Continuing Low Awareness and Use of Pre-exposure Prophylaxis (PrEP) for HIV among People Who Inject Drugs (PWID), San Francisco, 2022.

Clinical trials provide evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition including through sharing of injection equipment among people who inject drugs (PWID). However, uptake among many populations at risk for HIV has been slow, particularly among PWID. We examined data from the National HIV Behavioral Surveillance (NHBS) from San Francisco in 2022 to measure PrEP uptake and identify factors associated with PrEP awareness among PWID. Of 479 PWID with HIV-negative or unknown HIV status, 54.9% were aware of PrEP, 5.9% had discussed PrEP with a healthcare provider, and 1.5% had used PrEP in the past year. Lack of PrEP awareness was associated with being age 50 years and older (adjusted odds ratio [aOR] 0.40, 95% CI 0.27-0.60), being men who have sex with women (vs. men who have sex with men, aOR 0.47, 95% CI 0.24-0.92), having a disability (aOR 0.58, 95% CI 0.35-0.95), using heroin as their most frequently injected drug (aOR 0.51, 95% CI, 0.34-0.78), not having tested for HIV, HCV, or an STD in the past year (aOR 0.43, 95% CI 0.28-0.64), and not having access to new sterile needles in the past year (aOR 0.28, 95%CI 0.08-1.00). We found negligible change in the awareness and uptake of PrEP among PWID since previously measured in NHBS in 2018. Low PrEP use among PWID may be addressed by increasing provider discussion of PrEP with their PWID patients and clients during routine care, expanding testing for injection-related infections among PWID, and integrating PrEP access into harm reduction programs.

Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland.

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

Early vs. Later Experiences of Violence and Polysubstance Use Among Adults Who Inject Drugs.

BACKGROUND: People who inject drugs (PWID) experience high rates of violence, especially in early childhood, increasing their likelihood of engaging in risky substance use behavior in adulthood. Additionally, complex trauma has been reported among PWID due to witnessing and experiencing an overdose, further highlighting the need to examine the role of multiple experiences of trauma on their vulnerability to substance misuse. METHODS: Our study of 350 PWID from rural Kentucky examined differences in polysubstance use between participants who experienced violence earlier (≤15 years old) versus later (≥16 years old) in their childhood. RESULTS: Findings highlighted a direct association between experiences of early childhood violence and polysubstance use in adulthood. Additionally, our sample of PWID who experienced violence early in their childhood reported higher rates of severe substance use disorder and mental health distress. CONCLUSIONS: Tailored approaches that incorporate trauma-informed care may help to address the disproportionate rates of substance use and related adverse effects among PWID.

The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects.

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16-0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22-0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

RESUMEN: Realizamos una revisión sistemática y un metanálisis del impacto de los programas de intercambio de agujas y jeringas (NSP, por sus siglas en inglés) de los comportamientos de uso compartido de agujas tanto a nivel individual como comunitario y otros resultados relacionados con el VIH en países de ingresos bajos y medianos (LMIC, por sus siglas en inglés). Realizamos búsquedas sistemáticas en cinco bases de datos hasta julio de 2021 en busca de ensayos revisados por pares o estudios cuasiexperimentales. En general, 42 intervenciones informadas en 35 estudios entre 56 751 participantes cumplieron los criterios de inclusión. El metanálisis de efectos aleatorios de ocho estudios a nivel individual y 12 a nivel comunitario con 11 075 participantes en total mostró una asociación protectora significativa entre la exposición a NSP y los comportamientos de compartir agujas (individual: OR 0,25, IC95%: 0,16­0,39; comunidad: OR 0,39, IC95%:0,22­0,69), aunque con una heterogeneidad importante. Cuando se estratificó por la direccionalidad del intercambio de agujas, la exposición a NSP permaneció asociada con un intercambio receptivo reducido, pero no con un intercambio distributivo. La exposición a NSP también se asoció con una incidencia reducida del VIH y un aumento de las pruebas del VIH, pero no hubo asociaciones consistentes para la prevalencia de infecciones transmitidas por la sangre. La evidencia actual sugiere impactos positivos de los NSP en los LMIC.

