The IMPACT (Infection Management Plus Addiction Care Together) Pilot: A Case Series of Combined Contingency Management for Substance Use Disorders and Antibiotic Adherence in the Hospital Setting

OBJECTIVES

Psychostimulant-related mortality is rising alongside increasing substance use-related hospitalizations, which are commonly complicated by patient-directed (or "against medical advice") discharges. Contingency management (CM) is an underused evidence-based treatment for substance use disorders with proven efficacy to support medication adherence. Our objective was to describe feasibility and preliminary effectiveness of a novel CM intervention incentivizing both drug use reduction and antibiotic adherence in the hospital setting.

METHODS

We conducted a pilot intervention of twice weekly CM for stimulant and/or opioid use disorder and antibiotic adherence conducted on inpatient wards and/or an embedded skilled nursing facility in an urban public hospital. Based on point-of-care urine drug test results and objective antibiotic adherence review, participants earned increasing opportunities to receive incentives. We measured feasibility via number of visits attempted and cost of gift cards dispensed. We evaluated effectiveness via antibiotic completion, discharge type, and participant perception of intervention effectiveness collected via structured survey.

RESULTS

Of 13 participants enrolled, most had opioid use disorder (fentanyl in 10/13) and stimulant use disorder (methamphetamine in 7/13). Almost all were receiving treatment for osteomyelitis and/or endocarditis (12/13). Feasibility challenges included competing demands of acute care with variable range of completed visits per participant (1-12 visits). Despite this, antibiotic completion was high (92%, 12/13 participants) with only two patient-directed discharges. Participants described CM as very effective in aiding infection treatment but had greater variability in beliefs regarding CM facilitation of reduced drug use.

CONCLUSIONS

Providing CM in the hospital setting may represent an effective approach to improving health outcomes by increasing antibiotic adherence and addressing substance use.

Multiple Retained Needles in the Neck of a Drug User: A Case Report

Retained needles are frequently observed in intravenous drug users. However, an incidental discovery of multiple needles at the neck seldom occurs. These foreign bodies remain either asymptomatic or cause local and central complications that can be fatal. We report the case of a 43-year-old male having a medical record of human immunodeficiency virus and hepatitis C who presented to our department with a 3-day history of a febrile lateral neck swelling. He reported a history of repetitive intravenous drug use and previous abscesses that were surgically drained. We noted a left and tender 8 cm neck swelling with torticollis. Computed tomography scan showed a collected myositis of the sternocleidomastoid muscle in association to multiple metallic foreign bodies at the neck that were compatible with the aspect of broken needles. Imagery also showed a thrombosis of the ipsilateral jugular vein. No central embolism of a foreign body was noted. We performed a surgical drainage of the muscular abscess and managed to retrieve a 1 cm broken needle that was retained at the level of the collection. We did not retrieve the other needles since they were asymptomatic. The patient was placed under intravenous antibiotics for 1 week followed by oral amoxicillin-clavulanate with a total regression of the cellulitis. At the further follow-ups, the rest of the foreign bodies remained asymptomatic. Our study emphasizes on the importance of suspecting a retained foreign body in intravenous drug users to ensure an adequate management of the possible complications and to protect the medical team from incidental needle injuries.

Hepatitis C virus point-of-care microelimination approach in a vulnerable population in the South of Spain

Background

Since the introduction of direct-acting antivirals, thousands of chronic hepatitis C patients have been successfully treated. However, vulnerable populations have a higher prevalence of hepatitis C virus (HCV) infection and face barriers that impede their access to antivirals. We carried out an HCV microelimination program focused on vulnerable population groups in Malaga.

Methods

People in drug addiction treatment centers and homeless shelters in Malaga who participated in the program between October 2020 and October 2021 were included. After providing participants with educational information on HCV, a dry drop test (DDT) was used to collect blood for subsequent screening for HCV infection. The participants who were diagnosed with HCV infection were scheduled for comprehensive healthcare assessments, including blood tests, ultrasonography, elastography, and the prescription of antivirals, all conducted in a single hospital visit. Sustained viral response (SVR) was analysed 12 weeks after end of treatment.

Results

Of the 417 persons invited to participate, 271 (65%) agreed to participate in the program. These participants were screened for HCV infection and 28 of them were diagnosed with HCV infection (10%). These hepatitis C-infected patients had a mean age of 53 ± 9 years; 86% were males and 93% were or had been drug users. Among 23 patients with HCV infection, HCV genotype 1a predominated (74%). Medical exams showed that 19% (4/21) had advanced fibrosis (F3-4), and 5% (1/21) had portal hypertension. Finally, 23 infected patients received treatment with glecaprevir/pibrentasvir or sofosbuvir/velpatasvir and SVR was confirmed in 22 patients (96%).

Conclusions

Drug users and homeless people have a higher prevalence of HCV infection than the general population. The microelimination program with educational activity and screening tools achieved a high participation rate, easy healthcare access, and a high rate of SVR despite the SARS-CoV-2 pandemic.

HCV RNA Quantification by a Domestic Commercial Assay: A Case Study among People Who Inject Drugs in Vietnam

The desired performance of nucleic acid testing (NAT) may vary if used for disease diagnosis or for the evaluation of the therapeutic efficacy of a treatment, although in most cases, the same assay is used. However, these tests may not be affordable in many situations including in low/middle income countries that in response have developed domestic assays. Given the example of HCV NAT among people who inject drugs in Vietnam, we aimed at evaluating a domestic assay versus an FDA- and CE-approved assay. This cross-evaluation revealed that (i) the domestic assay had a poorer sensitivity with a threshold of detection above 104 IU/mL, and (ii) the FDA-approved assay had a percentage of false negative results close to 1%. Together, in the present study, the domestic assay had a performance compatible with diagnosis purposes (given that this population was 70% HCV seropositive) but not compatible with HCV treatment monitoring (given that treatment failures are rare and the observed viremia frequently below the threshold of detection). This study highlights the need for a proper evaluation of HCV RNA domestic assays in order to efficiently contribute to the WHO HCV elimination target by 2030.

Hepatitis C Virus Elimination Program among Prison Inmates, Israel

The Israeli Prison Services implemented a hepatitis C virus (HCV) elimination program in 2020. Inmates considered high risk for HCV were offered serology; HCV-seropositive participants were offered HCV RNA testing. Among participants, 7.0% had detectable HCV RNA and were offered antiviral drug therapy. This program reduced HCV burden among incarcerated persons.

Recovery Capital Gains May Precede Craving Reduction in Opioid Use Disorder

Purpose

Cravings for drugs and alcohol have been significantly associated with worse treatment outcomes. We investigated if improvements in recovery capital (RC) (eg, a measure of social capital/network, financial resources, education, and cultural factors) over time were associated with decreased reported cravings.

Patients and Methods

The original cohort consisted of 133 participants (63 females) with opioid use disorder seeking outpatient treatment, who completed the Assessment of Recovery Capital (ARC) (range 0 to 50) and the Brief Addiction Monitor (BAM) thrice over the 6-month study. Intervention was medication and case management. Analysis included one-way mixed models testing change over time for ARC total scores and single question craving rating (5-point Likert scale). Cross-lagged panel estimates used structural equation models with variables z-scored, allowing for path coefficient evaluation as standard deviations (sd).

Results

Total ARC significantly increased over the study (χ2 = 33.77, df = 2, p < 0.0001), with baseline of 36.6 (n = 114, sd = 11.1) and 6-month of 41.2 (n = 107, sd = 9.5). Craving also changed significantly (χ2 = 8.51, df = 2, p < 0.015), with baseline of 1.1 (n = 101, sd = 1.2) and 6-month of 0.9 (n = 107, sd = 1.1). The cross-lag from baseline RC to 3-month craving was significant (β = -0.28, SE = 0.11, z = -2.53, p < 0.011). The converse was not true; baseline craving did not affect later RC. Results were similarly significant when comparing 3-month to 6-month. The majority of sample was on buprenorphine.

Conclusion

As RC improves, the reported cravings at both 3- and 6-month study time points are significantly reduced. When evaluated inversely, there was not a significant association with baseline cravings and follow-up RC. Significant path coefficients provide an estimation of a directional effect from increased RC towards craving reduction.

