cocaine) from baseline to follow-up in both sites (Cochran-Armitage tests for trend, χ2 = 21.3, p < 0.001 for New York City; and χ2 = 3.9, p = 0.048 for Tallinn). Reducing transitions into injecting is a potentially very important method for reducing HIV transmission and other harms of drug use. Further investigation and implementation of AtN type interventions is warranted.

Implementing a peer-supported, integrated strategy for substance use disorder care in an outpatient infectious disease clinic is associated with improved patient outcomes

BACKGROUND

Substance use disorder (SUD) and infectious disease (ID) care integration may lead to improvements in SUD and ID outcomes. We assessed implementation of integrating peer-supported SUD care in an outpatient ID setting.

METHODS

In this implementation study, we describe REcovery in Specialty care Through medication and OutREach (RESTORE), a low-threshold SUD program implemented in a Baltimore outpatient ID clinic. Key program components were clinician training and support in SUD care, prescription of SUD treatment medications, and peer-based psychosocial support provided by peer recovery specialists. We assessed clinician adoption of RESTORE and compared patient outcomes from baseline to 6 months.

RESULTS

Between January 2019 and January 2022, the number of ID clinicians (N=61) who prescribed buprenorphine increased eightfold from 3 (5%) to 24 (39%). Of 258 ID patients referred to RESTORE, 182 (71%) engaged, 137 consented to study participation. Mean age in the study sample was 52.1 (SD=10.4), 63% were male, 84% were Black/African-American. Among 127 (93%) who completed 6-month follow-up, fewer participants reported illicit/non-prescribed opioid use in the past 30 days at follow-up (32%) compared to baseline (52%; p<0.001). Similar reductions were noted for cocaine use (47% to 34%; p=0.006), emergency department visits (23% to 9%; p=0.002), and inpatient hospitalizations (15% to 7%; p=0.025).

CONCLUSION

SUD care integration into an outpatient ID care setting using a peer-supported implementation strategy was adopted by clinicians and improved clinical outcomes for patients. This strategy is a promising approach to treating people with infectious diseases and SUD.

Associations of hepatitis C virus (HCV) antibody positivity with opioid, stimulant, and polysubstance injection among people who inject drugs (PWID) in rural U.S. communities

BACKGROUND

People who inject drugs (PWID) in the rural U.S. often inject stimulants, alone or with opioids. The impact of these substance use patterns may influence HCV risk behaviors. This analysis examines the associations of HCV antibody positivity with injecting only opioids, only stimulants (methamphetamine/cocaine), and opioids and stimulants together among rural PWID.

METHODS

The Rural Opioid Initiative (ROI) consists of eight research sites that enrolled people who use drugs in rural communities in ten U.S. states from 2018 to 2020. This cross-sectional analysis included adult participants who resided in a study area and injected any drug in the past 30 days. The primary outcome was HCV antibody positivity. The exposure of interest was injection drug use classified as only opioids, only stimulants, separate injections of opioids and stimulants, and same-syringe injection of both in the past 30 days. We used multivariable log-binomial regression with generalized linear mixed models to generate prevalence ratios (P.R.) adjusted for demographics, injection history, health insurance, and substance use treatment.

RESULTS

Among 3,084 participants enrolled in the ROI, 1,982 met inclusion criteria. Most participants injected opioids and stimulants in the same syringe (34%) or separately (21%), followed by injecting only stimulants (26%), and injecting only opioids (19%). Half (51%) were HCV antibody positive. Compared to people who injected only stimulants, HCV antibody positivity was more prevalent among people who injected opioids alone (aPR=1.62, 95% CI:(1.29-2.03)), injected both opioids and stimulants separately (aPR=1.61, 95% CI:(1.32-1.95)), and in the same syringe (aPR=1.54, 95% CI:(1.28-1.85)).

CONCLUSION

HCV antibody positivity, indicating prior exposure, was highest among those who had recently injected opioids, alone or with stimulants. Additional nucleic acid testing is necessary to confirm active infection. More research is needed to determine the underlying causes of HCV antibody positivity by injection use.

Community-Based Point-of-Diagnosis Hepatitis C Treatment for Marginalized Populations: A Nonrandomized Controlled Trial

Importance

Disparities persist in testing and treatment for hepatitis C virus (HCV), leaving socially marginalized populations less likely to benefit from curative treatment. Linkage services are often insufficient to overcome barriers to navigating the medical system and contextual factors.

Objective

To determine the feasibility, acceptability, and safety of HCV treatment at the point of HCV infection diagnosis disclosure in a nonclinical community setting.

Design, Setting, and Participants

In this single-arm nonrandomized controlled trial conducted between July 1, 2020, and October 31, 2021, street-outreach recruitment targeted people experiencing homelessness and injecting drugs in an urban US community who were eligible for simplified HCV treatment.

