Correlates of Recent HIV Testing Among People Who Inject Drugs in Rural Areas: A Multi-site Cross-Sectional Study, 2018-2020

The Rural Opioid Initiative surveyed 2693 people who inject drugs (PWID) in eight rural U.S. areas in 2018-2020 about self-reported HIV testing in the past 6 months. Correlates of interest included receipt of any drug-related services, incarceration history, and structural barriers to care (e.g., lack of insurance, proximity to syringe service programs [SSP]). Overall, 20% of participants reported receiving an HIV test within the past 6 months. Multivariable generalized estimating equations showed that attending substance use disorder (SUD) treatment (OR 2.11, 95%CI [1.58, 2.82]), having health insurance (OR 1.42, 95%CI [1.01, 2.00]) and recent incarceration (OR 1.49, 95%CI [1.08, 2.04]) were positively associated with HIV testing, while experiencing a resource barrier to healthcare (inability to pay, lack of transportation, inconvenient hours, or lack of child care) had inverse (OR 0.73, 95%CI [0.56, 0.94]) association with HIV testing. We found that the prevalence of HIV testing among rural PWID is low, indicating an unmet need for testing. While SUD treatment or incarceration may increase chances for HIV testing for rural PWID, other avenues for expanding HIV testing, such as SSP, need to be explored.

Hepatitis C Treatment Knowledge and Practice Among Family Medicine Physicians in Wisconsin During the Current Hepatitis C Epidemic

BACKGROUND

Curative treatment for hepatitis C virus (HCV) exists, making elimination of HCV possible. However, most people with HCV have not received treatment. One barrier is limited access to treatment providers. HCV treatment can be effectively provided by primary care providers and, since 2017, Wisconsin Medicaid allows nonspecialists to prescribe treatment. We surveyed family medicine physicians in Wisconsin to evaluate capacity for the provision of HCV treatment.

METHODS

We mailed a survey to family medicine physicians in Wisconsin from June 25, 2018 through September 7, 2018. Physicians were asked whether they prescribe HCV treatment and about their knowledge regarding HCV treatment and relevant statewide Medicaid policy. Using multivariable logistic regression, we evaluated physician characteristics associated with prescribing HCV treatment.

RESULTS

Of 1,333 physicians surveyed, 600 (45%) responded. Few respondents reported prescribing HCV treatment independently (1%; n = 4) or in consultation with a specialist (6%; n = 35). Only 6% (n = 36) reported having a "great deal" of knowledge about HCV treatment. Most (86%; n = 515) were not aware that family medicine physicians can now prescribe HCV treatment covered by Medicaid. Physicians who practiced in offices affiliated with health systems were less likely to prescribe HCV treatment than physicians who practiced in an independent office or a Rural Health Clinic.

CONCLUSIONS

Among family medicine physicians in Wisconsin, experience with and knowledge of HCV treatment was limited. Developing knowledge and skills among primary care providers is needed to expand treatment access and make progress toward HCV elimination. Studies are needed to evaluate treatment access in primary care offices affiliated with health systems.

Hepatitis C Virus Transmission Clusters in Public Health and Correctional Settings, Wisconsin, USA, 2016-20171

Ending the hepatitis C virus (HCV) epidemic requires stopping transmission among networks of persons who inject drugs. Identifying transmission networks by using genomic epidemiology may inform community responses that can quickly interrupt transmission. We retrospectively identified HCV RNA–positive specimens corresponding to 459 persons in settings that use the state laboratory, including correctional facilities and syringe services programs, in Wisconsin, USA, during 2016–2017. We conducted next-generation sequencing of HCV and analyzed it for phylogenetic linkage by using the Centers for Disease Control and Prevention Global Hepatitis Outbreak Surveillance Technology platform. Analysis showed that 126 persons were linked across 42 clusters. Phylogenetic clustering was higher in rural communities and associated with female sex and younger age among rural residents. These data highlight that HCV transmission could be reduced by expanding molecular-based surveillance strategies to rural communities affected by the opioid crisis.

Racial disparities in use of non-emergency outpatient care by Medicaid-eligible adults after release from prison: Wisconsin, 2015-2017

BACKGROUND

Black individuals with substance use disorders (SUD) are less likely to receive effective treatment and more likely to be incarcerated compared to White individuals. Despite this, research documenting racial disparities in healthcare use among people with SUD releasing from prison is limited.

OBJECTIVES

The goals of this study are to: 1) assess racial disparities in Medicaid enrollment among individuals released from prison with a history of substance use; and 2) characterize racial disparities in outpatient service use, emergency department (ED) use, and receipt of medication for opioid use disorder (MOUD) among those who do enroll in Medicaid.

METHODS

This study included individuals with a history of substance use that were released from Wisconsin state correctional facilities from April 2015 through June 2017. Medicaid enrollment and claims data were analyzed to compare healthcare utilization 6 months post-release between individuals identifying as Black, White, or other races. The total sample included 15,621 prison releases among 14,400 unique persons with a history of substance abuse.

