Posttraumatic stress disorder in people who use drugs: syringe services program utilization, treatment need, and preferences for onsite mental health care.

BACKGROUND: Syringe services programs (SSPs) are critical healthcare access points for people with opioid use disorder (OUD) who face treatment utilization barriers. Co-locating care for common psychiatric comorbidities, like posttraumatic stress disorder (PTSD), at SSPs may reduce harms and enhance the health of individuals with OUD. To guide the development of onsite psychiatric care at SSPs, we collected quantitative survey data on the prevalence of PTSD, drug use patterns, treatment experiences associated with a probable PTSD diagnosis, and attitudes regarding onsite PTSD care in a convenience sample of registered SSP clients in New York City. METHODS: Study participants were administered the PTSD Checklist for the DSM-5 (PCL-5) and asked about sociodemographic characteristics, current drug use, OUD and PTSD treatment histories, and desire for future SSP services using a structured interview. Probable PTSD diagnosis was defined as a PCL-5 score ≥ 31. RESULTS: Of the 139 participants surveyed, 138 experienced at least one potentially traumatic event and were included in the present analysis. The sample was primarily male (n = 108, 78.3%), of Hispanic or Latinx ethnicity (n = 76, 55.1%), and middle-aged (M = 45.0 years, SD = 10.6). The mean PCL-5 score was 35.2 (SD = 21.0) and 79 participants (57.2%) had a probable PTSD diagnosis. We documented frequent SSP utilization, significant unmet PTSD treatment need, and high interest in onsite PTSD treatment. CONCLUSIONS: Study findings point to the ubiquity of PTSD in people with OUD who visit SSPs, large gaps in PTSD care, and the potential for harm reduction settings like SSPs to reach people underserved by the healthcare system who have co-occurring OUD and PTSD.

High Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among Urban Syringe Service Program Participants.

BACKGROUND: Injectable opioid agonist treatment with hydromorphone (iOAT-H) is effective for persons who inject drugs (PWID) with opioid use disorder (OUD) but remains unavailable in the United States. Our objective was to determine interest in iOAT-H among syringe services program (SSP) participants. METHODS: We recruited PWID with OUD from SSPs in New York City. Interest in iOAT-H was assessed on a 4-point scale. We compared participants who were and were not interested in iOAT-H regarding sociodemographic characteristics and self-reported variables (past 30 days): heroin use, public injection practices, and participation in illegal activity other than drug possession. Participants reported their preferred OUD treatment and reasons for these preferences. RESULTS: Of 108 participants, most were male (69%), Hispanic (68%), and median age was 42 years. The median number of prior OUD treatment episodes was 6 (interquartile range: 2-12). Most (65%) were interested in iOAT-H. Interested participants (vs not interested) reported, over the prior 30 days, greater heroin use days (mean, 26.4 vs 22.3), injecting in public more times (median, 15 vs 6), and a higher percentage having participated in illegal activity (40% vs 16%). Preferences for OUD treatment were: iOAT-H (43%), methadone (39%), and buprenorphine (9%). Participants who preferred iOAT-H to conventional OUD treatments reported preferring injection as a route of administration and that available OUD treatments helped them insufficiently. CONCLUSIONS: SSP participants with OUD reported high interest in iOAT-H. Participants had attempted conventional treatments but still used heroin almost daily. We identified PWID at risk for opioid-related harms who potentially could benefit from iOAT-H.

Mitigation through on-site testing & education among formerly incarcerated individuals against Covid-19 - The MOSAIC study: Design and rationale.