Reasons for leaving home and pattern of child abuse and substance misuse among street children in Khartoum, Sudan: a cross-sectional survey

Street children are particularly susceptible to health-related adversities, including those resulting from substance abuse and child abuse. Information on street children is deficient in Sudan. This study provides basic data on characteristics, factors for leaving home, the pattern of child abuse and substance misuse among street children in Khartoum State, Sudan. This is a descriptive, cross-sectional, and community-based study. Data were collected through direct questioning of a sample of street children using a structured, standardized, and pretested interview-administered questionnaire. Two hundred and seventy-five (275) street children were interviewed. Most street children were males (83%). Of the interviewed children, 36.7% were illiterate, 66.1% had a single parent, and 36% did not recognize a home to return to. The commonest reported reasons for being on the streets were family conflicts and financial/economic difficulties (28.4 % and 27.5%), respectively. 89.1% of the children admitted to being substance abusers, mostly of glue (86.5%) and smoked tobacco (67.3%). Seventy-five-point three percent 75.3% of the children reported being subjected to a form of abuse, with physical and sexual abuse reported by 70.2% and 27%, respectively. Of the 74 children who reported sexual abuse, 49 were males (29% of males), and 25 were females (65% of females). The survey results are thought to guide further research and shape appropriate policymaking and coordinated interventions by concerned stakeholders, whether governmental or non-governmental.

Looking at the Molecular Target of NS5A Inhibitors throughout a Population Highly Affected with Hepatitis C Virus

Hepatitis C virus (HCV) is associated with liver damage and an increased progression rate to cirrhosis and hepatocellular carcinoma. In Portugal, it is prevalent in vulnerable populations such as injection drug users (IDU). HCV is characterized by a high intra-host variability, and the selecting driving forces could select variants containing resistance-associated substitutions (RAS) that reduce treatment effectiveness. The main goal of this study was to analyze the sequence variation of NS5A in treatment-naïve IDU. The epidemiological and clinical status of hepatitis C were analyzed, and samples were sequenced by Sanger and Next-Generation sequencing (NGS) to assess RAS and confirm HCV subtypes. Phylogenetic classification was concordant: 1a, 52.4%; 1b, 10.7%; 3a, 20.2%; 4a, 8.3%; 4d, 7.1%; and one 2k/1b recombinant. A 1a/3a mixed infection was detected by NGS. RAS were found in 34.5% (29/84) of samples using Sanger sequencing, while in 42.9% (36/84) using NGS. In sequences from subtypes 1a and 1b, RAS K24R, M28V, Q30H/R, H58D/P/Q/R, and RAS L31M and P58S were detected, respectively. In subtype 3a, RAS A30S/T, Y93H and polymorphisms in position 62 were identified. Additionally, RAS P58L was detected in genotype 4. The strategy used for the molecular survey of baseline HCV resistance is of particular importance to achieve treatment effectiveness and contribute to the elimination of hepatitis C.

Towards hepatitis C elimination in France: Scanvir, an effective model to test and treat drug users on dedicated days

According to the French recommendations, the elimination of the hepatitis C virus by 2025 could be a realistic public health goal. Screening policies are being intensified, and access to treatment is promoted for patients who escape the usual care pathway. The 'Scanvir' program is an original strategy based on dedicated screening days, as part of the 'test, treat and cure HCV' event in addiction care centers in a French region, during which innovative screening technologies (RDTs, FibroScan® and point-of-care HCV RNA testing) are brought on site and access to a multidisciplinary team is offered. A total of 392 patients attended the 67 regional Scanvir sessions: 31.6% were HCV Ab-positive and 66% of them were HCV RNA-positive. Treatment was initiated in 79.3% of the patients. RDTs were accepted by 62% of the PWIDs (including those who already knew their status) and FibroScan® by 99.5% of the patients. 80% of the viremic patients started their treatment on site and are now cured or still under treatment. Advanced fibrosis evaluated by FibroScan® (LSM > 8 KPa) was suspected in 13.4% and 14.1% of the global and the HCV population, respectively. Scanvir is an efficient strategy for HCV elimination based on dedicated days aimed at increasing cost-effectiveness and offering a multidisciplinary service while saving human care resources. It is an exportable strategy that also offers comprehensive screening of associated chronic liver diseases via the elastometry device and interviews.

Occult hepatitis C infection identified in injection drug users with direct antiviral agents therapy and spontaneous resolution of hepatitis C virus infection

BACKGROUND

Occult hepatitis C infection (OCI) is characterized by the detection of hepatitis C virus (HCV) RNA in hepatocytes and in peripheral blood mononuclear cells (PBMCs) without detection in serum. We aimed to evaluate OCI in drug and no drug users who achieved sustained virological response (SVR) after therapy with direct-acting antivirals (DAAs) and with HCV spontaneous resolution.

METHODS

Twenty-four patients in the AVP group (who achieved a SVR after DAAs therapy), 13 in the NAVP group (with HCV spontaneous resolution) and 7 HCV-RNA positive patients (CPP, control positive group) were included in the study. HCV/OCI-RNA was screened in serum and PBMCs samples of the patients by ddPCR for OCI patients' identification. Plasma and red blood cells (RBCs) samples of the patients were also evaluated for HCV/OCI-RNA detection by ddPCR.

RESULTS

OCI was presented in injection drug users (IDUs) in the AVP (20.8%) and NAVP (23.1%) groups by ddPCR with a higher statistically significant percentage detected in RBCs samples of the patients in the AVP group comparatively to NAVP (p<0.01) and CPP (p < 0.05) groups.

CONCLUSION

OCI was identified in IDUs patients of the AVP and NAVP groups by ddPCR. These results suggest that OCI patients in the AVP group might not be entirely cured, and that OCI patients in the NAVP group were not identified at clinical evaluation time when just serum samples were analysed. A higher percentage of HCV/OCI-RNA was detected in RBCs samples. Overall results recommends that HCV/OCI identification in patients with DAAs therapy and spontaneous resolution of HCV infection should be studied more accurately in future and in larger patient groups if possible. Additionally, suggest also PBMCs and RBCs samples as predictors for HCV/OCI diagnosis and management.

Years of life lost due to unintentional drug overdose relative to the leading underlying causes of death in the United States: a comparative analysis of excess mortality 2017-2019

The present study aims to compare Years of Life Lost for unintentional drug overdose and the leading underlying causes of death in the United States annually from 2017 to 2019. Years of Life Lost provide valuable context to incident deaths when comparing the relative mortality burden of underlying causes of death. Prior research has shown unintentional drug overdose was the third leading cause of Years of Life Lost in the state of Ohio in 2017. However, this finding has yet to be replicated at the national level in the US. Death statistics for 2017-2019 were accessed via CDC WONDER. Years of Life Lost were calculated for unintentional drug overdose and each of the top five causes of incident deaths in the US during the study period. Unintentional drug overdose caused nearly seven million Years of Life Lost in the US during the three-year period of study and was the fourth leading cause of Years of Life Lost after cancer, heart disease and other accidents. Incidence alone provides an incomplete picture of the effect of unintentional drug overdose on overall mortality burden in the US. Years of Life Lost give critical context to the overdose crisis, underscoring unintentional drug overdose as a leading cause of premature mortality.

Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative

PURPOSE

We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs.

METHODS

We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data.

RESULTS

Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients.

CONCLUSIONS

OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.

Cocirculation and replacement of SARS-CoV-2 variants in crowded settings and marginalized populations along the US-Mexico border

OBJECTIVE

To interrogate the circulating SARS-CoV-2 lin-eages and recombinant variants in persons living in migrant shelters and persons who inject drugs (PWID).

MATERIALS AND METHODS

We combined data from two studies with marginalized populations (migrants in shelters and persons who inject drugs) in Tijuana, Mexico. SARS-CoV-2 variants were identified on nasal swabs specimens and compared to publicly available genomes sampled in Mexico and California.

RESULTS

All but 2 of the 10 lineages identified were predomi-nantly detected in North and Central America. Discrepan-cies between migrants and PWID can be explained by the temporal emergence and short time span of most of these lineages in the region.

CONCLUSION

The results illustrate the temporo-spatial structure for SARS-CoV-2 lineage dispersal and the potential co-circulation of multiple lineages in high-risk populations with close social contacts. These conditions create the potential for recombination to take place in the California-Baja California border.

Men who have sex with men: An approach to social network analysis

BACKGROUND

Dating apps for men who have sex with men (MSM) have favored unprotected sexual encounters; other unsafe practices, including drug use, are widespread. No evidence is available from the perspective of the structure of their relationships, a personal aspect included in all nursing meta-paradigms.

AIM

To study the structure of MSM networks through dating and contact applications and this relationship to risky sexual activities such as condom use, chemsex (sex while using drug), and group sex.

DESIGN

Descriptive cross-sectional study.

