Case Series of Jamestown Canyon Virus Infections with Neurologic Outcomes, Canada, 2011-2016.

Jamestown Canyon virus (JCV) is a mosquitoborne orthobunyavirus in the California serogroup that circulates throughout Canada and the United States. Most JCV exposures result in asymptomatic infection or a mild febrile illness, but JCV can also cause neurologic diseases, such as meningitis and encephalitis. We describe a case series of confirmed JCV-mediated neuroinvasive disease among persons from the provinces of British Columbia, Alberta, Quebec, and Nova Scotia, Canada, during 2011-2016. We highlight the case definitions, epidemiology, unique features and clinical manifestations, disease seasonality, and outcomes for those cases. Two of the patients (from Quebec and Nova Scotia) might have acquired JCV infections during travel to the northeastern region of the United States. This case series collectively demonstrates JCV's wide distribution and indicates the need for increased awareness of JCV as the underlying cause of meningitis/meningoencephalitis during mosquito season.

PrEP for people who use opioids: A NIDA clinical trials network survey study in Southern U.S. cities where HIV incidence is high.

BACKGROUND: People who use opioids (PWUO) are at increased risk for HIV. Pre-exposure prophylaxis (PrEP) is effective but underutilized as HIV prevention among PWUO. This study examined predictors of willingness to take daily oral PrEP and long-acting injectable (LAI) PrEP among PWUO across eight Southern urban cities with high HIV incidence. METHODS: HIV-negative PWUO (N = 308) seeking services in community-based programs participated in this cross-sectional survey study. Measures included demographics, sexual risk behavior, substance use frequency, and awareness of and willingness to take oral and injectable PrEP. Data were analyzed using mixed-effects models. RESULTS: Willingness to take daily oral and LAI PrEP was moderately high (69.16% and 62.02%, respectively). Half had heard of PrEP, but only 4% had ever taken it. Only education and condomless vaginal sex predicted willingness to take oral PrEP. Only education predicted willingness to take LAI PrEP. Polysubstance use was prevalent, with substantial proportions of PWUO reporting frequent use of injection drugs (opioids or stimulants, 79.5%), non-injection opioids (73.3%), non-injection stimulants (71.1%), cannabis (62.6%), and hazardous drinking (29.6%). About 20% reported past-year condomless anal sex, and one-third reported past-year condomless vaginal sex. CONCLUSIONS: PWUO in this study were amenable to PrEP, particularly in light of education and condomless vaginal sex. Careful consideration for matching PrEP messaging to the PWUO audience is needed. PrEP promotion should expand beyond men who have sex with men to include groups such as these predominantly heterosexual, polysubstance-using PWUO with HIV risk who were open to both formulations of PrEP.

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.

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.

Evidence of a conserved mammalian immunosuppression mechanism in Lutzomyia longipalpis upon infection with Leishmania.

Introduction: Sand flies (Diptera: Phlebotominae) belonging to the Lutzomyia genus transmit Leishmania infantum parasites. To understand the complex interaction between the vector and the parasite, we have been investigating the sand fly immune responses during the Leishmania infection. Our previous studies showed that genes involved in the IMD, Toll, and Jak-STAT immunity pathways are regulated upon Leishmania and bacterial challenges. Nevertheless, the parasite can thrive in the vectors' gut, indicating the existence of mechanisms capable of modulating the vector defenses, as was already seen in mammalian Leishmania infections. Methods results and discussion: In this study, we investigated the expression of Lutzomyia longipalpis genes involved in regulating the Toll pathway under parasitic infection. Leishmania infantum infection upregulated the expression of two L. longipalpis genes coding for the putative repressors cactus and protein tyrosine phosphatase SHP. These findings suggest that the parasite can modulate the vectors' immune response. In mammalian infections, the Leishmania surface glycoprotein GP63 is one of the inducers of host immune depression, and one of the known effectors is SHP. In L. longipalpis we found a similar effect: a genetically modified strain of Leishmania amazonensis over-expressing the metalloprotease GP63 induced a higher expression of the sand fly SHP indicating that the L. longipalpis SHP and parasite GP63 increased expressions are connected. Immuno-stained microscopy of L. longipalpis LL5 embryonic cells cultured with Leishmania strains or parasite conditioned medium showed cells internalization of parasite GP63. A similar internalization of GP63 was observed in the sand fly gut tissue after feeding on parasites, parasite exosomes, or parasite conditioned medium, indicating that GP63 can travel through cells in vitro or in vivo. When the sand fly SHP gene was silenced by RNAi and females infected by L. infantum, parasite loads decreased in the early phase of infection as expected, although no significant differences were seen in late infections of the stomodeal valve. Conclusions: Our findings show the possible role of a pathway repressor involved in regulating the L. longipalpis immune response during Leishmania infections inside the insect. In addition, they point out a conserved immunosuppressive effect of GP63 between mammals and sand flies in the early stage of parasite infection.

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.

The environmentally-regulated interplay between local three-dimensional chromatin organisation and transcription of proVWX in E. coli.

