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Expanding Medicaid plays a large role in ensuring that people across the United States have access to health care services. Although North Carolina recently moved toward Medicaid expansion, the impact of expansion on overdoses and overdose mortality may vary based on the type of treatment (offering medications for opioid use disorder [MOUD] vs. offering inpatient medically managed withdrawal without linkage to further MOUD treatment or non-MOUD-based treatment) accessed by individuals newly eligible for treatment through expansion. Based on official North Carolina statistics and published peer-reviewed literature, we developed a simulation model that forecasts opioid overdose and mortality under different scenarios for type of treatment accessed (MOUD-based vs. non-MOUD-based) and Medicaid coverage levels. An optimistic scenario assuming 70 % of individuals newly eligible for treatment would enter treatment during the first year of expansion estimated that 332 (Simulation Interval: 246-412) overdose deaths would be averted. A scenario more in line with recent historical trends assuming 38 % of individuals newly eligible for treatment would enter treatment resulted in 213 (Simulation Interval: 157-263) averted overdose deaths. In all scenarios, MOUD-based treatment approaches increased the number of lives saved compared with approaches expanding opioid treatment through non-MOUD-based treatment. Our study emphasized the need to ensure access to MOUD-based treatment for individuals newly covered by the Medicaid expansion.
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BACKGROUND: Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. METHODS: The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. RESULTS: Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. DISCUSSION: The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.
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Naloxona , Antagonistas de Narcóticos , Trastornos Relacionados con Opioides , Humanos , Naloxona/uso terapéutico , Estados Unidos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Antagonistas de Narcóticos/uso terapéutico , Masculino , Femenino , Sobredosis de Droga/prevención & control , Sobredosis de Droga/tratamiento farmacológico , Adulto , Encuestas y Cuestionarios , Persona de Mediana Edad , Accesibilidad a los Servicios de Salud , Educación en Salud/métodosRESUMEN
BACKGROUND: Evidence-based practices for reducing opioid-related overdose deaths include overdose education and naloxone distribution, the use of medications for the treatment of opioid use disorder, and prescription opioid safety. Data are needed on the effectiveness of a community-engaged intervention to reduce opioid-related overdose deaths through enhanced uptake of these practices. METHODS: In this community-level, cluster-randomized trial, we randomly assigned 67 communities in Kentucky, Massachusetts, New York, and Ohio to receive the intervention (34 communities) or a wait-list control (33 communities), stratified according to state. The trial was conducted within the context of both the coronavirus disease 2019 (Covid-19) pandemic and a national surge in the number of fentanyl-related overdose deaths. The trial groups were balanced within states according to urban or rural classification, previous overdose rate, and community population. The primary outcome was the number of opioid-related overdose deaths among community adults. RESULTS: During the comparison period from July 2021 through June 2022, the population-averaged rates of opioid-related overdose deaths were similar in the intervention group and the control group (47.2 deaths per 100,000 population vs. 51.7 per 100,000 population), for an adjusted rate ratio of 0.91 (95% confidence interval, 0.76 to 1.09; P = 0.30). The effect of the intervention on the rate of opioid-related overdose deaths did not differ appreciably according to state, urban or rural category, age, sex, or race or ethnic group. Intervention communities implemented 615 evidence-based practice strategies from the 806 strategies selected by communities (254 involving overdose education and naloxone distribution, 256 involving the use of medications for opioid use disorder, and 105 involving prescription opioid safety). Of these evidence-based practice strategies, only 235 (38%) had been initiated by the start of the comparison year. CONCLUSIONS: In this 12-month multimodal intervention trial involving community coalitions in the deployment of evidence-based practices to reduce opioid overdose deaths, death rates were similar in the intervention group and the control group in the context of the Covid-19 pandemic and the fentanyl-related overdose epidemic. (Funded by the National Institutes of Health; HCS ClinicalTrials.gov number, NCT04111939.).
