Changes in Illicit Drug Use Among High School Students in Southeastern U.S. States-2009 to 2019.

To determine if decreasing lifetime use of methamphetamines, cocaine, ecstasy, and inhalants among high school students occurring from 2009 to 2019 in the U.S. also occurred in five southeastern states, Youth Risk Behavior Survey data representative of high school students in grades 9-12 in 2009 and 2019 were analyzed. In a classroom setting, lifetime use of methamphetamines, cocaine, ecstasy, and inhalants were self-reported. Students nationwide (n = 30,087) were compared to students in Alabama, Georgia, Louisiana, Mississippi, and South Carolina (n = 18,237). Lifetime methamphetamine use significantly increased from 4.8% in 2009 to 6.2% in 2019 in the southeast but decreased from 4.1 to 2.2% nationwide. Use of cocaine, ecstasy, and inhalants remained stable in the southeast while decreasing significantly nationwide from 2009 to 2019. During a period when use of methamphetamines, cocaine, ecstasy, and inhalants among high school students in the U.S. decreased, use in southeastern states did not change. Culturally specific programs and interventions may be needed to prevent illicit drug use in communities of southeastern states where youth remain at risk.

Naloxone Use During Pregnancy-Data from 26 US Jurisdictions, 2019-2020.

OBJECTIVES: We aimed to determine the prevalence of self-reported naloxone use during pregnancy among people in the United States with a recent live birth. A secondary objective was to characterize people at increased risk of overdose who did and did not use naloxone. METHODS: We analyzed data from the Pregnancy Risk Assessment Monitoring System from 26 US jurisdictions that conducted an opioid supplement survey from 2019 to 2020. Respondents with increased risk of experiencing an opioid overdose were identified based on self-reported use of illicit amphetamines, heroin, cocaine, or receiving medication for opioid use disorder (MOUD) during pregnancy. Weighted prevalence estimates and 95% confidence intervals were calculated for reported naloxone use at any point during pregnancy among people with an increased risk of overdose. RESULTS: Naloxone use during pregnancy was reported by <1% of the overall study population (unweighted N = 88/34,528). Prevalence of naloxone use was 5.0% (95% CI: 0.0-10.6) among respondents who reported illicit amphetamine use, 15.2% (1.8-28.6) among those who reported heroin use, and 17.6% (0.0-38.1) among those who reported cocaine use. Naloxone use was 14.5% (8.4-20.6) among those who reported taking MOUD. Among people with increased risk of overdose, no significant differences in naloxone use were observed by age, race/ethnicity, education level, residential metropolitan status, or insurance status. CONCLUSIONS: Prevalence of naloxone use among people with an increased risk of overdose during pregnancy ranged from 5.0% to 17.6%. Access to naloxone, overdose prevention education, and treatment for substance use disorders may help reduce morbidity and mortality.

Hepatitis C virus infection and co-infection with HIV among persons who inject drugs in 10 U.S. cities-National HIV Behavioral Surveillance, 2018.

BACKGROUND: Characterizing acute and chronic hepatitis C virus (HCV) infection and HIV/HCV co-infection among persons who inject drugs (PWID) can inform elimination efforts. METHODS: During 2018 National HIV Behavioral Surveillance in 10 U.S. metropolitan statistical areas (MSAs), PWID were recruited using respondent-driven sampling and offered a survey, HIV testing, and HCV antibody and RNA testing. We examined prevalence and associated characteristics of HCV infection and HIV/HCV co-infection. Associations were assessed using log-linked Poisson regression models with robust standard errors accounting for clustering by recruitment chain and adjusting for MSA and network size. RESULTS: Overall, 44.2% had current HCV infection (RNA detected), with 3.9% classified as acute infection (HCV antibody non-reactive/RNA detected) and 40.3% as chronic (HCV antibody reactive/RNA detected). Four percent had HIV/HCV co-infection. Current HCV infection was significantly higher among PWID who were male, White, injected >1 time/day, shared syringes in past year, and shared injection equipment in past year. PWID who were transgender, injecting >5 years, and most often injected speedball (heroin and cocaine together) or stimulants alone were more likely to have HIV/HCV co-infection. Among PWID who never previously had HCV infection, 9.9% had acute HCV infection. Among PWID who started injecting ≤5 years ago, 41.5% had already acquired HCV infection. CONCLUSIONS: Acute and chronic HCV infections were substantial among a sample of PWID in 10 U.S. MSAs. Accessibility to HCV RNA testing, promoting safer practices, and intervening early with harm reduction programs for recent injection initiates will be critical to disease elimination efforts for PWID.