Impact of COVID-19 & Response Measures on HIV-HCV Prevention Services and Social Determinants in People Who Inject Drugs in 13 Sites with Recent HIV Outbreaks in Europe, North America and Israel.

HIV/HCV prevention among people who inject drugs (PWID) is of key public health importance. We aimed to assess the impact of COVID-19 and associated response measures on HIV/HCV prevention services and socio-economic status of PWID in high-HIV-risk sites. Sites with recent (2011-2019) HIV outbreaks among PWID in Europe North America and Israel, that had been previously identified, were contacted early May 2020. Out of 17 sites invited to participate, 13 accepted. Semi-structured qualitative site reports were prepared covering data from March to May 2020, analyzed/coded and confirmed with a structured questionnaire, in which all sites explicitly responded to all 103 issues reported in the qualitative reports. Opioid maintenance treatment, needle/syringe programs and antiretroviral treatment /hepatitis C treatment continued, but with important reductions and operational changes. Increases in overdoses, widespread difficulties with food and hygiene needs, disruptions in drug supply, and increased homelessness were reported. Service programs rapidly reformed long established, and politically entrenched, restrictive service delivery policies. Future epidemic control measures should include mitigation of negative side-effects on service provision and socio-economic determinants in PWID.

RESUMEN: La prevención del VIH/VHC entre las personas que se inyectan drogas (PWID) es de vital importancia para la salud pública. Nuestro objetivo fue evaluar el impacto de COVID-19 y las medidas de respuesta asociadas en los servicios de prevención del VIH/VHC y el estado socioeconómico de las PWID en sitios de alto riesgo de VIH. Se contactó con sitios con brotes recientes (2011­2019) de VIH entre PWID en Europa, América del Norte e Israel, que habían sido previamente identificados, a principios de mayo de 2020. De los 17 sitios invitados a participar, 13 aceptaron. Se prepararon informes cualitativos semiestructurados del sitio que cubrían los datos de marzo a mayo de 2020, analizados/codificados y confirmados con un cuestionario estructurado, en el que todos los sitios respondieron explícitamente a los 103 asuntos reportados en los informes cualitativos. El tratamiento de mantenimiento con opiáceos, los programas de agujas/jeringas y el tratamiento antirretroviral/tratamiento de la hepatitis C continuaron, pero con importantes reducciones y cambios operativos. Se reportaron aumentos en las sobredosis, dificultades generalizadas con las necesidades alimentarias y de higiene, interrupciones en el suministro de medicamentos y aumento de personas sin hogar. Los programas de servicios reformaron rápidamente las políticas restrictivas de prestación de servicios, establecidas desde hace mucho tiempo y políticamente arraigadas. Las futuras medidas de control de epidemias deben incluir la mitigación de los efectos secundarios negativos en la prestación de servicios y los determinantes socioeconómicos en las PWID.

Hepatitis C antibody prevalence, correlates and barriers to care among people who inject drugs in Central California.

Hepatitis C (HCV) infection among people who inject drugs (PWID) is a major public health concern. We examined correlates of HCV antibody (anti-HCV) seropositivity and characteristics of prior HCV testing and treatment among PWID in Fresno, California, which has among the highest prevalence of injection drug use (IDU) in the United States. We surveyed 494 peer-recruited PWID (≥18 years of age) in 2016 about their experiences with HCV testing and treatment, and conducted HCV and HIV antibody testing for all participants. Bivariate analyses and multivariable logistic regressions were used to identify correlates of anti-HCV seropositivity. A majority (65%) tested positive for anti-HCV, with 32% of those being unaware of their HCV status. Anti-HCV seroprevalence was independently and positively associated with older age (AOR = 1.11 per year, 95% CI = 1.06, 1.17), years injecting (AOR = 1.08 per year, 95% CI = 1.03, 1.13), distributive syringe sharing (AOR = 2.76, 95% CI = 1.29, 5.94), having syringes confiscated by police (AOR = 2.65, 95% CI = 1.22, 5.74), ever trading sex (AOR = 3.51, 95% CI = 1.40, 8.81) and negatively associated with being Black/African American (non-Hispanic) (AOR = 0.06, 95% CI = 0.01, 0.47). Prior HCV testing was associated with older age, ever getting syringes from a syringe services program, and having interactions with police. For those aware of their anti-HCV seropositivity, only 11% had initiated treatment; reasons for not seeing a physician regarding diagnosis included not feeling sick (23%), currently using drugs/alcohol (19%) and not knowing where to go for HCV medical care (19%). Our findings highlight the importance of expanding community-based access to sterile syringes alongside HCV testing and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking testing and treatment.