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BACKGROUND: Recent policies have lessened restrictions around prescribing buprenorphine-naloxone (buprenorphine) for the treatment of opioid use disorder (OUD). The primary concern expressed by critics of these policies is the potential for buprenorphine diversion. However, the population-level effects of increased buprenorphine diversion are unclear. If replacing the use of heroin or fentanyl, use of diverted buprenorphine could be protective. METHODS: Our study aim was to estimate the impact of buprenorphine diversion on opioid overdose using an agent-based model calibrated to North Carolina. We simulated the progression of opioid misuse and opioid-related outcomes over a 5-year period. Our status quo scenario assumed that 50% of those prescribed buprenorphine diverted at least one dose per week to other individuals with OUD and 10% of individuals with OUD used diverted buprenorphine at least once per week. A controlled prescription only scenario assumed that no buprenorphine would be diverted, while an increased diversion scenario assumed that 95% of those prescribed buprenorphine diverted and 50% of individuals with OUD used diverted buprenorphine. We assumed that use of diverted buprenorphine replaced the use of other opioids for that day. Sensitivity analyses increased the risk of overdose when using diverted buprenorphine, increased the frequency of diverted buprenorphine use, and simulated use of diverted buprenorphine by opioid-naïve individuals. Scenarios were compared on opioid overdose-related outcomes over the 5-year period. RESULTS: Our status quo scenario predicted 10,658 (credible interval [CI]: 9699-11,679) fatal opioid overdoses. A scenario simulating controlled prescription only of buprenorphine (i.e., no diversion) resulted in 10,741 (9895-11,650) fatal opioid overdoses versus 10,301 (9439-11,244) within a scenario simulating increased diversion. Compared to the status quo, the controlled prescription only scenario resulted in a similar number of fatal overdoses, while the scenario with increased diversion of buprenorphine resulted in 357 (3.35%) fewer fatal overdoses. Even when increasing overdose risk while using diverted buprenorphine and incorporating use by opioid naïve individuals, increased diversion did not increase overdoses compared to a scenario with no buprenorphine diversion. CONCLUSIONS: A similar number of opioid overdoses occurred under modeling conditions with increased rates of buprenorphine diversion among persons with OUD, with non-statistical trends toward lower opioid overdoses. These results support existing calls for low- to no-barrier access to buprenorphine for persons with OUD.
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Buprenorfina , Sobredosis de Droga , Sobredosis de Opiáceos , Trastornos Relacionados con Opioides , Humanos , Buprenorfina/uso terapéutico , Analgésicos Opioides/uso terapéutico , Sobredosis de Opiáceos/tratamiento farmacológico , Reducción del Daño , Trastornos Relacionados con Opioides/tratamiento farmacológico , Sobredosis de Droga/prevención & control , Sobredosis de Droga/tratamiento farmacológico , Tratamiento de Sustitución de Opiáceos/métodosRESUMEN
Importance: Although opioid misuse has been decreasing among US youths and adolescents in recent years, it is unclear what has contributed to this trend and how this trend differs by age group and sex over time. Objective: To identify trends in opioid misuse among youths and young adults across and between ages, birth cohorts, and sexes. Design, Setting, and Participants: Cross-sectional National Survey on Drug Use and Health (NSDUH) public-use files were used to produce nationally representative pseudocohorts. The survey population includes the civilian US population in the 50 states and Washington, DC. Individuals without a fixed address and institutionalized individuals were excluded. Respondents to the NSDUH are a population-based sample selected using a stratified cluster design. For the years (January 1, 2002, to December 31, 2019) and ages (12-21 years) analyzed, the sample sizes ranged from 1607 to 3239 respondents. Data were analyzed from January 1, 2022, to April 12, 2023, for the main outcome by age, sex, and pseudocohort. Main Outcomes and Measures: Respondents were asked whether they misused prescription opioids or used heroin in the past year. The analysis hypotheses were formulated and tested after data collection. Results: In a total of 5 pseudocohorts, data from 114â¯412 respondents aged 12 to 21 years were analyzed; the unweighted distribution of male sex (complement was female) ranged from 47.7% to 52.6% (mean [SD], 50.6% [1.1%]). Response rates ranged from 45.8% to 