Opportunities for cancer prevention at syringe services programs: acceptability of HPV self-sampling and vaccination among people who inject drugs

INTRODUCTION

Despite having a high risk of acquiring sexually transmitted infections, people who inject drugs (PWID) often do not receive recommended HPV screenings due to barriers to healthcare. Guideline-based cervical HPV screening and vaccination can prevent cervical cancer. Low-cost, low-barrier methods for cancer screening and prevention are important for vulnerable communities such as PWID.

METHODS

We examined acceptability of HPV self-sampling at a syringe services program (SSP). Participants with a cervix (n = 49) participated in patient education followed by a survey to assess willingness to perform HPV self-sampling versus standard of care.

RESULTS

59% found self-sampling to be acceptable, citing privacy, ease, and quickness. Among those opting for HPV screening delivered by a provider (n = 16), participants cited concerns about adequate sampling (81%) and test accuracy (75%). Notably, only 18% of participants reported complete HPV vaccination.

CONCLUSION

Cervical HPV self-sampling was acceptable to PWID. SSP-based efforts to provide preventative health services could place tools for cancer screening into the hands of PWID, a need-to-reach community.

Project CHARIOT: study protocol for a hybrid type 1 effectiveness-implementation study of comprehensive tele-harm reduction for engagement of people who inject drugs in HIV prevention services

BACKGROUND

People who inject drugs (PWID) remain a high priority population under the federal Ending the HIV Epidemic initiative with 11% of new HIV infections attributable to injection drug use. There is a critical need for innovative, efficacious, scalable, and community-driven models of healthcare in non-stigmatizing settings for PWID. We seek to test a Comprehensive-TeleHarm Reduction (C-THR) intervention for HIV prevention services delivered via a syringe services program (SSP).

METHODS

The CHARIOT trial is a hybrid type I effectiveness-implementation study using a parallel two-arm randomized controlled trial design. Participants (i.e., PWID; n = 350) will be recruited from a syringe services program (SSP) in Miami, Florida. Participants will be randomized to receive either C-THR or non-SSP clinic referral and patient navigation. The objectives are: (1) to determine if the C-THR intervention increases engagement in HIV prevention (i.e., HIV pre-exposure prophylaxis; PrEP or medications for opioid use disorder; MOUD) compared to non-SSP clinic referral and patient navigation, (2) to examine the long-term effectiveness and cost-effectiveness of the C-THR intervention, and (3) to assess the barriers and facilitators to implementation and sustainment of the C-THR intervention. The co-primary outcomes are PrEP or MOUD engagement across follow-up at 3, 6, 9 and 12 months. For PrEP, engagement is confirmed by tenofovir on dried blood spot or cabotegravir injection within the previous 8 weeks. For MOUD, engagement is defined as screening positive for norbuprenorphine or methadone on urine drug screen; or naltrexone or buprenorphine injection within the previous 4 weeks. Secondary outcomes include PrEP adherence, engagement in HCV treatment and sustained virologic response, and treatment of sexually transmitted infections. The short and long term cost-effectiveness analyses and mixed-methods implementation evaluation will provide compelling data on the sustainability and possible impact of C-THR on comprehensive HIV prevention delivered via SSPs.

DISCUSSION

The CHARIOT trial will be the first to our knowledge to test the efficacy of an innovative, peer-led telehealth intervention with PWID at risk for HIV delivered via an SSP. This innovative healthcare model seeks to transform the way PWID access care by bypassing the traditional healthcare system, reducing multi-level barriers to care, and meeting PWID where they are.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05897099. Trial registry name: Comprehensive HIV and Harm Prevention Via Telehealth (CHARIOT). Registration date: 06/12/2023.

A confirmed case of xylazine-induced skin ulcers in a person who injects drugs in Miami, Florida, USA

BACKGROUND

Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the illicit drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who use drugs (PWUD). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida.

CASE PRESENTATION

A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at a Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits were informed by best clinical judgement due to lack of formal guidelines at the time. Wound outcomes are unknown as the patient has not returned to clinic.

CONCLUSIONS

Many PWUD at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system due to stigma. There is an urgent need for access to XTS for PWUD and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.

Improving access to HIV care among people who inject drugs through tele-harm reduction: a qualitative analysis of perceived discrimination and stigma

BACKGROUND

Tele-harm reduction (THR) is a telehealth-enhanced, peer-led, harm reduction intervention delivered within a trusted syringe services program (SSP) venue. The primary goal of THR is to facilitate linkage to care and rapid, enduring virologic suppression among people who inject drugs (PWID) with HIV. An SSP in Miami, Florida, developed THR to circumvent pervasive stigma within the traditional healthcare system.

METHODS

During intervention development, we conducted in-depth interviews with PWID with HIV (n = 25) to identify barriers and facilitators to care via THR. We employed a general inductive approach to transcripts guided by iterative readings of the raw data to derive the concepts, themes, and interpretations of the THR intervention.

RESULTS

Of the 25 PWID interviewed, 15 were in HIV care and adherent to medication; 4 were in HIV care but non-adherent; and 6 were not in care. Themes that emerged from the qualitative analysis included the trust and confidence PWID have with SSP clinicians as opposed to professionals within the traditional healthcare system. Several barriers to treatment were reported among PWID, including perceived and actual discrimination by friends and family, negative internalized behaviors, denial of HIV status, and fear of engaging in care. Facilitators to HIV care included empathy and respect by SSP staff, flexibility of telehealth location, and an overall destigmatizing approach.

CONCLUSION

PWID identified barriers and facilitators to receipt of HIV care through the THR intervention. Interviews helped inform THR intervention development, centered on PWID in the destigmatizing environment of an SSP.

Health, harm reduction, and social service providers' perspectives on the appropriateness and feasibility of peer distribution of HIV self-test kits among people who use drugs

BACKGROUND

People who use drugs (PWUD) experience elevated HIV risk and numerous barriers to facility-based HIV testing. HIV self-testing (HIVST) could circumvent many of those barriers and is acceptable among PWUD, yet HIVST implementation for PWUD is limited. Service providers' perspectives on specific HIVST delivery strategies could help increase availability for PWUD.

METHODS

From April-November 2021, we interviewed 16 health, harm reduction, and social service providers working with PWUD in San Diego, CA. Interviews and rapid thematic analysis explored perspectives on HIVST's utility and appropriateness, as well as the feasibility of and anticipated challenges with specific HIVST delivery strategies, including peer or secondary distribution.

RESULTS

Participants viewed HIV as a significant threat to PWUD health and confirmed the presence of numerous barriers to local facility-based HIV testing. Participants viewed HIVST as a promising and potentially empowering solution. Based on community familiarity with secondary distribution of harm reduction supplies (i.e., naloxone) and information, participants viewed secondary distribution of HIVST kits as an appropriate and feasible strategy for increasing the reach of HIVST, but also described potential barriers (e.g., engaging socially disconnected individuals, ensuring linkages to services following HIVST) and provided suggestions for alternative HIVST kit delivery models (e.g., harm reduction vending machines).

CONCLUSIONS

Service providers viewed secondary distribution of HIVST kits among PWUD as promising, appropriate, and feasible, yet specialized efforts may be needed to reach the most marginalized individuals and ensure consistent provision of educational information and referral supports that maximize the impact of this approach.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence of xylazine among people who inject drugs seeking medical care at a syringe services program clinic: Miami, Florida, 2023

Background

We aimed to report the preliminary xylazine prevalence among people who inject drugs (PWID) treated at a student-run free clinic in Miami, FL, USA and to identify characteristics associated with screening positive for xylazine.