Estimated Number of People Who Inject Drugs in the United States.

BACKGROUND: Public health data signal increases in the number of people who inject drugs (PWID) in the United States during the past decade. An updated PWID population size estimate is critical for informing interventions and policies aiming to reduce injection-associated infections and overdose, as well as to provide a baseline for assessments of pandemic-related changes in injection drug use. METHODS: We used a modified multiplier approach to estimate the number of adults who injected drugs in the United States in 2018. We deduced the estimated number of nonfatal overdose events among PWID from 2 of our previously published estimates: the number of injection-involved overdose deaths and the meta-analyzed ratio of nonfatal to fatal overdose. The number of nonfatal overdose events was divided by prevalence of nonfatal overdose among current PWID for a population size estimate. RESULTS: There were an estimated 3 694 500 (95% confidence interval [CI], 1 872 700-7 273 300) PWID in the United States in 2018, representing 1.46% (95% CI, .74-2.87) of the adult population. The estimated prevalence of injection drug use was highest among males (2.1%; 95% CI, 1.1-4.2), non-Hispanic Whites (1.8%; 95% CI, .9-3.6), and adults aged 18-39 years (1.8%; 95% CI, .9-3.6). CONCLUSIONS: Using transparent, replicable methods and largely publicly available data, we provide the first update to the number of people who inject drugs in the United States in nearly 10 years. Findings suggest the population size of PWID has substantially grown in the past decade and that prevention services for PWID should be proportionally increased.

A stakeholder-driven framework for measuring potential change in the health risks of people who inject drugs (PWID) during the COVID-19 pandemic.

BACKGROUND: People who inject drugs (PWID) have likely borne disproportionate health consequences of the COVID-19 pandemic. PWID experienced both interruptions and changes to drug supply and delivery modes of harm reduction, treatment, and other medical services, leading to potentially increased risks for HIV, hepatitis C virus (HCV), and overdose. Given surveillance and research disruptions, proximal, indirect indicators of infectious diseases and overdose should be developed for timely measurement of health effects of the pandemic on PWID. METHODS: We used group concept mapping and a systems thinking approach to produce an expert stakeholder-generated, multi-level framework for monitoring changes in PWID health outcomes potentially attributable to COVID-19 in the U.S. This socio-ecological measurement framework elucidates proximal and distal contributors to infectious disease and overdose outcomes, many of which can be measured using existing data sources. RESULTS: The framework includes multi-level components including policy considerations, drug supply/distribution systems, the service delivery landscape, network factors, and individual characteristics such as mental and general health status and service utilization. These components are generally mediated by substance use and sexual behavioral factors to cause changes in incidence of HIV, HCV, sexually transmitted infections, wound/skin infections, and overdose. CONCLUSION: This measurement framework is intended to increase the quality and timeliness of research on the impacts of COVID-19 in the context of the current pandemic and future crises. Next steps include a ranking process to narrow the drivers of change in health risks to a concise set of indicators that adequately represent framework components, can be written as measurable indicators, and are quantifiable using existing data sources, as well as a publicly available web-based platform for summary data contributions.

Impact of Social Isolation during the COVID-19 Pandemic on Mental Health, Substance Use, and Homelessness: Qualitative Interviews with Behavioral Health Providers.