Exploring the impact of the COVID-19 pandemic on syringe services programs in rural Kentucky.

BACKGROUND: The coronavirus pandemic (COVID-19) exacerbated risks for adverse health consequences among people who inject drugs by reducing access to sterile injection equipment, HIV testing, and syringe services programs (SSPs). Several decades of research demonstrate the public health benefits of SSP implementation; however, existing evidence primarily reflects studies conducted in metropolitan areas and before the COVID-19 pandemic. OBJECTIVES: We aim to explore how the COVID-19 pandemic affected SSP operations in rural Kentucky counties. METHODS: In late 2020, we conducted eighteen in-depth, semi-structured interviews with persons (10 women, 8 men) involved in SSP implementation in rural Kentucky counties. The interview guide broadly explored the barriers and facilitators to SSP implementation in rural communities; participants were also asked to describe how COVID-19 affected SSP operations. RESULTS: Participants emphasized the need to continue providing SSP-related services throughout the pandemic. COVID-19 mitigation strategies (e.g., masking, social distancing, pre-packing sterile injection equipment) limited relationship building between staff and clients and, more broadly, the pandemic adversely affected overall program expansion, momentum building, and coalition building. However, participants offered multiple examples of innovative solutions to the myriad of obstacles the pandemic presented. CONCLUSION: The COVID-19 pandemic impacted SSP operations throughout rural Kentucky. Despite challenges, participants reported that providing SSP services remained paramount. Diverse adaptative strategies were employed to ensure continuation of essential SSP services, demonstrating the commitment and ingenuity of program staff. Given that SSPs are essential for preventing adverse injection drug use-associated health consequences, further resources should be invested in SSP operations to ensure service delivery is not negatively affected by co-occurring crises.

Using nominal group technique to identify barriers and facilitators to preventing HIV using combination same-day pre-exposure prophylaxis and medications for opioid use disorder.

BACKGROUND: Preventing HIV transmission among people who inject drugs (PWID) is a key element of the US Ending the HIV Epidemic strategy and includes both pre-exposure prophylaxis (PrEP) and medications for opioid use disorder (MOUD). While both lead to decreases in HIV transmission, MOUD has other social and health benefits; meanwhile, PrEP has additional HIV prevention advantages from sexual risk and the injection of stimulants. However, these medications are often prescribed in different settings and require multiple visits before initiation. Strategies to integrate these services (i.e., co-prescription) and offer same-day prescriptions may reduce demands on patients who could benefit from them. METHODS: Nominal group technique, a consensus method that rapidly generates and ranks responses, was used to ascertain barriers and solutions for same-day delivery of PrEP and MOUD as an integrated approach among PWID (n = 14) and clinical (n = 9) stakeholders. The qualitative portion of the discussion generated themes for analysis, and the ranks of the proposed barriers and solutions to the program are presented. RESULTS: The top three barriers among PWID to getting a same-day prescription for both PrEP and MOUD were (1) instability of insurance (e.g., insurance lapses); (2) access to a local prescriber; and (3) client-level implementation factors, such as lack of personal motivation. Among clinical stakeholders, the three greatest challenges were (1) time constraints on providers; (2) logistics (e.g., coordination between providers and labs); and (3) availability of providers who can prescribe both medications. Potential solutions identified by both stakeholders included pharmacy delivery of the medications, coordinated care between providers and health care systems (e.g., case management), and efficiencies in clinical care (e.g., clinical checklists), among others. CONCLUSIONS: Implementing and sustaining a combined PrEP and MOUD strategy will require co-training providers on both medications while creating efficiencies in systems of care and innovations that encourage and retain PWID in care. Pilot testing the co-prescribing of PrEP and MOUD with quality performance improvement is a step toward new practice models.

