Patient and Clinician Experiences with the Implementation of Telemedicine and Related Adaptations in Office-Based Buprenorphine Treatment During the COVID-19 Pandemic: A Qualitative Study.

Background: Deaths from opioid overdose have increased dramatically in the past decade, representing an epidemic in the United States. For individuals with opioid use disorder (OUD), agonist medications such as methadone and buprenorphine reduce opioid-related morbidity and mortality. Historically, the provision of buprenorphine treatment in office-based settings has relied on frequent in-person contact, likely influencing patients' access to and retention in care. In response to the COVID-19 pandemic, providers of office-based buprenorphine treatment rapidly adapted their care processes, increasingly relying on telemedicine visits. To date, relatively few prior studies have combined patient and clinician perspectives to examine the implementation of telemedicine and related care adaptations, particularly in safety-net settings. Methods: Qualitative methods were used to explore clinician and patient experiences with telemedicine in an office-based buprenorphine treatment clinic affiliated with an urban safety-net hospital. From this clinic, we interviewed 25 patients and 16 clinicians (including prescribers and non-prescribers) to understand how telemedicine impacted treatment quality and engagement in care, as well as preferences for using telemedicine moving forward. Results: Five themes regarding the implementation of telemedicine and other COVID-19-related care adaptations arose from patient and clinician perspectives: 1) telemedicine integration precipitated openness to more flexibility in care practices, 2) concerns regarding telemedicine-related adaptations centered around safety and accountability, 3) telemedicine encounters required rapport and trust between patients and clinicians to facilitate open communication, 4) safety-net patient populations experienced unique challenges when using telemedicine, particularly in terms of the technology required and the need for privacy, and 5) there is an important role for telemedicine in office-based buprenorphine treatment moving forward, primarily through its use in hybrid models of care. Conclusions: Telemedicine implementation within office-based buprenorphine treatment has the potential to improve patients' engagement in care; however, our findings emphasize the need for tailored approaches to implementing telemedicine in office-based buprenorphine treatment, particularly within safety-net settings. Overall, this study supports the maintenance of changes to policy and practice that facilitate the use of telemedicine in office-based buprenorphine treatment beyond the COVID-19 public health emergency.

Comparison of Visit Rates Before vs After Telehealth Expansion Among Patients With Mental Health Diagnoses Treated at Federally Qualified Health Centers.

This cohort study assesses visit rates before and after telehealth expansion to assess whether telehealth availability at federally qualified health centers is associated with visit rates for patients with mental health diagnoses.

Implementation and sustainability of safe consumption sites: a qualitative systematic review and thematic synthesis.

BACKGROUND: Safe consumption sites (SCSs) serve diverse populations of people who use drugs (PWUD) and public health objectives. SCS implementation began in the 1980s, and today, there are at least 200 known SCSs operating in over twelve countries. While a growing literature supports their effectiveness as a harm reduction strategy, there is limited information on contextual factors that may support or hinder SCS implementation and sustainability. We aimed to fill this gap in knowledge by reviewing existing qualitative studies on SCSs. METHODS: We conducted a systematic review and thematic synthesis of qualitative studies. We identified all peer-reviewed, English-language qualitative studies on SCSs containing original data in PubMed, Web of Science, Google Scholar, and Science Direct as of September 23, 2019. Two authors independently screened, abstracted, and coded content relating to SCS implementation and sustainment aligned with the Exploration, Preparation, Implementation, Sustainment (EPIS) implementation science framework. RESULTS: After removing duplicates, we identified 765 unique records, of which ten qualitative studies met inclusion criteria for our synthesis. Across these ten studies, 236 total interviews were conducted. Overall, studies described how SCSs can (1) keep drug use out of public view while fostering a sense of inclusion for participants, (2) support sustainment by enhancing external communities' acceptability of SCSs, and (3) encourage PWUD utilization. Most studies also described how involving PWUD and peer workers (i.e., those with lived experience) in SCS operation supported implementation and sustainability. DISCUSSION: Our thematic synthesis of qualitative literature identified engagement of PWUD and additional factors that appear to support SCS planning and operations and are critical to implementation success. However, the existing qualitative literature largely lacked perspectives of SCS staff and other community members who might be able to provide additional insight into factors influencing the implementation and sustainability of this promising public health intervention.

"He Gave Me Spirit and Hope": Client Experiences with the Implementation of Community Health Worker Programs in HIV Care.

Community health workers (CHWs) are members of the frontline health workforce who serve as intermediaries between health services and communities. In the United States, the role of CHWs has begun to expand as they have been shown to improve outcomes and reduce inequities in care for chronic conditions. This study used qualitative methods to explore the experiences of clients in CHW programs to inform their implementation in HIV care. Thirty clients from 6 Ryan White HIV/AIDS Program care settings across the United States participated in individual semistructured interviews to learn more about their experiences working with a CHW. Four key themes arose from the client perspective. First, CHWs embodied key qualities. Some of the qualities clients attributed to CHWs included being caring and supportive, along with capable of fostering personal connections. Second, CHWs met clients where they were. Clients described the CHW approach as more holistic compared with other care team members; they emphasized CHWs were able to focus on whatever was needed in that moment. Third, CHWs occupied a unique role in the HIV care team. Clients noted CHWs had more time to dedicate to their interactions; they also saw CHWs as representing a different level of authority. Finally, CHWs influenced how clients engaged with care and accessed resources. This included empowering clients to access resources independently in the future. Overall, clients' perceptions of CHWs in terms of their qualities, approach, role, and influence on the HIV care experience suggest they are a valuable resource on the care team.

