Opioid Use Fueling HIV Transmission in an Urban Setting: An Outbreak of HIV Infection Among People Who Inject Drugs-Massachusetts, 2015-2018.

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID).Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors.Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses.Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response.Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative.

Using HIV Surveillance Laboratory Data to Identify Out-of-Care Patients.

HIV-associated laboratory tests reported to public health surveillance have been used as a proxy measure of care engagement of HIV+ individuals. As part of a Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Initiative, the Massachusetts Department of Public Health (MDPH) worked with three pilot clinical facilities to identify HIV+ patients whose last HIV laboratory test occurred at the participating facility but who then appeared to be out of care, defined as an absence of HIV laboratory test results reported to MDPH for at least 6 months. The clinical facilities then reviewed medical records to determine whether these patients were actually not in care, or if there was another reason that they did not have a laboratory test performed, and provided feedback to MDPH on each of the presumed out-of-care patients. In the first year of the pilot project, 37% of patients who appeared to be out of care based on laboratory data were confirmed to be out of care after review of clinical health records. Of those patients who were confirmed to be out of care, 55% had a subsequent laboratory test within 3 months, and 72% had a laboratory test within 6 months, indicating that they had re-engaged with a care provider. MDPH found that it was essential to have clinical staff confirm the care status of patients who were presumed to be out of care based on surveillance data.

Factors Associated with Pre-exposure Prophylaxis in a Highly Insured Population of Urban Men Who Have Sex with Men, 2014.

In the United States, an estimated 25% of men who have sex with men (MSM) have indications for receiving pre-exposure prophylaxis to prevent HIV infection (PrEP), but <4% reported PrEP use in the past 12 months. We evaluate factors associated with having heard of, willingness to use, and use of PrEP in a venue-based, time-spaced sample of 316 urban, highly insured Boston MSM in the 2014 NHBS. We found that 53.7% of respondents reported receiving usual medical care from a doctor's office or health maintenance organization, 57.6% had an indication for PrEP, 66.6% had heard of PrEP, 53.6% reported willingness to use PrEP, and 5.8% reported use of PrEP in the past 12 months. In multivariable analyses, an indication for PrEP was statistically associated with having heard of, willingness to use and use of PrEP in the past 12 months. Findings guide statewide efforts to evaluate and promote PrEP.

Sustained Reduction in HIV Diagnoses in Massachusetts, 2000-2014.

OBJECTIVES: To describe secular trends in reported HIV diagnoses in Massachusetts concurrent with treatment access expansion. METHODS: We characterized cases of HIV infection reported to the Massachusetts HIV/AIDS Surveillance Program between 2000 and 2014 by sex, age, race/ethnicity, and exposure mode. We used Poisson regression to test the statistical significance of trends in diagnoses. RESULTS: Between 2000 and 2014, annual new HIV infections diagnosed in Massachusetts decreased by 47% (P < .001 for trend). We observed significant reductions in diagnoses among women (58% when comparing 2000 with 2014), men (42%), Whites (54%), Blacks (51%), and Hispanics (35%; P < .001 for trend). New diagnoses decreased significantly among men who have sex with men (19%), persons who inject drugs (91%), and heterosexuals (86%; P < .001 for trend). We saw statistically significant downward trends among all men by race/ethnicity, but the trend among Black men who have sex with men was nonsignificant. CONCLUSIONS: Sustained reduction in new HIV diagnoses was concurrent with Massachusetts's Medicaid expansion, state health care reform, and public health strategies to improve care access. A contributory effect of expanded HIV treatment and population-level viral suppression is hypothesized for future research.

A qualitative study of service engagement and unmet needs among unstably housed people who inject drugs in Massachusetts.

INTRODUCTION: People who inject drugs (PWID) are disproportionately affected by HIV in the United States, and HIV prevention and care services may be inaccessible to or underutilized by PWID. In 2018, the Massachusetts Department of Public Health (MDPH) and the Centers for Disease Control and Prevention (CDC) investigated an increase in HIV diagnoses primarily among unstably housed PWID in Lawrence and Lowell. METHODS: The response team interviewed 34 PWID in Lawrence and Lowell, with and without HIV, to inform effective response strategies. Qualitative interviews were recorded, transcribed, and coded. Interviews were transcribed verbatim and coded using a thematic analysis approach structured around pre-designated research questions related to service engagement (including harm reduction services, substance use disorder treatment, medical services, shelters, and other community services), unmet needs, and knowledge gaps regarding HIV prevention. RESULTS: Participants ranged in age from 20 to 54 years (median: 32); 21 of the 34 participants (62%) were male, and 21 were non-Hispanic white. Fifteen (44%) self-reported being HIV positive. All 34 participants had experienced homelessness in the past 12 months, and 29 (85%) had ever received services at syringe service programs (SSP). We identified five key themes: substance use as a barrier to accessing health and social services; experiences of trauma and mental illness as factors impacting substance use and utilization of services; unstable housing as a barrier to accessing services; negative perceptions of medication for opioid use disorder (MOUD); and the desire to be treated with dignity and respect by others. CONCLUSIONS: Findings highlight the need for well-resourced and integrated or linked service provision for PWID, which includes mental health services, housing, MOUD, harm reduction, and infectious disease prevention and care services. Co-locating and integrating low-barrier services at trusted community locations, such as SSPs, could increase service engagement and improve health outcomes for PWID. Further implementation science research may aid the development of effective strategies for services for PWID and build trusting relationships between service providers and PWID.