RESULTS

Among the 15,621 prison releases, 10,836 (69.4%) were enrolled in Medicaid in the month of release. The proportion of prison releases among individuals of other races who enrolled in Medicaid (506/934, 54.2%) was significantly lower than the proportion among Black individuals (3679/5306, 69.3%) and White individuals (6651/9381, 70.9%). Among the subset of 7685 releases enrolled in Medicaid for 6 months post-release, 5040 (65.6%) had an outpatient visit within 6 months; 73.9% of White, 51.3% of Black, and 66.9% of other individuals. Relative to White individuals, Black individuals were 0.324 times less likely (P < 0.001) and individuals of other races were 0.591 times less likely (P = 0.004) to have an outpatient visit. Of the 7685 releases, 1016 (13.2%) had an ED visit within 6 months; 12.0% of White, 13.8% of Black and 25.1% of other individuals. Relative to White individuals, Black individuals were 1.23 times more likely (P = 0.019) and individuals of other races were 2.64 times more likely (P < 0.001) to have an ED visit. Black individuals were 0.100 times less likely (P < 0.001) and individuals of other races were 0.435 times less likely (P = 0.016) to receive MOUD post-release compared to White individuals.

CONCLUSIONS

Black adults with a history of substance use are significantly less likely than White adults to use non-emergency outpatient services after release from incarceration. Improving equitable access to outpatient services is needed to reduce health disparities across racial groups.

Prevalence of Tobacco Use Among Rural-Dwelling Individuals Who Inject Drugs

This cross-sectional study assesses the prevalence of smoking through a multisite survey of individuals aged 15 years or older living in rural Wisconsin who inject drugs.

Hepatitis A and Hepatitis B Vaccination Coverage Among Persons Who Inject Drugs and Have Evidence of Hepatitis C Infection

OBJECTIVES

Despite recommendations for vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) for all adults at increased risk of infection, several US states have reported increases in HAV and HBV infections among persons who inject drugs. We investigated hepatitis A and hepatitis B vaccination coverage among a sample of persons who reported injecting drugs and had evidence of hepatitis C virus (HCV) infection.

METHODS

We searched the Wisconsin Immunization Registry for the vaccination records of persons who underwent HCV testing at syringe services programs from January 1 through August 31, 2018, and were reported to the Wisconsin Division of Public Health as having positive HCV antibody test results and a history of injection drug use. We calculated the percentage of persons who were vaccinated according to national recommendations.

RESULTS

Of 215 persons reported, 204 (94.9%) had a client record in the Wisconsin Immunization Registry. Of these 204 persons, 66 (32.4%) had received ≥1 dose of hepatitis A vaccine, 46 (22.5%) had received 2 doses of hepatitis A vaccine, and 115 (56.4%) had received 3 doses of hepatitis B vaccine. Hepatitis B vaccine coverage decreased with increasing age, from 88.0% (22 of 25) among adults aged 20-24 to 30.3% (10 of 33) among adults aged 35-39.

CONCLUSIONS

These findings suggest that most persons who inject drugs in Wisconsin are susceptible to HAV infection and that most persons aged ≥35 who inject drugs are susceptible to HBV infection. In addition to routine vaccination of children, targeted hepatitis vaccination programs should focus on adults who inject drugs to help prevent future infections.

Association of blood cotinine level with cognitive and physical performance in non-smoking older adults

Background Studies show that active smoking may be associated with cognitive decline. However, the consequence of secondhand smoke on cognitive and physical performance remains unclear. The purpose of this study was to assess the association of secondhand smoke with cognitive performance and physical function using a population-based sample.

METHODS

Data of 2,542 non-smoking participants from the 1999-2002 National Health and Nutrition Examination Survey were analyzed. Secondhand smoke exposure level was estimated using blood cotinine concentrations. Cognitive performance was assessed with the Digit Symbol Substitution Test and self-reported confusion/memory problems. Physical performance was analyzed using visual gait speed (m/s) and self-reported physical function. Multivariate linear and logistic regression models were used to assess the association.

RESULTS

In never smokers, cognitive performance score decreased by 2.03 points (95% confidence interval (CI): -3.00, -1.05) per one unit increase in log-transformed blood cotinine level. After adjusting for potential confounders, including diabetes, hypertension, body mass index, alcohol, and blood lead level, change in cognitive performance score was still statistically significant (-1.17 95% CI: -2.32, -0.02). Similar trends were observed in former smokers. Gait speed decreased by 0.02m/s for one unit increase in log-transformed blood cotinine level. This was evident in both never and former smokers. The relationship remained significant after adjusting for potential confounders in former smokers.

CONCLUSIONS

Our study suggests that secondhand smoke may contribute to cognitive decline in never and former smokers. Considering the cross-sectional design and the limitations of this study, the relationship warrants further assessment.