Injecting Alone: Practices and Preferences among People Who Inject Drugs in New York City.

Injecting alone is a suspected risk factor for opioid overdose death among people who inject drugs (PWID). Better understanding of PWID's injecting practices and preferences could guide pragmatic harm reduction and overdose prevention interventions. We investigated injection practices and preferences among PWID attending syringe services programs (SSPs). We surveyed 108 PWID with opioid use disorder from 3 New York City SSPs between November 2020 and August 2021 to ascertain harm reduction service preferences. This secondary analysis examined injection behavior preferences, reasons for these preferences, and self-reported non-fatal lifetime overdoses. Slightly more participants preferred injecting alone (56%) than with someone present (44%), but most in both groups inject alone most of the time (97% vs 52%, p < 0.01). Commonly reported reasons for preferring to inject alone were privacy (82%) and not wanting to be judged (78%), whereas many preferred to inject with others to have someone present in case of overdose (92%), for camaraderie (69%), and to share drugs (65%). Those preferring to inject alone (vs. with someone present) self-reported higher mean number of lifetime overdoses (3.1 vs 2.6), but differences were not statistically significant. In conclusion, most participants injected alone regardless of preference. While not associated with prior non-fatal overdose, injection preference likely carries risk for future overdose. Participants preferred injecting alone to avoid shame or injecting with others in case of overdose, which can inform public health interventions that support both preferences. Reducing stigma while facilitating rapid overdose response can mitigate the risk of fatal overdose.

Mobile phone and internet use among people who inject drugs: Implications for mobile health interventions.

Background: Mobile health (mHealth) interventions have the potential to improve substance use treatment engagement and outcomes, and to reduce risk behaviors among people who inject drugs (PWID). However, there are few studies assessing mobile technology use among PWID and none have investigated continuity of mobile phone use. Methods: We surveyed 494 PWID. We used bivariate (independent-sample t- and chi-square tests) and multivariate (logistic regression) analyses to determine whether mobile phone and/or internet use differed as a function of participant- and/or injection-related characteristics. Results: Most participants (77%) had a mobile phone, with 67% having a phone that was free of charge. Participants with a phone were significantly less likely to be homeless (AOR = 0.28), to have shared syringes (AOR = 0.53), and to have reused syringes (AOR = 0.26) in the past 3 months. We observed high rates of phone and number turnover, with more than half reporting that they got a new phone (57%) and/or number (56%) at least once within the past 3 months. Most participants were familiar with using the internet (80% ever use), though participants who had ever used the internet were younger (AOR = 0.89), were less likely to be homeless (AOR = 0.38), were less likely to have shared syringes (AOR = 0.49), and were more likely to have injected methamphetamine by itself (AOR = 2.49) in the past 3 months. Conclusions: Overall, mobile technology and internet use was high among our sample of PWID. Several factors should be considered in recruiting diverse samples of PWID to minimize bias in mHealth study outcomes, including mobile phone access and protocol type (text- vs internet-based).

Use of Pre-exposure Prophylaxis Among People Who Inject Drugs: Exploratory Findings of the Interaction Between Race, Homelessness, and Trust.

Scale-up of pre-exposure prophylaxis (PrEP) in people who inject drugs (PWID) remains suboptimal. Patient-level factors are often complex and may contribute to scale-up. Using cross-sectional data from 234 opioid-dependent patients on methadone who met eligibility criteria for PrEP, we conducted logistic regression analyses to assess potential moderators associated with being on PrEP (n = 60). Mean provider trust was significantly higher among Blacks vs Whites (39.4 vs 34.9; p = 0.002) and non-homeless vs homeless participants (37.5 vs 34.8; p = 0.008). Though race/ethnicity was not a significant moderator on provider trust and PrEP use, increased provider trust was marginally associated with increased PrEP use among Blacks (p = 0.058). Additionally, homelessness significantly moderated provider trust and PrEP use (p = 0.024). Provider trust among non-homeless participants was positively correlated with PrEP use (p = 0.013) but not among homeless participants. Strategies that promote provider trust in Blacks and non-homeless PWID on methadone may improve PrEP scale-up.

