Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland.

BACKGROUND: Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs. METHODS: People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services. RESULTS: The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors). CONCLUSIONS: Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

Perceptions and Current Practices in Patient-Centered Care: A Qualitative Study of Ryan White HIV Providers in South Florida.

Background: Patient-centered care (PCC) improves HIV adherence and retention, though lack of consensus on its conceptualization and understanding how it is interpreted has hindered implementation. Methods: We recruited 20 HIV providers at Ryan White Programs in FL for in-depth interviews. Thematic analysis identified core consistencies pertaining to: 1) provider perceptions, 2) current practices promoting PCC. Results: Provider perceptions of PCC emerged under four domains: 1) holistic, 2) individualized care, 3) respect for comfort and security, and 4) patient engagement and partnership. PCC practices occurred at multiple levels: 1) individual psychosocial and logistical support, 2) interpersonal support within patient-provider relationships through respectful communication and active engagement, and 3) institutional practices including feedback mechanisms, service integration, patient convenience, and diverse staffing. Conclusions: Our findings highlight the central tenets of PCC as respectful, holistic, individualized, and engaging care. We offer an HIV-adapted framework of PCC as a multilevel construct to guide future intervention.

Patient-centered care perspectives among HIV care providersThis study explores HIV care provider perceptions of patient-centered care (PCC) by analyzing common themes that arose in interviews. We found that providers perceived PCC to be holistic, individualized care focused on respecting patient comfort and security and actively engaging them as partners in care. Providers discussed a variety of ways in which they practiced PCC at the individual service level through psychosocial and logistical support, through their interpersonal relationships with respectful communication and trust, and through more structured facility level policies and activities such as greater service integration and employing a diverse staff. PCC is rapidly becoming the new standard of care and this study hopes to offer insight into provider perceptions of PCC and examples of practice in the HIV care field.

Characterizing multimorbidity in ALIVE: Comparing single and ensemble clustering methods.

Multimorbidity, defined as having 2 or more chronic conditions, is a growing public health concern, but research in this area is complicated by the fact that multimorbidity is a highly heterogenous outcome. Individuals in a sample may have a differing number and varied combinations of conditions. Clustering methods, such as unsupervised machine learning algorithms, may allow us to tease out the unique multimorbidity phenotypes. However, many clustering methods exist and choosing which to use is challenging because we do not know the true underlying clusters. Here, we demonstrate the use of 3 individual algorithms (partition around medoids, hierarchical clustering, and probabilistic clustering) and a clustering ensemble approach (which pools different clustering approaches) to identify multimorbidity clusters in the AIDS Linked to the Intravenous Experience cohort study. We show how the clusters can be compared based on cluster quality, interpretability, and predictive ability. In practice, it is critical to compare the clustering results from multiple algorithms and to choose the approach that performs best in the domain(s) that aligns with plans to use the clusters in future analyses.

First-hand accounts of structural stigma toward people who use opioids on Reddit.

People who use opioids face multilevel stigma that negatively affects their health and well-being and drives opioid-related overdose. Little research has focused on lived experience of the structural levels of stigma toward opioid use. This study identified and qualitatively analyzed Reddit content about structural stigma toward opioid use. Iterative, human-in-the-loop natural language processing methods were used to identify relevant posts and comments from an opioid-related subforum. Ultimately, 273 posts and comments were qualitatively analyzed via directed content analysis guided by a prominent conceptualization of stigma. Redditors described how structures-including governmental programs and policies, the pharmaceutical industry, and healthcare systems-stigmatize people who use opioids. Structures were reported to stigmatize through labeling (i.e., particularly in medical settings), perpetuating negative stereotypes, separating people who use opioids into those who use opioids "legitimately" versus "illegitimately," and engendering status loss and discrimination (e.g., denial of healthcare, loss of employment). Redditors also posted robust formulations of structural stigma, mostly describing how it manifests in the criminalization of substance use, is often driven by profit motive, and leads to the pervasiveness of fentanyl in the drug supply and the current state of the overdose crisis. Some posts and comments highlighted interpersonal and structural resources (e.g., other people who use opioids, harm reduction programs, telemedicine) leveraged to navigate structural stigma and its effects. These findings reveal key ways by which structural stigma can pervade the lives of people who use opioids and show the value of social media data for investigating complex social processes. Particularly, this study's findings related to structural separation may help encourage efforts to promote solidarity among people who use opioids. Attending to first-hand accounts of structural stigma can help interventions aiming to reduce opioid-related stigma be more responsive to these stigmatizing structural forces and their felt effects.