BACKGROUND: Many of the largest COVID-19 outbreaks in the United States have occurred at carceral facilities. Criminal legal system (CLS)-involved individuals typically face structural barriers accessing medical care post-release. Improving COVID-19 testing and education for CLS-involved individuals could improve health outcomes for this vulnerable population and the communities to which they return. Community-based organizations (CBO) and community health workers (CHWs) fill care gaps by connecting CLS-involved individuals with essential re-entry services. The MOSAIC study will: 1) test an onsite CHW-led SARS-CoV-2 testing and education intervention in a reentry CBO and 2) model the cost-effectiveness of this intervention compared to standard care. METHODS: We will recruit 250 CLS-involved individuals who have left incarceration in the prior 90 days. Participants will be randomized to receive onsite Point-of-Care testing and education (O-PoC) or Standard of Care (SoC). Over one year, participants will complete quarterly questionnaires and biweekly short surveys through a mobile application, and be tested for SARS-CoV-2 quarterly, either at the CBO (O-PoC) or an offsite community testing site (SoC). O-PoC will also receive COVID-19 mitigation counseling and education from the CHW. Our primary outcome is the proportion of SARS-CoV-2 tests performed with results received by participants. Secondary outcomes include adherence to mitigation behaviors and cost-effectiveness of the intervention. DISCUSSION: The MOSAIC study will offer insight into cost effective strategies for SARS-CoV-2 testing and education for CLS-involved individuals. The study will also contribute to the growing literature on CHW's role in health education, supportive counseling, and building trust between patients and healthcare organizations.

Treatment History and Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among People Who Inject Drugs.

OBJECTIVES: Injectable opioid agonist treatment (iOAT) is a novel approach to treating opioid use disorder (OUD) that is typically reserved for treatment-experienced persons who inject drugs (PWID) with long-standing OUD. This study examined PWID's past OUD treatment histories and their attitudes toward iOAT with hydromorphone. METHODS: This cross-sectional study recruited syringe services program participants with OUD in New York City. Participants self-reported past OUD care episodes (detoxification; outpatient, inpatient, or medication treatment; or mutual aid groups) and current interest in iOAT with hydromorphone (assessed on a 4-point scale with 3 or 4 considered "interested"). Participants with 2 or more treatment episodes in the past 5 years were considered treatment-experienced. We examined whether the number of past care episodes was associated with interest in iOAT. RESULTS: Of 108 PWID, most participants were male (68.5%) and Hispanic (68.5%) with a mean age of 43 years (±10.8). Nearly all (98.1%) had severe OUD and had received past OUD care (96.3%), with the mean number of care episodes being 17.4 (SD, ±15.9). Most participants (59.8%) were treatment-experienced. Interest in iOAT with hydromorphone was high (64.8%), but there was no significant association between total past care episodes and expressing interest in iOAT (odds ratio, 1.02; 95% confidence interval, 0.99-1.05). CONCLUSION: Participants were highly treatment-experienced, and iOAT interest was high regardless of prior OUD treatment. New OUD treatment options, such as iOAT with hydromorphone, would be welcomed by PWID whose OUD has not remitted with conventional treatment as well as other PWID.

HIV testing in jails: Comparing strategies to maximize engagement in HIV treatment and prevention.

Despite 15,000 people enter US jails yearly with undiagnosed HIV infection, routine HIV testing is not standard. Maximizing the yield and speed of HIV testing in short-term detention facilities could promote rapid entry or re-entry of people living with HIV (PLWH) into care. The goal of this study was to evaluate the impact of third generation, rapid point-of-care (rPOC) vs. fourth generation, laboratory-based antigen/antibody (LBAg/Ab) testing on the HIV care cascade in a large urban jail during a planned transition. We used aggregate historical data to compare rPOC testing and LBAg/Ab testing in the D.C. Department of Corrections. We examined two time periods, January to August 2019 when rPOC testing was performed, and October 2019 to January 2020 after LBAg/Ab testing began. We calculated monthly rates of HIV tests performed, HIV test results received, HIV test results received among those tested, antiretroviral therapy (ART) initiation, and proportion of PLWH receiving discharge planning prior to release. We then conducted an interrupted time series analysis to assess the differences between testing periods. There were 14,237 entrants during the first time period and 7,569 entrants during the second. Transitioning from rPOC to LBAg/Ab testing increased the rate of test uptake by 38.5% (95% CI: 14.0, 68.3), decreased the rate of test results received among those tested by 13.1% (95% CI: -14.0, -12.1), and increased the combined rate of HIV tests performed and results received by 20.4% (95% CI: 1.5, 42.8). Although the rate of HIV testing was greater under LBAg/Ab, PLWH received results immediately through rPOC testing, which is critically important in short-stay enviroments. Increasing rPOC uptake would increase its value and combined testing may maximize the detection of HIV and receipt of results among persons passing through jails.