Methods

A retrospective chart review of 59 patients presenting to a syringe services program (SSP) clinic in was conducted between April 27th and August 17th, 2023. We measured presence of xylazine with rapid visual immunoassay strips on patient urine samples.

Results

Xylazine was present in 55.9 % (33/59) of urine samples including 2 without detected opioids. Xylazine presence was significantly associated with unsheltered homelessness (p = 0.018), presence of wound(s) (p = 0.008), and testing positive for hepatitis C antibody (p = 0.014), fentanyl (p = 0.005) and MDMA (p = 0.002).

Conclusions

A high prevalence of xylazine in the Southeastern United States furthers evidence of the geographical spread of xylazine and rapidly evolving illicit drug supply. Widespread xylazine screening is urgently needed to inform people who inject drugs and to studyinterventions to minimize harms associated with xylazine.

Adaptation of the Tele-Harm Reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: a retrospective cohort study

Background: At the start of the pandemic, relaxation of buprenorphine prescribing regulations created an opportunity to create new models of medications for opioid use disorder (MOUD) delivery and care. To expand and improve access to MOUD, we adapted and implemented the Tele-Harm Reduction (THR) intervention; a multicomponent, telehealth-based and peer-driven intervention to promote HIV viral suppression among people who inject drugs (PWID) accessing a syringe services program (SSP). This study examined buprenorphine initiation and retention among PWID with opioid use disorder who received the adapted THR intervention at the IDEA Miami SSP.Methods: A retrospective chart review of participants who received the THR intervention for MOUD was performed to examine the impact of telehealth on buprenorphine retention. Our primary outcome was three-month retention, defined as three consecutive months of buprenorphine dispensed from the pharmacy.Results: A total of 109 participants received the adapted THR intervention. Three-month retention rate on buprenorphine was 58.7%. Seeing a provider via telehealth at baseline or any follow up visit (aOR = 7.53, 95% CI: [2.36, 23.98]) and participants who had received an escalating dose of buprenorphine after baseline visit (aOR = 8.09, 95% CI: [1.83, 35.87]) had a higher adjusted odds of retention at three months. Participants who self-reported or tested positive for a stimulant (methamphetamine, amphetamine, or cocaine) at baseline had a lower adjusted odds of retention on buprenorphine at three months (aOR = 0.29, 95% CI: [0.09, 0.93]).Conclusions: Harm reduction settings can adapt dynamically to the needs of PWID in provision of critical lifesaving buprenorphine in a truly destigmatising approach. Our pilot suggests that an SSP may be an acceptable and feasible venue for delivery of THR to increase uptake of buprenorphine by PWID and promote retention in care.KEY MESSAGESThe Tele-Harm Reduction intervention can be adapted for initiating and retaining people who inject drugs with opioid use disorder on buprenorphine within a syringe services program settingUsing telehealth was associated with increased three-month buprenorphine retentionBaseline stimulant use was negatively associated with three-month buprenorphine retention.

Opioids exacerbate inflammation in people with well-controlled HIV

Introduction

People with HIV (PWH) are known to have underlying inflammation and immune activation despite virologic control. Substance use including opioid dependence is common in this population and is associated with increased morbidity and reduced lifespan. The primary objective of the present study termed opioid immunity study (OPIS), was to investigate the impact of chronic opioids in PWH.

Methods

The study recruited people with and without HIV who had opioid use disorder (OUD). Study participants (n=221) were categorized into four groups: HIV+OP+, n=34; HIV-OP+, n=66; HIV+OP-, n=55 and HIV-OP-, n=62 as controls. PWH were virally suppressed on ART and those with OUD were followed in a syringe exchange program with confirmation of OP use by urine drug screening. A composite cytokine score was developed for 20 plasma cytokines that are linked to inflammation. Cellular markers of immune activation (IA), exhaustion, and senescence were determined in CD4 and CD8 T cells. Regression models were constructed to examine the relationships of HIV status and opioid use, controlling for other confounding factors.

Results

HIV+OP+ participants exhibited highest inflammatory cytokines and cellular IA, followed by HIV-OP+ for inflammation and HIV+OP- for IA. Inflammation was found to be driven more by opioid use than HIV positivity while IA was driven more by HIV than opioid use. In people with OUD, expression of CD38 on CD28-CD57+ senescent-like T cells was elevated and correlated positively with inflammation.

Discussion

Given the association of inflammation with a multitude of adverse health outcomes, our findings merit further investigations to understand the mechanistic pathways involved.

Estimating the epidemiological impact of reaching the objectives of the Florida integrated HIV prevention and care plan in Miami-Dade County

Background

The US Ending the HIV Epidemic (EHE) initiative aims to reduce national HIV incidence 90% by 2030 and to address the disproportionate burden of HIV among different racial/ethnic populations. Florida's state-wide 2022-2026 Integrated HIV Prevention and Care Plan outlines objectives for reaching EHE goals. In Miami-Dade County, we determined the epidemiological impact of achieving the integrated plan's objectives individually and jointly.

Methods

We adapted an HIV transmission model calibrated to Miami-Dade County adjusting access to HIV testing, pre-exposure prophylaxis (PrEP) and antiretroviral treatment to model the effects of each objective between 2022 and 2030. We compared two service scale-up approaches: (a) scale-up proportionally to existing racial/ethnic group access levels, and (b) scale-up according to new diagnoses across racial/ethnic groups (equity-oriented). We estimated reductions in new HIV infections by each objective and approach, compared to the EHE's incidence reduction target.

Findings

The single most influential strategy was reducing new HIV diagnoses in Hispanic/Latinx men who have sex with men through increased PrEP uptake, resulting in 907/2444 (37.1%) fewer annual new HIV infections in 2030. Achieving all objectives jointly would result in 1537/2444 (62.9%) and 1553/2444 (63.5%) fewer annual new HIV infections with the proportional and equity-oriented approaches, respectively.

Interpretation

Achieving the goals of Florida's integrated care plan would significantly reduce HIV incidence in Miami-Dade County; however, further efforts are required to achieve EHE targets. Structural changes in service delivery and a focus on effective implementation of available interventions to address racial/ethnic disparities will be crucial to ending the HIV epidemic.

Funding

This work was supported by the National Institutes of Health/National Institute on Drug Abuse grant no. R01-DA041747.

Availability of telehealth-based services at syringe services programs under the COVID-19 Public Health Emergency

INTRODUCTION

The expanded capacity of syringe services programs (SSPs) in the USA to integrate telehealth services was largely related to flexibility of buprenorphine prescription in response to the COVID-19 pandemic. SSPs demonstrated the potential of using telehealth to reach participants with both medical and non-medical services. The present study examines the implementation of medical and non-medical telehealth-based health services in 2020 at SSPs in the USA and organizational characteristics associated with adopting specific telehealth services.

METHODS

We administered a cross-sectional survey among all known SSPs operating in the USA as of 2021. The two primary study outcomes were (1) implementation of medical telehealth and (2) implementation of non-medical telehealth in 2020. Medical services included HIV counseling/care, hepatitis C virus (HCV) counseling/care, and buprenorphine. Non-medical services included wellbeing/check-ins, overdose prevention training, health navigation, harm reduction and psychological counseling. Bivariate and multivariable mixed effects logistic regression models were used to directly estimate the odds ratio associated with organizational characteristics on the implementation of telehealth-based health services.

RESULTS

Thirty percent of programs (n = 290) reported implementing telehealth-based health services. In multivariable logistic regression models, community-based organization SSPs had higher odds of implementing medical (aOR = 4.69, 95% CI [1.96, 11.19]) and non-medical (aOR = 2.18, 95% CI [1.10, 4.31]) health services compared to public health department SSPs. SSPs that received governmental funding had higher odds of implementing medical services via telehealth (aOR = 2.45, 95% CI [1.35, 4.47]) compared to programs without governmental funding.