"I want to stay here": Patient and staff perspectives on transitioning from a low-threshold buprenorphine program to clinic-based care.

BACKGROUND: The Project Connections At Re-Entry (PCARE) Van is a low-threshold buprenorphine program operating outside the Baltimore City Detention Center. Like other low-threshold programs, PCARE seeks to engage a vulnerable population in care, stabilize patients, then transition patients to longer-term care; however, <10% of patients transition to clinic-based buprenorphine treatment. Our goal was to better understand these low transition rates and center patient perspectives in discussion of broader low-threshold program design. METHODS: From December 2022 to June 2023, semi-structured interviews were conducted with 20 former and current PCARE patients and 6 staff members. We used deductive and inductive coding followed by thematic content analysis to identify themes around treatment experiences and care preferences. RESULTS: There were strong preferences among current and former patients for continuing buprenorphine treatment at the PCARE Van. Several themes emerged from the data that explained patient preferences, including both advantages to continuing care at the van (preference for continuity, feeling respected by the program's structure and philosophy) and disadvantages to transitioning to a clinic (perceived harms associated with rigid or punitive care models). Staff noted limited program capacity, and patients expressed that if needed, they would transition to a clinic for altruistic reasons. Staff expressed varied perspectives on low-threshold care, emphasizing both larger systems factors, as well as beliefs about individual patient responsibility. CONCLUSIONS: While many low-threshold care settings are designed as transitional bridge models, this research highlights patient preference for long-term care at low-threshold programs and supports efforts to adapt low-threshold models to be sustainable as longitudinal care.

Drug Use-Related Discrimination in Healthcare Settings and Subsequent Emergency Department Utilization in a Prospective Cohort Study of People With a History of Injection Drug Use.

BACKGROUND:  People with a history of injection drug use face discrimination in healthcare settings that may impede their use of routine care, leading to greater reliance on the emergency department (ED) for addressing health concerns. The relationship between discrimination in healthcare settings and subsequent ED utilization has not been established in this population. METHODS:  This analysis used longitudinal data collected between January 2014 and March 2020 from participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based observational cohort study of people with a history of injection drug use in Baltimore, Maryland. Logistic regressions with generalized estimating equations were used to estimate associations between drug use-related discrimination in healthcare settings and subsequent ED utilization for the sample overall and six subgroups based on race, sex, and HIV status. RESULTS:  1,342 participants contributed data from 7,289 semiannual study visits. Participants were predominately Black (82%), mostly male (66%), and 33% were living with HIV. Drug use-related discrimination in healthcare settings (reported at 6% of study visits) was positively associated with any subsequent ED use (OR = 1.40, 95% CI: 1.15-1.72). Positive associations persisted after adjusting for covariates, including past sixth-month ED use and drug use, among the overall sample (aOR = 1.28, 95% CI: 1.04-1.59) and among some subgroups. CONCLUSIONS:  Drug use-related discrimination in healthcare settings was associated with greater subsequent ED utilization in this sample. Further exploration of mechanisms driving this relationship may help improve care and optimize healthcare engagement for people with a history of injection drug use.

Forecasting the effect of HIV-targeted interventions on the age distribution of people living with HIV: a case study from Kenya.

OBJECTIVES: Expansion of ART and increases to life expectancy have led to aging among people living with HIV (PWH). DESIGN: Kenyan decisionmakers need accurate forecasts of the age distribution of PWH to inform future policies. METHODS: We developed a model of HIV in Kenya, calibrated to historical estimates of HIV epidemiology. We forecasted changes in population size and age distribution of new HIV infections and PWH under the status quo and under scale-up of HIV services. RESULTS: Without scale-up, new HIV infections were forecasted to fall from 34,000 [28,000-41,000] in 2025 to 29,000 [15,000-57,000] in 2040; the percent of new infections occurring among persons over 30 increased from 33% [20-50%] to 40% [24-62%]. The median age of PWH increased from 39 years [38-40] in 2025 to 43 years [39-46] in 2040, and the percent of PWH over age 50 increased from 26% [23-29%] to 34% [26-43%]. Under the full intervention scenario, new infections were forecasted to fall to 6,000 [3,000-12,000] in 2040. The percent of new infections occurring in people over age 30 increased to 52% [34-71%] in 2040, and there was an additional shift in the age structure of PWH (forecasted median age of 46 [43-48] and 40% [33-47%] over age 50). CONCLUSIONS: PWH in Kenya are forecasted to age over the next 15 years; improvements to the HIV care continuum are expected to contribute to the growing proportion of older PWH.