The Pre-exposure Prophylaxis (PrEP) Care Cascade in People Who Inject Drugs: A Systematic Review.

Injection drug use is a key risk factor for the transmission of HIV. Prevention strategies, such as the use of pre-exposure prophylaxis (PrEP), are effective at reducing the risk of HIV transmission in people who inject drugs (PWID). Following PRISMA guidelines, a literature search was conducted to identify the current state of the PrEP care cascade in PWID. Twenty-three articles were evaluated in this systematic review. A decline in engagement throughout the stages of the PrEP care cascade was found. High awareness and willingness to use PrEP was found, yet PrEP uptake was relatively low (0-3%). There is a lack of research on interventions to increase engagement of PrEP across all levels of the care cascade in PWID. Implications from the interventions that have been published provide insight into practice and public policy on efficacious strategies to reduce HIV incidence in PWID. Our findings suggest that more efforts are needed to identify and screen PWID for PrEP eligibility and to link and maintain them with appropriate PrEP care.

Exploring and understanding HCV patient journeys- HEPCARE Europe project.

BACKGROUND: Hepatitis C Virus (HCV) is a leading cause for chronic liver diseases worldwide. The European Union and World Health Organization aspire to eliminate HCV by 2030. However, among at-risk populations, including, homeless people, prisoners and People Who Inject Drugs, access to diagnosis and treatment is challenging. Hepcare Europe is an integrated model of care developed to address this by assessing potential reasons for these restrictions and determining measures needed to improve HCV diagnosis, treatment and access to care within different communities. OBJECTIVES: HepCare Europe is an EU-supported project involving collaboration between five institutions in: Ireland, United Kingdom, Spain and Romania. We aim to explore the journey of care experienced by those living with HCV with a focus on previous care disruptions (loss to follow up) and the new HepCare Europe Programme. METHODS: Research teams conducted semi-structured interviews with patients who accessed services through HepCare Europe thus, patients were recruited by purposeful sampling. Patients interviewed had received, or were in the final weeks of receiving, treatment. The interviews were audio recorded, transcribed and translated into English, and sent to the Dublin team for inductive thematic analysis. Researchers from the HepCare Europe research team coded the data separately, then together. RESULTS: Common themes are introduced to present similarities, following individual site themes to highlight the importance of tailored interventions for each country. Key themes are: 1) Hepatitis C patients lost to follow up 2) HepCare improved access to treatment and 3) the need for improved HCV education. Individual themes also emerged for each site. These are: Ireland: New opportunities associated with achieving Sustained Virologic Responses (SVR). Romania: HCV is comparatively less crucial in light of Human Immunodeficiency Viruses (HIV) coinfections. UK: Patients desire support to overcome social barriers and Spain: Improved awareness of HCV, treatment and alcohol use. CONCLUSION: This study identified how the tailored HepCare interventions enabled improved HCV testing and linkage to care outcomes for these patients. Tailored interventions that targeted the needs of patients, increased the acceptability and success of treatment by patients. HepCare demonstrated the need for flexibility in treatment delivery, and provided additional supports to keep patients engaged and educated on new treatment therapies.

What is required for achieving hepatitis C virus elimination in Singapore? A modeling study.