CONCLUSION

Community-based organization SSPs and those with government funding had the highest odds of telehealth implementation in response to the COVID-19 Public Health Emergency. Federal, state, and local governments must increase funding for low-barrier venues like SSPs to support telehealth implementation to serve the needs of people who use drugs.

A Confirmed Case of Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Miami, Florida, USA

Background

Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the street drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who inject drugs (PWID). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida.

Case Presentation

A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at the IDEA Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits are discussed below. Wound outcomes are unknown as the patient has not returned to clinic.

Conclusions

Many PWID at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system. There is an urgent need for access to XTS for PWID and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.

How do contextual factors influence naloxone distribution from syringe service programs in the USA: a cross-sectional study

BACKGROUND

Naloxone is a medication that can quickly reverse an opioid overdose. Syringe service programs (SSPs) are community-based prevention programs that provide a range of evidence-based interventions in the USA, including naloxone distribution. Attributes of SSPs make them ideal settings for naloxone distribution-they have staff and delivery models that are designed to reach people who use drugs where they are. We assessed which outer and inner setting factors of SSPs were associated with naloxone distribution in the USA.

METHODS

We surveyed SSPs in the USA known to the North American Syringe Exchange Network in 2019. Using the exploration, preparation, implementation and maintenance framework, we assessed inner and outer contextual factors associated with naloxone distribution among SSPs (n = 263 or 77% of SSPs). We utilized negative binomial regression to assess which factors were associated with the number of naloxone doses distributed and people receiving naloxone.

RESULTS

SSPs reported distributing 710,232 naloxone doses to 230,506 people in the prior year. Regarding outer setting, SSPs located in areas with high levels of community support had a higher level of naloxone distribution (aIRR = 3.07; 95% confidence interval (CI): 2.09-4.51; p < 0.001) and 110% (p = 0.022) higher rate of people receiving naloxone (aIRR = 2.10; 95% CI 1.46-3.02; p < 0.001) in the past 12 months. The legal status of SSPs and the level of need was not significantly associated with naloxone distribution. Regarding inner setting, SSPs with proactive refill systems (aIRR = 2.08; 95% CI 1.27-3.41; p = 0.004), greater number of distribution days (aIRR = 1.09 per day; 95% CI 1.06-1.11; p < 0.001) and older programs (aIRR = 1.06 per year; 95% CI 1.02-1.11; p = 0.004) were associated with higher levels of naloxone distribution. Also, SSPs with proactive refill systems (aIRR = 2.23; 95% CI 1.38-3.58; p = 0.001); greater number of distribution days (aIRR = 1.04; 95% CI 1.02-1.07; p < 0.001) and older programs (aIRR = 1.11; 95% CI 1.05-1.17; p < 0.001) were associated with a higher number of people receiving naloxone.

CONCLUSION

We identified outer and inner setting factors of SSPs that were associated with greater naloxone distribution. It is critical to ensure SSPs are adequately resourced to build community support for services and develop service delivery models that maximize naloxone distribution to address the nation's opioid overdose crisis.

Project T-SHARP: study protocol for a multi-site randomized controlled trial of tele-harm reduction for people with HIV who inject drugs

BACKGROUND

The resurgence of HIV outbreaks and rising prevalence among people who inject drugs (PWID) remain exigent obstacles to Ending the HIV Epidemic in the USA. Adapting a low threshold, comprehensive treatment model for PWID with HIV can leverage syringe services programs (SSPs) to increase availability and accessibility of antiretrovirals (ART), medications for opioid use disorder (MOUD), and hepatitis C cure. We developed Tele-Harm Reduction, a telehealth-enhanced, harm reduction intervention delivered within an SSP venue.

METHODS

The T-SHARP trial is an open-label, multi-site, randomized controlled superiority trial with two parallel treatment arms. Participants (n=240) recruited from SSPs in Miami, Ft. Lauderdale, and Tampa, Florida, who are PWID with uncontrolled HIV (i.e., HIV RNA>200) will be randomized to Tele-Harm Reduction or off-site linkage to HIV care. The primary objective is to compare the efficacy of Tele-Harm Reduction for initiation of ART at SSPs vs. off-site linkage to an HIV clinic with respect to viral suppression across follow-up (suppression at 3, 6, and 12 months post randomization). Participants with HIV RNA<200 copies/ml will be considered virally suppressed. The primary trial outcome is time-averaged HIV viral suppression (HIV RNA <200 copies/ml) over 3-, 6-, and 12-month follow-up. Secondary outcomes include initiation of MOUD measured by urine drug screen and HCV cure, defined as achieving 12-week sustained virologic response (negative HCV RNA at 12 weeks post treatment completion). A cost-effectiveness analysis will be performed.

DISCUSSION

The T-SHARP Trial will be the first to our knowledge to test the efficacy of an innovative telehealth intervention with PWID with uncontrolled HIV delivered via an SSP to support HIV viral suppression. Tele-Harm Reduction is further facilitated by a peer to support adherence and bridge the digital divide. This innovative, flipped healthcare model sets aside the traditional healthcare system, reduces multi-level barriers to care, and meets PWID where they are. The T-SHARP trial is a pragmatic clinical trial that seeks to transform the way that PWID access HIV care and improve HIV clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05208697. Trial registry name: Tele-Harm Reduction. Registration date: January 26, 2022.

Principles for Ending Human Immunodeficiency Virus as an Epidemic in the United States: A Policy Paper of the Infectious Diseases Society of America and the HIV Medical Association

While we have the tools to achieve this goal, the persistent barriers to healthcare services experienced by too many individuals will need to be addressed to make significant progress and improve the health and quality of life of all people with human immunodeficiency virus (HIV). The necessary structural changes require actions by federal, state, and local policymakers and range from ensuring universal access to healthcare services to optimizing care delivery to ensuring a robust and diverse infectious diseases and HIV workforce. In this article, we outlines 10 key principles for policy reforms that, if advanced, would make ending the HIV epidemic in the United States possible and could have much more far-reaching effects in improving the health of our nation.

Integrating Persons With Lived Experience in Opioid Use Disorder Education: A Small Group Exercise and Patient Panel

OBJECTIVES

Based on increasing drug overdose deaths and a shortage of healthcare professionals trained in the management of opioid use disorder (OUD), it is imperative to improve health professional education in addiction medicine. This small group learning exercise and patient panel was designed to provide first year medical students with insights into the lives of people with OUD-through a lens of harm reduction-and to connect biomedical knowledge to the core values and professional themes of their doctoring courses.

METHODS

Facilitators were assigned to each small group of 8 students for the harm reduction-centered Long and Winding Road small group case exercise. This was followed by a patient panel of 2 to 3 persons with OUD. The small group was conducted with first-year medical students as a virtual training session due to the COVID-19 pandemic. Students completed pre- and post-session surveys about agreement with statements pertaining to the learning objectives.

RESULTS

The small group and patient panel were delivered over 8 sessions and attended by all first-year medical students (N = 201). Survey response rate was 67%. Post-session, there was significantly greater agreement with knowledge on all learning objectives compared to pre-session. Two relevant multiple-choice questions on the medical student final exam were answered correctly by 79% and 98% of students.

CONCLUSION

Centering on people with lived experience, we completed small groups and patient panels to introduce concepts of OUD and harm reduction to first year medical students. Pre- and post-session surveys showed short-term achievement of the learning objectives.