SAMPLE

A total of 32 MSM participants from Madrid (Spain).

MEASUREMENTS

Socio-demographic and structural variables with Social Network Analysis (SNA) metrics. Data on condom use, drug use during encounters, and group sex were included.

RESULTS

Twenty-five percent of respondents practiced chemsex, and 75% of these used poppers. MSM with higher socioeconomic status participated in group sex sessions more frequently than those with lower socioeconomics. Within the network analysis, the relationships strong showed greater ease in having unprotected anal intercourse.

CONCLUSION

SNA can be effective in the study of MSM sexual networks and their risk behaviors for community nurses to improve their interventions in sexual health promotion.

Spatial heterogeneity of risk factors associated with HIV prevalence among men who inject drugs in India: An analysis of the data from the integrated bio-behavioral surveillance, India

People who inject drugs (PWID) are India's third-largest vulnerable population to human immunodeficiency virus (HIV) infection. PWID in India are confined to certain geographic locations and exhibit varying injecting and sexual risk behaviors, contributing considerably to increasing HIV trends in specific regions. Spatial heterogeneity in risk factors among vulnerable PWID influences HIV prevalence, transmission dynamics, and disease management. Stratified analysis of HIV prevalence based on risk behaviors and geographic locations of PWID will be instrumental in strategic interventions. To stratify the male PWID based on their risk behaviors in each state and determine the HIV prevalence for each stratum. The behavioral data and HIV prevalence of the national integrated biological and behavioural surveillance (IBBS), a nationwide cross-sectional community-based study conducted in 2014 to 2015, was analyzed. Data from 19,902 men who inject drugs across 53 domains in 29 states of India were included. Women who inject drugs were excluded at the time of IBBS, and hence PWID in this study refers to only men who inject drugs. PWID were categorized based on their risk profile, and the corresponding HIV prevalence for each state was determined. HIV prevalence was the highest (29.6%) in Uttar Pradesh, with a high prevalence of risk behaviors among PWID. High HIV prevalence ranging between 12.1% and 22.4% was observed in a few states in East and North-East India and most states in central and North India. Unsafe injecting and sexual practices were significantly (P < .05) associated with higher HIV prevalence and more significantly in National Capital Territory of Delhi (P < .001). Unsafe injecting practices among PWID were proportionally higher in Western and Central India, whereas unsafe sexual behaviors were widespread among most states. Unsafe sexual practices among male PWID were common. The high prevalence of unsafe injecting had significant HIV infection and transmission risks in Western and Central India. The results emphasize the need for stratified, region-specific interventions and combination approaches for harm reduction among PWID. Strengthening the measures that facilitate the reduction of high-risk behaviors, adoption of safe practices, and utilization of HIV services will positively impact HIV prevention measures among PWID.

In a Real-Life Setting, Direct-Acting Antivirals to People Who Inject Drugs with Chronic Hepatitis C in Turkey

BACKGROUND

People who inject drugs (PWID) should be treated in order to eliminate hepatitis C virus in the world. The aim of this study was to compare direct-acting antivirals treatment of hepatitis C virus for PWID and non-PWID in a real-life setting.

METHODS

We performed a prospective, non-randomized, observational multicenter cohort study in 37 centers. All patients treated with direct-acting antivirals between April 1, 2017, and February 28, 2019, were included. In total, 2713 patients were included in the study among which 250 were PWID and 2463 were non-PWID. Besides patient characteristics, treatment response, follow-up, and side effects of treatment were also analyzed.

RESULTS

Genotype 1a and 3 were more prevalent in PWID-infected patients (20.4% vs 9.9% and 46.8% vs 5.3%). The number of naïve patients was higher in PWID (90.7% vs 60.0%), while the number of patients with cirrhosis was higher in non-PWID (14.1% vs 3.7%). The loss of follow-up was higher in PWID (29.6% vs 13.6%). There was no difference in the sustained virologic response at 12 weeks after treatment (98.3% vs 98.4%), but the end of treatment response was lower in PWID (96.2% vs 99.0%). In addition, the rate of treatment completion was lower in PWID (74% vs 94.4%).

CONCLUSION

Direct-acting antivirals were safe and effective in PWID. Primary measures should be taken to prevent the loss of follow-up and poor adherence in PWID patients in order to achieve World Health Organization's objective of eliminating viral hepatitis.

Point-of-care hepatitis C testing and treatment strategy for people attending harm reduction and addiction centres for hepatitis C elimination

According to WHO goals, the elimination of Hepatitis C Virus (HCV) by 2030 requires enhancing and simplifying HCV testing. Our aim was to create a model to assess and compare different strategies for HCV testing, linkage to care and treatment among people who access harm reduction centres (HRC) and Addiction Centres in Catalonia. A decision tree model was designed to evaluate two strategies: Hepatitis C Point-of-care (POC) "test and treat", at the community versus standard-of-care (SOC), in which HCV testing was performed at community and therapy at the hospital. Both strategies were assessed separately in HRCs (6,878 users) and Addiction Centres (13,778 users). with a time horizon of 18 months. Healthcare outcomes were HCV testing, linkage to care, treatment outcomes and reinfection rate. HCV testing was performed in 3,178 (46%) of the HRC users. Compared with SOC, POC increased access to treatment by 57% (63% vs. 6%). SVR rates were 64% in POC vs. 23% in SOC. Reinfection rates were 21% with POC compared to 24% with SOC. With POC, losses to follow-up were reduced by 41%. In the Addiction Centres, 12,566 users (91%) were screened using the two strategies. Compared to the SOC, POC increased access to treatment and linkage to care by 19% along with SVR at the same rate. Reinfection rates decreased by 6%. Thus, the implementation of a POC "test and treat" strategy at HRCs and Addiction Centres has shown to be an effective public health strategy to help eliminating HCV in accordance with WHO goal.

Alarming Tuberculosis Rate Among People Who Inject Drugs in Vietnam

BACKGROUND

The tuberculosis (TB) epidemic is not homogeneous in the general population but presents high-risk groups. People who inject drugs (PWID) are such a group. However, TB among PWID remains largely undocumented. Our goal was to assess the prevalence of TB and the risk factors associated with TB among PWID in Vietnam.

METHODS

We implemented a cross-sectional survey among 2 community-based cohorts of human immunodeficiency virus (HIV)-positive and HIV-negative PWID in Hai Phong. Participants were screened for TB using questions on TB symptoms. Those who reported any symptom were accompanied by peers to the TB clinic for chest x-ray. If the latter was abnormal, a sputum was collected to perform an Xpert MTB/RIF test.

RESULTS

A total of 885 PWID were screened for TB. For both cohorts, most PWID were male (>90.0%), with a median age of 42 years. Beside heroin injection, 52.5% of participants reported smoking methamphetamine, and 63.2% were on methadone. Among HIV-positive PWID (N = 451), 90.4% were on antiretroviral therapy and 81.6% had a viral load <1000 copies/mL. Using a complete-case analysis, the estimated TB prevalence was 2.3% (95% confidence interval [CI], 1.0-4.5) and 2.1% (95% CI, 0.8-4.2) among HIV-positive and HIV-negative people, respectively. Living as a couple, arrest over the past 6 months, homelessness, and smoking methamphetamine were independently associated with TB but not HIV infection.

CONCLUSIONS

In the context of very large antiretroviral therapy coverage, this extremely high rate of TB among PWID requires urgent actions.

Invasive Burkholderia cepacia Complex Infections among Persons Who Inject Drugs, Hong Kong, China, 2016-2019

During March 2016–January 2019, Burkholderia cepacia complex (BCC) infection developed in 13 persons who inject drugs (PWID) in Kowloon West Region, Hong Kong, China. Seven cases were infective spondylitis, 2 endocarditis, 2 septic arthritis, 1 intramuscular abscess and bacteremia, and 1 necrotizing fasciitis. Pulsed-field gel electrophoresis revealed that the isolates from 9 patients were clonally related. This clone caused major illness, and 11 of the 13 patients required surgical treatment. Clinicians should be aware of this pathogen and the appropriate broad-spectrum antimicrobial drugs to empirically prescribe for PWID with this life-threatening infection. Close collaboration among public health authorities, outreach social workers, and methadone clinics is essential for timely prevention and control of outbreaks in the PWID population.