Interventions

Study procedures were designed to reflect the community environment and services needed to provide HCV testing, disclosure, and treatment in a nonclinical site. The test-and-treat No One Waits (NOW) model of care provided a 2-week starter pack of 400 mg of sofosbuvir and 100 mg of velpatasvir at time of HCV RNA results disclosure. Participants were transitioned to insurance-provided sofosbuvir-velpatasvir when feasible to complete a 12-week treatment course.

Main Outcomes and Measures

The primary end point was sustained virologic response at posttreatment week 12 or later (SVR12). Acceptability end points were treatment initiation and completion. Safety end points were treatment discontinuation because of a late exclusion criterion and adverse events.

Results

Of the 492 people (median [IQR] age, 48 [37-58] years; 62 [71%] male) who underwent anti-HCV testing, 246 (50%) tested anti-HCV positive, and 111 (23%) tested HCV RNA positive and were eligible for simplified HCV treatment. Eighty-nine of the 111 eligible participants (80%) returned for confirmatory RNA results, and 87 (98%) accepted and initiated HCV treatment. Seventy (80%) were currently injecting drugs, 83 (97%) had an income below the poverty line, and 53 (61%) were currently unsheltered. Most had HCV genotype 1a (45 [52%]) or 3 (20 [23%]). Sixty-nine (79%) completed 12 weeks of sofosbuvir-velpatasvir treatment, 2 stopped treatment because of low adherence, and 16 were lost to follow-up. Of the 66 participants who completed treatment and had a successful blood draw, 61 (92%) had undetectable HCV RNA at treatment completion. Of the 87 treated patients, 58 achieved SVR12, leading to a treatment response of 67% (95% CI, 56%-76%) among the intention-to-treat group and 84% (95% CI, 73%-92%) among the per-protocol group. There were no adverse events, late exclusions, or deaths.

Conclusions and Relevance

In this nonrandomized controlled trial of HCV treatment at the point of diagnosis, the NOW model of care reduced steps between HCV testing and treatment initiation and resulted in high levels of treatment initiation, completion, and cure. The NOW model of care can expand the current HCV test-and-treat toolkit by reaching a broader population of marginalized communities and expediting curative therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03987503.

Enhancing Hepatitis A and B Vaccinations Through Electronic Clinical Decision Support Systems and Staff Education in a Correctional Facility

BACKGROUND

Despite the prevalence and risks for hepatitis A virus (HAV) and hepatitis B virus (HBV) infection and the availability of safe and effective vaccines, HAV/HBV vaccinations are disproportionately low in jails. This quality improvement project evaluated the effectiveness of clinical decision support systems: electronic standing orders to nurses, clinical alerts to nurses and healthcare providers, and secondarily staff education in enhancing HAV and HBV vaccination and knowledge of hepatitis infection.

METHODS

We distributed a validated self-report hepatitis knowledge questionnaire (α = 0.7-0.8) before and after an educational presentation to nurses, nurse practitioners, and physicians ( N = 26) at a Northeastern state jail and then embedded electronic clinical alerts and standing orders in the electronic medical record. The questionnaire assessed pre- and posteducation knowledge scores. The number of vaccine status screenings and vaccinations was retrieved from the electronic medical record 3 months pre- and post-implementation. Descriptive statistics and the Wilcoxon signed-ranks test were used for data analysis.

RESULTS

Twenty-one participants completed the pretest, 18 attended the educational intervention, and 15 completed the posttest. Vaccine status screening increased by 97.5%, and HAV and HBV vaccinations increased by 8.7%. Knowledge scores improved significantly post-intervention ( p = 0.04), with an effect size of r = 0.67).

DISCUSSION/CONCLUSION

Using the Donabedian quality of care model, we showed that quality initiatives are feasible in a jail setting. Implementing a clinical decision support system and education improved the vaccination rate, which may decrease HAV/HBV incidence in the jail and prevent community spread.

Phenotype and fate of liver-resident CD8 T cells during acute and chronic hepacivirus infection

Immune correlates of hepatitis C virus (HCV) clearance and control remain poorly defined due to the lack of an informative animal model. We recently described acute and chronic rodent HCV-like virus (RHV) infections in lab mice. Here, we developed MHC class I and class II tetramers to characterize the serial changes in RHV-specific CD8 and CD4 T cells during acute and chronic infection in C57BL/6J mice. RHV infection induced rapid expansion of T cells targeting viral structural and nonstructural proteins. After virus clearance, the virus-specific T cells transitioned from effectors to long-lived liver-resident memory T cells (TRM). The effector and memory CD8 and CD4 T cells primarily produced Th1 cytokines, IFN-γ, TNF-α, and IL-2, upon ex vivo antigen stimulation, and their phenotype and transcriptome differed significantly between the liver and spleen. Rapid clearance of RHV reinfection coincided with the proliferation of virus-specific CD8 TRM cells in the liver. Chronic RHV infection was associated with the exhaustion of CD8 T cells (Tex) and the development of severe liver diseases. Interestingly, the virus-specific CD8 Tex cells continued proliferation in the liver despite the persistent high-titer viremia and retained partial antiviral functions, as evident from their ability to degranulate and produce IFN-γ upon ex vivo antigen stimulation. Thus, RHV infection in mice provides a unique model to study the function and fate of liver-resident T cells during acute and chronic hepatotropic infection.

