Comparative effectiveness of urine drug screening strategies alongside opioid agonist treatment in British Columbia, Canada: a population-based observational study protocol.

INTRODUCTION: Urine drug tests (UDTs) are commonly used for monitoring opioid agonist treatment (OAT) responses, supporting the clinical decision for take-home doses and monitoring potential diversion. However, there is limited evidence supporting the utility of mandatory UDTs-particularly the impact of UDT frequency on OAT retention. Real-world evidence can inform patient-centred approaches to OAT and improve current strategies to address the ongoing opioid public health emergency. Our objective is to determine the safety and comparative effectiveness of alternative UDT monitoring strategies as observed in clinical practice among OAT clients in British Columbia, Canada from 2010 to 2020. METHODS AND ANALYSIS: We propose a population-level retrospective cohort study of all individuals 18 years of age or older who initiated OAT from 1 January 2010 to 17 March 2020. The study will draw on eight linked health administrative databases from British Columbia. Our primary outcomes include OAT discontinuation and all-cause mortality. To determine the effectiveness of the intervention, we will emulate a 'per-protocol' target trial using a clone censoring approach to compare fixed and dynamic UDT monitoring strategies. A range of sensitivity analyses will be executed to determine the robustness of our results. ETHICS AND DISSEMINATION: The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.

Knowledge, attitudes, and behaviors related to the fentanyl-adulterated drug supply among people who use drugs in Oregon.

INTRODUCTION: Nonpharmaceutical fentanyl has reconfigured the U.S. illicit drug market, contributing to a drastic increase in overdose drug deaths. While illicit fentanyl has subsumed the drug supply in the Northeast and Midwest, it has more recently reached the West. For this study, we explored knowledge, attitudes, and behaviors among people who use drugs in Oregon in the context of the emergence of fentanyl in the drug supply. METHODS: We conducted in-depth interviews by phone with 34 people who use drugs in Oregon from May to June 2021. We used thematic analysis to analyze transcripts and construct themes. RESULTS: People who use drugs knew about fentanyl, expressed doubt that fentanyl could be found in methamphetamine; believed those who were younger or less experienced were at higher risk for harm; and received information about fentanyl from drug dealers, syringe service programs, or peers (other people who use drugs). Preference for fentanyl's presence in drugs like heroin or methamphetamine was mixed. Some felt that their preference was irrelevant since fentanyl was unavoidable. Participants reported engaging in harm reduction practices, including communicating about fentanyl with dealers and peers, testing for fentanyl, using smaller quantities of drugs, switching from injecting to smoking, and using naloxone. CONCLUSION: People who use drugs are responding to the rise of fentanyl on the West Coast and are concerned about the increasing uncertainty and hazards of the drug supply. They are willing and motivated to adopt harm reduction behaviors. Harm reduction promotion from syringe service programs and public health agencies is essential to reduce injury and death from nonpharmaceutical fentanyl.

Predictors of timely opioid agonist treatment initiation among veterans with and without HIV.

BACKGROUND: Opioid use disorder (OUD) is prevalent among people with HIV (PWH). Opioid agonist therapy (OAT) is the most effective treatment for OUD and is associated with improved health outcomes, but is often not initiated. To inform clinical practice, we identified factors predictive of OAT initiation among patients with and without HIV. METHODS: We identified 19,698 new clinical encounters of OUD between 2000 and 2012 in the Veterans Aging Cohort Study (VACS), a national observational cohort of PWH and matched uninfected controls. Mixed effects models examined factors predictive of OAT initiation within 30-days of a new OUD clinical encounter. RESULTS: 4.9% of both PWH and uninfected patients initiated OAT within 30 days of a new OUD clinical encounter. In adjusted models, participants with a psychiatric diagnosis (aOR = 0.54, 95% CI 0.47 - 0.62), PWH (aOR = 0.79, 95% CI 0.68-0.92), and rural residence (aOR = 0.56, 95% CI 0.39-0.78) had a lower likelihood of any OAT initiation, while African-American patients (aOR = 1.60, 95% CI 1.34-1.92), those with an alcohol related diagnosis (aOR = 1.76, 95% CI 1.48-2.08), diagnosis year 2005-2008 relative to 2000-2004 (aOR = 1.24, 95% CI 1.05-1.45), and patients with HCV (aOR = 1.50, 95% CI 1.27-1.77) had a greater likelihood of initiating any OAT within 30 days. Predictive factors were similar in the total sample and PWH only models. CONCLUSIONS: PWH were less likely to receive timely OAT initiation than demographically similar uninfected patients. Given the health benefits of such treatment, the low rate of OAT initiation warrants focused efforts in both PWH and uninfected populations.