Mitochondrial Genotoxicity of Hepatitis C Treatment among People Who Inject Drugs

Antiviral nucleoside analogues (ANA) are newly used therapeutics acting against the hepatitis C virus (HCV). This class of drug is well known to exhibit toxicity on mitochondrial DNA (mtDNA). People who inject drugs (PWID) are particularly affected by HCV infection and cumulated mitotoxic drug exposure from HIV treatments (antiretrovirals, ARV) and other illicit drugs. This study aims to explore the impact of direct-acting antiviral (DAA) treatments on mtDNA among PWID. A total of 470 actively injecting heroin users were included. We used quantitative PCR on whole blood to determine the mitochondrial copy number per cell (MCN) and the proportion of mitochondrial DNA deletion (MDD). These parameters were assessed before and after DAA treatment. MDD was significantly increased after HCV treatment, while MCN did not differ. MDD was even greater when subjects were cotreated with ARV. In multivariate analysis, we identified that poly-exposure to DAA and daily heroin injection or regular consumption of methamphetamines were positively associated with high MCN loss while DAA and ARV treatments or methadone use were identified as risk factors for having mtDNA deletion. These observations deserve attention since they were previously associated with premature cell ageing or cell transformation and therefore call for a long-term follow-up.

Sexualized drug use and specialist service experience among MSM attending urban and rural sexual health clinics in England and Scotland

Background: To date, evidence on whether sexualized drug use (SDU) and chemsex occur less frequently in rural compared to urban areas in Britain has been conflicting. This study aimed to better measure and understand whether attending urban versus rural sexual health clinics in the United Kingdom was associated with a difference in men who have sex with men's (MSM) experience of SDU or their access to SDU support. Methods: Men from 29 sexual health services across England and Scotland were recruited by self-completing a waiting room survey. Results: A total of 2655 men (864 MSM) took part. There was no statistically significant difference in recent SDU or chemsex identified in MSM attending rural compared to urban clinics. Gamma-Hydroxybutyrate/Gamma-Butyrolactone (GHB/GBL) was the most commonly reported chemsex drug used in a sexual setting, with equal prevalence of use in urban and rural MSM attendees. Distance travelled for SDU was not significantly different for rural compared to urban MSM. Rural MSM reported a higher rate of unmet need for SDU specific services, although this difference was not statistically significant. Conclusion: Within this sample of MSM, there were no significant differences in sexualized drug use behaviours between those attending rural compared to urban sexual health settings.

International Multicenter Study on Drug Consumption in Nursing Students

Background: The prevalence of illicit drug use among young people is high, with many being highly vulnerable to substance abuse. The nursing profession is not immune to the impacts of substance misuse. Knowing the current levels of consumption of illicit drugs in nursing students will allow for the introduction of preventive actions. Methods: Multi-center, descriptive, and cross-sectional study involving nursing schools from four different countries (Spain, Belgium, France, and Brazil). A total of seven centers participated. An adapted version of the Global School-based Student Health Survey (GSHS) was used as a tool, which selected only the module on illicit drugs. Standard logistic regression analysis was performed. Results: A total of 496 nursing students participated in the study. Illicit drug shows positive representation among nursing students. A significant difference was observed between the gender and the age of first drug use, illicit drug consumption, cannabis use, and cocaine use ever in life, with higher use of illicit drugs by male, although at later ages than girls. The bivariate analysis, gender, problems as result of drugs, and nationality were significantly associated with the consumption of illicit drugs, cannabis, cocaine, and ecstasy ever in life. Conclusions: High rates of illicit drug use were found among nursing students, as well as factors that can influence consumption such as nationality or gender. These results can serve as a basis for the development of educational and policy interventions within nursing schools that are based on evidence, with significant implications for nurse educators, academic administrators, and practice.

Model of Care for Microelimination of Hepatitis C Virus Infection among People Who Inject Drugs

Background: People who inject drugs (PWID) are the largest group at risk for HCV infection. Despite the direct acting antivirals (DAA) advancements, HCV elimination has been hindered by real-life difficulties in PWID. Aims: This study aimed to assess the impact of a multidisciplinary intervention strategy where HCV screening, treatment and follow-up were performed at the same location on efficacy and safety of DAA-therapy in real-life PWID population. Methods: All HCV-infected PWID referred to five specialized outpatient centers for drug addicts (SerDs) in Northern Italy were prospectively enrolled from May 2015 to December 2019. Hepatologists and SerDs healthcare workers collaborated together in the management of PWID inside the SerDs. Sustained virologic response (SVR), safety of treatment, proportion of patients lost to follow-up and reinfection rate were evaluated. Results: A total of 358 PWID started antiviral treatment. About 50% of patients had advanced fibrosis/cirrhosis, 69% received opioid substitution treatment, and 20.7% self-reported recent injecting use. SVR was achieved in 338 (94.4%) patients. Two patients died during treatment; one prematurely discontinued, resulting in a non-responder; twelve were lost during treatment/follow-up; and five relapsed. No serious adverse events were reported. SVR was lower in recent PWID than in former ones (89.2% vs. 95.8%; p = 0.028). Seven reinfections were detected, equating to an incidence of 1.25/100 person-years. Reinfection was associated with recent drug use (OR 11.07, 95%CI 2.10–58.38; p = 0.005). Conclusion: Our embedded treatment model could be appropriate to increase the linkage to care of HCV-infected PWID. In this setting, DAA regimens are well tolerated and highly effective, achieving a lower rate of reinfection.

Persons with Substance Abuse Disorders and Other Addictions: Coping with the COVID-19 Pandemic

Cuba implemented policies mandating social distancing on March 11, 2020, which were still in place at the time of this study. During such periods of isolation, people with psychoactive substance-related disorders and other addictions may be tempted to reduce tension, stress, uncertainty and possible distress by increasing the use of substances or practices they have abused. This can mean relapses and setbacks for patients undergoing treatment. A multidisciplinary team of health professionals specializing in addiction at the Center for Academic Development in Drug Addiction, in Havana, Cuba, cares for people with these disorders and followed their evolution during the initial period of COVID-19 social isolation. With the aim of characterizing strategies employed by patients undergoing treatment for substance abuse and addictions, we conducted a qualitative study from April 2020 through May 2020, using a convenience sample of 37 patients (all students) who had been progressing towards recovery from addictive behaviors when face-to-face encounters were suspended due to COVID-19 restrictions. Contact was maintained through information and communication technologies. The research used telepsychology and focused on understanding patient life experiences. Patients were interviewed using a semi-structured survey, which was then transcribed and coded thematically using a grounded-theory approach. We found that patients' ability to cope successfully with challenges presented by COVID-19 were influenced by: 1) the individual's own methods for maintaining self-control (commitment to studies, projects, and work with therapists) that aided them in their goals concerning abstinence; 2) difficulties faced in addressing specific events and situations (doubts, uncertainties, disagreements, isolation and time use); 3) perpetuation and revivification of myths related to substances and addictive activities (exacerbation of supposed benefits of tobacco, alcohol, marijuana, overuse of social networks); and 4) tendencies toward irrationality and lack of emotional control (fear, sadness, anger, constant worry and self-imposed demands). Our findings suggest that despite the potential negative psychological impact of preventive social isolation during the COVID-19 pandemic, individual coping mechanisms developed by these patients, aiming at improved self-control, allowed most to avoid setbacks that could have affected their recovery. Nevertheless, patients faced challenges to their recovery that were compounded by difficulties in specific situations, myths related to substances and addictive activities, and tendencies toward irrationality or lack of emotional control.

A Multi-Site Cross-Sectional Study of Anxiety Symptoms and the Associated Factors Among Chinese Drug Users Undergoing Compulsory Detoxification Treatment

Compulsory drug detoxification treatment (CDT) is currently the major drug rehabilitation modality in China, and drug users often suffer from extraordinary levels of stress during CDT, leading to a high prevalence of anxiety symptoms. This study assesses anxiety symptoms of the drug users undergoing CDT and explores the associated factors. A cross-sectional study with cluster sampling was conducted in three cities in Liaoning Province of Northeast China. Nine hundred CDT drug users were interviewed face-to-face with Chinese questionnaires. Hierarchical multiple regression (HMR) analysis was conducted to explore the factors associated with anxiety symptoms. The prevalence of anxiety symptoms among the CDT drug users was substantially high (33.2%). HMR analysis indicated perceived stress and characteristics of drug use such as types of drugs, were the most important contributors to anxiety symptoms. Optimism (LOT-R) played a protective role in reducing anxiety symptoms in this population. Anxiety symptoms of drug users undergoing CDT were present in a significant proportion of the CDT population. Optimism is a protective factor which could attenuate the detrimental effects of perceived stress on anxiety symptoms and potentially improve treatment outcomes.