71.3%. High school-aged youths and young adults had distinctly lower rates of opioid misuse in later pseudocohorts compared with earlier ones. Rates of misuse among individuals aged 16 years were 2.80% (95% CI, 1.06%-4.54%) higher in 2002 vs 2008; among those aged 18 years, rates were 4.36% (95% CI, 1.85%-6.87%) higher in 2002. Similarly, rates of misuse among individuals aged 16 years were 3.93% (95% CI, 2.15%-5.71%) higher in 2008 vs 2014; among those aged 17 years, rates were 3.41% (95% CI, 1.94%-4.88%) higher in 2008. Similar patterns were observed by sex. In earlier cohorts, younger female participants had higher rates of opioid misuse than their male counterparts and older male participants had higher rates than their female counterparts. Sex differences decreased in later cohorts. Conclusions and Results: The findings of this cross-sectional study of US youths and young adults suggest that high school-aged individuals consistently misused fewer opioids in later pseudocohorts overall and by sex. Sex differences in opioid rates also diminished in later pseudocohorts. A decrease in drug availability and general exposure to the harms of opioid use could be contributing to these findings. Future planned research using this pseudocohort approach will examine polysubstance use and evaluate how substance use differs by other sociodemographic characteristics.
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Trastornos Relacionados con Opioides , Mal Uso de Medicamentos de Venta con Receta , Adulto Joven , Adolescente , Humanos , Masculino , Femenino , Niño , Analgésicos Opioides/uso terapéutico , Estudios Transversales , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/tratamiento farmacológico , HeroínaRESUMEN
We used an individual-based microsimulation model of North Carolina to determine what facility-level policies would result in the greatest reduction in the number of individuals with SARS-CoV-2 entering the nursing home environment from 12/15/2021 to 1/3/2022 (e.g., Omicron variant surge). On average, there were 14,287 (Credible Interval [CI]: 13,477-15,147) daily visitors and 17,168 (CI: 16,571-17,768) HCW coming from the community into 426 nursing home facilities. Policies requiring a negative rapid test or vaccinated status for visitors resulted in the greatest reduction in the number of individuals with SARS-CoV-2 infection entering the nursing home environment with a 29.6% (26.9%-32.0%) and 24.0% (CI: 22.2%-25.5%) reduction, respectively. Policies halving visits (21.2% [20.0%-28.2%]), requiring all vaccinated HCW to receive a booster (7.8% [CI: 7.4%-8.7%]), and limiting visitation to a primary visitor (6.5% [CI: 3.5%-9.7%]) reduced infectious contacts to a lesser degree.
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COVID-19 , Humanos , COVID-19/epidemiología , COVID-19/prevención & control , SARS-CoV-2 , Casas de Salud , PolíticasRESUMEN
OBJECTIVE: Current guidance states that asymptomatic screening for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) prior to admission to an acute-care setting is at the facility's discretion. This study's objective was to estimate the number of undetected cases of SARS-CoV-2 admitted as inpatients under 4 testing approaches and varying assumptions. DESIGN AND SETTING: Individual-based microsimulation of 104 North Carolina acute-care hospitals. PATIENTS: All simulated inpatient admissions to acute-care hospitals from December 15, 2021, to January 13, 2022 [ie, during the SARS-COV-2 ο (omicron) variant surge]. INTERVENTIONS: We simulated (1) only testing symptomatic patients, (2) 1-stage antigen testing with no confirmatory polymerase chain reaction (PCR) test, (3) 1-stage antigen testing with a confirmatory PCR for negative results, and (4) serial antigen screening (ie, repeat antigen test 2 days after a negative result). RESULTS: Over 1 month, there were 77,980 admissions: 13.7% for COVID-19, 4.3% with but not for COVID-19, and 82.0% for non-COVID-19 indications without current infection. Without asymptomatic screening, 1,089 (credible interval [CI], 946-1,253) total SARS-CoV-2 infections (7.72%) went undetected. With 1-stage antigen screening, 734 (CI, 638-845) asymptomatic infections (67.4%) were detected, with 1,277 false positives. With combined antigen and PCR screening, 1,007 (CI, 875-1,159) asymptomatic infections (92.5%) were detected, with 5,578 false positives. A serial antigen testing policy detected 973 (CI, 845-1,120) asymptomatic infections (89.4%), with 2,529 false positives. CONCLUSIONS: Serial antigen testing identified >85% of asymptomatic infections and resulted in fewer false positives with less cost per identified infection compared to combined antigen plus PCR testing.