Longitudinal patterns of use of stimulants and opioids in the AIDS linked to the IntraVenous experience cohort, 2005-2019.

BACKGROUND: Overdoses involving opioids and stimulants are on the rise, yet few studies have examined longitudinal trends in use of both substances. We sought to describe use and co-use of opioids and stimulants, 2005-2019, in the AIDS Linked to the Intravenous Experience (ALIVE) cohort - a community-based cohort of people with a history of injection drug use living in or near Baltimore, MD. METHODS: We included 2083 ALIVE participants, who had at least two visits during the study period. Our outcome was based on self-reported use of opioids and stimulants in the prior 6 months. We estimated prevalence of 4 categories of use (neither stimulants nor opioids, only stimulants, only opioids, stimulants and opioids), using a non-parametric multi-state model, accounting for the competing event of death and weighting for informative loss to follow-up. All analyses were stratified by enrollment cohort, with the main analysis including participants who enrolled prior to 2015 and a sub-analysis including participants who enrolled 2015-2018. RESULTS: In the main analysis, prevalence of using stimulants and opioids decreased from 38 % in 2005 to 12 % 2013 but stabilized from 2014 onwards (13-19 %). The prevalence of using only stimulants (7-11 %) and only opioids (5-10 %) was stable across time. Participants who reported using both were more likely to report homelessness, depression, and other substance use (e.g., marijuana and heavy alcohol use) than participants in the other use categories. On average, 65 % of visits with use of both were followed by a subsequent visit with use of both; of participants transitioning out of using both, 13% transitioned to using neither. CONCLUSIONS: While use of stimulants and opioids declined in the cohort through 2013, a meaningful proportion of participants persistently used both. More research is needed to understand and develop strategies to mitigate harms associated with persistent use of both stimulants and opioids.

Reported xylazine exposure highly associated with overdose outcomes in a rapid community assessment among people who inject drugs in Baltimore.

BACKGROUND: Addressing xylazine harms are now a critical harm reduction priority, but relatively little epidemiological information exists to determine prevalence, magnitude, and correlates of xylazine use or related outcomes. METHODS: We conducted a rapid behavioral survey among people who inject drugs (n = 96) in Baltimore November-December 2022. Using a novel indicator of self-reported presumed xylazine effects, we examined prevalence and sociodemographic correlates of past year presumed xylazine effects and association with overdose and wound-related outcomes. Chi-square and descriptive statistics were used to examine bivariate associations overall and separately for those who reported xylazine by name and by reported fentanyl use frequency. RESULTS: Almost two-thirds (61.5%) reported experiencing xylazine effects. There were no differences by socio-demographics, but xylazine effects were more commonly reported among those who reported injecting alone (66% vs 38%%, p < 0.007) and daily fentanyl use (47% vs 24% p < 0.003). Those reporting xylazine exposure was three times as likely to report overdose (32% vs 11%, p < 0.03) and twice as likely to have used naloxone (78% vs 46%, p < 0.003). They also more commonly reported knowing someone who died of an overdose (92% vs 76%, p < 0.09) and to report an abscess requiring medical attention (36% vs 19%, p < 0.80). These associations were higher among respondents who specifically named xylazine and those who used fentanyl more frequently, but fentanyl frequency did not fully explain the heightened associations with xylazine effects. CONCLUSIONS: This study provides insight into the scope of xylazine exposure and associated health concerns among community-based PWID and suggests measures that may be instrumental for urgently needed research.

Understanding motivations and resilience-associated factors to promote timely linkage to HIV care: a qualitative study among people living with HIV in western Kenya.