Nucleoid associated proteins (NAPs) maintain the architecture of bacterial chromosomes and regulate gene expression. Thus, their role as transcription factors may involve three-dimensional chromosome re-organisation. While this model is supported by in vitro studies, direct in vivo evidence is lacking. Here, we use RT-qPCR and 3C-qPCR to study the transcriptional and architectural profiles of the H-NS (histone-like nucleoid structuring protein)-regulated, osmoresponsive proVWX operon of Escherichia coli at different osmolarities and provide in vivo evidence for transcription regulation by NAP-mediated chromosome re-modelling in bacteria. By consolidating our in vivo investigations with earlier in vitro and in silico studies that provide mechanistic details of how H-NS re-models DNA in response to osmolarity, we report that activation of proVWX in response to a hyperosmotic shock involves the destabilization of H-NS-mediated bridges anchored between the proVWX downstream and upstream regulatory elements (DRE and URE), and between the DRE and ygaY that lies immediately downstream of proVWX. The re-establishment of these bridges upon adaptation to hyperosmolarity represses the operon. Our results also reveal additional structural features associated with changes in proVWX transcript levels such as the decompaction of local chromatin upstream of the operon, highlighting that further complexity underlies the regulation of this model operon. H-NS and H-NS-like proteins are wide-spread amongst bacteria, suggesting that chromosome re-modelling may be a typical feature of transcriptional control in bacteria.

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.

An unexpected abundance of bidirectional promoters within Salmonella Typhimurium plasmids.

Transcription of the DNA template, to generate an RNA message, is the first step in gene expression. The process initiates at DNA sequences called promoters. Conventionally, promoters have been considered to drive transcription in a specific direction. However, in recent work, we showed that many prokaryotic promoters can drive divergent transcription. This is a consequence of key DNA sequences for transcription initiation being inherently symmetrical. Here, we used global transcription start site mapping to determine the prevalence of such bidirectional promoters in Salmonella Typhimurium. Surprisingly, bidirectional promoters occur three times more frequently in plasmid components of the genome compared to chromosomal DNA. Implications for the evolution of promoter sequences are discussed.

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.

Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study.

BACKGROUND: Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention. METHODS: Participants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs. RESULTS: Implementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team's advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing. CONCLUSION: Integration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.

The influence of schooling on performance in chess and at the Olympics.

At the macro-level, it is hard to test the hypothesis that increased schooling in a country will raise labour productivity but sectoral analyses may be tractable. In sports, output is homogenous in that countries' achievements are measurable in the same way. We examine country performances at the Chess Olympiad and the Olympic Games, contrasting tournaments where players in the first use only their minds but most in the second supply substantial physical effort or work with costly physical capital. Modelling success in either leads to a set of results familiar from sports literature: country performance depends on economic resources, represented by population size and per capita income. Supplementary variables capture over-performance by communist/ former communist countries. We then introduce a measure of average years of schooling. This significantly reduces the role of income, especially in chess. It also takes power away from the 'communist' variables, especially at the Olympics. These results suggest that much of any effect from income is mediated through schooling: investment in education is associated with elevated productivity. Increased productivity is observed in both settings, one a knowledge-intensive sub-sector and the other dependent to a significant extent on either raw physical strength or expensive capital input. Supplementary Information: The online version contains supplementary material available at 10.1007/s00181-022-02259-9.

"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.

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.

Opioid Use Disorder Curriculum: Preclerkship Pharmacology Case-Based Learning Session.

Introduction: During the first year of the COVID-19 pandemic, over 93,000 Americans lost their lives to a preventable overdose. Medications for opioid use disorder (OUD) have been shown to decrease mortality in OUD but are underutilized. Through this case-based learning exercise, first-year medical students applied physiologic and pharmacologic principles to the diagnosis and treatment of OUD. Methods: Faculty facilitated a case discussion over a 1-hour large-group case-based learning (CBL) session. Facilitators utilized PowerPoint slides to illustrate graphs and figures while discussing the case. To evaluate students on the CBL learning objectives, three pharmacology exam questions were administered; students also evaluated the CBL's effectiveness in meeting educational objectives on three Likert-scale questions and via open-ended feedback. Results: First-year medical students (n = 200) completed the CBL. The mean score on the exam questions was 91%. Students agreed or strongly agreed that the CBL was an effective way to learn pharmacology principles (69%), that it reinforced pharmacologic fundamentals (70%), and that it showed how pharmacology fundamentals were important in the real world of clinical medicine (86%). Qualitative feedback on the CBL was generally positive, including satisfaction with the small-group setting and practical applications of pharmacology to clinical practice. Discussion: This CBL exercise contains content critical for preparing students to combat the modern opioid epidemic. The exercise provides an opportunity for learners to review fundamental pharmacodynamic and pharmacokinetic principles so as to ready them for clinical clerkships and beyond.

Xenogeneic silencing strategies in bacteria are dictated by RNA polymerase promiscuity.