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COVID-19 , Humanos , COVID-19/diagnóstico , COVID-19/epidemiología , SARS-CoV-2 , Infecciones Asintomáticas/epidemiología , Prueba de COVID-19 , HospitalesRESUMEN
AIM: To estimate the number of treatment initiations, averted fatal opioid overdoses and the cost-effectiveness associated with offering buprenorphine-naloxone (buprenorphine) treatment on-site within existing syringe service programs (SSPs) in Massachusetts, USA. DESIGN, SETTING AND PARTICIPANTS: This was a cohort-based mathematical model and cost-effectiveness analysis. We derived model inputs from state and national surveillance data, clinical trials and observational cohort studies. We compared an intervention scenario where 30% of SSP clients initiated buprenorphine treatment on-site at least once annually to a status quo scenario where no buprenorphine was available on-site among community treatment providers in Massachusetts, 2020-30. In individuals with opioid use disorder (OUD) we assumed that 80% of SSP clients had recently injected drugs and that treatment within SSPs would have similar or improved retention compared with standard-of-care buprenorphine programs, but higher rates of active opioid use while in treatment. MEASUREMENTS: Number of treatment initiations (i.e. individuals began treatment on a medication for opioid use disorder or entered medically managed withdrawal), averted fatal opioid overdoses, quality-adjusted life-years (QALYs) and life-time discounted costs from a health sector and a limited societal perspective. FINDINGS: The status quo scenario resulted in 23 051 fatal overdoses and 1 511 613 treatment initiations over a 10-year simulation period. An intervention scenario with on-site SSP buprenorphine treatment averted 4797 (-20.8%) fatal opioid overdoses and resulted in 129 359 (+8.6%) additional treatment initiations compared with the status quo. The intervention scenario was the dominating scenario: providing OUD treatment through Massachusetts SSPs cost less (-$3612 per person) with patients accumulating more QALYs (0.2 per person) compared with the status quo scenario. CONCLUSIONS: Offering buprenorphine treatment on-site within syringe service programs has the potential to decrease fatal overdoses substantially, improve treatment engagement and save on costs.
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Buprenorfina , Sobredosis de Droga , Sobredosis de Opiáceos , Trastornos Relacionados con Opioides , Analgésicos Opioides/uso terapéutico , Buprenorfina/uso terapéutico , Combinación Buprenorfina y Naloxona/uso terapéutico , Análisis Costo-Beneficio , Sobredosis de Droga/tratamiento farmacológico , Humanos , Antagonistas de Narcóticos , Tratamiento de Sustitución de Opiáceos/métodos , Trastornos Relacionados con Opioides/epidemiología , JeringasRESUMEN
IMPORTANCE: Emerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use-associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown. OBJECTIVE: To compare the added value of inpatient addiction care services and the cost-effectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE. DESIGN, SETTING, AND PARTICIPANTS: This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Cost-effectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty. INTERVENTIONS: The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy). MAIN OUTCOMES AND MEASURES: Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs). RESULTS: All modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416â¯570 per person, with 77.6% of hospitalized patients completing treatment. Life expectancy was extended by each alternative strategy. The partial oral antibiotic strategy yielded the highest treatment completion rate (80.3%) compared with the OPAT strategy (78.8%) and the usual care/addiction care strategy (77.6%). The OPAT strategy was the least expensive at $412â¯150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163â¯370 per LY. Increasing IDU-IE treatment uptake and decreasing treatment discontinuation made the partial oral antibiotic strategy more cost-effective compared with the OPAT strategy. When assuming that all patients with IDU-IE were eligible to receive partial oral antibiotic therapy, the strategy was cost-saving and resulted in 0.0247 additional discounted LYs. When treatment discontinuation was decreased from 3.30% to 2.65% per week, the partial oral antibiotic strategy was cost-effective compared with OPAT at the $100 000 per LY threshold. CONCLUSIONS AND RELEVANCE: In this decision analytical modeling study, incorporation of OPAT or partial oral antibiotic approaches along with addiction care services for the treatment of patients with IDU-IE was associated with increases in the number of people completing treatment, decreases in mortality, and savings in cost compared with the usual care strategy of providing inpatient IV antibiotic therapy alone.