Incidence and risk factors of HPV-related and HPV-unrelated Head and Neck Squamous Cell Carcinoma in HIV-infected individuals.

OBJECTIVES: To examine the risk and trends of HPV-related and HPV-unrelated Head and Neck Squamous Cell Carcinoma (HNSCC) in HIV-infected individuals and assess whether immunosuppression (measured through CD4 cell count) and other risk factors impact HNSCC risk. MATERIALS AND METHODS: Incident HNSCCs at HPV-related and HPV-unrelated anatomic sites were detected in HIV-infected participants from pooled data from 17 prospective studies in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) between 1996 and 2009. HNSCC cases were validated using chart review or cancer registry matching. Risk factors for incident HPV-related and HPV-unrelated HNSCC were explored using mixed effects Poisson regression in a full prospective analysis, and the effect of CD4 prior to cancer diagnosis was examined in a nested case control analysis. RESULTS: 66 HPV-related and 182 HPV-unrelated incident HNSCCs were detected among 82,375 HIV-infected participants. Standardized incidence ratios (SIRs) for both HPV-related (SIR=3.2, 95%CI=2.5-3.4) and HPV-unrelated (SIR=3.0, 95%CI=2.5-4.1) HNSCC were significantly elevated in HIV-infected individuals compared with the US general population. Between 1996 and 2009, the age-standardized HPV-related HNSCC incidence increased non-significantly from 6.8 to 11.4per 100,000 person-years (p-trend=0.31) while the age-standardized incidence of HPV-unrelated HNSCC decreased non-significantly from 41.9 to 29.3 per 100,000 person-years (p-trend=0.16). Lower CD4 cell count prior to cancer diagnosis was significantly associated with increased HPV-related and HPV-unrelated HNSCC risk. CONCLUSION: The standardized incidence of HPV-related and HPV-unrelated HNSCC are both elevated in HIV-infected individuals. Immunosuppression may have a role in the development of both HPV-related and HPV-unrelated HNSCC.

Hepatitis C virus testing in adults living with HIV: a need for improved screening efforts.

OBJECTIVES: Guidelines recommend hepatitis C virus (HCV) screening for all people living with HIV (PLWH). Understanding HCV testing practices may improve compliance with guidelines and can help identify areas for future intervention. METHODS: We evaluated HCV screening and unnecessary repeat HCV testing in 8,590 PLWH initiating care at 12 U.S. HIV clinics between 2006 and 2010, with follow-up through 2011. Multivariable logistic regression examined the association between patient factors and the outcomes: HCV screening (≥1 HCV antibody tests during the study period) and unnecessary repeat HCV testing (≥1 HCV antibody tests in patients with a prior positive test result). RESULTS: Overall, 82% of patients were screened for HCV, 18% of those screened were HCV antibody-positive, and 40% of HCV antibody-positive patients had unnecessary repeat HCV testing. The likelihood of being screened for HCV increased as the number of outpatient visits rose (adjusted odds ratio 1.02, 95% confidence interval 1.01-1.03). Compared to men who have sex with men (MSM), patients with injection drug use (IDU) were less likely to be screened for HCV (0.63, 0.52-0.78); while individuals with Medicaid were more likely to be screened than those with private insurance (1.30, 1.04-1.62). Patients with heterosexual (1.78, 1.20-2.65) and IDU (1.58, 1.06-2.34) risk compared to MSM, and those with higher numbers of outpatient (1.03, 1.01-1.04) and inpatient (1.09, 1.01-1.19) visits were at greatest risk of unnecessary HCV testing. CONCLUSIONS: Additional efforts to improve compliance with HCV testing guidelines are needed. Leveraging health information technology may increase HCV screening and reduce unnecessary testing.