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

BACKGROUND

We assessed prevalence of testing for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection among persons who inject drugs (PWID).

METHODS

Using a nationwide health insurance database for claims paid during 2010-2017, we identified PWID by using codes from the International Classification of Diseases, Current Procedural Terminology, and National Drug Codes directory. We then estimated the percentage of PWIDs tested for HIV or HCV within 1 year of an index encounter, and we used multivariate logistic regression models to assess demographic and clinical factors associated with testing.

RESULTS

Of 844 242 PWIDs, 71 938 (8.5%) were tested for HIV and 65 188 (7.7%) were tested for HCV infections. Missed opportunities were independently associated with being male (odds ratios [ORs]: HIV, 0.50 [95% confidence interval {CI}, 0.49-0.50], P < .001; HCV, 0.66 [95% CI, 0.65-0.72], P < .001), rural residence (ORs: HIV, 0.67 [95% CI, 0.65-0.69], P < .001; HCV, 0.75 [95% CI, 0.73-0.77], P < .001), and receiving services for skin infections or endocarditis (adjusted ORs: HIV, 0.91 [95% CI, 0.87-0.95], P < .001; HCV, 0.90 [95% CI, 0.86-0.95], P < .001).

CONCLUSIONS

Approximately 90% of presumed PWIDs missed opportunities for HIV or HCV testing, especially male rural residents with claims for skin infections or endocarditis, commonly associated with injection drug use.

Joint effects of alcohol and stimulant use disorders on self-reported sexually transmitted infections in a prospective study of Cambodian female entertainment and sex workers

Female entertainment and sex workers (FESW) have high rates of alcohol and amphetamine-type stimulant (ATS) use, increasing risk for HIV/sexually transmitted infections (STI), and other negative outcomes. A prospective cohort of 1,198 FESW in a HIV/ATS use prevention intervention in Cambodia was assessed for alcohol and stimulant use disorders (AUD and SUD) using the Alcohol and Substance Use Involvement (ASSIST) scale. STI history was measured by self-report at baseline and at quarterly follow-up visits. Participants were asked if they had been diagnosed with an STI by a medical provider in the past 3 months. Marginal structural models were used to estimate joint effects of AUD and SUD on recent STI. At baseline, one-in-four screened AUD positive and 7% screened positive for SUD. At 18-months, 26% reported ≥1 recent STI. Accounting for time-varying and other known confounders, the adjusted odds ratio (AOR) for recent STI associated with AUD alone and SUD alone were 2.8 (95% CI:1.5-5.1) and 3.5 (95% CI:1.1-11.3), respectively. The AOR for joint effects of AUD and SUD was 5.7 (95% CI:2.2-15.2). AUD and SUD are independently and jointly associated with greater odds of STI among Cambodian FESW. Further research is critical for understanding how AUD and SUD potentiate biological and behavioural pathways that influence STI acquisition and to inform HIV risk-reduction interventions in FESW.

Depressive symptoms and use of HIV care and medication-assisted treatment among people with HIV who inject drugs

OBJECTIVE

Vietnam, Indonesia, and Ukraine have major burdens of IDU and HIV. We estimated the prevalence of depressive symptoms at baseline among people living with HIV who inject drugs, evaluated associations between depression at baseline and 12-month HIV care outcomes and medication-assisted treatment (MAT), and evaluated the study intervention effect by baseline depression subgroups.

DESIGN

HPTN 074 was a randomized study. The study intervention included psychosocial counseling, systems navigation, and antiretroviral treatment (ART) at any CD4+ cell count.

METHODS

Moderate-to-severe depression was defined as a Patient Health Questionnaire-9 score of 10 or above. ART and MAT were self-reported. Eligibility criteria were: 18-60 years of age, active IDU, and viral load of at least 1000 copies/ml. Adjusted probability differences (aPD) were estimated using inverse-probability weighting.

RESULTS

A total of 502 participants enrolled from April 2015 to June 2016. Median age was 35 years; 85% identified as men. Prevalence of baseline moderate-to-severe depression was 14% in Vietnam, 14% in Indonesia, and 56% in Ukraine. No evident associations were detected between baseline depression and ART, viral suppression, or MAT at 12-month follow-up. The study intervention improved the proportions of people who inject drugs achieving 12-month viral suppression in both the depressed [intervention 44%; standard of care 24%; estimated aPD = 25% (95% confidence interval: 4.0%, 45%)] and nondepressed subgroups [intervention 38%; standard of care 24%; aPD = 13% (95% confidence interval: 2.0%, 25%)].

CONCLUSION

High levels of depressive symptoms were common among people living with HIV who inject drugs in Ukraine but were less common in Vietnam and Indonesia. The study intervention was effective among participants with or without baseline depression symptoms.

Directly Acting Antiviral-Based Treatment for HCV-Infected Persons Who Inject Drugs: A Multicenter Real-Life Study

BACKGROUND

We aimed to evaluate the factors associated with a virological response in a cohort of Hepatitis C virus (HCV)-infected people who inject drugs (PWID) treated with direct acting antivirals (DAAs).

METHODS

We conducted a multicenter retrospective cohort study enrolling HCV-infected PWID treated with DAAs. The primary outcome evaluated was the sustained virological response (SVR12) rate.

RESULTS

Five hundred and twenty HCV-infected PWID treated with all-oral DAA-based regimens were enrolled; a total of 168 (32.3%) patients presented genotype 1a, 109 (21.0%) genotype 1b, and 174 (33.5%) genotype 3; a total 152 of the 520 subjects (29.2%) were cirrhotics; a total 118 (22.7%) and 373 (71.7%) were treated with DAA regimens of second and third generation, respectively; a total 169 (33.6%) patients were receiving an opioid agonist at the start of antiviral therapy. Only 11 subjects (2.1%) did not show an SVR12. A significant correlation was found between treatment with opioid substitution therapy (p < 0.001), Human Immunodeficiency Virus (HIV) coinfection (p = 0.002), and treatment with first- or second-generation regimens (p = 0.0015) and HCV failure. Upon multivariate analysis, treatment with a first- or second-generation DAA was the only factor independently associated with failure (OR 10.4, 95% CI: 1.43 to 76.1, p = 0.02).

CONCLUSIONS

Treatment with DAAs led to a high SVR12 rate (97.9%) in a large cohort of HCV-infected PWID. The only predictor of viral failure found in our analysis was treatment with first- and second-generation DAA.

Prevalence and factors associated with substance use among Chinese immigrants in Spain: A mixed-design study

OBJECTIVE

To explore the use of tobacco, alcohol, and illicit drugs and its associated factors among Chinese immigrants living in Spain.

DESIGN AND MEASURES

A mixed-method design, using surveys and semi-structured interviews.

SAMPLE

A total of 133 Chinese immigrants and stakeholders were assessed in the quantitative study and 7 stakeholders were interviewed in the qualitative study.

RESULTS

The use of tobacco and alcohol was higher than the use of illicit drugs in Chinese immigrants. The prevalence of daily smokers was greater in men than in women (37.3% vs. 2.5%, p < .001). Men consumed more alcohol (76% vs. 50.6%, p = .004) and more frequently (21.6% daily vs. 2.4%, p = .024) than women. The use of illicit drugs was low and Cannabis was the most illicit drug consumed (4%). Qualitative data revealed that due to a great workload, the workers tended to avoid behaviors of illicit drug consumption, but not of alcohol and tobacco, in which the consumption is associated with business meetings and leisure.

CONCLUSION

This study found that Chinese immigrants in Spain consume more alcohol and tobacco than illicit drugs and that men have a high consumption compared to women. These findings reveal important cultural differences that should be addressed by public health managers in order to develop strategies that consider the characteristics of this population.

Toward microelimination of hepatitis C and HIV coinfection in NHS Tayside, Scotland: Real-world outcomes

BACKGROUND AND AIMS

NHS Tayside is a health board in Scotland which serves around 400 000 residents. Approximately, 2761 are estimated to be persons who inject drugs (PWID), and therefore at risk of infections such as hepatitis C (HCV) and HIV. There are few studies exploring mechanisms and success of eliminating HCV in HIV co-infected PWID using real-world data. This study aims to empirically assess HCV treatment outcomes in people living with HIV (PLHIV) to evaluate progress toward microelimination of HCV in the HIV-positive population in Tayside.

METHODS

HCV testing and treatment details for PLHIV stored on clinical databases dating from 2001 were extracted and anonymized. HCV treatment uptake among co-infected patients eligible for HCV treatment was calculated. Reinfection incidence was calculated in person years. Confidence intervals were calculated assuming Poisson distribution. Caldicott Guardian approval was obtained to access patient data (ref: IGTCAL 5677).