Integrated Infectious Disease and Substance Use Disorder Care for the Treatment of Injection Drug Use-Associated Infections: A Prospective Cohort Study With Historical Control

Background

To address the infectious disease (ID) and substance use disorder (SUD) syndemic, we developed an integrated ID/SUD clinical team rooted in harm reduction at a county hospital in Miami, Florida. The Severe Injection-Related Infection (SIRI) team treats people who inject drugs (PWID) and provides medical care, SUD treatment, and patient navigation during hospitalization and after hospital discharge. We assessed the impact of the SIRI team on ID and SUD treatment and healthcare utilization outcomes.

Methods

We prospectively collected data on patients seen by the SIRI team. A diagnostic code algorithm confirmed by chart review was used to identify a historical control group of patients with SIRI hospitalizations in the year preceding implementation of the SIRI team. The primary outcome was death or readmission within 90 days post-hospital discharge. Secondary outcomes included initiation of medications for opioid use disorder (MOUD) and antibiotic course completion.

Results

There were 129 patients included in the study: 59 in the SIRI team intervention and 70 in the pre-SIRI team control group. SIRI team patients had a 45% risk reduction (aRR, 0.55 [95% confidence interval CI, .32-.95]; 24% vs 44%) of being readmitted in 90 days or dying compared to pre-SIRI historical controls. SIRI team patients were more likely to initiate MOUD in the hospital (93% vs 33%, P < .01), complete antibiotic treatment (90% vs 60%, P < .01), and less likely to have patient-directed discharge (17% vs 37%, P = .02).

Conclusions

An integrated ID/SUD team was associated with improvements in healthcare utilization, MOUD initiation, and antibiotic completion for PWID with infections.

Ending the HIV Epidemic: We Have the Tools, Do We Have the Will?

This Viewpoint identifies several barriers to ending the HIV epidemic and urges increasing expertise in HIV medicine in underserved areas like the South challenging legislation designed to keep students ignorant.

"We want everything in a one-stop shop": acceptability and feasibility of PrEP and buprenorphine implementation with mobile syringe services for Black people who inject drugs

INTRODUCTION

A recent surge in HIV outbreaks, driven by the opioid and stimulant use crises, has destabilized our progress toward targets set forth by Ending the HIV Epidemic: A Plan for America for the high-priority community of people who inject drugs (PWID), particularly Black PWID.

METHODS

In order to ascertain the acceptability and feasibility of using a mobile syringe services program (SSP) for comprehensive HIV prevention via PrEP and medications for opioid use disorder (MOUD), our mixed methods approach included a quantitative assessment and semi-structured qualitative interviews with Black PWID (n = 30) in Miami-Dade County who were actively engaged in mobile syringe services.

RESULTS

Participants felt that delivery of MOUD and PrEP at a mobile SSP would be both feasible and acceptable, helping to address transportation, cost, and stigma barriers common within traditional healthcare settings. Participants preferred staff who are compassionate and nonjudgmental and have lived experience.

CONCLUSIONS

A mobile harm reduction setting could be an effective venue for delivering comprehensive HIV prevention services to Black PWID, a community that experiences significant barriers to care via marginalization and racism in a fragmented healthcare system.

Application of machine learning algorithms for localized syringe services program policy implementation - Florida, 2017

BACKGROUND

People who inject drugs (PWID) are at an amplified vulnerability for experiencing a multitude of harms related to their substance use, including viral (e.g. HIV, Hepatitis C) and bacterial infections (e.g. endocarditis). Implementation of evidence-based interventions, such as syringe services programs (SSPs), remains imperative, particularly in locations at an increased risk of HIV outbreaks. This study aims to identify communities in Florida that are high-priority locations for SSP implementation by examining state-level data related to the substance use and overdose crises.

METHODS

State-level surveillance data were aggregated at the ZIP Code Tabulation Area (ZCTA) (n = 983) for 2017. We used confirmed cases of acute HCV infection as a proxy of injection drug use. Least Absolute Selection and Shrinkage Operator (LASSO) regression was used to develop a machine learning model to identify significant indicators of acute HCV infection and high-priority areas for SSP implementation due to their increased vulnerability to an HIV outbreak.

RESULTS

The final model retained three variables of importance: (1) the number of drug-associated skin and soft tissue infection hospitalizations, (2) the number of chronic HCV infections in people aged 18-39, and 3) the number of drug-associated endocarditis hospitalizations. High-priority SSP implementation locations were identified in both urban and rural communities outside of current Ending the HIV Epidemic counties.

CONCLUSION

SSPs are long researched, safe, and effective evidence-based programs that offer a variety of services that reduce disease transmission and assist with combating the overdose crisis. Opportunities to increase services in needed regions across the state now exist in Florida as supported by the expansion of the Infectious Disease Elimination Act of 2019. This study provides details where potential areas of concern may be and highlights regions where future evidence-based harm reduction programs, such as SSPs, would be useful to reduce opioid overdoses and disease transmission among PWID.Key messagesThe rate of acute HCV in Florida in 2017 was 1.9 per 100,000, nearly twice the national average.Serious injection related infections among PWID are significant indicators of acute HCV infection.High-priority SSP implementation locations in Florida were identified in both urban and rural communities, including those outside of current Ending the HIV Epidemic counties.

Availability of medications for opioid use disorder in outpatient and inpatient pharmacies in South Florida: a secret shopper survey

Background

Despite the proven efficacy of medications for opioid use disorder (MOUD) and recent reduction in barriers to prescribers, numerous obstacles exist for patients seeking MOUD. Prior studies have used telephone surveys to investigate pharmacy-related barriers to MOUD. We applied this methodology to evaluate inpatient and outpatient pharmacy barriers to MOUD in South Florida.

Methods

Randomly selected pharmacies in South Florida (Miami-Dade, Broward, and Palm Beach Counties) were called using a standardized script with a “secret shopper” approach until 200 successful surveys had been completed. The primary outcome was the availability of any buprenorphine products. Second, a list of all 48 acute care hospitals within the aforementioned counties was compiled, and hospitals were contacted by telephone using a second structured script.

Results

A total of 1374 outpatient pharmacies and 48 inpatient pharmacies were identified. 378 randomly selected outpatient pharmacies were contacted to accrue 200 successful calls (53% success rate). All 48 inpatient pharmacies were contacted to successfully complete 25 inpatient surveys (52%). Of the 200 outpatient pharmacies contacted, 38% had any buprenorphine available. There was a significant difference in buprenorphine availability by county, with Miami-Dade having the least availability and Palm Beach having the most availability (27% vs. 47%, respectively; p = 0.04). Of the 38% with buprenorphine available, 82% had a sufficient supply for a two-week prescription of buprenorphine 8 mg twice daily. Of the pharmacies that did not have buprenorphine, 55% would be willing to order with a median estimated time to receive an order of 2 days (IQR 1.25–3 days). Of the 25 surveyed inpatient pharmacies, 88% reported having buprenorphine on inpatient formulary, and 55% of hospitals had at least one restriction on ordering of buprenorphine beyond federal regulations.

Conclusions

The results of this study highlight significant pharmacy-related barriers to comprehensive OUD treatment across the healthcare system including both acute care hospital pharmacies and outpatient community pharmacies. Despite efforts to increase the number of MOUD providers, there still remain downstream obstacles to MOUD access.

Buprenorphine implementation at syringe service programs following waiver of the Ryan Haight Act in the United States

INTRODUCTION

Among people with an opioid use disorder in the United States, only 10% receive buprenorphine treatment. The Ryan Haight Act is a federal law that has regulated buprenorphine delivery, requiring an in-person examination between a patient and provider before initiating treatment. At the beginning of the COVID-19 pandemic, federal agencies waived in-person examination requirements for buprenorphine treatment initiation. We examined whether Ryan Haight Act waiver improved implementation of telehealth buprenorphine within syringe service programs (SSPs) - organizations that serve people with historically low access to treatment.