Understanding motivations and resilience-associated factors that help people newly diagnosed with HIV link to care is critical in the context of universal test and treat. We analyzed 30 in-depth interviews (IDI) among adults aged 18 and older in western Kenya diagnosed with HIV during home-based counseling and testing and who had linked to HIV care. A directed content analysis was performed, categorizing IDI quotations into a table based on linkage stages for organization and then developing and applying codes from self-determination theory and the concept of resilience. Autonomous motivations, including internalized concerns for one's health and/or to provide care for family, were salient facilitators of accessing care. Controlled forms of motivation, such as fear or external pressure, were less salient. Social support was an important resilience-associated factor fostering linkage. HIV testing and counseling programs which incorporate motivational interviewing that emphasizes motivations related to one's health or family combined with a social support/navigator approach, may promote timely linkage to care.

Understanding healthcare engagement for people who inject drugs.

People who inject drugs (PWID) are at an increased risk of multimorbid mental health and chronic diseases, which are frequently underdiagnosed and under-treated due to systemic barriers and ongoing substance use. Healthcare engagement is essential to address these conditions and prevent excess morbidity and mortality. The goal of this study was to understand how PWID engage in care for their chronic health conditions and substance use treatment given the known historic and pervasive barriers. We conducted 24 semistructured qualitative interviews informed by the Behavioral Model for Vulnerable Populations between July-September 2019. Participants were sampled across a range of comorbidities, including co-occurring mental health disorders. Thematic analysis was conducted to explore experiences of healthcare engagement for multimorbid chronic diseases, mental health, and treatment for substance use disorder. Mean age for participants was 58 years; 63% reported male sex and 83% reported Black race. Interviews yielded themes regarding healthcare access and wraparound services, positive patient-provider relationships, service integration for substance use treatment and mental health, healthcare needs alignment, medication of opioid use disorder stigma, and acceptance of healthcare. Taken together, participants described how these themes enabled healthcare engagement. Engagement in care is crucial to support health and recovery. Clinical implications include the importance of strengthening patient-provider relationships, encouraging integration of medical and mental health services, and counseling on substance use treatment options in a non- stigmatizing manner. Additionally, policy to reimburse wrap-around support for substance use recovery can improve care engagement and outcomes related to chronic diseases, mental health, and substance use among PWID. No Patient or Public Contribution: While we acknowledge and thank ALIVE participants for their time for data collection and sharing their perspectives, no ALIVE participants, other people who use drugs, and service users were involved in data collection, analysis or interpretation of data, or in preparation of the manuscript.

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

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

Time-to-completion of COVID-19 vaccination primary series varies by HIV viral load status among people who inject drugs in Baltimore, Maryland.

People who inject drugs (PWID) may have diminished access to essential preventive services like COVID-19 vaccination given structural and substance use barriers. We aimed to assess the role of HIV on COVID-19 vaccination uptake among adult PWID participating in the ALIVE cohort study in Baltimore, Maryland who were alive as of April 2021. We abstracted COVID-19 vaccination data from electronic medical records via the regional health information exchange. We used Kaplan-Meier method to estimate time from universal vaccine eligibility (April 6, 2021) to completion of the COVID-19 vaccination primary series (1 dose J&J or 2 doses mRNA) by HIV viral load status (uninfected, PWH [HIV-RNA < 400 copies/mL], PWH [HIV-RNA ≥ 400 copies/mL]) and Cox Proportional Hazards regression to adjust for potential confounders. Our sample (N = 960) was primarily black (77%) and male (65%) with 31% reporting recent injection drug use. Among 265 (27%) people living with HIV (PWH) in our sample, 84% were virally suppressed. As of February 22, 2022, 539 (56%) completed the primary series, 131 (14%) received a single dose of mRNA vaccine and 290 (30%) remained unvaccinated. Compared to PWID without HIV, virally suppressed PWH were more likely to complete the primary series (Adjusted Hazard Ratio [aHR]:1.23,95% Confidence Interval [95 %CI]:1.07,1.50), while PWH who were not virally suppressed were less likely (aHR:0.72,95 %CI:0.45,1.16), although this was not statistically significant. We conclude that among PWID, HIV infection and viral suppression is associated with quicker vaccination uptake, likely due to HIV care engagement. Targeted improvements along the HIV care continuum may bolster vaccine uptake.