RESULTS

Ninety-six percent of PLHIV were tested for HCV across nine services and aware of their HCV status. From 2001 to 2019, 58 PLHIV were HCV co-infected. Four left the area and five died prior to HCV treatment. Forty-nine were eligible for HCV treatment. Thirty were treated with PEGylated interferon (Peg-IFN); 18 with direct acting antivirals (DAA). One is yet to be treated. Twelve treated with Peg-IFN did not achieve sustained viral response (SVR12); 10 were retreated, two died prior to re-treatment. Injecting drug use was the mode of HCV transmission for 39 of 49 patients. Proportion who achieved SVR12 is 75%; 92% if treated with DAAs. Annual proportions of PLHIV treated for HCV increased from 3.57% in the Peg-IFN era to 66.67% in the DAA era. Reinfection incidence is 0.2 per 100 person years (CI -0.3 to 0.7).

CONCLUSIONS

NHS Tayside has made progress toward microelimination of HCV among PLHIV. The most common mode of HCV transmission in PLHIV in NHS Tayside is injecting drug use. DAAs increased the proportion of co-infected PLHIV treated for HCV and produced superior SVR12 results compared to Peg-IFN.

Engagement in the Hepatitis C care continuum among people who use drugs

Despite high rates of Hepatitis C virus (HCV) infection among people who use drugs (PWUDs), access to the HCV care continuum combined with the receipt of medications for addiction treatment in primary care settings remains suboptimal. A qualitative study was conducted among adults admitted for inpatient detoxification for opioid use disorder (OUD) in New York City (n=23) to assess barriers and facilitators with HCV prevention, screening, treatment, interactions with primary care providers, and experiences with integrated care approaches. Study findings yielded six major themes related to HCV care. Major gaps persist in knowledge regarding HCV harm reduction strategies, voluntary HCV testing services, and eligibility for HCV treatment. Treatment coordination challenges reinforce the importance of enhancing linkages to HCV care in key access-points utilized by PWUDs (e.g., emergency rooms, specialty addiction treatment settings). Peer networks combined with frequent patient-physician communication were elicited as important factors in facilitating linkage to HCV care. Additional care coordination needs in primary care settings included access to integrated treatment of HCV and OUD, and administrative support for enrollment in Medicaid, subsidized housing, and access to transportation vouchers.

Nutritional status and eating habits of people who use drugs and/or are undergoing treatment for recovery: a narrative review

A comprehensive overview is presented of the nutritional issues faced by people who use drugs or are undergoing treatment for recovery. Chronic substance use affects a person’s nutritional status and body composition through decreased intake, nutrient absorption, and dysregulation of hormones that alter the mechanisms of satiety and food intake. Anthropometrics alone is not the best indicator of nutritional status, because this population has hidden deficiencies and disturbed metabolic parameters. Socioeconomic factors (eg, higher education, higher income, presence of a partner, living at home) positively affect nutritional status. Scarce available data on users undergoing treatment indicate improvement in anthropometric and metabolic parameters but with micronutrient intake remaining suboptimal. Weight gain is noted especially among women who use drugs and potentially increases their risk of relapse. Finally, specific amino acids and omega-3 fatty acids are promising in decreasing relapse and improving mental health during treatment; however, additional high-quality studies are needed. Nutrition intervention for people who use drugs or are undergoing treatment for recovery is underused; comprehensive programs addressing this population’s unique needs are necessary. Future research will identify which components are needed.

Impact of Recent Methamphetamine Use on Vancomycin Clearance

PURPOSE

To determine whether recent methamphetamine use increases vancomycin clearance.

METHODS

This was a multi-center, retrospective, IRB-approved study at two tertiary care medical centers. Adult patients with a urine drug screen, ≥3 consecutive vancomycin doses, and an appropriately drawn vancomycin trough were assessed and classified as amphetamine positive or amphetamine negative. The primary outcome was vancomycin clearance.

RESULTS

88 patients were included in the analysis, with 44 patients in each group. Vancomycin clearance was greater in the amphetamine positive group (94.54 vs. 86.84 mL/min, p = 0.042, 95% CI 0.29-15.09). There was no significant difference in goal vancomycin trough achievement between groups (34.1% amphetamine positive vs. 43.2% amphetamine negative; p = 0.512). Per multifactorial logistic regression analysis, older age and male gender were associated with decreased vancomycin clearance, while higher BMI and cocaine positive urine drug screen were associated with increased vancomycin clearance.

CONCLUSION

Recent methamphetamine use may increase vancomycin clearance. Larger prospective trials with protocolized vancomycin dosing strategies are needed to further elucidate the impact of methamphetamine use on attainment of goal vancomycin troughs in addition to the potential impact on vancomycin clearance.

Human T-cell lymphotropic virus 1/2 and human immunodeficiency virus antibodies identification among transactional sex workers and drug users in the Dominican Republic

BACKGROUND

Human immunodeficiency virus (HIV) increases the risk of acquiring human T-cell lymphotropic virus (HTLV) and subsequently HTLV's progression to tropical spastic paraparesis/HTLV-1-associated myelopathy (TSP/HAM). Existing data have exclusively reported generalized rates of HIV and HTLV-1 chronic viral infections in the Dominican Republic. To our knowledge, no published studies have focused on the rates of HTLV-1/2 in transactional sex workers and drug users, both higher risk groups, in the Dominican Republic.

METHODS

From December 2012 to April 2013 we conducted a study to estimate the seroprevalence of HTLV-1/2 immunoglobulin G (IgG) and HIV antibodies among transactional sex workers and intravenous drug users in Santo Domingo, Dominican Republic. Serological status was analysed with behaviour and demographic data.

RESULTS

We collected and analysed plasma from 200 participants with a mean age of 27.4 y in men and 25.2 y in women. The overall weighted seroprevalence of HTLV-1/2 IgG antibodies was 13.91% (95% CI 7.59 to 20.23) in men and 10.59% (95% CI 4.05 to 17.13) in women. The overall weighted seroprevalence of HIV-1 was 13.91% (95% CI 7.59 to 20.23%) in men and 17.65% (95% CI 9.55 to 25.75) in women. Male intravenous drug users had an exceptionally high rate of HTLV-positive HIV co-infection, at 75% (95% CI 44.99 to 105.01). Although there an association has been found between HTLV/HIV co-infections and sex work, the adjusted odds revealed a confounding role of HIV infection.

CONCLUSIONS

The results highlight the urgent need for enhanced public health preventive strategies among high-risk populations in the Dominican Republic and other resource-constrained Caribbean settings, as well as global adoption of routine screening for HTLV-associated infections, particularly in these high-risk, underserved populations.

The seroprevalence of untreated chronic hepatitis C virus (HCV) infection and associated risk factors in male Irish prisoners: a cross-sectional study, 2017

IntroductionData on chronic hepatitis C (HCV) infection prevalence in European prisons are incomplete and impact the public health opportunity that incarceration provides.AimsWe aimed to estimate the seroprevalence of untreated chronic HCV infection and to identify associated risk factors in an Irish male prison.MethodsWe conducted a cross-sectional study involving a researcher-administered questionnaire, review of medical records and HCV serology.ResultsOf 422 prisoners (78.0% of the study population) who participated in the study, 298 (70.6%) completed the questionnaire and 403 (95.5%) were tested for HCV antibodies. Of those tested, 92 (22.8%) were HCV antibody-positive, and of those, 53 (57.6%) were HCV RNA-positive, 23 (25.0%) had spontaneous clearance, 16 (17.4%) had a sustained viral response, 10 (11.0%) were co-infected with HIV and six (6.0%) with HBV. The untreated chronic HCV seroprevalence estimate was 13.1% and the seroprevalence of HCV among prisoners with a history of injecting drug use (IDU) was 79.7%. Risk factors significantly associated with past HCV infection were IDU (p < 0.0001), having received a prison tattoo (p < 0.0001) or a non-sterile community tattoo (p < 0.0001), sharing needles and other drug-taking paraphernalia (p < 0.0001). Small numbers of prisoners had a history of sharing razors (n=10; 3.4%) and toothbrushes (n=3; 1.0%) while incarcerated. On multivariable analysis, history of receiving a non-sterile community tattoo was the only significant risk factor associated with HCV acquisition (after IDU was removed from the model) (p = 0.005, β = 0.468).ConclusionThe level of untreated chronic HCV infection in Irish prisons is high, with IDU the main associated risk.