METHODS

We surveyed all known SSPs operating in the US in 2021 (N = 421) of which 77% responded (n = 325). We calculated the prevalence and accompanying 95% confidence intervals (CI) for implementation of telehealth buprenorphine inductions at SSPs in 2020. Multivariable logistic regression was used to assess differences in implementing telehealth buprenorphine inductions by organizational characteristics.

RESULTS

In 2020, the prevalence of implementing buprenorphine inductions via telehealth was 24% (95% CI:19-30%). Non-governmental SSPs had a higher odds of telehealth buprenorphine inductions (adjusted odds ratio (aOR)= 2.92; 95% CI:1.22-7.00; p = 0.016), compared to governmental SSPs. Furthermore, the larger the organization's annual budget, the higher the odds of telehealth buprenorphine implementation (aOR=2.00 per quartile (95% CI:1.33-2.99; p = 0.001). SSPs located in states with higher opioid overdose mortality rates did not have significantly higher likelihood of telehealth buprenorphine implementation.

CONCLUSION

A substantial number of SSPs implemented telehealth buprenorphine after waiver of the Ryan Haight Act. Permanent adoption of this waiver will be critical and providing financial resources to SSPs is vital to support implementation of new innovations.

Opioid Use Disorder Curriculum: Medicine Clerkship Standardized Patient Case, Small-Group Activity, and Patient Panel

Introduction

The overdose crisis remains a critical public health problem, creating an urgent need to train physicians in the treatment and management of opioid use disorder (OUD). Our medicine clerkship module aimed to close this gap by training and assessing students' motivational interviewing skills, harm reduction knowledge, and use of nonstigmatizing language in the treatment of patients with OUD.

Methods

We evaluated the impact of a small-group, case-based activity and patient panel on the clinical documentation skills of students in a medicine clerkship. Clinical documentation was based on an observed structured clinical examination of a standardized patient with OUD and was evaluated using a grading rubric that followed the module learning objectives. Students also submitted reflections on the curriculum.

Results

Qualitative responses (n = 40) from students evaluating the small-group activity and patient panel exercise revealed overall student satisfaction with the patient panel and exposure to patients living with OUD. Three themes emerged from student reflections: (1) humanity, (2) different paths to recovery, and (3) using nonstigmatizing language. For the quantitative test, students' (n = 39) mean clinical documentation scores before and after the small-group activity and patient panel increased from 10.1 to 11.3 out of 13.5 possible points. There was a significant difference between mean pretest and posttest scores (p < .001).

Discussion

The medicine clerkship provided an acceptable and feasible opportunity for implementing a multifaceted educational experience for students with significant immediate impact on their evaluation of patients with OUD.

Injection and Sexual Behavior Profiles among People Who Inject Drugs in Miami, Florida

BACKGROUND

The dynamics of injection drug use and higher-risk sexual practices compound the risk of HIV and HCV acquisition. Published literature on people who inject drugs (PWID) has examined risk of infection assuming homogeneity of cohort behavior. Categorizing subgroups by injection and sexual risk can inform a more equitable approach to how syringe services programs (SSPs) adapt harm reduction resources and implementation of evidence-based interventions. We explored injection and sexual risk profiles among PWID to determine significant predictors of class membership.

METHODS

Data were collected from 1,272 participants at an SSP in Miami-Dade County. Latent Class Analysis (LCA) examined how 10 injection/sexual behavior indicators cluster together to create profiles. Model fit statistics and multivariable multinomial latent class regression identified the optimal class structure and significant predictors of class membership. We assessed SSP visits, naloxone access, HIV/HCV testing and prevalence, and incidence of self-reported wounds.

RESULTS

Three distinct profiles of injection/sexual risk were determined: Low Injection/High Sexual (LIHS) (9.4%); High Injection/Moderate Sexual (HIMS) (18.9%); and Low Injection/Low Sexual (LILS) (71.7%). Participants reporting gay/bisexual orientation and methamphetamine injection more likely belonged to the LIHS class. LIHS class members had higher prevalence of HIV, while those of HIMS reported increased hepatitis C prevalence. Compared to members of LILS, those of HIMS more likely experienced unstable housing, gay/bisexual orientation, heroin or speedball injection, and identifying as women. HIMS cohort members had more SSP visits, naloxone accessed, and higher wound incidence than those of LILS.

CONCLUSIONS

Understanding PWID subgroups amplifies the importance of implementing evidencebased interventions such as PrEP for those engaging in highest risk behavior, with focused interventions of antiretroviral management and access to condoms for members of the LIHS class and HCV screening with wound care for those belonging to HIMS.

Harm reduction for the treatment of patients with severe injection-related infections: description of the Jackson SIRI Team

INTRODUCTION

Hospitalizations for severe injection-related infections (SIRI), such as endocarditis, osteomyelitis, and skin and soft tissue infections (SSTI) are increasingly common. People who inject drugs (PWID) experiencing SIRIs often receive inadequate substance use disorder (SUD) treatment and lack of access to harm reduction services. This translates into lengthy hospitalizations with high rates of patient-directed discharge, readmissions, and post-hospitalization mortality. The purpose of this study was to describe the development of an integrated "SIRI Team" and its initial barriers and facilitators to success.

MATERIALS AND METHODS

The Jackson SIRI Team was developed to improve both hospital and patient-level outcomes for individuals hospitalized with SIRIs at Jackson Memorial Hospital, a 1550-bed public hospital in Miami, Florida, United States. The SIRI Team provides integrated infectious disease and SUD treatment across the healthcare system starting from the inpatient setting and continuing for 90-days post-hospital discharge. The team uses a harm reduction approach, provides care coordination, focuses on access to medications for opioid use disorder (MOUD), and utilizes a variety of infection and addiction treatment modalities to suit each individual patient.

RESULTS

Over the initial 8-months of the SIRI Team, 21 patients were treated with 20 surviving until discharge. Infections included osteomyelitis, endocarditis, bacteraemia/fungemia, SSTIs, and septic arthritis. All patients had OUD and 95% used stimulants. All patients were discharged on MOUD and 95% completed their prescribed antibiotic course. At 90-days post-discharge, 25% had been readmitted and 70% reported taking MOUD.

CONCLUSIONS

A model of integrated infectious disease and SUD care for the treatment of SIRIs has the potential to improve infection and addiction outcomes. Providing attentive, patient-centered care, using a harm reduction approach can facilitate engagement of this marginalized population with the healthcare system.KEY MESSAGESIntegrated infectious disease and addiction treatment is a novel approach to treating severe injection-related infections.Harm reduction should be applied to treating patients with severe injection-related infections with a goal of facilitating antibiotic completion, remission from substance use disorder, and reducing hospital readmissions.

Implementation and first-year operating costs of an academic medical center-based syringe services program

BACKGROUND

Syringe services programs (SSPs) remain highly effective, cost-saving interventions for the prevention of blood-borne infections among people who inject drugs. However, there have been restrictions regarding financial resources allocated to these programs, particularly in the US South. This study aimed to provide cost data regarding the implementation and first-year operations of an academic-based SSP utilizing fixed and mobile strategies, including the integration of onsite wound care.

METHODS

We conducted a micro-costing study that retrospectively collected detailed resource utilization and unit cost data for both the fixed and mobile SSP strategies, including onsite wound care, from both healthcare and societal perspectives. A three-step approach was used to identify, measure, and value intervention costs, and cost components were categorized into implementation, variable program, and time-dependent costs. Sensitivity analysis was performed to examine the impact of SSP operational changes (i.e., needs-based distribution and opt-out HIV/HCV testing) on the cost-per-participant. Cost data we presented as overall cost and cost-per-participant adjusted to 2017 US dollars.