Trends in self-reported non-fatal overdose and patterns of substance use before and during the COVID-19 pandemic in a prospective cohort of adults who have injected drugs - Baltimore, Maryland, 2014-2022.

BACKGROUND: Overdose deaths increased during the COVID-19 pandemic in the United States. Less is known about drug use behavior changes during the same time period. We examined differences in non-fatal overdose and drug use behaviors before and after the start of the COVID-19 pandemic in a community-recruited cohort of adults who have injected drugs. METHODS: 721 participants attended 7401 visits between Jan 2014 and Mar 2022. Outcomes (non-fatal overdose, drug route of administration, type of drugs used) were assessed via self-report in the last six months. We compared pre-pandemic (Jan 2014-Mar 2020) to inter-pandemic (Dec 2020-Mar 2022) prevalence of each outcome using Cohcrane-Maentel-Haeszel odds ratios (CMH-OR). We then estimated probabilities for transitioning between specific behaviors from participants' last pre-pandemic visit to their first inter-pandemic visit. RESULTS: Comparing pre-pandemic visits to inter-pandemic visits, the prevalence of non-fatal overdose did not change (CMH-OR 1.06, 95% CI 0.75-1.50); the prevalence of injection (CMH-OR 0.13, 95% CI 0.1-0.17) and non-injection (CMH-OR 0.51, 95% CI 0.42-0.61) drug use declined. More than a third (35.7%) of persons using both injection and non-injection drugs pre-pandemic transitioned to exclusive non-injection use during the pandemic. By contrast, few (4.0%) persons using non-injection drugs exclusively pre-pandemic transitioned to injecting during the pandemic. CONCLUSION: Among adults who have injected drugs, the start of the COVID-19 pandemic was associated with a reduced drug use prevalence and transitions from injection to non-injection use. Average overdose prevalence was unchanged, but these behavior changes may have helped mitigate overdose harm.

Prevalence and correlates of SARS-CoV-2 seropositivity among people who inject drugs in Baltimore, Maryland.

Background: SARS-CoV-2 serosurveys can help characterize disparities in SARS-CoV-2 infection and identify gaps in population immunity. Data on SARS-CoV-2 seroprevalence among people who inject drugs (PWID) are limited. Methods: We conducted a cross-sectional study between December 2020 and July 2022 among 561 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study-a community-based cohort of current and former PWID in Baltimore, Maryland. Serum samples were assayed for infection-induced anti-nucleocapsid (anti-N) and infection and/or vaccination-induced anti-spike-1 (anti-S) SARS-CoV-2 IgG. We estimated adjusted prevalence ratios (aPR) via modified Poisson regression models. Results: The median age was 59 years, 35% were female, 84% were non-Hispanic Black, and 16% reported recent injection drug use. Anti-N antibody prevalence was 26% and anti-S antibody prevalence was 63%. Anti-N and anti-S antibody prevalence increased over time. Being employed (aPR=1.53 [95%CI=1.11-2.11]) was associated with higher anti-N prevalence, while a cancer history (aPR=0.40 [95%CI=0.17-0.90]) was associated with lower anti-N prevalence. HIV infection was associated with higher anti-S prevalence (aPR=1.13 [95%CI=1.02-1.27]), while younger age and experiencing homelessness (aPR=0.78 [95%CI=0.60-0.99]) were factors associated with lower anti-S prevalence. Substance use-related behaviors were not significantly associated with anti-N or anti-S prevalence. Conclusions: SARS-CoV-2 seroprevalence increased over time among current and former PWID, suggesting cumulative increases in the incidence of SARS-CoV-2 infection and vaccination; however, there were disparities in infection-induced seroprevalence and infection and/or vaccine-induced seroprevalence within this study sample. Dedicated prevention and vaccination programs are needed to prevent disparities in infection and gaps in population immunity among PWID during emerging epidemics.

Population-Based Estimates and Predictors of Child and Adolescent Linkage to HIV Care or Death in Western Kenya.