Estimating prevalence from dried blood spots without using biological cut-offs: application of a novel approach to hepatitis C virus in drug users in France (ANRS-Coquelicot survey)

Seroprevalence estimation using cross-sectional serosurveys can be challenging due to inadequate or unknown biological cut-off limits of detection. In recent years, diagnostic assay cut-offs, fixed assay cut-offs and more flexible approaches as mixture modelling have been proposed to classify biological quantitative measurements into a positive or negative status. Our objective was to estimate the prevalence of anti-HCV antibodies among drug users (DU) in France in 2011 using a biological test performed on dried blood spots (DBS) collected during a cross-sectional serosurvey. However, in 2011, we did not have a cut-off value for DBS. We could not use the values for serum or plasma, knowing that the DBS value was not necessarily the same. Accordingly, we used a method which consisted of applying a two-component mixture model with age-dependent mixing proportions using penalised splines. The component densities were assumed to be log-normally distributed and were estimated in a Bayesian framework. Anti-HCV prevalence among DU was estimated at 43.3% in France and increased with age. Our method allowed us to provide estimates of age-dependent prevalence using DBS without having a specified biological cut-off value.

Characteristics of psychiatric inpatients diagnosed with mental and behavioral disorders caused by psychoactive substances (F11-19 block), with a focus on NPS and psychiatric co-morbidities

OBJECTIVES

This study analyzed the prevalence of new psychoactive substance (NPS) use in the analyzed group and compared demographic features and psychoactive substance profiles between the 2 subgroups (NPS users, non-NPS users). The secondary measure was used to determine the prevalence of psychiatric comorbidities in study group and to compare demographic features and psychoactive substance profiles between 2 subgroups (the F11-19 only diagnosed group and the F11-19 group with psychiatric comorbidities according to ICD-10).

MATERIAL AND METHODS

A 12-month retrospective cross-sectional analysis of medical records compiled for adult psychiatric patients who had been admitted to the Regional Psychiatric Hospital in Olsztyn, Poland, in October 1, 2016 - September 30, 2017 was conducted. After analyzing the available medical records, 157 cases were included and analyzed. Data for the study were collected in a specially designed monitoring card from discharge reports, including data from psychiatric examinations, especially anamnesis.

RESULTS

The most commonly declared psychoactive substances were amphetamine (AMF) - 54% and cannabinoids - 46%. The prevalence of NPS use in the study group was 34%. Inpatients taking NPS, as compared with non-NPS users, were younger and more often admitted to hospital through the Emergency Department. It was also found that NPS users more often took AMF or cannabinoids, and less frequently benzodiazepines (BDZ) or opioids. However, the taking of AMF, cannabinoids and BDZ was also age-dependent.

CONCLUSIONS

The prevalence of psychiatric comorbidities in the study group was 9%. Inpatients with psychiatric comorbidities were older and took BDZ significantly more often than AMF. In addition, NPS use affects different groups, including a specific group as the analyzed sample, which shows a similar NPS use profile as different groups described in the literature. Int J Occup Med Environ Health. 2020;33(2):125-36.

Differences in Gut Microbial Diversity are Driven by Drug Use and Drug Cessation by Either Compulsory Detention or Methadone Maintenance Treatment

In this work, we investigate differences in gut microbial diversity driven by drug use or by the widely used methods for drug cessation: methadone maintenance treatment (MMT) and compulsory detention (CD). Methods: 99 participants (28 CD participants, 16 MMT patients, 27 drug users, and 28 healthy controls) were selected using strict inclusion criteria. Nutritional intake and gut microbial diversity were analyzed with bioinformatics tools and SPSS 20.0. Results: Alpha diversity was not significantly different among groups, whereas beta diversity of gut microbiota and nutrient intake were significantly higher among MMT patients. Taxa were unevenly distributed between groups, with drug users having the highest proportion of Ruminococcus and MMT patients having the highest abundance of Bifidobacterium and Lactobacillus. Conclusion: Drug use, cessation method, and diet contribute to shaping human gut communities. High beta diversity among MMT patients is likely driven by methadone use and high nutrient intake, leading to increased orexin A and enrichment for beneficial bacteria, while diversity in CD participants is largely influenced by diet.

Understanding HIV-positive drug users' experiences of taking highly active antiretroviral treatment: Identity-Values-Conscious engagement model

AIM

To explore HIV-positive drug users' experiences of taking antiretroviral medications in Taiwan and further develop a conceptual model that can be used to understand their adherence to the long-term treatment.

BACKGROUND

The global vision of ending AIDS by 2030 cannot be achieved without addressing HIV-positive drug users' experience of taking antiretroviral treatment. There remains a paucity of qualitative evidence on HIV-positive drug users' experiences of taking antiretroviral medications globally and in East Asia. Nurses play a key role in supporting HIV-positive drug users throughout their treatment process. Therefore, it is pivotal to understand HIV-positive drug users' experiences of managing long-term anti-HIV treatment.

DESIGN

This qualitative study drew on a constructivist grounded theory approach to achieve the aims. Semi-structured in-depth interviews with 22 HIV-positive drug users were conducted in Taiwan between September 2015 and July 2016. Data were analysed using Charmaz's coding principles. The integration and formation of the model began with focused coding and proceeded through the subsequent analytic process. The reporting of this study was based on the Consolidated Criteria for Reporting Qualitative Research checklist.

RESULTS

This study shows that integrating HIV-positive identity into sense of self laid a solid foundation for the acceptance of self and antiretroviral treatment. Valuing of antiretroviral treatment played a central role in driving their medication-taking behaviour. While valuing the treatment appeared to drive participants' behavioural change, data revealed that conscious engagement was an important element for their behaviour maintenance.

CONCLUSION

The evidence from this study can extend our knowledge of the mechanisms that influence the change and maintenance of HIV-positive drug users' adherence to antiretroviral treatment.

RELEVANCE TO CLINICAL PRACTICE

The Identity-Values-Conscious engagement model developed and proposed in this study can serve as a guide for the development of tailored adherence assessment and associated nursing interventions for this population.

Factors associated with the physical and mental health of drug users participating in community-based drug rehabilitation programmes in China

Since the promulgation and implementation of a new anti-drug law in 2008, the Chinese central government has encouraged local governments to carry out community-based drug rehabilitation programmes. This study explores the association between community-based drug rehabilitation programmes and drug users' physical and mental health. This study collected data between October 2018 and February 2019 from a community-based rehabilitation programme in a community in Foshan Municipality in Guangdong Province of China. A total of 162 drug users participating in a community-based drug rehabilitation program were selected to complete a self-administered and anonymous questionnaire. A cover letter interpreting the purpose of the study and a self-administered questionnaire was provided to the drug users. Ethics approval for this study was obtained from the Academic Committee of School of Public Administration, JiNan University, Guangzhou, China. All participants gave verbal informed consent. Four multiple linear regression models were used to explain social services that influence drug users' physical and mental health. The findings show that the number of service items provided by the social service organization was significantly associated with physical and mental health among drug users. Particularly, the employment assistance service influenced the drug user's physical and mental health status significantly.

An institutional ethnography of prevention and treatment services for substance use disorders in the Dominican Republic

The Dominican Republic is thought to have significant epidemics of illicit drug use but lacks surveillance and formal analyses of the policy context of drug prevention and treatment services. We conducted an institutional ethnography of 15 drug service organisations in Santo Domingo and Boca Chica, Dominican Republic, to explore barriers and resources for drug abuse prevention and treatment. Here, we present a typology of drug service organisations based on their services, methods, and approach. We then draw on interviews with representatives of drug service institutions to describe the primary barriers to drug treatment and prevention services for drug users. We conclude with a focus on the policy priorities that could improve the conditions of health care for marginalised drug users in the Dominican Republic.

Psychological distress among Cambodian people who use drugs

INTRODUCTION AND AIMS

People who use drugs (PWUD) face several mental health problems. This report aims to examine the prevalence of and factors associated with psychological distress among Cambodian PWUD.

DESIGN AND METHODS

Data used in our analysis were from the national survey of 1626 PWUD recruited through respondent-driven sampling method in Cambodia in 2012 to 2013. Distress was measured through self-report by using the 10-item Kessler Psychological Distress Scale (K10). All analyses were weighted.

RESULTS

Approximately half of PWUD had mild to severe psychological distress in the past four weeks (K10 ≥ 20). In the adjusted analysis, being female (odds ratio 1.60; 95% confidence interval 1.22, 2.12) and having experienced living in rehabilitation centres (odds ratio 2.46; 95% confidence interval 1.56, 3.87) were associated with a higher risk of having moderate or severe psychological distress (K10 ≥ 25).