RESULTS

A total of 452 and 129 participants enrolled in fixed and mobile SSP services, respectively. The total cost associated with implementation and first year operations for the fixed site was $407,217.22 or $729.72 per participant and $311,625.52 or $2415.70 per participant for the mobile unit. The largest cost component for both modalities was time-dependent costs (personnel and overhead), while intervention materials (syringes, injection equipment, naloxone) were less than 15% of the total program cost.

DISCUSSION/CONCLUSION

Implementation and operation of new SSP models continue to be low cost compared to treatment for the multitude of harms PWID face without access to evidence-based prevention. Future cost-effectiveness and cost-benefit analyses integrating a comprehensive SSP model within an academic institution, including onsite wound care and other medical services, will provide a more comprehensive understanding of this model, and state-level policy action must be taken to lift the prohibition of state and local funds for the implementation, sustainability, and maintenance of these programs in Florida.

Attributing health benefits to preventing HIV infections versus improving health outcomes among people living with HIV: an analysis in six US cities

OBJECTIVE

Combination strategies generate health benefits through improved health outcomes among people living with HIV (PLHIV) and prevention of new infections. We aimed to determine health benefits attributable to improved health among PLHIV versus HIV prevention for a set of combination strategies in six US cities.

DESIGN

A dynamic HIV transmission model.

METHODS

Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City (NYC) and Seattle, we assessed the health benefits of city-specific optimal combinations of evidence-based interventions implemented at publicly documented levels and at ideal (90% coverage) scale-up (2020-2030 implementation, 20-year study period). We calculated the proportion of health benefit gains (measured as quality-adjusted life-years) resulting from averted and delayed HIV infections; improved health outcomes among PLHIV; and improved health outcomes due to medication for opioid use disorder (MOUD).

RESULTS

The HIV-specific proportion of total benefits ranged from 68.3% (95% credible interval: 55.3-80.0) in Seattle to 98.5% (97.5-99.3) in Miami, with the rest attributable to MOUD. The majority of HIV-specific health benefits in five of six cities were attributable HIV prevention, and ranged from 33.1% (26.1-41.1) in NYC to 83.1% (79.6-86.6) in Atlanta. Scaling up to ideal service levels resulted in three to seven-fold increases in additional health benefits, mostly from MOUD, with HIV-specific health gains primarily driven by HIV prevention.

CONCLUSION

Optimal combination strategies generated a larger proportion of health benefits attributable to HIV prevention in five of six cities, underlining the substantial benefits of antiretroviral therapy engagement for the prevention of HIV transmission through viral suppression. Understanding to whom benefits accrue may be important in assessing the equity and impact of HIV investments.

Effect of initiation of medications for opioid use disorder on hospitalization outcomes for endocarditis and osteomyelitis in a large private hospital system in the United States, 2014-18

BACKGROUND AND AIMS

Opioid use disorder (OUD) has led to not only increases in overdose deaths, but also increases in endocarditis and osteomyelitis secondary to injection drug use (IDU). We studied the association between initiation of medications for opioid use disorder (MOUD) and treatment outcomes for people with infectious sequelae of IDU and OUD.

DESIGN AND SETTING

This is a retrospective cohort study reviewing encounters at 143 HCA Healthcare hospitals across 21 states of the United States from 2014 to 2018.

PARTICIPANTS

Adults aged 18-65 with the ICD diagnosis code for OUD and endocarditis or osteomyelitis (n = 1407).

MEASUREMENTS

Main exposure was the initiation of MOUD, defined as either methadone or buprenorphine at any dosage started during hospitalization. Primary outcomes were defined as patient-directed discharge (PDD), 30-day re-admission and days of intravenous antibiotic treatment. Covariates included biological sex, age, ethnicity, other co-occurring substance use disorders, and insurance status.

FINDINGS

MOUD was initiated among 269 (19.1%) patients during hospitalization. Initiation of MOUD was not associated with decreased odds of PDD. Initiation of MOUD did not impact 30-day re-admission. Patients who received MOUD, on average, had 5.7 additional days of gold-standard intravenous antibiotic treatment compared with those who did not [β = 5.678, 95% confidence interval (CI) = 3.563, 7.794), P < 0.05].

CONCLUSION

For people with opioid use disorder hospitalized with endocarditis or osteomyelitis, initiation of methadone or buprenorphine appears to be associated with improved receipt of gold-standard therapy, as quantified by increased days on intravenous antibiotic treatment.

A missed opportunity: underutilization of inpatient behavioral health services to reduce injection drug use sequelae in Florida

Background

People who inject drugs (PWID) suffer high morbidity and mortality from injection related infections (IRI). The inpatient setting is an ideal opportunity to treat underlying substance use disorder (SUD), but it is unclear how often this occurs.

Objectives

To quantify the utilization of behavioral health services for PWID during inpatient admissions for IRI.

Methods

Data for all hospital admissions in Florida in FY2017 were obtained from the Agency for Healthcare Administration. Hospitalization for IRI were obtained using a validated ICD-10 algorithm and treatment for substance use disorder was quantified using ICD-10-Procedure Coding System (ICD-10-PCS) codes.

Result

Among the 20,001 IRI admissions, there were 230 patients who received behavioral health services as defined by ICD-10-PCS SAT codes for treatment for SUD.

Conclusions

In a state with a large number of IRI, only a very small portion of admissions received behavioral health services. Increased efforts should be directed to studying referral patterns among physicians and other providers caring for this population and increasing utilization of behavioral health services.

Hospital Costs of Injection Drug Use in Florida

People who inject drugs (PWID) experience significant injection-related infections (IRIs) at significant healthcare system cost. This study used and validated an algorithm based on the International Classification of Diseases, Tenth Revision, to estimate hospitalized PWID populations, assess the total statewide morbidity for IRIs among PWID, and calculate associated costs of care.

Reduction in injection risk behaviors after implementation of a syringe services program, Miami, Florida

INTRODUCTION

Syringe services programs (SSPs) are evidence-based HIV prevention programs for people who inject drugs. However, not all SSPs operate evidence-based syringe distribution models, such as needs-based distribution. This study aims to provide preliminary evidence from the IDEA SSP on changes in injection risk behaviors over time, and to examine factors, including syringe coverage, associated with injection risk behavior trajectories over time under a one-for-one syringe distribution model.

METHODS

We used a prospective observational study design to generate a cohort of SSP clients who completed three behavioral assessments at SSP service visits between December 2016 and January 2020 (N = 115). The study used generalized estimating equations (GEE) to examine the relationship between covariate measures and the primary outcomes. The primary outcomes were 1) sharing of any injection equipment (e.g. syringes, needles, cookers, cottons) in the previous 30 days (yes/no) and 2) reusing of needles/syringes in the previous 30 days (yes/no).

RESULTS

Men were more likely to report reusing syringes (aRR = 1.15, 95% CI: 1.01-1.37) and those who reported injecting in public were less likely to report reusing syringes (aRR = 0.90, 95% CI: 0.82-0.99). HCV-positive clients had a 62% reduction in sharing injection equipment and those who reported public injection had a 62% increase in sharing injection equipment over time. Most importantly, increasing syringe coverage was associated with a decrease in both sharing injection equipment (aRR = 0.42, 95% CI: 0.25-0.72) and reusing syringes (aRR = 0.79, 95% CI: 0.66-0.95).