BACKGROUND: Population-level estimates of linkage to HIV care among children and adolescents (CAs) can facilitate progress toward 95-95-95 goals. SETTING: This study was conducted in Bunyala, Chulaimbo, and Teso North subcounties, Western Kenya. METHODS: Linkage to care was defined among CAs diagnosed with HIV through Academic Model Providing Access to Healthcare (AMPATH)'s home-based counseling and testing initiative (HBCT) by merging HBCT and AMPATH Medical Record System data. Using follow-up data from Bunyala, we examined factors associated with linkage or death, using weighted multinomial logistic regression to account for selection bias from double-sampled visits. Based on the estimated model, we imputed the trajectory for each person in 3 subcounties until a simulated linkage or death occurred or until the end of 8 years when an individual was simulated to be censored. RESULTS: Of 720 CAs in the analytic sample, 68% were between 0 and 9 years and 59% were female. Probability of linkage among CAs in the combined 3 subcounties was 48%-49% at 2 years and 64%-78% at 8 years while probability of death was 13% at 2 years and 19% at 8 years. Single or double orphanhood predicted linkage (adjusted odds ratio [aOR]: 2.66, 95% confidence interval [CI]: 1.33 to 5.32) and death (aOR: 9.85 [95% CI: 2.21 to 44.01]). Having a mother known to be HIV-positive also predicted linkage (aOR = 1.94, 95% CI: 0.97 to 3.86) and death (aOR: 14.49, 95% CI: 3.32 to 63.19). CONCLUSION: HIV testers/counselors should continue to ensure linkage among orphans and CAs with mothers known to be HIV-positive and also to support other CAs to link to HIV care.

Context and correlates of providing assistance with someone's first injection in the AIDS linked to the IntraVenous Experience cohort, Baltimore, MD.

BACKGROUND: The social processes around initiating injection may be well-suited to intervention, yet there is substantial heterogeneity in the reported experiences of people who inject drugs (PWID) who assist with another individual's first drug injection. We aimed to describe the lifetime prevalence and context of providing initiation assistance among a cohort of PWID. METHODS: Participants of the AIDS Linked to the IntraVenous Experience (ALIVE) cohort of PWID in Baltimore, Maryland (n=848) were surveyed during 2019-2020 about assisting with another person's first injection. Associations between factors related to injection risk and history of providing assistance were estimated using logistic regression models adjusted for sociodemographic and behavioral characteristics. RESULTS: At baseline, participants were primarily male (66.1%), black (82.9%), aged a median of 42 years, and had been injecting a median of 18 years. Overall, 19% (n=157) of participants reported ever providing assistance for a median of 2 people (Interquartile Range: 1-4). Having hepatitis C infection (adjusted Odds Ratio [95% Confidence Interval]: 2.5 [1.4-4.6]), syringe sharing (2.2 [1.2-3.9]), and injecting ≥3 times per day (2.0 [1.2-3.4]) at study enrollment were associated with a history of assistance. Participants primarily assisted friends (58.0%), acquaintances (29.9%), and partners (21.7%). Common reasons for assisting were the other person's lack of injection knowledge (73.7%) or sharing drugs (44.9%). Additional reasons included to prevent injury. CONCLUSION: PWID with a history of assisting with another person's first injection exhibited heightened vulnerability to infections and more frequent substance use. Expanding implementation of interventions with an emphasis on harm reduction is needed.

Trajectories of drug treatment and illicit opioid use in the AIDS Linked to the IntraVenous Experience cohort, 2014-2019.

BACKGROUND: Medication for opioid use disorder (MOUD) is an effective intervention to combat opioid use disorder and overdose, yet there is limited understanding of engagement in treatment over time in the community, contextualized by ongoing substance use. We aimed to identify concurrent trajectories of methadone prescriptions, buprenorphine prescriptions, and illicit opioid use among older adults with a history of injection drug use. METHODS: We used data on 887 participants from the AIDS Linked to the IntraVenous Experience cohort, who were engaged in the study in 2013 and attended ≥1 visit during follow-up (2014-2019). Outcomes were self-reported MOUD prescription and illicit opioid use in the last 6 months. To identify concurrent trajectories in all 3 outcomes, we used group-based multi-trajectory modeling. We examined participant characteristics, including sociodemographics, HIV status, and other substance use, overall and by cluster. RESULTS: We identified 4 trajectory clusters: (1) no MOUD and no illicit opioid use (43%); (2) buprenorphine and some illicit opioid use (11%); (3) methadone and no illicit opioid use (28%); and (4) some methadone and illicit opioid use (18%). While prevalence of each outcome was stable across time, transitions on/off treatment or on/off illicit opioid use occurred, with the rate of transition varying by cluster. The rate of transition was highest in Cluster 3 (0.74/person-year) and lowest in Cluster 1 (0.18/person-year). We saw differences in participant characteristics by cluster, including that the buprenorphine cluster had the highest proportion of people with HIV and participants who identified as non-Hispanic Black. CONCLUSIONS: Most participants had discontinued illicit opioid use and were also not accessing MOUD. Trajectories defined by engagement with buprenorphine or methadone had distinct sociodemographic and behavioral characteristics, indicating that tailored interventions to expand access to both types of treatment are likely needed to reduce harms associated with untreated opioid use disorder.