BACKGROUND AND AIM: The vast majority of hepatitis C virus (HCV) infection in Singapore is among those with a history of injecting drug use (IDU), yet harm reduction is not available and what is required to achieve the World Health Organization (WHO) HCV elimination targets (80% incidence reduction and 65% mortality reduction by 2030) is unknown. We model the intervention scale-up required to achieve WHO targets in Singapore. METHODS: A dynamic model of HCV transmission and progression among those with a history of IDU was calibrated to Singapore, a setting with declining IDU and no harm reduction (~11 000 people with IDU history in 2017 and 45% HCV seropositive). We projected HCV treatment scale-up from 2019 required to achieve WHO targets with varying prioritization scenarios, with/without opiate substitution therapy scale-up (to 40% among people who inject drugs [PWID]). RESULTS: We estimated 3855 (95% confidence interval: 2635-5446) chronically HCV-infected individuals with a history of IDU and 148 (87-284) incident HCV cases in Singapore in 2019. Reaching the HCV incidence target requires 272 (187-384) treatments in 2019, totaling 2444 (1683-3452) across 2019-2030. By prioritizing PWID or PWID and cirrhotics, 60% or 30% fewer treatments are required, respectively, whereas the target cannot be achieved with cirrhosis prioritization. Opiate substitution therapy scale-up reduces treatments required by 21-24%. Achieving both WHO targets requires treating 631 (359-1047) in 2019, totaling 3816 (2664-5423) across 2019-2030. CONCLUSIONS: Hepatitis C virus elimination is achievable in Singapore but even with declining IDU requires immediate treatment scale-up among PWID. Harm reduction provision reduces treatments required and provides additional benefits.

Barriers and facilitators of HIV and hepatitis C care among people who inject drugs in Nairobi, Kenya: a qualitative study with peer educators.

BACKGROUND: In Kenya, people who inject drugs (PWID) are disproportionately affected by HIV and hepatitis C (HCV) epidemics, including HIV-HCV coinfections; however, few have assessed factors affecting their access to and engagement in care through the lens of community-embedded, peer educators. This qualitative study leverages the personal and professional experiences of peer educators to help identify HIV and HCV barriers and facilitators to care among PWID in Nairobi, including resource recommendations to improve service uptake. METHODS: We recruited peer educators from two harm reduction facilities in Nairobi, Kenya, using random and purposive sampling techniques. Semi-structured interviews explored circumstances surrounding HIV and HCV service access, prevention education and resource recommendations. A thematic analysis was conducted using the Modified Social Ecological Model (MSEM) as an underlying framework, with illustrative quotes highlighting emergent themes. RESULTS: Twenty peer educators participated, including six women, with 2-months to 6-years of harm reduction service. Barriers to HIV and HCV care were organized by (a) individual-level themes including the competing needs of addiction and misinterpreted symptoms; (b) social network-level themes including social isolation and drug dealer interactions; (c) community-level themes including transportation, mental and rural healthcare services, and limited HCV resources; and (d) policy-level themes including nonintegrated health services, clinical administration, and law enforcement. Stigma, an overarching barrier, was highlighted throughout the MSEM. Facilitators to HIV and HCV care were comprised of (a) individual-level themes including concurrent care, personal reflections, and religious beliefs; (b) social network-level themes including community recommendations, navigation services, family commitment, and employer support; (c) community-level themes including quality services, peer support, and outreach; and (d) policy-level themes including integrated health services and medicalized approaches within law enforcement. Participant resource recommendations include (i) additional medical, social and ancillary support services, (ii) national strategies to address stigma and violence and (iii) HCV prevention education. CONCLUSIONS: Peer educators provided intimate knowledge of PWID barriers and facilitators to HIV and HCV care, described at each level of the MSEM, and should be given careful consideration when developing future initiatives. Recommendations emphasized policy and community-level interventions including educational campaigns and program suggestions to supplement existing HIV and HCV services.

Consider the Source: Associations between Syringe Sources and Risky Injection Behaviors in California's Central Valley.