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Antiinfecciosos , Endocarditis Bacteriana , Endocarditis , Adulto , Analgésicos Opioides/uso terapéutico , Antibacterianos/uso terapéutico , Antiinfecciosos/uso terapéutico , Análisis Costo-Beneficio , Endocarditis/tratamiento farmacológico , Endocarditis Bacteriana/tratamiento farmacológico , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: The syndemic of injection drug use and serious injection-related infections is leading to increasing mortality in the USA. Although outpatient treatment with medications for opioid use disorder reduces overdose risk and recurrent infections, hospitalisation remains common. We evaluated the clinical impact, costs, and cost-effectiveness of hospital-based strategies to address the US opioid epidemic. METHODS: We developed a microsimulation model to compare the cost-effectiveness of: standard hospital care-detoxification for opioids, no addiction consult service (status quo); expanded inpatient prescribing of medications for opioid use disorder, including bridge prescriptions (ie, medication until they can see an outpatient provider) when possible (medications for opioid use disorder with bridge); implementation of addiction consult services within the hospital (addiction consult services alone); and a combined medication for opioid use disorder with addiction consult services strategy (combined). We used clinical trials and observational cohorts to inform model inputs. Outcomes were life-years, discounted costs, incremental cost-effectiveness ratios, hospitalisations, and deaths. We did deterministic sensitivity analyses on key model inputs related to costs and sequelae of drug use and probabilistic sensitivity analysis to further address uncertainty. FINDINGS: Among people who inject opioids in the USA, we estimated that expanding medications for opioid use disorder with bridge prescriptions would reduce hospitalisations and overdose deaths by 3·2% and 3·6%, respectively, and the combination of expanded medications with opioid use disorder along with addiction consult sevices would reduce hospitalisations and overdoses by 5·2% and 6·6%, respectively, compared with the status quo. Mean lifetime costs ranged from US$731 400 (95% credible interval 447 911-859 189 for the medications for opioid use disorder strategy) to $741 200 (470 930-868 551 for the combined strategy) per person. Assuming a willingness-to-pay threshold of $100 000 per life-year gained, medications for opioid use disorder with bridge and combined strategies were cost-effective ($7600 and $14 300, respectively). A scenario that assumed ideal access to harm reduction services came to the same conclusions as the base case and our results were robust in deterministic and probabilistic sensitivity analyses. INTERPRETATION: The combined interventions of expanding hospital-based prescribing of medications for opioid use disorder and implementing addiction consult services could improve life expectancy, be cost-effective, and could be the basis for a comprehensive hospital-based strategy for addressing the opioid epidemic in the USA and countries with similar opioid epidemics. FUNDING: National Institute on Drug Abuse and National Institute of Allergy and Infectious Diseases.