The United States is experiencing a syndemic of homelessness, substance use disorder, and mental health conditions, which has been further exacerbated by the COVID-19 pandemic. Although it is expected that mitigation strategies will curb community transmission of COVID-19, the unintended consequences of social isolation on mental health and substance use are a growing public health concern. Awareness of changing mental health and substance use treatment needs due to the pandemic is critical to understanding what additional services and support are needed during and post-pandemic, particularly among people experiencing homelessness who have pre-existing serious mental illness or substance use disorder. To evaluate these effects and support our understanding of mental health and substance use outcomes of the COVID-19 pandemic, we conducted a qualitative study where behavioral health providers serving people experiencing homelessness described the impact of COVID-19 among their clients throughout the United States. Behavioral health providers shared that experiencing social isolation worsened mental health conditions and caused some people to return to substance use and fatally overdose. However, some changes initiated during the pandemic resulted in positive outcomes, such as increased client willingness to discuss mental health topics. Our findings provide additional evidence that the social isolation experienced during the pandemic has been detrimental to mental health and substance use outcomes, especially for people experiencing homelessness.

Vaccination barriers and opportunities at syringe services programs in the United States, June-August 2021-A cross-sectional survey.

BACKGROUND: Syringe services programs (SSPs) are an important venue for reaching people who inject drugs (PWID) to offer preventive services; however, not all SSPs offer vaccinations. We aimed to describe barriers and opportunities for SSPs to offer vaccinations. METHODS: During June-August 2021, we conducted a descriptive, cross-sectional survey of SSP providers in the United States. SSPs were recruited from national listservs using purposive sampling to ensure geographic diversity. The survey included questions about SSP characteristics, client demographics, existing vaccination resources, resource needs, and staff perspectives on client vaccination barriers. Statistical comparisons were made using Pearson's chi-square test. RESULTS: In total, 105 SSPs from 34 states responded to the survey; 46 SSPs (43.8%) offered on-site vaccinations. SSPs without on-site vaccinations were more likely operated by community-based organizations (81.4% vs 30.4%, p < 0.001) in urban areas (71.4% vs 40.0%, p = 0.002) than SSPs offering on-site vaccinations. The most common staffing need was for personnel licensed to administer vaccines (74/98, 75.5%). Over half of SSPs reported vaccine supply, administration supplies, storage equipment, and systems to follow-up clients for multidose series as important resource needs. The most common resource need was for reminder/recall systems for vaccines with multidose series (75/92, 81.5%). Vaccine safety concerns (92/95, 96.8%) and competing priorities (92/96, 95.8%) were the most common staff-reported client barriers to vaccinations. CONCLUSIONS: Addressing missed opportunities for offering vaccinations to PWID who use SSPs will require increased numbers of on-site personnel licensed to administer vaccines and additional training, vaccination supplies, and storage and handling equipment.

Prevalence and Types of Drugs Used Among Hepatitis A Patients During Outbreaks Associated with Person-to-Person Transmission, Kentucky, Michigan, and West Virginia, 2016-2019.

Background: People who use drugs are at increased risk for hepatitis A virus infection. Since 1996, the Advisory Committee on Immunization Practices has recommended hepatitis A vaccination for people who use drugs. Since 2016, the U.S. has experienced widespread hepatitis A outbreaks associated with person-to-person transmission. Purpose: To describe the prevalence of drug use, route of use, and drugs used among hepatitis A outbreak-associated patients. Methods: State outbreak and medical records were reviewed to describe the prevalence, type, and route of drug use among a random sample of 812 adult outbreak-associated hepatitis A patients from Kentucky, Michigan, and West Virginia during 2016-2019. Differences in drug-use status were analyzed by demographic and risk-factor characteristics using the X 2 test. Results: Among all patients, residents of Kentucky (55.6%), Michigan (51.1%), and West Virginia (60.1%) reported any drug use, respectively. Among patients that reported any drug use, methamphetamine was the most frequently reported drug used in Kentucky (42.3%) and West Virginia (42.1%); however, opioids were the most frequently reported drug used in Michigan (46.8%). Hepatitis A patients with documented drug use were more likely (p<0.05) to be experiencing homelessness/unstable housing, have been currently or recently incarcerated, and be aged 18-39 years compared to those patients without documented drug use. Implications: Drug use was prevalent among person-to-person hepatitis A outbreak-associated patients, and more likely among younger patients and patients experiencing homelessness or incarceration. Increased hepatitis A vaccination coverage is critical to prevent similar outbreaks in the future.