BACKGROUND: Sterile syringe access is critical to prevent serious viral and bacterial infections among people who inject drugs (PWID) but many areas across the United States lack sufficient access. Although California law allows nonprescription pharmacy syringe sales and syringe services programs (SSPs), access gaps remain in the largely rural Central Valley. OBJECTIVE: The purpose of this study was to examine syringe access and related injection behaviors among PWID in Fresno, California. METHODS: We used respondent driven sampling to recruit 494 individuals for a survey about syringe access and injection behaviors between April and September 2016. Participants were ≥18 years old and injected at least twice in the past 30 days. Descriptive statistics examined syringe access and logistic regression determined if discrete syringe source categories were significantly associated with syringe sharing and/or reuse. RESULTS: A majority (67%) obtained syringes from an authorized source; SSPs were most common (59%), while few reported pharmacy purchase (14%). Unauthorized sources were even more common (79%), primarily friends (64%) or someone on the street (37%). Compared to PWID who used only authorized sources, those using only unauthorized sources had a higher odds of syringe sharing (AOR = 3.40, 95% CI: 1.66, 6.95) and syringe reuse (AOR = 6.22; 95% CI: 2.24, 17.29), as did those who reported mixed sources (AOR = 3.78; 95% CI: 1.90, 7.54 and AOR = 4.64; 95% CI: 2.08, 10.35). CONCLUSIONS: Our findings demonstrate a need to expand syringe access in nonurban California to prevent the syringe sharing and reuse that contributes to serious viral and bacterial infections among PWID.

Purposeful Fentanyl Use and Associated Factors among Opioid-Dependent People Who Inject Drugs.

Introduction: In recent years, opioid-related mortality has increased steadily in the United States. Fentanyl, a synthetic opioid, has been a primary driver of the current wave of overdose-related deaths. Little is known, however, about fentanyl use among opioid-dependent people who inject drugs (PWID). We, therefore, sought to characterize purposeful fentanyl use among PWID. Methods: A cross-sectional survey was administrated to 104 opioid-dependent PWID on methadone who self-reported drug- or sex-related risk behaviors. Participants were recruited between July 2018 and October 2019 from a methadone clinic in New Haven, Connecticut. Multivariable logistic regressions were used to identify independent correlates of purposeful fentanyl use. Results: Overall, 43.2% and 22.1% of the participants reported any (lifetime) or recent (past 30 days) purposeful fentanyl use, respectively. Independent correlates of any purposeful fentanyl use were younger age (aOR= 0.94; p = 0.021), recent daily injection (aOR= 3.52; p = 0.047), recent cocaine use (aOR= 3.54; p = 0.041), and moderate/severe depression (aOR= 3.82; p = 0.028). Independent correlates of recent purposeful fentanyl use were moderate/severe depression (aOR= 10.94; p = 0.031), recently sharing injection equipment (aOR= 2.96; p = 0.044), and recently engaging in transactional sex (aOR= 3.60; p = 0.026). Conclusions: These findings indicate that opioid-dependent PWID on methadone remain at increased risk for overdose given the high prevalence of ongoing purposeful fentanyl exposure. Interventions to reduce the harms associated with fentanyl use should target young PWID and active fentanyl users, with an emphasis on achieving adequate methadone dosage and screening and treating depression in methadone-maintained patients who preferentially seek fentanyl.

A Comparison of Medication for Opioid Use Disorder Treatment Strategies for Persons Who Inject Drugs With Invasive Bacterial and Fungal Infections.

BACKGROUND: Patients with opioid use disorder (OUD) are frequently admitted for invasive infections. Medications for OUD (MOUD) may improve outcomes in hospitalized patients. METHODS: In this retrospective cohort of 220 admissions to a tertiary care center for invasive infections due to OUD, we compared 4 MOUD treatment strategies: methadone, buprenorphine, methadone taper for detoxification, and no medication to determine whether there were differences in parenteral antibiotic completion and readmission rates. RESULTS: The MOUDs were associated with increased completion of parenteral antimicrobial therapy (64.08% vs 46.15%; odds ratio [OR] = 2.08; 95% CI, 1.23-3.61). On multivariate analysis, use of MOUD maintenance with either buprenorphine (OR = 0.38; 95% CI, .17-.85) or methadone maintenance (OR = 0.43; 95% CI, .20-.94) and continuation of MOUD on discharge (OR = 0.35; 95% CI, .18-.67) was associated with lower 90-day readmissions. In contrast, use of methadone for detoxification followed by tapering of the medication without continuation on discharge was not associated with decreased readmissions (OR = 1.87; 95% CI, .62-5.10). CONCLUSIONS: Long-term MOUDs, regardless of selection, are an integral component of care in patients hospitalized with OUD-related infections. Patients with OUD should have arrangements made for MOUDs to be continued after discharge, and MOUDs should not be discontinued before discharge.