Geographic variation in HCV treatment penetration among people who inject drugs in Baltimore, MD

We evaluated geographic heterogeneity in hepatitis C virus (HCV) treatment penetration among people who inject drug (PWID) across Baltimore, MD since the advent of direct-acting antivirals (DAAs) using space-time clusters of HCV viraemia. Using data from a community-based cohort of PWID, the AIDS Linked to the IntraVenous Experience (ALIVE) study, we identified space-time clusters with higher-than-expected rates of HCV viraemia between 2015 and 2019 using scan statistics. We used Poisson regression to identify covariates associated with HCV viraemia and used the regression-fitted values to detect adjusted space-time clusters of HCV viraemia in Baltimore city. Overall, in the cohort, HCV viraemia fell from 77% in 2015 to 64%, 49%, 39% and 36% from 2016 to 2019. In Baltimore city, the percentage of census tracts where prevalence of HCV viraemia was ≥85% dropped from 57% to 34%, 25%, 22% and 10% from 2015 to 2019. We identified two clusters of higher-than-expected HCV viraemia in the unadjusted analysis that lasted from 2015 to 2017 in East and West Baltimore and one adjusted cluster of HCV viraemia in West Baltimore from 2015 to 2016. Neither differences in age, sex, race, HIV status, nor neighbourhood deprivation were able to explain the significant space-time clusters. However, residing in a cluster with higher-than-expected viraemia was associated with age, sex, educational attainment and higher levels of neighbourhood deprivation. Nearly 4 years after DAAs became available, HCV treatment has penetrated all PWID communities across Baltimore city. While nearly all census tracts experienced improvements, change was more gradual in areas with higher levels of poverty.

Diminished health and social outcomes among men who have sex with men who use drugs in Zimbabwe

No abstract available.

Implementing Promising Strategies to Reduce the Risk for Viral Hepatitis and Liver Cancer Among People Who Inject Drugs

PURPOSE

To describe a 3-year demonstration project with selected Centers for Disease Control and Prevention National Comprehensive Cancer Control Program (NCCCP) award recipients to build partnerships with local organizations to improve knowledge and awareness of the association between injecting drugs and the risk for viral hepatitis and liver cancer, improve delivery of viral hepatitis services, and implement comprehensive syringe services programs.

DESIGN

A mixed-methods descriptive evaluation of selected evidence-based interventions or promising strategies that each award recipient implemented based on the needs of their population.

SETTING

Selected provider and patient populations served by NCCCP award recipients in Iowa, Minnesota (American Indian Cancer Foundation), Mississippi, and West Virginia.

SUBJECTS

Four award recipients that implemented individually-tailored strategies and activities.

MEASURES

Processes were assessed through monitoring and tracking tools. Challenges, lessons learned, and recommendations were collected via qualitative interviews.

ANALYSIS

We used descriptive statistics to analyze quantitative data. We analyzed award recipient interviews using thematic analysis.

RESULTS

Activities were implemented across four strategies. Strong public-private partnerships, ongoing technical assistance, a deep understanding of individual populations, and a shared commitment to remaining flexible were main factors.

CONCLUSION

While challenges existed, award recipients implemented key strategies and activities in their populations. Findings contribute to the scaling of best practices to the larger cancer control community especially those whose populations are at higher risk for viral hepatitis.

Trends and correlates of abscess history among people who inject drugs in Massachusetts: A mixed methods exploration of experiences amidst a rapidly evolving drug supply

Background

Injection drug use poses significant risk for skin and soft tissue infections, such as abscesses. In places with endemic fentanyl and an increasingly contaminated drug supply, injecting and injection-related harms may be increasing, yet are understudied. We aimed to explore abscess prevalence, experiences, and themes among people who inject drugs (PWID) in the context of an evolving drug supply.

Methods

Between 2019 and 2022, we surveyed and interviewed Massachusetts- based PWID about current drug use behaviors and abscess experiences. Chi-square tests explored correlates of abscess history and trends for past-year abscess percentages over time. Transcribed interview data were analyzed to identify themes related to abscess risk and opportunities for intervention.