Correlates of HIV risk behaviors among homeless and unstably housed young adults.

OBJECTIVES: Homeless young adults are exposed to multiple risk factors for HIV infection. We identified HIV risk behaviors and their correlates among homeless young adults in Portland, Oregon. METHODS: We conducted a community-based, cross-sectional survey of HIV risk behaviors among homeless young adults aged 18-25 years in 2010. Participants completed three study components: (1) an interviewer-administered survey of HIV risk behaviors; (2) a brief, client-centered HIV risk-based counseling session; and (3) rapid HIV testing. RESULTS: Among 208 participants, 45.8% identified as racial/ethnic minority groups, 63.8% were male, and 35.7% self-identified as nonheterosexual. Six participants, all from sexual minority groups, had positive HIV screening results (two newly identified, four previously known) for a seropositivity rate of 2.9%. Female sex, belonging to a sexual minority group, frequent traveling between cities, depression, and alcohol use to intoxication were significantly associated with unprotected sex in univariate analysis. Female sex and high perceived risk of HIV were significantly associated with unprotected sex in multivariate analysis. CONCLUSIONS: Our findings support the need for enhanced HIV prevention interventions for homeless young adults.

Screening for HIV: systematic review to update the 2005 U.S. Preventive Services Task Force recommendation.

BACKGROUND: A 2005 U.S. Preventive Services Task Force (USPSTF) review found good evidence that HIV screening is accurate and that antiretroviral therapy (ART) for immunologically advanced disease is associated with substantial clinical benefits, but insufficient evidence to determine the effects on transmission or in less immunologically advanced disease. PURPOSE: To update the 2005 USPSTF review on benefits and harms of HIV screening in adolescents and adults, focusing on research gaps identified in the prior review. DATA SOURCES: MEDLINE (2004 to June 2012) and the Cochrane Library (through the second quarter of 2012). STUDY SELECTION: Randomized trials and observational studies that compared HIV screening strategies and reported clinical outcomes, evaluated the effects of starting ART at different CD4 cell count thresholds and long-term harms, or reported the effects of interventions on transmission risk. DATA EXTRACTION: 2 authors abstracted and checked study details and quality using predefined criteria. DATA SYNTHESIS: No study directly evaluated the effects on clinical outcomes of screening versus no screening for HIV infection. A randomized trial and a subgroup analysis from a randomized trial found that ART initiation at CD4 counts less than 0.250 × 109 cells/L was associated with a higher risk for death or AIDS-defining events than initiation at CD4 counts greater than 0.350 × 109 cells/L (hazard ratios, 1.7 [95% CI, 1.1 to 2.5] and 5.3 [CI, 1.3 to 9.6]). Large, fair-quality cohort studies also consistently found that ART initiation at CD4 counts of 0.350 to 0.500 × 109 cells/L was associated with lower risk for death or AIDS-defining events than delayed initiation. New evidence from good-quality cohorts with longer-term follow-up confirms a previously observed small increased risk for cardiovascular events associated with certain antiretrovirals. Strong evidence from 1 good-quality randomized trial and 7 observational studies found that ART was associated with a 10- to 20-fold reduction in risk for sexual transmission of HIV. LIMITATIONS: Only English-language articles were included. Observational studies were included. Studies done in resource-poor or high-prevalence settings were included but might have limited applicability to general screening in the United States. CONCLUSION: Previous studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective in patients with advanced immunodeficiency. New evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Implementing rapid HIV testing with or without risk-reduction counseling in drug treatment centers: results of a randomized trial.