CONCLUSION

This study provides preliminary evidence of reductions in injection-related risk behaviors from the IDEA SSP and highlights potential high priority groups, such as people experiencing homelessness, that may need additional intervention. In addition, improving syringe coverage among SSP clients may be an important factor in reducing behaviors that place individuals at risk for contracting HIV and HCV.

Correlates of injection-related wounds and skin infections amongst persons who inject drugs and use a syringe service programme: A single center study

Risk factors associated with wounds and skin infections amongst persons who inject drugs may have changed in the era of fentanyl and now stimulant coinjection. We assessed the number of injection site wounds and skin infections and associated factors amongst 675 persons who inject drugs in a syringe services programme. Of this sample, 173 participants reported a total of 307 wounds and skin infections. Significant factors associated with increased number of wounds and skin infections were age 30 or older, female gender, ever experiencing homelessness, cocaine injection, and injecting between 5 and 10 years. Wounds and skin infections were common amongst syringe services programme clients and are associated with certain risk factors that may help to design effective interventions. Given the high prevalence of wounds in syringe services programme clients, wound care clinicians can make a significant difference and improve outcomes. We also shed light on correlates of wounds and skin infections in persons who inject drugs in order to spur further research to devise efficacious interventions for this underserved group.

Implementation of a medical student-run telemedicine program for medications for opioid use disorder during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic led to the closure of the IDEA syringe services program medical student-run free clinic in Miami, Florida. In an effort to continue to serve the community of people who inject drugs and practice compassionate and non-judgmental care, the students transitioned the clinic to a model of TeleMOUD (medications for opioid use disorder). We describe development and implementation of a medical student-run telemedicine clinic through an academic medical center-operated syringe services program.

METHODS

Students advertised TeleMOUD services at the syringe service program on social media and created an online sign-up form. They coordinated appointments and interviewed patients by phone or videoconference where they assessed patients for opioid use disorder. Supervising attending physicians also interviewed patients and prescribed buprenorphine when appropriate. Students assisted patients in obtaining medication from the pharmacy and provided support and guidance during home buprenorphine induction.

RESULTS

Over the first 9 weeks in operation, 31 appointments were requested, and 22 initial telehealth appointments were completed by a team of students and attending physicians. Fifteen appointments were for MOUD and 7 for other health issues. All patients seeking MOUD were prescribed buprenorphine and 12/15 successfully picked up medications from the pharmacy. The mean time between appointment request and prescription pick-up was 9.5 days.

CONCLUSIONS

TeleMOUD is feasible and successful in providing people who inject drugs with low barrier access to life-saving MOUD during the COVID-19 pandemic. This model also provided medical students with experience treating addiction during a time when they were restricted from most clinical activities.

Evaluating differences in opioid and stimulant use-associated infectious disease hospitalizations in Florida, 2016-2017

Background

The opioid epidemic has led to increases in injection drug use (IDU)-associated infectious diseases; however, little is known about how more recent increases in stimulant use have affected the incidence and outcomes of hospitalizations for infections among people who inject drugs (PWID).

Methods

All hospitalizations of PWID for IDU-associated infections in Florida were identified using administrative diagnostic codes and were grouped by substance used (opioids, stimulants, or both) and site of infection. We evaluated the association between substance used and the outcomes: patient-directed discharge (PDD, or “against medical advice”) and in-hospital mortality.

Results

There were 22 856 hospitalizations for infections among PWID. Opioid use was present in 73%, any stimulants in 43%, and stimulants-only in 27%. Skin and soft tissue infection was present in 50%, sepsis/bacteremia in 52%, osteomyelitis in 10%, and endocarditis in 10%. PWID using opioids/stimulants were youngest, most uninsured, and had the highest rates of endocarditis (16%) and hepatitis C (44%). Additionally, 25% of patients with opioid/stimulant use had PDD versus 12% for those using opioids-only. In adjusted models, opioid/stimulant use was associated with PDD compared to opioid-only use (aRR 1.28, 95% CI 1.17–1.40). Younger age and endocarditis were also associated with PDD. Compared to opioid-only use, stimulant-only use had higher risk of in-hospital mortality (aRR 1.26, 95% CI 1.03–1.46).

Conclusions

While opioid use contributed to most IDU-associated infections, many hospitalizations also involved stimulants. Increasing access to harm reduction interventions could help prevent these infections, while further research on the acute management of stimulant use disorder-associated infections is needed.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Correction to: When is an abscess more than an abscess? Syringe services programs and the harm reduction safety-net: a case report

An amendment to this paper has been published and can be accessed via the original article.

Baseline prevalence and correlates of HIV and HCV infection among people who inject drugs accessing a syringe services program; Miami, FL

Background

Blood-borne viral infections, such as HIV and hepatitis C (HCV), are common infections among people who inject drugs (PWID). This study aims to determine the prevalence of HIV and HCV infection among PWID accessing the first legal syringe services program (SSP) in the state of Florida, along with examining baseline correlates of HIV and HCV infection.

Methods

Baseline behavioral enrollment assessments of 837 participants accessing an SSP for the first time were analyzed. Patients self-reporting or testing HIV or HCV positive at the enrollment visit were included. Socio-demographic, drug use, and injection-related risk behaviors in the last 30 days were compared across groups defined by all combinations of HIV and HCV serostatus.

Bivariate and multivariable logistic regression models were used to assess correlates of baseline HCV and HIV infection independently.

Results

Overall prevalence for HCV and HIV infection were 44.4% and 10.2%, respectively. After adjusting for confounders, the most significant correlates of baseline HCV infection were age (aOR = 1.01), lower education level (aOR = 1.13), currently homeless (aOR = 1.16), injecting more than seven times a day (aOR = 1.14), reusing syringes (aOR = 1.18), and sharing injection equipment (aOR = 1.13). The most significant predictors of baseline HIV infection were age (aOR = 1.01), non-Hispanic Black race (aOR = 1.28), Hispanic ethnicity (aOR = 1.12), gay or bisexual orientation (aOR = 1.22), and methamphetamine injection (aOR = 1.22). In addition, heroin injection (aOR = 0.92) was significantly associated with a lower odds of HIV infection.

Discussion/conclusion

Baseline behavioral predictors differed between HIV infection and HCV infection among participants accessing syringe services. Understanding the risk factors associated with each infection should be considered when developing additional harm reduction interventions tailored for diverse PWID populations served at SSPs.

When is an abscess more than an abscess? Syringe services programs and the harm reduction safety-net: a case report

Background

Syringe services programs (SSPs) are able to offer wrap-around services for people who inject drugs (PWID) and improve health outcomes.

Case presentation

A 47-year-old man screened positive for a skin and soft tissue infection (SSTI) at an SSP and was referred to a weekly on-site student-run wound care clinic. He was evaluated by first- and third-year medical students, and volunteer attending physicians determined that the infection was too severe to be managed on site. Students escorted the patient to the emergency department, where he was diagnosed with a methicillin-resistant Staphylococcus aureus arm abscess as well as acute HIV infection.

Conclusion

Student-run wound care clinics at SSPs, in conjunction with ongoing harm reduction measures, screenings, and treatment services, provide a safety-net of care for PWID and help mitigate the harms of injection drug use.

Hospital admissions among people who inject opioids following syringe services program implementation

Background

Syringe services programs (SSPs) are an evidence-based harm reduction strategy that reduces dangerous sequelae of injection drug use among people who inject drugs (PWID) such as overdose. SSP services include safer injection education and community-based naloxone distribution programs. This study evaluates differences in overdose-associated hospital admissions following the implementation of the first legal SSP in Florida, based in Miami-Dade County.