Supervised Injection Facilities as Harm Reduction: A Systematic Review.

CONTEXT: Supervised injection facilities are harm reduction interventions that allow people who inject drugs to use previously obtained substances under the supervision of health professionals. Although currently considered illegal under U.S. federal law, several U.S. cities are considering implementing supervised injection facilities anyway as a response to the escalating overdose crisis. The objective of this review is to determine the effectiveness of supervised injection facilities, compared with that of control conditions, for harm reduction and community outcomes. EVIDENCE ACQUISITION: Studies were identified from 2 sources: a high-quality, broader review examining supervised injection facility-induced benefits and harms (from database inception to January 2014) and an updated search using the same search strategy (January 2014‒September 2019). Systematic review methods developed by the Guide to Community Preventive Services were used (screening and analysis, September 2019‒December 2020). EVIDENCE SYNTHESIS: A total of 22 studies were included in this review: 16 focused on 1 supervised injection facility in Vancouver, Canada. Quantitative synthesis was not conducted given inconsistent outcome measurement across the studies. Supervised injection facilities in the included studies (n=number of studies per outcome category) were mostly associated with significant reductions in opioid overdose morbidity and mortality (n=5), significant improvements in injection behaviors and harm reduction (n=7), significant improvements in access to addiction treatment programs (n=7), and no increase or reductions in crime and public nuisance (n=7). CONCLUSIONS: For people who inject drugs, supervised injection facilities may reduce the risk of overdose morbidity and mortality and improve access to care while not increasing crime or public nuisance to the surrounding community.

"Part of getting to where we are is because we have been open to change" integrating community health workers on care teams at ten Ryan White HIV/AIDS program recipient sites.

BACKGROUND: Community Health Workers (CHWs) have long been integrated in the delivery of HIV care in middle- and low-income countries. However, less is known about CHW integration into HIV care teams in the United States (US). To date, US-based CHW integration studies have studies explored integration in the context of primary care and patient-centered medical homes. There is a need for research related to strategies that promote the successful integration of CHWs into HIV care delivery systems. In 2016, the Health Resources and Services Administration HIV/AIDS Bureau launched a three-year initiative to provide training, technical assistance and evaluation for Ryan White HIV/AIDS Program (RWHAP) recipient sites to integrate CHWs into their multidisciplinary care teams, and in turn strengthen their capacity to reach communities of color and reduce HIV inequities. METHODS: Ten RWHAP sites were selected from across eight states. The multi-site program evaluation included a process evaluation guided by RE-AIM to understand how the organizations integrated CHWs into their care teams. Site team members participated in group interviews to walk-the-process during early implementation and following the program period. Directed content analysis was employed to examine program implementation. Codes developed using implementation strategies outlined in the Expert Recommendations for Implementing Change project were applied to group interviews (n = 20). FINDINGS: Implementation strategies most frequently described by sites were associated with organizational-level adaptations in order to integrate the CHW into the HIV care team. These included revising, defining, and differentiating professional roles and changing organizational policies. Strategies used for implementation, such as network weaving, supervision, and promoting adaptability, were second most commonly cited strategies, followed by training and Technical Assistance strategies. CONCLUSIONS: Wrapped up in the implementation experience of the sites there were some underlying issues that pose challenges for healthcare organizations. Organizational policies and the ability to adapt proved significant in facilitating CHW program implementation. The integration of the CHWs in the delivery of HIV care requires clearly distinguishing their role from the roles of other members of the healthcare delivery team.

Client Satisfaction with Community Health Workers in HIV Care Teams.

Community health workers (CHWs) integrated in human immunodeficiency virus (HIV) care teams undertake a variety of tasks to help patients navigate health care, develop care plans, and address social needs. Given the broad role of CHWs in HIV care, we sought to understand which client attributes are associated with various dimensions of CHW satisfaction using a sample of 204 people with HIV (PWH) from various geographic regions across the United States. Multivariable linear regressions were used to determine which client attributes were associated with complete satisfaction with CHWs using 10 validated measures. The mean age of participants was 40.6 years old (SD = 12.8) and over 70% were Black or African American. Adjusted models reveal clients who were female, have marginal health literacy, or have a substance use disorder diagnosis were more likely to not be completely satisfied across multiple dimensions (p ≤ .05). Conversely, being housed and having a mental health diagnosis were associated with being more likely to be completely satisfied (p ≤ .04). Clients' sociodemographic characteristics and health conditions may be indicative of unique needs, leading to differing expectations of CHWs. CHW training modalities should consider the complex interplay of care needs based upon different client backgrounds and experiences among PWH. Addressing unique needs resulting from social determinants of health and that arise from conditions co-occurring with HIV, such as substance use disorders, should be incorporated into CHW service delivery.