Coping with COVID in corrections: a qualitative study among the recently incarcerated on infection control and the acceptability of wastewater-based surveillance.

BACKGROUND: Correctional settings are hotspots for SARS-CoV-2 transmission. Social and biological risk factors contribute to higher rates of COVID-19 morbidity and mortality among justice-involved individuals. Rapidly identifying new cases in congregate settings is essential to promote proper isolation and quarantine. We sought perspectives of individuals incarcerated during COVID-19 on how to improve carceral infection control and their perspectives on acceptability of wastewater-based surveillance (WBS) accompanying individual testing. METHODS: We conducted semi-structured interviews with 20 adults who self-reported being incarcerated throughout the United States between March 2020 and May 2021. We asked participants about facility enforcement of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines, and acceptability of integrating WBS into SARS-CoV-2 monitoring strategies at their most recent facility. We used descriptive statistics to characterize the study sample and report on acceptability of WBS. We analyzed qualitative data thematically using an iterative process. RESULTS: Participants were predominantly Black or multiple races (50%) and men (75%); 46 years old on average. Most received a mask during their most recent incarceration (90%), although only 40% received counseling on proper mask wearing. A quarter of participants were tested for SARS-CoV-2 at intake. Most (70%) believed they were exposed to the virus while incarcerated. Reoccurring themes included (1) Correctional facility environment leading to a sense of insecurity, (2) Perceptions that punitive conditions in correctional settings were exacerbated by the pandemic; (3) Importance of peers as a source of information about mitigation measures; (4) Perceptions that the safety of correctional environments differed from that of the community during the pandemic; and (5) WBS as a logical strategy, with most (68%) believing WBS would work in the last correctional facility they were in, and 79% preferred monitoring SARS-CoV-2 levels through WBS rather than relying on just individual testing. CONCLUSION: Participants supported routine WBS to monitor for SARS-CoV-2. Integrating WBS into existing surveillance strategies at correctional facilities may minimize the impact of future COVID-19 outbreaks while conserving already constrained resources. To enhance the perception and reality that correctional systems are maximizing mitigation, future measures might include focusing on closer adherence to CDC recommendations and clarity about disease pathogenesis with residents.

Predictors of hepatitis C cure among people who inject drugs treated with directly observed therapy supported by peer case managers in Kenya.

BACKGROUND & AIMS: Directly observed therapy (DOT) maximizes adherence and minimizes treatment gaps. Peer case managers (PCM) have also shown promise as a component of integrated HCV treatment strategies. DOT and PCM-support have been underexplored, particularly in low- and middle-income countries (LMICs). The objective of this study was to evaluate predictors of sustained virologic response (SVR) among people who inject drugs (PWID) attending medication-assisted treatment (MAT) and needle and syringe programs (NSP) sites in Kenya. METHODS: We recruited PWID accessing MAT and NSP in Nairobi and Coastal Kenya. PWID were treated with ledipasvir/sofosbuvir using DOT supported by PCMs. We used bivariate and multivariate logistic regression to examine the impact of sociodemographic, behavioral, and clinical factors on SVR. RESULTS: Among 92 PWID who initiated HCV treatment, 79 (86%) were male with mean age of 36.3 years (SD=±6.5); 38 (41%) were HIV-positive, and 87 (95%) reported injecting drugs in the last 30 days. Just over half of participants were genotype 1a (55%), followed by genotype 4a (41%) and mixed 1a/4a (3%). Most participants, 85 (92%) completed treatment and 79 (86%) achieved SVR. While sociodemographic and behavioral factors including recent injection drug use were not significantly associated with achieving SVR, being fully adherent (p=0.042), number of doses taken (p=0.008) and treatment completion (p= 0.001) were associated with higher odds of achieving SVR. CONCLUSIONS: DOT with PCM-support was an effective model for HCV treatment among PWID in this LMIC setting. Adherence was the most important driver of SVR suggesting DOT and PCM support can overcome other factors that might limit adherence. Further research is necessary to ascertain the effectiveness of other models of HCV care for PWID in LMICs given NSP and MAT access is variable, and DOT may not be sustainable with limited resources.