Partnering With State Health Departments to Address Injection-Related Infections During the Opioid Epidemic: Experience at a Safety Net Hospital.

Massachusetts is one of the epicenters of the opioid epidemic and has been severely impacted by injection-related viral and bacterial infections. A recent increase in newly diagnosed human immunodeficiency virus (HIV) infections among persons who inject drugs in the state highlights the urgent need to address and bridge the overlapping epidemics of opioid use disorder (OUD) and injection-related infections. Building on an established relationship between the Massachusetts Department of Public Health and Boston Medical Center, the Infectious Diseases section has contributed to the development and implementation of a cohesive response involving ambulatory, inpatient, emergency department, and community-based services. We describe this comprehensive approach including the rapid delivery of antimicrobials for the prevention and treatment of HIV, sexually transmitted diseases, systemic infections such as endocarditis, bone and joint infections, as well as curative therapy for chronic hepatitis C virus in a manner that is accessible to patients on the addiction-recovery continuum. We also provide an overview of programs that provide access to medications for OUD, harm reduction services including overdose education, and distribution of naloxone. Finally, we outline lessons learned to inform initiatives in other settings.

Leveraging Health Department Capacities, Partnerships, and Health Insurance for Infectious Disease Response in Massachusetts, 2014-2018.

Policies facilitating integration of public health programs can improve the public health response, but the literature on approaches to integration across multiple system levels is limited. We describe the efforts of the Massachusetts Department of Public Health to integrate its HIV, viral hepatitis, sexually transmitted infection (STI), and tuberculosis response through policies that mandated contracted organizations to submit specimens for testing to the Massachusetts State Public Health Laboratory; co-test blood specimens for HIV, hepatitis C virus (HCV), and syphilis; integrate HIV, viral hepatitis, and STI disease surveillance and case management in a single data system; and implement an integrated infectious disease drug assistance program. From 2014 through 2018, the number of tests performed by the Massachusetts State Public Health Laboratory increased from 16 321 to 33 674 for HIV, from 11 054 to 33 670 for HCV, and from 19 169 to 30 830 for syphilis. Service contracts enabled rapid response to outbreaks of HIV, hepatitis A, and hepatitis B. Key challenges included lack of a billing infrastructure at the Massachusetts State Public Health Laboratory; the need to complete negotiations with insurers and to establish a retained revenue account to receive health insurance reimbursements for testing services; and time to train testing providers in phlebotomy for required testing. Investing in laboratory infrastructure; creating billing mechanisms to maximize health insurance reimbursement; proactively engaging providers, community members, and other stakeholders; and building capacity to transform practices are needed. Using multilevel policy approaches to integrate the public health response to HIV, STI, viral hepatitis, and tuberculosis is feasible and adaptable to other public health programs.

Health care experiences of HIV-infected women with fertility desires in Mexico: a qualitative study.

Increased access to antiretroviral therapy has enabled Mexican HIV-infected women to resume healthy sexual and reproductive lives and reduce the risk of mother-to-child transmission of HIV infection. However, little information is available on the experiences of HIV-infected women desiring children. In this qualitative study, we conducted in-depth interviews with 31 HIV-infected women in four Mexican cities. The findings indicated that most of the women were given limited information on their pregnancy options. With some exceptions, the women felt they were denied the option to have (or to have more) children and advised to undergo tubal ligations or abortions. The findings of this study indicate that ongoing efforts are needed to promote the reproductive rights of HIV-infected women in Mexico and to ensure that they receive options aligned with their fertility desires.

Screening for Hepatitis C as a Prevention Enhancement (SHAPE) for HIV: an integration pilot initiative in a Massachusetts County correctional facility.

OBJECTIVES: The Massachusetts Department of Public Health (MDPH) and the Barnstable County Sheriff's Department (BCSD) in Massachusetts initiated a pilot program in July 2009 offering education and hepatitis C virus (HCV) antibody testing to inmates and detainees, concurrent with routine HIV testing. The initiative was implemented to assess the feasibility of integrating HCV screening into an HIV screening program in a correctional setting and the efficacy of linking HCV antibody-positive inmates to clinical care upon release. METHODS: Through the Screening for Hepatitis C as a Prevention Enhancement initiative, HCV and HIV testing were offered to inmates and detainees shortly after admission, and by request at any time during incarceration. In preparation for release, referrals were made to community-based medical providers for HCV follow-up care. Data from BCSD were compared with routine surveillance data received by MDPH. Confirmatory HCV test results received by April 15, 2012, were considered indicators of appropriate post-release clinical care. RESULTS: From July 2009 through December 2011, 22% (n=596) and 25% (n=667) of 2,716 inmates/detainees accepted HCV and HIV testing, respectively. Of those tested for HCV antibody, 20.5% (n=122) were positive. Of those tested for HIV antibody, 0.8% (n=5) were positive. Of the inmates who tested HCV positive at BCSD and had been released, 37.8% were identified as receiving post-release medical care. CONCLUSIONS: We determined that integration of HCV education and screening into correctional facilities is feasible and reveals high rates of HCV infection. Although this model presupposes programmatic infrastructure, elements of the service design and integration could inform a range of correctional programs. Effective linkage to care, while substantial, was not routine based on our analysis, and may require additional resources given its cost and complexity.