Methods

We performed a retrospective analysis of hospitalizations for injection drug-related sequelae at a county hospital before and after the implementation of the SSP. An algorithm utilizing ICD-10 codes for opioid use and sequelae was used to identify people who inject opioids (PWIO). Florida Department of Law Enforcement Medical Examiners Commission Report data was used to analyze concurrent overdose death trends in Florida counties.

Results

Over the 25-month study period, 302 PWIO admissions were identified: 146 in the pre-index period vs. 156 in the post-index period. A total of 26 admissions with PWIO overdose were found: 20 pre-index and 6 post-index (p = 0.0034).

Conclusions

Declining overdose-associated admissions among PWIO suggests early impacts following SSP implementation. These results indicate a potential early benefit of SSP that should be further explored for its effects on future hospital admission and mortality.

Interest in linkage to PrEP among people who inject drugs accessing syringe services; Miami, Florida

Background

People who inject drugs (PWID) are at an increased risk for HIV infection due to injection and sexual risk behaviors. This study aims to examine PrEP knowledge, awareness, and willingness to be linked to PrEP services at a syringe services program (SSP), and examine the relationship between substance use and interest in PrEP linkage.

Methods

Data were collected using a cross-sectional survey of IDEA SSP clients in Miami, FL (N = 157). Based on reported substance injected, participants were classified into opioid-only injection or polysubstance injection. Socio-demographics and HIV risk were examined using Pearson’s Chi-Squared analysis. Bivariate and multivariable logistic regression models were used to test for significant correlates of interest in PrEP linkage.

Results

Only 28.3% of PWID surveyed had previously heard of PrEP. However, 57.2% were interested in receiving more information about PrEP. In the adjusted model, people with opioid-only use were significantly less likely to report interest in being linked to PrEP.

Conclusion

Knowledge, awareness, and interest in being linked to PrEP were low among PWID surveyed. No participants of the study were successfully linked to PrEP services through direct referrals. Further research is needed to examine low threshold service delivery of PrEP to PWID at SSPs.

Examining risk behavior and syringe coverage among people who inject drugs accessing a syringe services program: A latent class analysis

INTRODUCTION

Injection drug use (IDU) remains a significant public health problem. IDU has been associated closely with the opioid crisis; driving overdose, HIV, and Hepatitis C (HCV) infection nationwide. Syringe services programs (SSPs) remain pivotal evidence-based interventions to reduce harm and engage subgroups of people who inject drugs (PWID). This study aims to provide policy considerations from the IDEA SSP, the first legal SSP in the state of Florida.

METHODS

We performed a latent class analysis on patterns of substance use among participants (N = 982) newly enrolled in a syringe services program (SSP). Associations between classes of substance use and sociodemographic variables, risky injection and sex behaviors, HIV/HCV status and syringe coverage were analyzed using the R3STEP and BCH 3-step procedures in latent class regression.

RESULTS

We found a three-class solution: Heroin-Dominant class (73.9%), Methamphetamine-Dominant class (9.5%) and Heroin/Cocaine class (16.6%). Compared to Heroin-Dominant class, the Heroin/Cocaine class were more likely to report homelessness, sharing works, unprotected sex, public injection, and to be HCV positive. Compared to both Heroin-Dominant and Heroin/Cocaine classes, the Methamphetamine-Dominant class were more likely to be male, Hispanic, gay or bisexual orientation, HIV positive, to report unprotected sex and sex with PWID. In addition, the lowest and highest syringe coverage were among those in the Heroin/Cocaine and Methamphetamine-Dominant classes, respectively.

CONCLUSION

Existing interventions among this population to mitigate infectious disease risk, such as SSPs, can be a used to engage differing PWID populations. However, multi-component, targeted preventive interventions and need-based syringe distribution policies are required to further reduce HIV and HCV risk among various PWID populations.

Implementation of an Immediate HIV Treatment Initiation Program in a Public/Academic Medical Center in the U.S. South: The Miami Test and Treat Rapid Response Program

Test and Rapid Response Treatment (TRRT) linkage programs have demonstrated improved HIV suppression rates. This paper describes the design and implementation of the Miami TRRT initiative and its clinical impact. Assisted by a dedicated care navigator, patients receiving a reactive HIV rapid test at the Florida Department of Health STD Clinic were offered same-day HIV care at the University of Miami/Jackson Memorial Medical Center Adult HIV Outpatient Clinic. Patient retention and labs were tracked for 12 months. Of the 2337 individuals tested, 46 had a reactive HIV test; 41 (89%) consented to participate. For the 36 patients in continued care for a year, 33 (91.7%) achieved virological suppression (< 200 copies/mL) within 70 days of their reactive HIV rapid test; at 12 months, 35 (97.2%) remained suppressed, and mean CD4 T cell counts increased from 452 ± 266 to 597 ± 322 cells/mm³. The Miami TRRT initiative demonstrated that immediate linkage to care is feasible and improves retention and suppression in a public/academic medical center in the U.S. South.

Baseline differences in characteristics and risk behaviors among people who inject drugs by syringe exchange program modality: an analysis of the Miami IDEA syringe exchange

Background

In March of 2016, Florida passed the Infection Disease Elimination Act (IDEA), legalizing the formation of the first syringe exchange program in Florida, which opened in December of 2016 at a fixed site in Overtown, Miami. Since that time, the exchange expanded in April of 2017 to include a mobile van unit that provides the same services at different locations throughout Miami-Dade County.

Methods

Trained interviewers conducted face-to-face interviews from all first-time participants at the IDEA Exchange, both at the fixed site and the mobile van unit.

Results

Among 718 first-time enrollees, 74.8% were male, 52.1% were non-Hispanic White, 85.9% completed high school, 59.8% were unemployed, 42.1% were homeless, 54.2% reported an annual income of less than $15,000, and the mean age was 38 years. Participants at the fixed site and mobile van unit reported differences in socioeconomic status, injection drug-related behaviors, and pre-existing hepatitis C virus (HCV) infection status.

Conclusions

Taken together, these results suggest that the mobile unit is capturing a subset of PWID in Miami that the fixed site is not, and vice-versa. As the opioid crisis extends into all demographics, such multimodal efforts to target various populations of PWID should be kept in mind, especially when unveiling future syringe exchanges in Florida and other late-adopting states.

A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs

BACKGROUND

The United States (U.S.) approved use of federal funds for needle and syringe programs (NSPs) in December 2009. This study compares syringe disposal practices in a U.S. city with NSPs to a U.S. city without NSPs by examining the prevalence of improperly discarded syringes in public places and the self-reported syringe disposal practices of injection drug users (IDUs) in the two cities.

METHODS

We conducted visual inspection walkthroughs in a random sample of the top-quartile of drug-affected neighborhoods in San Francisco, California (a city with NSPs) and Miami, Florida (a city without NSPs). We also conducted quantitative interviews with adult IDUs in San Francisco (N=602) and Miami (N=448).

RESULTS

In the visual inspections, we found 44 syringes/1000 census blocks in San Francisco, and 371 syringes/1000 census blocks in Miami. Survey results showed that in San Francisco 13% of syringes IDUs reported using in the 30 days preceding the study interviews were disposed of improperly versus 95% of syringes by IDUs in Miami. In multivariable logistic regression analysis, IDUs in Miami had over 34 times the adjusted odds of public syringe disposal relative to IDUs in San Francisco (adjusted odds ratio=34.2, 95% CI=21.92, 53.47).

CONCLUSIONS

We found eight-fold more improperly disposed syringes on walkthroughs in the city without NSPs compared to the city with NSPs, which was corroborated by survey data. NSPs may help IDUs dispose of their syringes safely in cities with large numbers of IDUs.