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.

Challenges and best practices for hepatitis C care among people who inject drugs in resource limited settings: focus group discussions with healthcare providers in Kenya.

People who inject drugs (PWID) living with Hepatitis C (HCV) in low- and middle-income countries face substantial barriers to HCV care. We sought to gain healthcare providers' perspectives on challenges and best practices for HCV care provision among PWID in Kenya. We conducted three focus group discussions (FGD) with 23 healthcare providers working with PWID living with HCV in Nairobi and Mombasa. Transcribed interviews were analysed thematically. Overarching themes regarding HCV prevention and treatment were: (1) lack of HCV-related knowledge at the provider and patient levels; (2) stigmatisation of people living with HCV and PWID; and (3) difficulties among PWID with navigating the healthcare system. Some providers suggested systematically integrating HCV care into existing PWID-specific harm reduction programs to improve HCV care provision as well as creating national HCV guidelines to guide clinicians. This study highlights the need for national HCV treatment guidelines and increased public HCV education, as well as culturally sensitive models integrating HCV care into programs PWID are already accessing. These strategies will be useful in improving access to HCV care among PWID and has the potential to decrease HCV transmission and prevalence among this vulnerable population.

Impact of COVID-19 on substance use disorder treatment services in Kenya: Qualitative findings from healthcare providers.

BACKGROUND: People who inject drugs are at an increased risk for contracting SARS-CoV-2 and have experienced barriers to accessing harm reduction services during the COVID-19 pandemic. Understanding how to best provide these services is essential for COVID-19 mitigation. The goal of this study was to ascertain challenges and successes for caring for people who inject drugs in Kenya during the COVID-19 pandemic. METHODS: We conducted focus group discussions and one-on-one key informant interviews with healthcare providers who work with people who inject drugs in Kenya. Interviews explored how COVID-19 and social distancing measures impacted service provision, as well as what strategies were used to overcome these barriers. We used thematic analysis to analyze transcribed interviews. RESULTS: Participants included 29 service providers from 11 healthcare professions at three medication assisted treatment (MAT) and four drop-in center (DIC) sites (N=15 males and N=14 females, with an average age of 35 years). Four overarching themes emerged in our thematic analysis in which providers described both barriers to providing care and solutions to overcome them: (1) COVID-19-related misconceptions; (2) Limited COVID-19 testing and screening; (3) Structural changes related to service provision; and (4) Access to material resources such as meals, needle and syringe program kits, and personal protective equipment. CONCLUSIONS: Our findings demonstrate the COVID-19 pandemic-imposed challenges for substance use disorder treatment providers and patients, however with ingenuity many of these challenges were able to be overcome.

Onsite buprenorphine inductions at harm reduction agencies to increase treatment engagement and reduce HIV risk: Design and rationale.

BACKGROUND: Despite dramatic increases in opioid use disorder (OUD) and overdose deaths, the U.S. has been unable to consistently deliver OUD treatment to those who need it. Syringe services programs (SSPs) can engage an out-of-treatment population of people with OUD that has elevated overdose risk. Buprenorphine treatment is safe and effective, and US regulations allow for prescribing from diverse locations, including SSPs. This study's objective is to test buprenorphine treatment initiation at SSPs. We hypothesize that offering onsite buprenorphine treatment initiation will improve OUD treatment engagement without reducing buprenorphine treatment effectiveness or safety. METHODS: We will recruit 250 out-of-treatment SSP participants with OUD in a large urban area. Participants will be randomized to onsite buprenorphine treatment initiation or enhanced referral. Over 2 weeks, participants in the onsite treatment arm will see a buprenorphine provider twice at the SSP, receive weekly medication packs, and then their care will be transferred to a community health center for treatment continuation. In the control arm, within one week, participants will receive an appointment at the same community health center as in the intervention arm for buprenorphine initiation and continuation. Participants will be assessed with urine drug tests, questionnaires, and medical record review. The primary outcome will be engagement in buprenorphine treatment at 30 days. Secondary outcomes include buprenorphine diversion, opioid-free urine drug tests, and intervention cost-effectiveness. DISCUSSION: Our study will contribute to the growing literature on SSPs as a conduit to OUD treatment. SSPs hold promise to deliver needed care to people with OUD.

