The willingness of people who inject drugs in Boston to use a supervised injection facility.

BACKGROUND: In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness. METHODS: A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%). RESULTS: Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9-15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8-14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2-21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6-14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9-18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2-14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2-14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2-10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3-8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2-8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2-7.4; P = .02). CONCLUSIONS: Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.

Insurance Barriers, Gendering, and Access: Interviews with Central North Carolinian Women About Their Health Care Experiences.

BACKGROUND: Women face unique logistical and financial barriers to health care access. They also have higher health care expenditures and higher rates of morbidity. Women's experiences while utilizing health care are historically less well researched and warrant exploration. METHODS: We conducted 14 semistructured interviews about women's health care experiences with 11 women health consumers and 3 women health care practitioners in central North Carolina. RESULTS: When discussing their experiences, participants noted scheduling challenges, barriers related to insurance and cost, and dismissive or negative in-person encounters. Participants frequently discussed lack of resources for care postpartum. Practitioners noted lack of knowledge of disease burden, overmedicalization of women's care, lack of care postpartum, and trends around changes in primary care.Women health consumers in this study faced challenges related to access and in-person experience of care delivery, which were echoed by the clinician interviewees. Barriers to optimal women's health care exist even for those with insurance coverage and point to systemwide constraints as well as deficits in organizational culture. CONCLUSION: Future clinical and research efforts should include 1) increasing awareness of and facilitating access to affordable postpartum care, 2) easing burdens around scheduling appointments and improved care coordination, and 3) more research exploring women's experiences during in-person health care encounters. Concerns and barriers that women described may be due to systems-level requirements and constraints.

Estimating the Prevalence of Advanced Fibrosis in Homeless Adults with Hepatitis C in Boston.

BACKGROUND AND AIMS: Hepatitis C virus (HCV) infection is highly prevalent among homeless individuals, but the scope of HCV-associated liver fibrosis in this population is poorly understood. METHODS: Using the FIB-4 Index, we describe the prevalence and correlates of advanced fibrosis among a retrospective cohort of all homeless-experienced adults with HCV seen at Boston Health Care for the Homeless Program (BHCHP) over a one-year period. RESULTS: Of 832 BHCHP patients with HCV, 15.8% had advanced fibrosis. In multivariable regression analysis, alcohol use disorder (adjusted odds ratio [aOR] 2.50, 95% confidence interval [CI] 1.65-3.81) and having unknown or poorly characterized housing circumstances (aOR 2.88, 95% CI 1.02-8.14, relative to housed patients) were independently associated with advanced fibrosis. CONCLUSIONS: The prevalence of advanced fibrosis in this cohort of homeless adults with HCV appears similar to national estimates among housed individuals, but their psychosocial complexity is greater, especially among those who are older.

Changes in public order after the opening of an overdose monitoring facility for people who inject drugs.

BACKGROUND: In the face of an increasingly fatal opioid crisis, Boston Health Care for the Homeless Program (BHCHP) opened the Supportive Place for Observation and Treatment (SPOT), a unique low-threshold harm reduction program for monitoring people who have injected drugs and are at imminent risk of overdose. This study examines the impact of the opening of the SPOT program on measures of injection drug-related public order in the neighborhood surrounding the facility. METHODS: Data was collected at 10 weeks prior and 12 weeks post SPOT implementation on: number of over-sedated individuals in public, publicly discarded syringes, publicly discarded injection-related litter, and instances of active injection drug use or exchange of drugs. Changes were evaluated using Poisson log-linear regression models. Potential confounders such as weather and police presence were measured and controlled for. RESULTS: The average number of over-sedated individuals observed in public significantly decreased by 28% (4.3 [95% Confidence Interval (CI) 2.7-6.9] v 3.1 [CI 1.4-6.8]) after SPOT opened. The opening of SPOT did not have a significant effect on the other measures of public order. The daily average number of publicly discarded syringes (28.5 [CI 24.5-33.1] v 28.4 [CI 22.0-36.5]), pieces of publicly discarded injection-related litter (376.3 [CI 358.6-394.8] v 375.0 [CI 345.8-406.6]), and observed instances of active use or exchange of drugs (0.2 [CI 0.1-0.9] v 0.1 [CI 0.0-0.1]) were not statistically significantly different after the opening of SPOT. CONCLUSIONS: The opening of SPOT was associated with a significant decrease in observed over-sedated individuals. Other measures of injection-drug related public order did not improve or worsen with the opening of SPOT, however, they have been shown to improve with the implementation of a supervised injection facility.

Prevalence and risk factors for MRSA nasal colonization among persons experiencing homelessness in Boston, MA.

Homeless individuals face an elevated risk of methicillin-resistant Staphylococcus aureus (MRSA) infection. Identifying the prevalence and risk factors for MRSA nasal colonization may reduce infection risk. A cross-sectional study was conducted at a health clinic for homeless persons in Boston, MA, USA (n=194). In-person interviews and nasal swab specimens were collected. MRSA isolates were genotyped using pulse-field gel electrophoresis (PFGE) and assessed for antibiotic susceptibility. The prevalence of MRSA nasal colonization was 8.3 %. Seventy-five percent of isolates reflected clonal similarity to USA300. USA100 (18.8 %) and USA500 (6.3 %) were also recovered. Resistance to erythromycin (81.3 %), levofloxacin (31.3 %) and clindamycin (23.1 %) was identified. Recent inpatient status, endocarditis, haemodialysis, heavy drinking, not showering daily and transience were positively associated with MRSA nasal colonization. Carriage of community-acquired MRSA strains predominated in this population, although nosocomial strains co-circulate. Attention to behavioural and hygiene-related risk factors, not typically included in MRSA prevention efforts, may reduce risk.