OBJECTIVES: We examined the effectiveness of risk reduction counseling and the role of on-site HIV testing in drug treatment. METHODS: Between January and May 2009, we randomized 1281 HIV-negative (or status unknown) adults who reported no past-year HIV testing to (1) referral for off-site HIV testing, (2) HIV risk-reduction counseling with on-site rapid HIV testing, or (3) verbal information about testing only with on-site rapid HIV testing. RESULTS: We defined 2 primary self-reported outcomes a priori: receipt of HIV test results and unprotected anal or vaginal intercourse episodes at 6-month follow-up. The combined on-site rapid testing participants received more HIV test results than off-site testing referral participants (P<.001; Mantel-Haenszel risk ratio=4.52; 97.5% confidence interval [CI]=3.57, 5.72). At 6 months, there were no significant differences in unprotected intercourse episodes between the combined on-site testing arms and the referral arm (P=.39; incidence rate ratio [IRR]=1.04; 97.5% CI=0.95, 1.14) or the 2 on-site testing arms (P=.81; IRR=1.03; 97.5% CI=0.84, 1.26). CONCLUSIONS: This study demonstrated on-site rapid HIV testing's value in drug treatment centers and found no additional benefit from HIV sexual risk-reduction counseling.

Factors affecting clinician educator encouragement of routine HIV testing among trainees.

BACKGROUND: Adoption of CDC recommendations for routine, voluntary HIV screening of all Americans age 13­64 years has been slow. One method to increase adherence to clinical practice guidelines is through medical school and residency training. OBJECTIVE: To explore the attitudes, barriers, and behaviors of clinician educators (CEs) regarding advocating routine HIV testing to their trainees. DESIGN/PARTICIPANTS: We analyzed CE responses to a 2009 survey of Society of General Internal Medicine members from community, VA, and university-affiliated clinics regarding HIV testing practices. MAIN MEASURES: Clinician educators were asked about their outpatient practices, knowledge and attitudes regarding the revised CDC recommendations and whether they encouraged trainees to perform routine HIV testing. Associations between HIV testing knowledge and attitudes and encouraging trainees to perform routine HIV testing were estimated using bivariate and multivariable logistic regression. RESULTS: Of 515 respondents, 367 (71.3%) indicated they supervised trainees in an outpatient general internal medicine clinic. These CEs demonstrated suboptimal knowledge of CDC guidelines and over a third reported continued risk-based testing. Among CEs, 196 (53.4%) reported that they encourage trainees to perform routine HIV testing. Higher knowledge scores (aOR 5.10 (2.16, 12.0)) and more positive attitudes toward testing (aOR 8.83 (4.21, 18.5)) were independently associated with encouraging trainees to screen for HIV. Reasons for not encouraging trainees to screen included perceived low local prevalence (37.2%), competing teaching priorities (34.6%), and a busy clinic environment (34.0%). CONCLUSIONS: Clinician educators have a special role in the dissemination of the CDC recommendations as they impact the knowledge and attitudes of newly practicing physicians. Despite awareness of CDC recommendations, many CEs do not recommend universal HIV testing to trainees. Interventions that improve faculty knowledge of HIV testing recommendations and address barriers in resident clinics may enhance adoption of routine HIV testing.

Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Each year in the United States, 6000 to 7000 women with HIV give birth. The management and outcomes of prenatal HIV infection have changed substantially since the U.S. Preventive Services Task Force issued recommendations in 1996. PURPOSE: To synthesize current evidence on risks and benefits of prenatal screening for HIV infection. DATA SOURCES: MEDLINE, the Cochrane Library, reference lists, and experts. STUDY SELECTION: Studies of screening, risk factor assessment, accuracy of testing, follow-up testing, and efficacy of interventions. DATA EXTRACTION: Data on settings, patients, interventions, and outcomes were abstracted for included studies; quality was graded according to criteria developed by the Task Force. DATA SYNTHESIS: No published studies directly link prenatal screening for HIV with clinical outcomes. In developed countries, the rate of mother-to-child transmission from untreated HIV-infected women is 14% to 25%. Targeted screening based on risk factors would miss a substantial proportion of infected women. "Opt-out" testing policies appear to increase uptake rates. Standard HIV testing is highly (>99%) sensitive and specific, and initial studies of rapid HIV tests found that both types of testing had similar accuracy. Rapid testing can facilitate timely interventions in persons testing positive. Recommended interventions (combination antiretroviral regimens, elective cesarean section in selected patients, and avoidance of breastfeeding) are associated with transmission rates of 1% to 2% and appear acceptable to pregnant women. LIMITATIONS: Long-term safety data for antiretroviral agents are not yet available. Data are insufficient to accurately estimate the benefits of screening on long-term maternal disease progression or other clinical outcomes, such as horizontal transmission. CONCLUSIONS: Identification and treatment of asymptomatic HIV infection in pregnant women can greatly decrease mother-to-child transmission rates.

Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: HIV infection affects 850,000 to 950,000 persons in the United States. The management and outcomes of HIV infection have changed substantially since the U.S. Preventive Services Task Force issued recommendations in 1996. PURPOSE: To synthesize the evidence on risks and benefits of screening for HIV infection. DATA SOURCES: MEDLINE, the Cochrane Library, reference lists, and experts. STUDY SELECTION: Studies of screening, risk factor assessment, accuracy of testing, follow-up testing, and efficacy of interventions. DATA EXTRACTION: Data on settings, patients, interventions, and outcomes were abstracted for included studies; quality was graded according to criteria developed by the Task Force. DATA SYNTHESIS: No trials directly link screening for HIV with clinical outcomes. Many HIV-infected persons in the United States currently receive diagnosis at advanced stages of disease, and almost all will progress to AIDS if untreated. Screening based on risk factors could identify persons at substantially higher risk but would miss a substantial proportion of those infected. Screening tests for HIV are extremely (>99%) accurate. Acceptance rates for screening and use of recommended interventions vary widely. Highly active antiretroviral therapy (HAART) substantially reduces the risk for clinical progression or death in patients with immunologically advanced disease. Along with other adverse events, HAART is associated with an increased risk for cardiovascular complications, although absolute rates are low after 3 to 4 years. LIMITATIONS: Data are insufficient to estimate the effects of screening and interventions on transmission rates or in patients with less immunologically advanced disease. Long-term data on adverse events associated with HAART are not yet available. CONCLUSIONS: Benefits of HIV screening appear to outweigh harms. The yield from screening higher-prevalence populations would be substantially higher than that from screening the general population.

Lipid screening in HIV-infected veterans.

BACKGROUND: Lipid screening is recommended for patients taking protease inhibitors (PIs). METHODS: We examined data from the Veterans Administration Immunology Case Registry to assess lipid screening among HIV-infected veterans who received PIs for at least 6 consecutive months during 1999 and 2001. We estimated crude and adjusted associations between lipid screening and patient characteristics (age, gender, HIV exposure, and race/ethnicity), comorbidities (AIDS, cardiovascular disease, diabetes, hypertension, smoking, and hyperlipidemia), and facility characteristics (urban location, case management, guidelines, and quality improvement programs). RESULTS: Among 4065 patients on PIs, clinicians screened 2395 (59%) for lipids within 6 months of initiating treatment. Adjusting for patient characteristics, comorbidities, facility traits, and clustering, lipid screening was more common among patients who were cared for in urban areas (relative risk [RR] = 1.3, confidence limits: 1.0-1.5), diabetic (RR = 1.2, confidence limits: 1.1-1.3), or previously hyperlipidemic (RR = 1.4, confidence limits: 1.3-1.5) and less common among patients with a history of intravenous drug use (IVDU) (RR = 0.90, confidence limits: 0.79-1.0) or unknown HIV risk (RR = 0.85, confidence limits: 0.75-0.95). CONCLUSIONS: Six in 10 patients taking PIs receive lipid screening within 6 months of PI use. Systemic interventions to improve overall HIV quality of care should also address lipid screening, particularly among patients with unknown or IVDU HIV risk and those cared for in nonurban areas.