Geographic variation in HCV treatment penetration among people who inject drugs in Baltimore, MD.

We evaluated geographic heterogeneity in hepatitis C virus (HCV) treatment penetration among people who inject drug (PWID) across Baltimore, MD since the advent of direct-acting antivirals (DAAs) using space-time clusters of HCV viraemia. Using data from a community-based cohort of PWID, the AIDS Linked to the IntraVenous Experience (ALIVE) study, we identified space-time clusters with higher-than-expected rates of HCV viraemia between 2015 and 2019 using scan statistics. We used Poisson regression to identify covariates associated with HCV viraemia and used the regression-fitted values to detect adjusted space-time clusters of HCV viraemia in Baltimore city. Overall, in the cohort, HCV viraemia fell from 77% in 2015 to 64%, 49%, 39% and 36% from 2016 to 2019. In Baltimore city, the percentage of census tracts where prevalence of HCV viraemia was ≥85% dropped from 57% to 34%, 25%, 22% and 10% from 2015 to 2019. We identified two clusters of higher-than-expected HCV viraemia in the unadjusted analysis that lasted from 2015 to 2017 in East and West Baltimore and one adjusted cluster of HCV viraemia in West Baltimore from 2015 to 2016. Neither differences in age, sex, race, HIV status, nor neighbourhood deprivation were able to explain the significant space-time clusters. However, residing in a cluster with higher-than-expected viraemia was associated with age, sex, educational attainment and higher levels of neighbourhood deprivation. Nearly 4 years after DAAs became available, HCV treatment has penetrated all PWID communities across Baltimore city. While nearly all census tracts experienced improvements, change was more gradual in areas with higher levels of poverty.

Temporal association of pre-pandemic perceived social support with psychological resilience and mental well-being during the COVID-19 pandemic among people with a history of injection drug use.

BACKGROUND: There are limited data on whether modifiable social factors foster psychological resilience and mental well-being among people who use drugs following Big Events. We examined the temporal association of pre-pandemic perceived social support with psychological resilience and negative mental health symptoms during the COVID-19 pandemic among people with a history of injection drug use. METHODS: Between June and September 2020, we conducted a telephone survey among 545 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study: a community-based cohort of adults with a history of injection drug use. Leveraging data from study visits in 2018-early 2020, associations of pre-pandemic perceived social support with psychological resilience scores (range=1-5) and the probability of negative mental health symptoms during the pandemic were assessed using multivariable linear and modified Poisson regression models, respectively. RESULTS: Participants' median age was 58 years, 38.2% were female, 83.3% identified as Black, and 30.3% were living with HIV. During the pandemic, 14.5% had low (<3) resilience scores, 36.1% experienced anxiety, and 35.8% reported increased loneliness. Compared to participants in the lowest tertile of pre-pandemic social support, participants in the highest tertile had higher mean resilience scores (ß = 0.27 [95% CI = 0.12, 0.43]), a lower probability of anxiety (prevalence ratio [PR] = 0.71 [95% CI = 0.52, 0.96]), and a lower probability of increased loneliness (PR = 0.62 [95% CI = 0.45, 0.84]). CONCLUSIONS: Pre-pandemic perceived social support was associated with greater psychological resilience and generally better mental well-being during the pandemic. Interventions that improve social support may foster psychological resilience and protect the mental well-being of people who use drugs, especially during periods of social disruption.