Results

Of the 297 PWID surveyed, 65.3% reported having an abscess at the injection site in their lifetime; 67.5% of these instances occurred within the last year. Reported past-year abscesses increased from 36.7% to 75.6% between 2019 and 2022. Correlates of past-year abscesses included frequent injection; methamphetamine, crack, or fentanyl use; and injection into the neck or calf. Methadone treatment was associated with significantly fewer recent abscesses. Interview data (n=151) confirmed the identified abscess risks, including syringe sharing and lack of hygienic supplies. Qualitative interviews provided additional data regarding healthcare provider stigma contributing to healthcare avoidance and the self-treatment of abscesses with adverse results.

Conclusions

Abscesses are an increasing concern among PWID residing in areas of high fentanyl prevalence and a contaminated drug supply. Community drug checking, overdose prevention sites, injection hygiene interventions, and improved access to care are indicated.

Implementing Better Standard Instruments for Detecting Cirrhosis in Hepatitis C Patients

An increasing number of hepatitis C diagnoses in the younger population could partly be due to the rising opioid epidemic and intravenous drug use. Using hepatic venous portal gradient (HVPG) and liver stiffness tests, this study investigates better early diagnostic markers in identifying cirrhosis-related complications compared to percutaneous liver biopsy in hepatitis C patients. Scholarly journal articles were surveyed using PubMed and MeSH terms. Articles published more than 15 years ago were excluded. Various databases from the New England Journal of Medicine and the Centers for Disease Control and Prevention were also referenced to support the hypothesis. There is substantial affirmation from cohort and clinical studies that transient elastography and HVPG can indicate advancing chronic inflammatory and fibrotic stages of cirrhosis in comparison to liver biopsy. Additionally, they are helpful in predicting overall mortality from complications such as esophageal varices. The use of liver stiffness measurements and HVPG appears to be equivalent and/or superior to liver biopsy in assessing advancing cirrhosis. As hepatitis C cases continue to rise, it is crucial to search for alternative methods to better suit the needs of the patients and to improve their overall prognosis and potential treatments. Liver biopsy as the gold standard for cirrhosis assessment is questionable when less invasive instrumental tools are available in practice that have been shown to predict progressing fibrosis.

Little Evidence for the Role of Disgust Sensitivity in Implicit Disgust to Images of White People Engaged in Injecting Drug Use (IDU)

Background: Previous research has shown that People Who Inject Drugs (PWID) are subject to public stigma, which affects access to, and provision and quality of, treatment and support services. Less is known about the socio-cognitive processes that support the development and maintenance of public stigma toward PWID. The present study investigated the role of disgust sensitivity in implicit disgust to injecting drug use. Methods: 126 participants took part in an online Implicit Association Task (IAT) measuring implicit disgust to pictorial stimuli of injecting drug use or medical injecting. Participants also completed The Disgust Scale Revised, Injecting Phobia Scale (Short Form), Attitudes to People Who Use Drugs (PWUD) scale and a substance use inventory. Results: Average IAT score was negative indicating significantly higher implicit disgust to injecting drug use. Hierarchical linear regression found that injecting phobia predicted implicit disgust to injecting drug use. Questionnaire measures of disgust did not predict implicit disgust. While animal reminder disgust and injecting phobia were significantly correlated with each other, animal reminder disgust did not predict implicit disgust scores. Conclusions: On the basis of our findings, stigma toward PWID may not be a result of feelings of disgust toward injecting drug use. We discuss findings in the context of the underlying cortical processes supporting implicit and explicit representations of disgust. Future research should seek to investigate neurophysiological evidence for disgust to and stigmatization of injecting drug use and the potential role of domains of disgust in this.

Screening for cervical cancer among women with behavioral health conditions-A systematic review

Cervical cancer screening is credited with dramatically reducing cervical cancer mortality in the United States. There is a lack of consensus on whether women with behavioral health conditions (mental health or substance use) receive cervical cancer screening at rates similar to women without the conditions. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we searched for articles and abstracts of conference proceedings in PubMed, EMBASE, Web of Science and the EBSCO databases: CINAHL, PsycINFO, Psychosocial and Behavioral Science Collection, Academic Search Premier Databases, and the ProQuest database Applied Social Sciences Index and Abstracts from January 1, 2000 to July 31, 2020. Eligibility criteria included studies conducted in the United States, published in English, and comparing cervical cancer screening rates of women with and without behavioral health conditions. Of 1,242 unique articles screened, 52 were included in the full text review. And after title/abstract/and full-text review, 14 articles met the eligibility criteria. Six studies examined both mental health and substance use conditions, two studies only examined substance use disorders, and six studies examined only mental health conditions. Substance use disorders were associated with a decreased likelihood of receiving screening. This study yeilded inconclusive findings on the relationship between mental health conditions and cervical cancer screening. More research is needed to better understand the relationship between behavioral health conditions and cervical cancer screening.