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Sobredosis de Droga/prevención & control , Administración Hospitalaria/economía , Epidemia de Opioides/estadística & datos numéricos , Trastornos Relacionados con Opioides/terapia , Derivación y Consulta/economía , Análisis Costo-Beneficio , Servicios de Salud/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Modelos Económicos , Método de Montecarlo , Trastornos Relacionados con Opioides/mortalidad , Aceptación de la Atención de Salud/estadística & datos numéricos , Medicamentos bajo Prescripción/economíaRESUMEN
Longitudinal analyses of opioid use and overall disease severity among people with HIV (PWH) are lacking. We used joint-trajectory and Cox proportional hazard modeling to examine the relationship between self-reported opioid use and the Veterans Aging Cohort Study (VACS) Index 2.0, a validated measure of disease severity and mortality, among PWH engaged in care. Using data from 2002 and 2018, trajectory modeling classified 20% of 3658 PWH in low (i.e., lower risk of mortality), 40% in moderate, 28% in high, and 12% in extremely high VACS Index trajectories. Compared to those with moderate VACS Index trajectory, PWH with an extremely high trajectory were more likely to have high, then de-escalating opioid use (adjusted odds ratio [AOR], 95% confidence interval [CI] 5·17 [3·19-8·37]) versus stable, infrequent use. PWH who report high frequency opioid use have increased disease severity and mortality risk over time, even when frequency of opioid use de-escalates.
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Infecciones por VIH , Veteranos , Envejecimiento , Analgésicos Opioides , Estudios de Cohortes , Infecciones por VIH/tratamiento farmacológico , Humanos , AutoinformeRESUMEN
BACKGROUND: We examined the impact of expanded access to medications for opioid use disorder (MOUD) in a unified prison and jail system on post-release, opioid-related overdose mortality. METHODS: We developed a microsimulation model to simulate a population of 55,000 persons at risk of opioid-related overdose mortality in Rhode Island. The effect of an extended-release (XR) naltrexone only intervention and the effect of providing access to all three MOUD (i.e., methadone, buprenorphine, and XR-naltrexone) at release from incarceration on cumulative overdose death over eight years (2017-2024) were compared to the standard of care (i.e., limited access to MOUD). RESULTS: In the standard of care scenario, the model predicted 2385 opioid-related overdose deaths between 2017 and 2024. An XR-naltrexone intervention averted 103 deaths (4.3% reduction), and access to all three MOUD averted 139 deaths (5.8% reduction). Among those with prior year incarceration, an XR-naltrexone only intervention and access to all three MOUD reduced overdose deaths by 22.8% and 31.6%, respectively. CONCLUSIONS: Expanded access to MOUD in prison and jail settings can reduce overdose mortality in a general, at-risk population. However, the real-world impact of this approach will vary by levels of incarceration, treatment enrollment, and post-release retention.
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Buprenorfina , Trastornos Relacionados con Opioides , Humanos , Cárceles Locales , Trastornos Relacionados con Opioides/tratamiento farmacológico , Prisiones , Rhode IslandRESUMEN
OBJECTIVE: We aimed to determine the effectiveness of various preexposure prophylaxis (PrEP) prescription strategies for African-American women impacted by mass incarceration within an urban setting. DESIGN: An agent-based model was utilized to evaluate prevention strategies in an efficient, ethical manner. By defining agents, their characteristics and relationships, we assessed population-level effects of PrEP on HIV incidence. METHODS: We tested hypothetical PrEP prescription strategies within a simulation representing the African-American population of Philadelphia, Pennsylvania. Four strategies were evaluated: PrEP for women meeting CDC indicators regarding partner characteristics, PrEP for women with a recently incarcerated male partner, PrEP for women with a recently released male partner and couples-based PrEP at time of release. Interventions occurred alongside scale-up of HAART. We evaluated reductions in HIV transmissions, the number of persons on PrEP needed to avert one HIV transmission (NNT) and the resulting proportions of people on PrEP. RESULTS: Scenarios prescribing PrEP based on criminal justice system involvement reduced HIV transmissions. The NNT ranged from 147 (couples-based scenario) to 300 (recently released scenario). The percentage of the female population covered by PrEP at any one time ranged from 0.14% (couples-based) to 10.8% (CDC-based). CDC-guideline scenarios were consistently less efficient compared to the justice-involved interventions. CONCLUSION: Expanding PrEP for African-American women and their male partners affected by incarceration should be considered in national HIV prevention goals and correctional facilities leveraged as intervention sites. Partner characteristics in the current CDC indications may be more effective and efficient if guidelines considered criminal justice involvement.