Hepatitis C-related knowledge, attitudes and perceived risk behaviours among people who inject drugs in Kenya: A qualitative study.

Despite disproportionately high rates of Hepatitis C (HCV) among people who inject drugs (PWID) in low- and middle-income countries (LMICs), understanding of HCV-related knowledge, attitudes and perceived risk behaviours among this population remains limited. We aimed to elucidate knowledge, attitudes and experiences that could minimise transmission risk and maximise HCV treatment engagement among PWID in Kenya following the integration of HCV screening and education with needle and syringe programmes in drop-in-centres (DICs). We recruited 40 PWID with chronic HCV attending DICs in Nairobi and Coastal Kenya. Semi-structured interviews revealed a general understanding of HCV and awareness of HCV risk behaviours among participants; however, many felt limited control over their transmission risk due to factors such as 'local doctors', or individuals who perform a high volume of high-risk injections. Financial barriers, distance to clinic, poor health status and HCV-related stigma were all noted as barriers to HCV treatment. In conclusion, basic knowledge of and motivation for HCV treatment among PWID accessing DICs in Kenya was high; however, structural barriers and stigma complicate access to care. Local education programmes can address knowledge gaps, and behavioural and structural interventions can maximise the impact of HCV care in LMICs.

Aiming for Zero: Reducing Transmission of Coronavirus Disease 2019 in the D.C. Department of Corrections.

BACKGROUND: Washington, District of Columbia lowered severe acute respiratory syndrome coronavirus 2 transmission in its large jail while community incidence was still high. METHODS: Coordinated clinical and operational interventions brought new cases to near zero. RESULTS: Aggressive infection control and underlying jail architecture can promote correctional coronavirus disease 2019 management. CONCLUSIONS: More intensive monitoring could help confirm that in-house transmission is truly zero.

Hepatitis C Resistance-Associated Substitutions Among People Who Inject Drugs Treated With Direct-Acting Antiviral-Containing Regimens.

BACKGROUND: Resistance-associated substitutions (RASs) to HCV direct-acting antivirals (DAAs) can contribute to virologic failure and limit retreatment options. People who inject drugs (PWID) are at highest risk for transmission of resistant virus. We report on RASs at baseline and after virologic failure in DAA-naive and protease inhibitor-experienced PWID. METHODS: We sequenced the NS3/4A, NS5A, and NS5B regions from 150 PWID with genotype 1 (GT1) viruses; 128 (85.3%) GT1a, 22 (14.7%) GT1b. RESULTS: Among the 139 (92.7%) DAA-naive PWID, 85 of 139 (61.2%) had baseline RASs-67 of 139 (48.2%) in NS3 (predominantly Q80K/L); 25 of 139 (18.0%) in NS5A; and 8 of 139 (5.8%) in NS5B. Of the 11 protease inhibitor-experienced participants, 9 had baseline NS3 RASs (V36L N = 1, Q80K N = 9) and 4 had baseline NS5A RASs (M28V N = 2, H58P N = 1, A92T N = 1). Among the 11 participants who had posttreatment samples with detectable virus (7 treatment failures, 1 late relapse, 3 reinfections), 1 sofosbuvir/ledipasvir failure had a baseline H58P. Two sofosbuvir/ledipasvir-treated participants developed new NS5A mutations (Q30H, Y93H, L31M/V). Otherwise, no RASs were detected. CONCLUSIONS: Our results demonstrate RAS prevalence among DAA-naive PWID is comparable to that in the general population. Only 2 of 150 (1.3%) in our longitudinal cohort developed treatment-emergent RASs. Concern for transmission of resistant virus may therefore be minimal.