DISCUSSION AND CONCLUSIONS

Psychological distress was prevalent among Cambodian PWUD. PWUD who were female or experienced living in rehabilitation centres were more likely to report distress. Policy makers should consider shifting further from compulsory institutionalised treatment model to community-based treatment program. Mental health assessment and mental health care services should be included in drug treatment programs and should be gender-sensitive. Further research investigating other mental disorders among PWUD are also needed.

Factors in the Transition from Legal to Illicit Drug Use in Young Adults from Northern Mexico

OBJECTIVES

This research sought to analyze the predictive effect of personal (personality traits), social (social support and social stigma) and community factors (characteristic of the neighborhood and exposure to consumption) on the transition of drug use in young adults.

METHODS

Case and control study. The cases were 70 individuals from 18 to 34 years of age who had already transitioned into illicit drug use and the controls were 210 legal drug usuers (tobacco or alcohol) in the same age range who had not had the transition. A data file was applied along with seven instruments that measured the transition and consumption variables.

RESULTS

Marihuana was the illicit drug of highest transition. It was shown that greater personality traits of neuroticism, extraversion, and openness to the experience meant higher probability of drug use transition; while greater personality traits of agreeableness and conscience meant lower probability for the transition. The characteristics of the neighborhood environment and exposure to the opportunity of consumption increase the probability of the drug use transition. Social support and social stigma influenced negatively upon the drug use transition.

CONCLUSIONS

Personality traits, neighborhood characteristics, exposure to drug use, social support, and the social stigma of drug use are factors that intervene in the transition from legal to illicit drug use.

Dentists' intentions to manage drug users: Role of theory of planned behaviour and continuing education

OBJECTIVES

To assess dentists' intention to manage drug users (DUs) and to evaluate the role of the theory of planned behavior (TPB) and continuing education (CE) in explaining this intention.

MATERIALS AND METHODS

A cross-sectional study was conducted in 2017, including dentists from three major Saudi cities. A questionnaire assessed personal and professional background and components of TPB: attitude, perceived social norms, perceived control and intention to manage DUs. Respondents expressed their agreement on a scale from 1 (disagree) to 7 (agree). Receiving CE to manage DUs was also assessed. Adjusted linear regression was used to assess the impact of the TPB constructs and receiving CE on dentists' intention.

RESULTS

Response rate = 72% (255/354), mean (SD) age = 35.2 (11.9). The mean (SD) for positive intention to manage DUs = 5.34 (1.37), negative attitude = 4.03 (1.10), positively perceived norms = 5.78 (1.06) and perception of no control = 4.45 (1.08). Only 9% received CE to manage DUs. Positive intention was associated with perception of positive norms (B = 0.73, 95% CI = 0.59, 0.87) and perception of no control (B = -0.47, 95% CI = -0.63, -0.32) but not with receiving CE (P = 0.58).

CONCLUSION

In major Saudi cities, dentists' intention to manage DUs was positive and was explained by TPB components: perception of norms and perception of control. Modified and targeted CE is needed to address this problem.

Validation of the sixth version of the Addiction Severity Index (ASI-6) for patients in a clinical population of Colombia

Introduction: The Addiction Severity Index (ASI-6) is recommended for identifying the needs of addicted patients and assessing the effectiveness of a program. Objective: To develop a version of the ASI-6 suitable for Colombia and trans-linguistically and trans-culturally equivalent to the original. Additionally, this study also sought to assess the reliability and construct validity of the resulting version. Materials and methods: The study included Colombian adults with harmful substance use or dependence syndrome who were being treated at drug addiction centers. The original English version underwent a cultural adaptation process. The scale was translated and back-translated to assess its equivalence. Reliability was assessed in terms of internal consistency and interrater and test-retest reliability. The convergent aspect of the construct validity was assessed via the correlation of the instrument with other scales measuring similar underlying constructs. Results: We found an adequate internal consistency for the subscales of the ASI-6 for its Cronbach´s alpha coefficient was above 0.7 with the exception of the social problems subscale (α=0.66). In addition, interrater and test-retest reliability was high, since their intraclass correlation coefficient (ICC) was above 0.7 for all the subscales. Construct validity was demonstrated by a Spearman correlation coefficient ranging from 0.53 to 0.88 between the ASI-6 subscales and other similar scales. Conclusion: The version of the ASI-6 adapted to the Colombian context was found to have good reliability and validity, thus it can be introduced into clinical practice. However, additional studies are needed to evaluate its responsiveness and structural validity.

Compliance to antibiotic guidelines leads to more appropriate use of antibiotics in skin and soft tissue infections in injecting drug users

Background: Knowledge about the treatment of skin and soft tissue infections in injecting drug users in countries with a low prevalence of antibiotic resistance is limited. We investigated bacterial antibiotic resistance and treatment of skin and soft tissue infections in Norwegian drug users. Methods: We performed a two year clinical cross-sectional observational study in a Norwegian hospital. Data were collected retrospectively from hospital records. We examined bacteriological findings and antibiotic resistance, and evaluated compliance to treatment guidelines and appropriateness of empirical antibiotic therapy relative to results of cultures and susceptibility testing. Descriptive and univariate analyses were performed. Results: Hundred and thirty-five injecting drug users were admitted with skin and soft tissue infection in the study period. Cultures were obtained from 103 (77%) abscesses and eight (24%) erysipelas and cellulitis, with bacterial growth in 80 (78%) and five (63%), respectively. Streptococci and staphylococci were the most prevalent bacteria, but methicillin-resistant Staphylococcus aureus was found in only one patient. Compliance to hospital antibiotic guidelines was 70%. Ninety-one per cent of patients in the compliant and 79% in the non-compliant group were given effective empirical antibiotics (p = .334). In the non-compliant group, significantly more patients received broad-spectrum empirical antibiotics (p < .001). In 30 cases where adjustment of antibiotic therapy was possible according to susceptibility testing, this was performed in only 14 cases. Conclusions: Bacteria and resistance patterns did not differ significantly from the skin and soft tissue infections in the general population in Norway. Compliance to antibiotic guidelines led to significantly less use of broad-spectrum antibiotics and to good bacterial coverage. General guidelines for treatment should be applied to injecting drug users with skin and soft tissue infections.

Estimating the size of key populations for HIV in Singapore using the network scale-up method

Objectives

To develop a localised instrument and Bayesian statistical method to generate size estimates—adjusted for transmission error and barrier effects—of at-risk populations in Singapore.

Methods

We conducted indepth interviews and focus group to guide the development of the survey questionnaire. The questionnaire was administered between July and August 2017 in Singapore. Using the network scale-up method (NSUM), we developed a Bayesian hierarchical model to estimate the number of individuals in four hidden populations at risk of HIV. The method accounted for both transmission error and barrier effects using social acceptance measures and demographics.

Results

The adjusted size estimate of the population of male clients of female sex workers was 72 000 (95% CI 51 000 to 100 000), of female sex workers 4200 (95% CI 1600 to 10 000), of men who have sex with men 210 000 (95% CI 140 000 to 300 000) and of intravenous drug users 11 000 (95% CI 6500 to 17 000).

Conclusions

The NSUM with adjustment for attitudes and demographics allows national-level estimates of multiple priority populations to be determined from simple surveys of the general population, even in relatively conservative societies.

Geographically Diverse Clusters of Nontoxigenic Corynebacterium diphtheriae Infection, Germany, 2016-2017

From 2016 through the middle of 2017, the German Consiliary Laboratory on Diphtheria noted an increase in nontoxigenic Corynebacterium diphtheriae isolates submitted from cities in northern Germany. Many patients for whom epidemiologic data were available were homeless, alcohol or drug abusers, or both. After performing routine diagnostics and multilocus sequence typing (MLST), we analyzed isolates of sequence type (ST) 8 and previously submitted isolates by whole-genome sequencing. Results were analyzed for phylogenetic relationship by core genome MLST (cg-MLST) and whole-genome single-nucleotide polymorphism profiles. Next-generation sequencing–based cg-MLST revealed several outbreak clusters caused by ST8; the geographic focus was in the metropolitan areas of Hamburg and Berlin. To achieve enhanced analytical depth, we used additional cg-MLST target genes and genome-wide single-nucleotide polymorphisms. We identified patient characteristics and detected transmission events, providing evidence that nontoxigenic C. diphtheriae infection is a potential public health threat in industrialized countries.