Estimated number of injection-involved drug overdose deaths, United States, 2000 - 2018.

BACKGROUND: In the United States, drug overdose mortality has increased. Death records categorize overdose deaths by type of drug involved, but do not include information about the route of drug administration. METHODS: We utilized data from drug treatment admissions (Treatment Episodes Dataset, TEDS-A) and National Vital Statistics Systems to estimate the percentage of reported drug overdose deaths that were injection-involved from 2000 to 2018 in the U.S. Data on reported route of administration at admission were used to calculate the percent injecting each drug type, by demographic group (race/ethnicity, sex, age group) and year. Using the resulting probabilities, we estimated the number of overdose deaths that were injection-involved. Estimates were compared across drug types, demographic characteristics, and year. FINDINGS: The number of overdose deaths among adults increased more than 3-fold from 2000 (n = 17,196) to 2018 (n = 67,021). During that timeframe, the number of estimated injection-involved overdose deaths increased more than 8-fold from 2000 (n = 3467, 95% CI: 3449-3485) to 2018 (n = 28,257, 95% CI: 28,192-28,322). From 2000-2007, the percent of overdose deaths that were injection-involved remained stable around 20%. From 2007-2018, the percent of overdose deaths that were injection-involved increased from 18.4% (95% CI: 18.3-18.6%) to 42.2% (95% CI: 42.1-42.3%). In 2018, most estimated injection-involved overdose deaths were due to injecting heroin/synthetic opioids (n = 24,860, 95% CI: 24,800-24,919), which accounted for 88.0% of all injection-involved deaths. CONCLUSIONS: Much of the recent increase in overdose mortality is likely attributable to rising injection-involved overdose deaths.

High-Risk Injection-Related Practices Associated with anti-HCV Positivity among Young Adults Seeking Services in Three Small Cities in Wisconsin.

BACKGROUND: Hepatitis C virus (HCV) infection has been increasing among people who inject drugs (PWID), younger than 30 years, and living in rural or suburban areas. We examined injection-related behaviors of young PWID to determine factors associated with HCV infection. METHODS: From September 2013-May 2015, respondent-driven and snowball sampling were used in 3 suburban areas of Wisconsin to recruit PWID 18-29 years who reported injection drug use in the previous 12 months. Participants were tested for HCV antibody (anti-HCV) and reported injection-related behaviors/practices via self-administered computer-based survey. We calculated anti-HCV prevalence and assessed associated factors using multivariable logistic regression. RESULTS: Forty-two percent (117/280) of participants were male, 83% (231/280) were white, and median age was 23 years. Overall HCV prevalence was 33%, but HCV prevalence among males was 39%. Adjusting for age, sex, race/ethnicity, education, relationship status, insurance status and income, anti-HCV positivity was associated with higher injection frequency (> 100 times in the past six months) (aOR = 3.07; 95% Confidence Interval (95% CI): 1.72-5.45), ever shared syringes (aOR = 5.15; 95% CI: 2.52-10.51), past week/last use receptive rinse water sharing (aOR = 1.88; 95% CI: 1.06-3.33), past week/last use receptive filter sharing (aOR = 3.25; 95% CI: 1.61-6.54), reusing syringes (aOR = 1.91, 95% CI: 1.08-3.37), history of overdose (aOR = 8.82; 95% CI: 2.26-3.95), and having ever injected another PWID (aOR = 8.82; 95%CI 3.94-19.76). DISCUSSION: Anti-HCV positivity is associated with high-risk injection practices. Young PWID would benefit from access to evidence-based interventions that reduce their risk of infection, link those infected to HCV treatment, and provide education to reduce further transmission.