Examining the implementation of police-assisted referral programs for substance use disorder services in Massachusetts.

BACKGROUND: In response to the dramatic increase in opioid overdose deaths in recent years, police departments and community partners across the United States have begun to implement programs focused on connecting individuals to substance use disorder services. We examined the implementation of police-assisted referral programs from the perspectives of different team members to understand the key components of these programs and strategies used to implement them. METHODS: Qualitative research methods were used to examine the implementation of police-assisted referral programs in five Massachusetts communities between June 2019 and March 2020. Focus groups and interviews were conducted with 33 individuals, including 5 police chiefs, 12 police officers, 6 outreach workers, 4 community-based organization (CBO) directors, 2 interns, 1 clinician, 1 program manager, 1 religious representative, and 1 prevention specialist. RESULTS: Five key themes emerged regarding the implementation of police-assisted referral programs across the communities: 1) program development was an ongoing process; 2) partnerships between police departments and community stakeholders were essential for starting and sustaining a program; 3) high-level leadership influenced program priorities and facilitated implementation; 4) program success was defined in multiple ways; and 5) programs contributed to shifts in beliefs about substance use and addiction among police officers. CONCLUSIONS: Police-assisted referral programs in Massachusetts have adopted a variety of models of service delivery, evolving from post-overdose outreach and walk-in models to more complex hybrid forms. Implementation was facilitated by the support of departmental leadership, particularly the police chief, and the development of key partnerships across institutional boundaries. Communities continue to develop their programs to incorporate additional components, such as new mechanisms of outreach, harm reduction services, and long-term engagement activities. Further evaluation of these programs is needed to understand how each of these unique components may influence a program's impact on future overdoses, entry to treatment, and long-term recovery.

Feasibility of Assessing Economic and Sexual Risk Behaviors Using Text Message Surveys in African-American Young Adults Experiencing Homelessness and Unemployment: Single-Group Study.

BACKGROUND: Text messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings. OBJECTIVE: This study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys. METHODS: We conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback. RESULTS: Overall, 65% (n=11/17) of the participants responded to at least one text message survey compared with 35% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64%) of the responders were women. The majority (n=4/6, 67%) of nonresponders were men. An average of 7.6 participants (69%) responded in a given week. Response rates among ever responders ranged from 64% to 82% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90% of all questions), ranging from 72% to 100%. An average of 6.4 participants (84%) answered all 14 text message questions in a given week, ranging from 57% to 100%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives. CONCLUSIONS: Longitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors. TRIAL REGISTRATION: ClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871.

Lessons learned from using respondent-driven sampling (RDS) to assess sexual risk behaviors among Kenyan young adults living in urban slum settlements: A process evaluation.

BACKGROUND: Respondent-driven sampling (RDS) is a peer-referral sampling methodology used to estimate characteristics of underserved groups that cannot be randomly sampled. RDS has been implemented in several settings to identify hidden populations at risk for HIV, but few studies have reported the methodological lessons learned on RDS design and implementation for assessing sexual risk behaviors in marginalized youth. METHODS: We used RDS to recruit N = 350 young adults, aged 18 to 22, who were living in urban slum settlements in Nairobi, Kenya. A structured survey was used to assess sexual risk behaviors. Twenty seeds were selected and asked to recruit up to three eligible peers. We used small monetary incentives and a three-day recruitment coupon with sequential numbers linking recruiters to their recruits. RESULTS: Data collection was completed in 8 days with a maximum chain length of 6 waves. Each seed yielded 16 to 21 eligible recruits. Three (15%) seeds were unproductive and were replaced. RDS benefits were high identification rates (90% coupons returned per coupons given), high eligibility rates (100% eligible recruits per coupons returned), and high efficiency (~39 eligible recruits per day). 44% of the sample was female. Most recruits (74%) reported being "friends" for 7+ years with their recruiter. RDS overcame feasibility concerns of household-, clinic-, and school-based sampling methodologies in that underserved youth who were unemployed (68%), out of school (48%), ethnic minorities (26%), and having prior residential instability (≥2 moves in the past year) (20%) were successfully recruited, based on weighted analyses. Youth reporting HIV risk behaviors, including unprotected sex (38%), sex while high/drunk (35%), and sex exchange for pay (14%), were also enrolled. However, 28% were not sexually active within the last 6 months. Challenges included managing wait times during peaks and participant referral expectations. Community engagement, use of study-stamped coupons, broad inclusion criteria, incentives, and study sites within walking distances all contributed to the successful implementation of the sampling methodology. CONCLUSION: RDS is an important tool in reaching a diverse sample of underserved and at-risk young adults for study participation. Implications for optimizing RDS for behavioral studies in this population are discussed.

Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial.

BACKGROUND: Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages ("nudges") that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. METHODS/DESIGN: In total, 40 young adults who are African-American, aged 18-24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group ("comparison") will receive text messages with information on job openings. The second group ("experimental") will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention. DISCUSSION: This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03766165 . Registered on 4 December 2018.