Sharing the cure: Building primary care and public health infrastructure to improve the hepatitis C care continuum in Maryland.

In 2014, trained healthcare provider capacity was insufficient to deliver care to an estimated 70 000 persons in Maryland with chronic hepatitis C virus (HCV) infection. The goal of Maryland Community Based Programs to Test and Cure Hepatitis C, a public health implementation project, was to improve HCV treatment access by expanding the workforce. Sharing the Cure (STC) was a package of services deployed 10/1/14-9/30/18 that included enhanced information technology and public health infrastructure, primary care provider training and practice transformation. Nine primary care sites enrolled. HCV clinical outcomes were documented among individuals who presented for care at sites and met criteria for HCV testing including risk factor or birth cohort (born between 1945 and 1965) based testing. Fifty-three providers completed the STC training. STC providers identified 3237 HCV antibody-positive patients of which 2624 (81%) were RNA+. Of those HCV RNA+, 1739 (66%) were staged, 932 (36%) were prescribed treatment, 838 (32%) started treatment, 721 (27%) completed treatment and 543 (21%) achieved cure. Among 1739 patients staged, 693 (40%) patients had a liver fibrosis assessment score < F2, rendering them ineligible for treatment under Maryland Medicaid guidelines. HCV RNA testing among HCV antibody-positive people increased from 40% (baseline) to 95% among STC providers. Of 554 patients with virologic data reported, 543 (98%) achieved cure. Primary care practices can effectively serve as HCV treatment centers to expand treatment access. However, criteria by insurance providers in Maryland were a major barrier to treatment.

Retention and Overdose Risk among Patients Receiving Substance Use Disorder Treatment, Mental Health Care and Peer Recovery Support: A Longitudinal Analysis.

BACKGROUND: Drug overdose remains a major crisis in the United States. Expanding substance use disorder (SUD) treatment and recovery support services is critical for reducing overdose risk during disasters such as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic. We evaluated the outcomes of an innovative multicomponent service, inclusive of medications for SUD, and peer support, colocated in an outpatient infectious disease clinic in Baltimore City. Our goal was to examine whether a multicomponent SUD program can support patients in recovery during a pandemic. METHODS: One hundred five patients in the RESTORE service between 2019-2020 completed baseline, 3-month, and 6-month surveys. Telemedicine and phone-based support groups were implemented in March 2020 after statewide restrictions on face-to-face services due to SARS-CoV2. Data from surveys and electronic medical records were integrated and analyzed using mixed-effects regression models. RESULTS: At baseline, most patients (88%) reported using drugs/alcohol in the preceding 30 days; 48% of patients reported a history of drug overdose, as well anxiety (23%) and depression (28%) symptoms. Despite pandemic-related disruptions and procedural changes, retention in RESTORE was high (83% after 3 months, 76% after 6 months). Mixed-effects regression models indicated decreased anxiety, alcohol use, heroin use, and nonfatal overdose after 6 months of enrollment (all P < 0.05). CONCLUSIONS: Multicomponent SUD services that are colocated within infectious disease specialty services could help patients to successfully manage their overdose risk and mental health even during future disasters. This model of care could be implemented in other specialty settings that see high rates of SUD.

Implementing a peer-supported, integrated strategy for substance use disorder care in an outpatient infectious disease clinic is associated with improved patient outcomes.

BACKGROUND: Substance use disorder (SUD) and infectious disease (ID) care integration may lead to improvements in SUD and ID outcomes. We assessed implementation of integrating peer-supported SUD care in an outpatient ID setting. METHODS: In this implementation study, we describe REcovery in Specialty care Through medication and OutREach (RESTORE), a low-threshold SUD program implemented in a Baltimore outpatient ID clinic. Key program components were clinician training and support in SUD care, prescription of SUD treatment medications, and peer-based psychosocial support provided by peer recovery specialists. We assessed clinician adoption of RESTORE and compared patient outcomes from baseline to 6 months. RESULTS: Between January 2019 and January 2022, the number of ID clinicians (N=61) who prescribed buprenorphine increased eightfold from 3 (5%) to 24 (39%). Of 258 ID patients referred to RESTORE, 182 (71%) engaged, 137 consented to study participation. Mean age in the study sample was 52.1 (SD=10.4), 63% were male, 84% were Black/African-American. Among 127 (93%) who completed 6-month follow-up, fewer participants reported illicit/non-prescribed opioid use in the past 30 days at follow-up (32%) compared to baseline (52%; p<0.001). Similar reductions were noted for cocaine use (47% to 34%; p=0.006), emergency department visits (23% to 9%; p=0.002), and inpatient hospitalizations (15% to 7%; p=0.025). CONCLUSION: SUD care integration into an outpatient ID care setting using a peer-supported implementation strategy was adopted by clinicians and improved clinical outcomes for patients. This strategy is a promising approach to treating people with infectious diseases and SUD.

Comparison of hepatitis C virus testing recommendations in high-income countries.

AIM: To investigate hepatitis C virus (HCV) testing recommendations from the United States and other high-income countries. METHODS: A comprehensive search for current HCV testing recommendations from the top quartile of United Nations Human Development Index (HDI) countries (very high HDI) was performed using Google and reviewed from May 1 - October 30, 2014 and re-reviewed April 1 - October 2, 2017. RESULTS: Of the 51 countries identified, 16 had HCV testing recommendations from a government body or recommendations issued collaboratively between a government and a medical organization. Of these 16 countries, 15 had HCV testing recommendations that were primarily risk-based and highlight behaviors, exposures, and conditions that are associated with HCV transmission in that region. In addition to risk-based testing, the HCV Guidance Panel (United States) incorporates recommendations for a one-time test for individuals born during 1945-1965 (the birth cohort) without prior ascertainment of risk into their guidance. In addition to the United States, six other countries either have an age-based testing recommendation or recommend one-time testing for all adults independent of risk factors typical of the region. CONCLUSION: This review affirmed the similarities of the HCV Guidance Panel's guidance with those of recommendations from very high HDI countries.

Alcohol Use and Unintended Sexual Consequences among Women Attending an Urban Sexually Transmitted Infections Clinic.

BACKGROUND: Although alcohol use has been linked with a variety of sexual behaviors, we lack an understanding of what precise events occur when women drink that may lead to emotional or physical harms. METHODS: To fill this gap, we qualitatively explored the unintended sexual events occurring while drinking among a particularly at-risk clinic population: urban women attending a public sexually transmitted infections (STI) clinic. This was a secondary data analysis of 20 semistructured, in-depth interviews conducted between December 2009 and August 2010 with 20 sexually active adult women attending the Baltimore City Health Department STI Clinic. We purposively sampled women presenting for care in the STI clinic who reported either binge drinking in the past 6 months or engaging in vaginal or anal intercourse while under the influence of alcohol. Interviews were analyzed using a grounded theory approach. RESULTS: Five major unintended sexual events emerged: sex with new partners; alternative sexual activities, including anal sex and "rough" sex; unprotected sex; blacked out sex or sex occurring during alcohol-related amnesia; and rape. Themes often overlapped, and sexual victimization was a common thread throughout multiple themes. An additional theme, alcohol and prey, largely occurring in bars and nightclubs, emerged as an important precursor to many of the unintended events described. CONCLUSIONS: Alcohol use was associated with a variety of--often dangerous--unintended sexual events. Our results highlight the link between alcohol use and sexual victimization and the need for intervention development to reduce the emotional and physical harms resulting from the unintended consequences of alcohol use.