Trends in pharmacy-based dispensing of buprenorphine, extended-release naltrexone, and naloxone during the COVID-19 pandemic by age and sex - United States, March 2019 - December 2020.

BACKGROUND: COVID-19 stay-at-home orders may reduce access to substance use treatment and naloxone, an opioid overdose reversal drug. The objective of this analysis was to compare monthly trends in pharmacy-based dispensing rates of medications for opioid use disorder (MOUD) (buprenorphine and extended-release [ER] naltrexone) and naloxone in the United States during March 2019-December 2020 by age and sex. METHODS: We calculated monthly prescription dispensing rates per 100,000 persons using IQVIA New to Brand. We used Joinpoint regression to calculate monthly percent change in dispensing rates and Wilcoxon Rank Sum tests to examine differences in median monthly rates overall, and by age and sex between March 2019-December 2019 and March 2020-December 2020. RESULTS: Buprenorphine dispensing increased among those aged 40-64 years and ≥ 65 years from March 2019 to December 2020. Median rates of total ER naltrexone dispensing were lower in March 2020-December 2020 compared to March 2019-December 2019 for the total population, and for females and males. From March 2019 to December 2020, ER naltrexone dispensing decreased and naloxone dispensing increased for those aged 20-39 years. CONCLUSIONS: Dispensing ER naltrexone declined during the study period. Given the increase in substance use during the COVID-19 pandemic, maintaining equivalent access to MOUD may not be adequate to accommodate rising numbers of new patients with opioid use disorder. Access to all MOUD and naloxone could be further expanded to meet potential needs during and after the public health emergency, given their importance in preventing opioid overdose-related harms.

Risk factors for COVID-19 among persons with substance use disorder (PWSUD) with hospital visits - United States, April 2020-December 2020.

INTRODUCTION: Sociodemographic factors and chronic conditions associated with coronavirus disease 2019 (COVID-19) among persons with substance use disorder (PWSUD) are not well understood. We identified risk factors associated with COVID-19 among PWSUD with hospital visits. METHODS: Using the Premier Healthcare Database Special COVID-19 Release, we conducted a case-control study using ICD-10-CM codes to identify PWSUD aged 12 years and older with hospital visits for any reason during April-December 2020. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to identify factors associated with COVID-19 diagnosis among PWSUD (age, sex, race/ethnicity, U.S. Census Region, urban/rural classification, insurance payor type, comorbidities, and substance use disorder [SUD] type), and then stratified by SUD type. RESULTS: From April-December 2020, 18,298 (1.3%) of 1,429,154 persons with SUD in the database had a COVID-19 diagnosis. Among PWSUD, opioid use disorder (OUD; aOR = 1.24, 95% CI = 1.18-1.32), alcohol use disorder (AUD; aOR = 1.16, 95% CI = 1.11-1.22), cocaine or other stimulant use disorder (COUD; aOR = 1.28, 95% CI = 1.22-1.34), and multiple SUDs (aOR = 1.20, 95% CI = 1.15-1.26) were associated with higher odds of COVID-19, as were comorbidities such as chronic lower respiratory disease (aOR = 1.32, 95% CI = 1.26-1.37), chronic hepatitis (aOR = 1.45, 95% CI = 1.34-1.57), and diabetes (aOR = 1.78, 95% CI = 1.71-1.86). CONCLUSIONS: Among a sample of PWSUD, OUD, AUD, COUD, multiple SUDs, and associated comorbidities were associated with COVID-19 diagnosis. Integration of COVID-related care, care of other comorbidities, and SUD treatment may benefit PWSUD. Future studies are needed to better understand COVID-19 prevention in this population and to reduce disparities among subpopulations at increased risk.