Horizontal gene transfer facilitates dissemination of favourable traits among bacteria. However, foreign DNA can also reduce host fitness: incoming sequences with a higher AT content than the host genome can misdirect transcription. Xenogeneic silencing proteins counteract this by modulating RNA polymerase binding. In this work, we compare xenogeneic silencing strategies of two distantly related model organisms: Escherichia coli and Bacillus subtilis. In E. coli, silencing is mediated by the H-NS protein that binds extensively across horizontally acquired genes. This prevents spurious non-coding transcription, mostly intragenic in origin. By contrast, binding of the B. subtilis Rok protein is more targeted and mostly silences expression of functional mRNAs. The difference reflects contrasting transcriptional promiscuity in E. coli and B. subtilis, largely attributable to housekeeping RNA polymerase σ factors. Thus, whilst RNA polymerase specificity is key to the xenogeneic silencing strategy of B. subtilis, transcriptional promiscuity must be overcome to silence horizontally acquired DNA in E. coli.

Examining the Psychometrics of the National HIV Behavioral Surveillance Measure for Community HIV-Related Stigma.

The research tested the psychometrics of the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS) community HIV-related stigma scale. Data was from men who have sex with men (MSM) NHBS cycles conducted 2011-2017 in Miami-Dade, Florida among n = 1455 participants. MSM were cis-gender male, 18+ years old, reported lifetime oral/anal sex with a male, and lived in Miami-Dade County. We assessed reliability using Cronbach's alpha and McDonald's omega, determined factors using principal factor analysis, and assessed construct validity using five a priori hypotheses. The scale was unidimensional, had questionable internal reliability (α = 0.68, ω = 0.69), and met four of five a priori hypotheses in the expected direction. Correlations were medium-weak in strength and only one was consistently met. Future iterations of the NHBS survey should consider replacing the 4-item community HIV-related stigma scale with an instrument that has superior internal reliability, measures multiple HIV-related stigma dimensions, and demonstrates stronger evidence of validity.

RESUMEN: La investigación evaluó la psicometrías de la escala comunitaria de estigma relacionada con el VIH de La Vigilancia del Comportamiento Nacional del VIH de los Centros de Control y la Prevención de Enfermedades (National HIV Behavioral Surveillance, NHBS por sus siglas en Ingles). Los datos fueron de hombres que tienen sexo con hombres (HSH) ciclos NHBS realizados 2011­2027 en Miami-Dade, Florida entre n = 1455 participantes. Los HSH eran hombres cisgénero, mayores de 18 años, reportando haber tenido sexo oral/anal de toda la vida con un hombre y vivían en el condado de Miami-Dale. Evaluamos la confiabilidad usando el alfa de Cronbach y el omega de McDonald, determinamos los factores usando el análisis de factores principales y evaluamos la validez de constructo usando cinco hipótesis a priori. La escala era unidimensional, tenía una fiabilidad interna cuestionable (α = 0.68, ω = 0.69), y cumplía cuatro de cinco hipótesis a priori en la dirección esperada. Las correlaciones fueron de intensidad media-débil y solo una se cumplió de manera consistente. Las iteraciones futuras de la encuesta NHBS debería considerar reemplazar la escala comunitaria de estigma relacionada con el VIH de 4 ítems por un instrumento que tenga una confiabilidad interna superior, mida múltiples dimensiones del estigma relacionado con el VIH y demuestre una evidencia mas solida de validez.

Acceptability, feasibility, and pilot results of the tele-harm reduction intervention for rapid initiation of antiretrovirals among people who inject drugs.

BACKGROUND: People who inject drugs (PWID) have been a marginalized and a stigmatized population since the beginning of the AIDS epidemic and have not experienced the same life-changing benefits of antiretroviral therapy as others. Tele-Harm Reduction (THR) is a telehealth-enhanced, harm reduction intervention, delivered within a trusted SSP venue. It aims to facilitate initiation of care and achieve rapid HIV viral suppression among PWID living with HIV. METHODS: In this mixed-methods study, we employed the Practical, Robust, Implementation and Sustainability Model (PRISM) implementation science framework to identify multilevel barriers and facilitators to implementing the THR intervention. Focus groups (n = 2, 16 participants), stakeholder interviews (n = 7) and in-depth interviews were conducted with PWID living with HIV (n = 25). In addition, to assess feasibility and acceptability, we pilot tested the THR intervention and reported viral suppression at 6 months. RESULTS: Focus groups and stakeholder interviews revealed system and organizational level barriers to implementation including requirements for identification and in person visits, waiting times, stigma, case management inexperience, multiple electronic health records, and billing. A potential facilitator was using telehealth for case management and initial provider visit. In the in depth interviews conducted with PWID living with HIV, participants expressed that the SSP creates a convenient, comfortable, confidential environment for delivering multiple, non-stigmatizing PWID-specific services. 35 PWID living with HIV were enrolled in the pilot study, 35 initiated antiretroviral therapy, and 25 (78.1%) were virally suppressed at six months. CONCLUSION: Rooted in harm reduction, the THR intervention shows promise in being an acceptable and feasible intervention that may facilitate engagement in HIV care and viral suppression among PWID.

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.

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.