Cost-effectiveness of strategies to improve HCV screening, linkage-to-care and treatment in remand prison settings in England.

BACKGROUND: A simplified cascade-of-care may improve screening and treatment uptake among incarcerated individuals. We assessed the cost-effectiveness of traditional and simplified screening and treatment in a London remand prison. METHODS: Using empirical data from Her Majesty's Prison (HMP) Wormwood Scrubs, London, we designed a decision tree and Markov transition state model using national average data for HCV screening and treatment for the base-case scenario. This compared two alternative strategies; (a) general prison population screening and treatment and (b) prioritising screening and treatment among people who inject drugs (PWID) combined with general prison population screening and treatment. Strategies varied the rates of screening (47%-90%), linkage-to-care (60%-86%) and treatment (21%-85%). Cost, utility and disease transition rates were obtained from existing literature. Outcome measures were as follows: screening, treatment and disease-related costs per admitted individual, quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICERs) were calculated for each intervention. All costs and utilities were discounted at a rate of 3.5% per annum. Both univariate and probabilistic sensitivity analyses have been conducted. RESULTS: In our cohort of 5239 incarcerated individuals with an estimated chronic HCV prevalence of 2.6%, all strategy ICER values (£3565-10 300) fell below the national willingness to pay threshold (£30 000). Increased successful treatment (7%-54%) was observed by an optimising cascade-of-care. A robust sensitivity analysis identified treatment cost of, QALY for mild liver disease and probability of completing treatment as important factors that impact the ICER value. CONCLUSION: In our remand setting, optimising adherence to the cascade-of-care is cost-effective. Where universal screening is not practical, a stratified approach focused on intensive screening and treatment of PWID also results in increased treatment uptake and is highly cost-effective.

In-field evaluation of Xpert® HCV viral load Fingerstick assay in people who inject drugs in Tanzania.

BACKGROUND: Although novel hepatitis C virus (HCV) RNA point-of-care technology has the potential to enhance the diagnosis in resource-limited settings, very little real-world validation of their utility exists. We evaluate the performance of HCV RNA quantification using the Xpert® HCV viral load Fingerstick assay (Xpert® HCV VL Fingerstick assay) as compared to the World Health Organisation pre-qualified plasma Xpert® HCV VL assay among people who inject drugs (PWID) attending an opioid agonist therapy (OAT) clinic in Dar-es-Salaam, Tanzania. METHODS: Between December 2018 and February 2019, consecutive HCV seropositive PWID attending the OAT clinic provided paired venous and Fingerstick samples for HCV RNA quantification. These were processed onsite using the GeneXpert® platform located at the Central tuberculosis reference laboratory. RESULTS: A total of 208 out of 220 anti-HCV-positive participants recruited (94.5%) had a valid Xpert® HCV VL result available; 126 (61%; 95% CI 53.8-67.0) had detectable and quantifiable HCV RNA. About 188 (85%) participants had paired plasma and Fingerstick whole blood samples; the sensitivity and specificity for the quantification of HCV RNA levels were 99.1% and 98.7% respectively. There was an excellent correlation (R2  = .95) and concordance (mean difference 0.13 IU/mL, (95% CI -0.9 to 0.16 IU/mL) in HCV RNA levels between plasma samples and Fingerstick samples. CONCLUSION: This study found excellent performance of the Xpert® HCV VL Fingerstick assay for HCV RNA detection and quantification in an African-field setting. Its clinical utility represents an important watershed in overcoming existing challenges to HCV diagnosis, which should play a crucial role in HCV elimination in Africa.