Program Adaptations to Provide Harm Reduction Services During the COVID-19 Pandemic: A Qualitative Study of Syringe Services Programs in the U.S.

Syringe services programs (SSPs) are essential to preventing injection drug use-related infections and overdose death among people who use drugs (PWUD). The novel coronavirus (COVID-19) pandemic initially impeded SSPs' operations. To effectively support these programs, information is needed regarding SSPs' experiences adapting their services and the challenges posed by COVID-19. We conducted qualitative interviews with leadership and staff from a sample of 31 U.S. SSPs. Respondents discussed urgent concerns including reduced reach of services, suspended HIV/hepatitis C testing, high COVID-19 risk among PWUD, and negative impacts of isolation on overdose and mental health. They also noted opportunities to improve future services for PWUD, including shifting to evidence-based distribution practices and maintaining regulatory changes that increased access to opioid use disorder medications post-pandemic. Findings can inform efforts to support SSPs in restoring and expanding services, and provide insight into SSPs' role in engaging PWUD during the COVID-19 response and future emergencies.

RESUMEN: Los programas de servicios de jeringas (reconocido como SSP en inglés) son esenciales para prevenir las infecciones relacionadas con el consumo de drogas inyectables y la muerte por sobredosis entre las personas que consumen drogas (reconocidos como PWUD en ingles). La nueva pandemia del coronavirus (COVID-19) inicialmente impidió las operaciones de los SSP. Para apoyar eficazmente estos programas, se necesita información sobre las experiencias de los SSP que adaptan sus servicios y los desafíos que plantea COVID-19. Realizamos entrevistas cualitativas con el liderazgo y el personal de una muestra de 31 SSPs de EE.UU. Los encuestados discutieron las preocupaciones urgentes, incluyendo la reducción del alcance de los servicios, la suspensión de las pruebas de VIH/hepatitis C, el alto riesgo de COVID-19 entre la PWUD, y los impactos negativos del aislamiento en las sobredosis y la salud mental. También identificaron las oportunidades de mejorar los servicios futuros para las PWUD, incluyendo el cambio a prácticas de distribución basadas en evidencias y el mantenimiento de cambios regulatorios que aumentaran el acceso a medicamentos para el trastorno por consumo de opiáceos después de la pandemia. La información que se encontró en este estudio se puede utilizar junto los esfuerzos para apoyar a los SSP en la restauración y expansión de los servicios, y proporcionar información sobre el papel de los SSP en la participación de PWUD durante la respuesta covid-19 futuras emergencias.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them.

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.

Access to HIV, Viral Hepatitis, and Substance Use Disorder Treatment/Overdose Prevention Services: A Qualitative Analysis of Syringe Service Programs (SSPs) Serving Rural PWID.

BACKGROUND: Syringe service programs (SSP) increasingly serve rural areas of the United States, yet little is known about access and perceived need for their services. Objectives: This paper presents the HIV and viral hepatitis prevention, testing, and treatment, and, substance use disorder treatment and overdose prevention services offered at three SSPs and which services their clients accessed. Across the three SSPs, 45 clients (people who inject drugs [PWID]), 11 staff, and five stakeholders were interviewed. Results: Most clients (n = 34) reported accessing SSP services weekly and primarily for sterile syringes and injection-related supplies. All clients reported testing for HIV at least once, though concern for acquiring or transmitting HIV was divided between some or no concern. Most clients (n = 43) reported testing for hepatitis C virus (HCV). Concern for acquiring or transmitting HCV was also mixed. Vaccination for hepatitis A and/or B teetered around half (HAV: n = 23) to a third (HBV: n = 15). Most clients (n = 43) knew where to access the overdose countering medication, Narcan. Feelings about substance use treatment options varied, yet most felt not enough were available. Of note, not all assessed services were offered by the sampled SSPs. Conclusions/Importance: The findings help us understand PWIDs' rationale regarding services accessed and preference for particular services. The need for some services was not perceived by those at risk for the illness the services addressed. Discussing risk and providing tailored education is important when providing SSP services to rural residing PWIDs.

