Implementation of a bundle to improve HIV testing during hospitalization for people who inject drugs.

Background: Increased HIV testing is essential to ending the HIV epidemic. People who inject drugs (PWID) are among the highest risk for HIV infection. Previous research at Tufts Medical Center identified low HIV testing rates in hospitalized PWID. Our research team aimed to identify and overcome barriers to inpatient HIV screening of PWID using implementation science methods. Methods: Stakeholders were engaged to gather perspectives on barriers and facilitators of HIV testing. A PWID care bundle was developed and implemented, which included (1) HIV screening; (2) hepatitis A, B, and C testing and vaccination; (3) medications for opioid use disorder; and (4) naloxone prescription. Strategies from all nine Expert Recommendations for Implementing Change (ERIC) clusters guided the implementation plan. Stakeholder feedback was gathered throughout implementation, and implementation outcomes of acceptability and feasibility were assessed. Results: PWID overall felt comfortable with HIV testing being offered while hospitalized. Clinicians cited that the main barriers to HIV testing were discomfort and confusion around consenting requirements. Many resident physicians surveyed reported that, at times, they forgot HIV testing for PWID. Overall, though, resident physicians felt that the PWID bundle was useful and did not distract from other patient care responsibilities. Conclusions: Engagement of key stakeholders to increase HIV testing in an inpatient setting led to the implementation of a PWID bundle, which was feasible and acceptable. Bundling evidence-informed care elements for inpatient PWID should be investigated further.

People who inject drugs (PWID) are at an increased risk of contracting HIV. HIV testing is a key strategy to stop the spread of HIV. Our study created a bundle of services and tests to offer to all PWID who were admitted to the hospital. The bundle included HIV testing; hepatitis A, B, and C testing and vaccination; medications for opioid use disorder; and prescription for Narcan, a medication that can reverse opioid overdose. We then asked doctors and patients how they felt about the bundle and any barriers and facilitators that they predicted for expanding HIV testing to PWID while admitted to the hospital. Patients were accepting of expanding HIV testing, and resident physicians felt it was important as well and was a manageable addition to their list of responsibilities. However, the most likely part of the bundle to be forgotten was HIV testing. This study lays the groundwork for bundling services for PWID while they are hospitalized. We also highlight areas for future exploration.

"To Be Honest, You Probably Would Have to Read It 50 Times": Stakeholders Views on Using the Opt-Out Approach for Vaccination in Jails.

Background: Despite national guidelines on infectious disease testing and vaccination in prisons, there is heterogeneity on the implementation of these practices in jails. We sought to better understand perspectives on the implementation of opt-out vaccination for infectious diseases in jails by interviewing a broad group of stakeholders involved in infectious diseases vaccination, testing, and treatment in Massachusetts jails. Methods: The research team conducted semistructured interviews with people incarcerated in Hampden County Jail (Ludlow, Massachusetts), clinicians working in jail and community settings, corrections administrators, and representatives from public health, government, and industry between July 2021 and March 2022. Results: Forty-eight people were interviewed, including 13 people incarcerated at the time of interview. Themes that emerged included the following: misunderstandings of what opt-out means, indifference to the way vaccines are offered, belief that using the opt-out approach will increase the number of individuals who receive vaccination, and that opt-out provides an easy way for vaccine rejection and reluctance to accept vaccination. Conclusions: There was a clear divide in stakeholders' support of the opt-out approach, which was more universally supported by those who work outside of jails compared to those who work within or are incarcerated in jails. Compiling the perspectives of stakeholders inside and outside of jail settings on the opt-out approach to vaccination is the first step to develop feasible and effective strategies for implementing new health policies in jail settings.

"The bottom line is that it is all about trust": Interviews with Health Services Administrators about perceived barriers and facilitators to vaccine administration in jails.

Background: Compared to the general population, individuals incarcerated in jails and prisons are more vulnerable to infection and mortality from communicable diseases, such as COVID-19 and influenza. However, vaccination rates among incarcerated individuals as well as staff who work in jails and prisons remain disproportionately low. Healthcare administrators working in jails have first-hand experience about barriers to vaccine provision, but their perspectives are infrequently collected and analyzed. Methods: We reached out to Health Services Administrators (HSAs) from all 14 Massachusetts (MA) county jails for qualitative in-depth interviews to understand how their personal and professional feelings about vaccination relate to the barriers and facilitators that surround administration of vaccines in jail. Results: Eight people participated in the study (8/14 = 57% response rate). Key themes emerged, including 1) HSAs expressed divergent opinions on incarceration as the correct opportunity to vaccinate individuals, 2) HSAs' personal views on vaccines influenced their operationalization of vaccination in jail, and 3) opinions varied on whether their institutions' vaccine protocols needed modification. Conclusions: Our findings highlight the critical need to leverage the feedback and influence of stakeholders such as HSAs in efforts to improve preventative healthcare delivery in carceral health systems.

Implementation of rapid COVID-19 testing at Massachusetts trial courts.