The Changing Epidemiology of Hepatitis C Virus Infection in the United States During the Years 2010 to 2018.

Hepatitis C virus (HCV) infection remains an important cause of morbidity and mortality throughout the world, leading to serious health problems among those who are chronically infected. Since 1992, the Centers for Disease Control and Prevention has been collecting data on the incidence of HCV infection in the United States. In 2018, more than 50 000 individuals were estimated to have acute HCV infection.The most recently reported data on the prevalence of infection indicate that approximately 2.4 million people are living with hepatitis C in the United States. Transmission of HCV occurs predominantly through sharing contaminated equipment for injecting drugs.Two major events have had a significant impact on the incidence and prevalence of hepatitis C in the past few decades: the US opioid crisis and the discovery of curative treatments for HCV infection. To better understand the impact of these events, we examine reported trends in the incidence and prevalence of infection.

Randomized Trial of a Vaccine Regimen to Prevent Chronic HCV Infection.

BACKGROUND: A safe and effective vaccine to prevent chronic hepatitis C virus (HCV) infection is a critical component of efforts to eliminate the disease. METHODS: In this phase 1-2 randomized, double-blind, placebo-controlled trial, we evaluated a recombinant chimpanzee adenovirus 3 vector priming vaccination followed by a recombinant modified vaccinia Ankara boost; both vaccines encode HCV nonstructural proteins. Adults who were considered to be at risk for HCV infection on the basis of a history of recent injection drug use were randomly assigned (in a 1:1 ratio) to receive vaccine or placebo on days 0 and 56. Vaccine-related serious adverse events, severe local or systemic adverse events, and laboratory adverse events were the primary safety end points. The primary efficacy end point was chronic HCV infection, defined as persistent viremia for 6 months. RESULTS: A total of 548 participants underwent randomization, with 274 assigned to each group. There was no significant difference in the incidence of chronic HCV infection between the groups. In the per-protocol population, chronic HCV infection developed in 14 participants in each group (hazard ratio [vaccine vs. placebo], 1.53; 95% confidence interval [CI], 0.66 to 3.55; vaccine efficacy, -53%; 95% CI, -255 to 34). In the modified intention-to-treat population, chronic HCV infection developed in 19 participants in the vaccine group and 17 in placebo group (hazard ratio, 1.66; 95% CI, 0.79 to 3.50; vaccine efficacy, -66%; 95% CI, -250 to 21). The geometric mean peak HCV RNA level after infection differed between the vaccine group and the placebo group (152.51×103 IU per milliliter and 1804.93×103 IU per milliliter, respectively). T-cell responses to HCV were detected in 78% of the participants in the vaccine group. The percentages of participants with serious adverse events were similar in the two groups. CONCLUSIONS: In this trial, the HCV vaccine regimen did not cause serious adverse events, produced HCV-specific T-cell responses, and lowered the peak HCV RNA level, but it did not prevent chronic HCV infection. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT01436357.).

Responding to Outbreaks of Human Immunodeficiency Virus Among Persons Who Inject Drugs-United States, 2016-2019: Perspectives on Recent Experience and Lessons Learned.

In 2015, a large human immunodeficiency virus (HIV) outbreak occurred among persons who inject drugs (PWID) in Indiana. During 2016-2019, additional outbreaks among PWID occurred across the United States. Based on information disseminated by responding health departments and Centers for Disease Control and Prevention (CDC) involvement, we offer perspectives about characteristics of and public health responses to 6 such outbreaks. Across outbreaks, injection of opioids (including fentanyl) or methamphetamine predominated; many PWID concurrently used opioids and methamphetamine or cocaine. Commonalities included homelessness or unstable housing, previous incarceration, and hepatitis C virus exposure. All outbreaks occurred in metropolitan areas, including some with substantial harm reduction and medical programs targeted to PWID. Health departments experienced challenges locating case patients and contacts, linking and retaining persons in care, building support to strengthen harm-reduction programs, and leveraging resources. Expanding the concept of vulnerability to HIV outbreaks and other lessons learned can be considered for preventing, detecting, and responding to future outbreaks among PWID.

Bacterial and Fungal Infections in Persons Who Inject Drugs - Western New York, 2017.

During 2014-2017, CDC Emerging Infections Program surveillance data reported that the occurrence of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections associated with injection drug use doubled among persons aged 18-49 years residing in Monroe County in western New York.* Unpublished surveillance data also indicate that an increasing proportion of all Candida spp. bloodstream infections in Monroe County and invasive group A Streptococcus (GAS) infections in 15 New York counties are also occurring among persons who inject drugs. In addition, across six surveillance sites nationwide, the proportion of invasive MRSA infections that occurred in persons who inject drugs increased from 4.1% of invasive MRSA cases in 2011 to 9.2% in 2016 (1). To better understand the types and frequency of these infections and identify prevention opportunities, CDC and public health partners conducted a rapid assessment of bacterial and fungal infections among persons who inject drugs in western New York. The goals were to assess which bacterial and fungal pathogens most often cause infections in persons who inject drugs, what proportion of persons who inject use opioids, and of these, how many were offered medication-assisted treatment for opioid use disorder. Medication-assisted treatment, which includes use of medications such as buprenorphine, methadone, and naltrexone, reduces cravings and has been reported to lower the risk for overdose death and all-cause mortality in persons who use opioids (2,3). In this assessment, nearly all persons with infections who injected drugs used opioids (97%), but half of inpatients (22 of 44) and 12 of 13 patients seen only in the emergency department (ED) were not offered medication-assisted treatment. The most commonly identified pathogen was S. aureus (80%), which is frequently found on skin. Health care visits for bacterial and fungal infections associated with injection opioid use are an opportunity to treat the underlying opioid use disorder with medication-assisted treatment. Routine care for patients who continue to inject should include advice on hand hygiene and not injecting into skin that has not been cleaned or to use any equipment contaminated by reuse, saliva, soil, or water (4,5).

Prevalence of Risk and Protective Factors Associated with HIV and HCV Infections Among Male High School Students Who Have Sex with Males-Hawai'i, 2013, 2015, and 2017.

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections are increasing among young adults, and males who have sex with males (MSM) are at high risk for both infections. Limited Hawai'i data exists on the extent to which populations, such as MSM, are engaging in behaviors that place them at increased risk for either infection. This analysis quantified the proportion of Hawai'i public high school students who are MSM and are at risk for HCV and HIV infections. Data from the 2013, 2015, and 2017 Hawai'i Youth Risk Behavior Surveys (YRBS) were combined (n=16,751) to investigate the prevalence of risk factors associated with HIV and HCV infections (eg, sexual risk behaviors, substance use) and protective factors among MSM public high school students. Among sexually experienced male students (n=3,391), 13.1% were classified as MSM and among these, 40.3% identified as heterosexual despite reporting same-sex sexual contact. Multivariate modeling demonstrated that MSM students are significantly more likely than non-MSM students to engage in behaviors that increase their risk for HIV and HCV infections (composite risk variable; adjusted Prevalence Ratio: 1.40, 95% CI 1.15 - 1.70) and are significantly less likely to have protective factors. Evidence-based prevention strategies for reducing HIV and HCV risk behaviors while improving protective factors among sexual minority youth in Hawai'i are necessary and must address sexual behavior along with other dimensions of sexual orientation.