BACKGROUND: COVID-19 shut down trial courts across the country, prolonging case resolution of charged, detained, and incarcerated people. We report on the implementation of rapid COVID-19 testing at Trial Courts in Massachusetts (MA), focusing on the outcomes of adoption and acceptability. METHODS: Guided by the Expert Recommendations in Implementing Change (ERIC) framework, we chose six strategies to guide implementation. After assembling a group of stakeholders, including representatives of the Trial Court, Department of Public Health (DPH) and vendors providing COVID-19 testing, we implemented rapid COVID-19 testing at Trial Court locations in December 2021. We collected data on (1) adoption of COVID-19 testing, (2) number of stakeholders who attended meetings, (3) number of tests performed at Trial Court sites, and (4) acceptability of COVID-19 testing using a QR-code anonymous survey. RESULTS: There was a high percentage of attendance at stakeholder meetings (> 70% at each meeting). 243 COVID-19 tests were conducted on eight occasions at four Trial Court sites between December 2021 and February 2022. Participants who responded to the QR-code survey reflected favorably on COVID-19 testing at MA Trial Court sites. CONCLUSION: COVID-19 testing at Massachusetts Trial Court sites was possible through stakeholder engagement. Several cases of COVID-19 were identified prior to entry into the Trial Court. Funding for rapid COVID-19 testing should be provided to help keep trial courts open as the pandemic continues to evolve.

Surgeons' Perspectives on Valve Surgery in People With Drug Use-Associated Infective Endocarditis.

BACKGROUND: Hospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons' perspectives about the process of decision making around operation for people with DUA-IE are largely unknown. METHODS: This multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University. RESULTS: Nineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care. CONCLUSIONS: Cardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

"They Just Assume That We're All Going to Do the Wrong Thing With It. It's Just Not True": Stakeholder Perspectives About Peripherally Inserted Central Catheters in People Who Inject Drugs.

Background: In the absence of adequate harm reduction opportunities, people who inject drugs (PWID) are at increased risk for serious infections. Infectious diseases guidelines recommend extended periods of intravenous antibiotic treatment through peripherally inserted central catheters (PICCs), but PWID are often deemed unsuitable for this treatment. We conducted semi-structured interviews and focus groups to understand the perspectives and opinions of patients and clinicians on the use of PICCs for PWID. Methods: We approached patients and clinicians (doctors, nurses, PICC nurses, social workers, and case workers) involved in patient care at Tufts Medical Center (Boston, Massachusetts) between August 2019 and April 2020 for semi-structured interviews and focus groups. Results: Eleven of 14 (79%) patients agreed to participate in an in-depth interview, and 5 role-specific clinician focus groups (1 group consisting of infectious diseases, internal medicine, and addiction psychiatry doctors, 2 separate groups of floor nurses, 1 group of PICC nurses, and 1 group of social workers) were completed. Emergent themes included the overall agreement that PICCs improve healthcare, patients' feelings that their stage of recovery from addiction was not taken into consideration, and clinicians' anecdotal negative experiences driving decisions on PICCs. Conclusions: When analyzed together, the experiences of PWID and clinicians shed light on ways the healthcare system can improve the quality of care for PWID hospitalized for infections. Further research is needed to develop a system of person-centered care for PWID that meets the specific needs of patients and improves the relationship between them and the healthcare system.

Racial and Ethnic Disparities in HIV Testing in People Who Use Drugs Admitted to a Tertiary Care Hospital.

Ending the HIV epidemic requires increased testing, diagnosis, and linkage to care. In the past 10 years, rates of HIV have increased among people with substance use disorder (SUD). HIV testing is recommended during hospitalization. Despite rising rates of infections and recommendations, HIV testing remains suboptimal. This study sought to detect differences in HIV testing by race and ethnicity in people who use drugs (PWUD) admitted to Tufts Medical Center (TuftsMC). This study is a retrospective review of hospitalized PWUD admitted from January 1, 2017 to December 31, 2020. PWUD were identified through toxicology results, medication prescribed for SUD, and nursing intake questions. The primary outcome of interest was whether an HIV test was ordered during hospitalization. The indicator of interest was race and ethnicity. Of 13,486 PWUD admitted to TuftsMC, only 10% had an HIV test ordered. Compared with White patients, Black patients [adjusted odds ratio (AOR): 0.69, 95% confidence interval (CI) (0.59-0.83)] and Hispanic patients [AOR: 0.68, 95% CI (0.55-0.84)] had decreased odds of receiving an HIV test. Our report is the first to show racial and ethnic differences in HIV testing ordering for hospitalized PWUD. Without access to harm reduction tools and expanded systems-based testing strategies, the HIV epidemic will continue and disproportionately impact minoritized communities.

Plant controls on Late Quaternary whole ecosystem structure and function.

Plants and animals influence biomass production and nutrient cycling in terrestrial ecosystems; however, their relative importance remains unclear. We assessed the extent to which mega-herbivore species controlled plant community composition and nutrient cycling, relative to other factors during and after the Late Quaternary extinction event in Britain and Ireland, when two-thirds of the region's mega-herbivore species went extinct. Warmer temperatures, plant-soil and plant-plant interactions, and reduced burning contributed to the expansion of woody plants and declining nitrogen availability in our five study ecosystems. Shrub biomass was consistently one of the strongest predictors of ecosystem change, equalling or exceeding the effects of other biotic and abiotic factors. In contrast, there was relatively little evidence for mega-herbivore control on plant community composition and nitrogen availability. The ability of plants to determine the fate of terrestrial ecosystems during periods of global environmental change may therefore be greater than previously thought.