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Fármacos Anti-VIH , Infecciones por VIH , Profilaxis Pre-Exposición , Negro o Afroamericano , Fármacos Anti-VIH/uso terapéutico , Terapia Antirretroviral Altamente Activa , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/prevención & control , Humanos , Incidencia , MasculinoRESUMEN
BACKGROUND: Medications for opioid use disorder (OUD) are the most effective treatment for OUD, but uptake of these life-saving medications has been extremely limited in US prisons and jail settings, and limited data are available to guide policy decisions. The objective of this study was to estimate the impact of screening and treatment with medications for OUD in US prisons and jails on post-release opioid-related mortality. METHODS: We used data from the National Center for Vital Statistics, the Bureau of Justice Statistics, and relevant literature to construct Monte Carlo simulations of a counterfactual scenario in which wide scale uptake of screening and treatment with medications for OUD occurred in US prisons and jails in 2016. RESULTS: Our model predicted that 1840 (95% Simulation Interval [SI]: -2757 - 4959) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated. The model also predicted that approximately 4400 (95% SI: 2675 - 5557) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated and were retained in treatment post-release. These estimates correspond to 668 (95% SI: -1008 - 1812) and 1609 (95% SI: 972 - 2037) lives saved per 10,000 persons incarcerated, respectively. CONCLUSIONS: Prison and jail-based programs that comprehensively screen and provide treatment with medications for OUD have the potential to produce substantial reductions in opioid-related overdose deaths in a high-risk population; however, retention on treatment post-release is a key driver of population level impact.
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Analgésicos Opioides/uso terapéutico , Instalaciones Correccionales/estadística & datos numéricos , Tablas de Vida , Tamizaje Masivo/mortalidad , Trastornos Relacionados con Opioides/mortalidad , Utilización de Procedimientos y Técnicas/estadística & datos numéricos , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Método de Montecarlo , Trastornos Relacionados con Opioides/diagnóstico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Factores de Riesgo , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Women living with HIV who use illicit drugs may be particularly vulnerable to HIV-1 RNA viral load (VL) rebound. METHODS: We used longitudinal data from 2006 to 2017 to evaluate the impact of sociodemographic, behavioral, social-structural, and clinical factors on the hazard of viral rebound for women enrolled in the ACCESS study, a prospective cohort with systematic VL monitoring. Women were included if they achieved VL suppression (<50 copies/mL) following antiretroviral therapy (ART) initiation and had more than one study interview. Sociodemographic as well as substance use, social-structural, addiction treatment, and HIV clinical factors were evaluated as predictors of viral rebound (VLâ¯>â¯1000 copies/mL). Cox regressions using a recurrent events framework, time-varying covariates, robust standard errors, and a frailty component were used. RESULTS: Of the 185 women included, 62 (34%) experienced at least one viral rebound event over an 11-year period, accumulating a total of 87 viral rebound events. In adjusted analysis, stimulant use more than doubled the hazard of viral rebound (adjusted hazard ratio [AHR]: 2.35, 95% confidence interval [CI]: 1.07-5.14) while the only factor protective against viral rebound was receipt of opioid agonist treatment (OAT) in the past six months (AHR: 0.46, 95% CI: 0.26-0.81). After adjusting for ART adherence in the past six months, the effect of OAT was attenuated (AHR: 0.57, 95% CI: 0.32-1.02). CONCLUSIONS: Efforts to improve access to and retention within OAT programs and decrease stimulant use may improve rates of viral suppression for HIV-positive women who use illicit drugs.
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Analgésicos Opioides/uso terapéutico , Terapia Antirretroviral Altamente Activa/psicología , Infecciones por VIH/psicología , Cumplimiento de la Medicación/psicología , Trastornos Relacionados con Sustancias/tratamiento farmacológico , Adulto , Estudios de Cohortes , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , VIH-1/genética , Humanos , Drogas Ilícitas/efectos adversos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sustancias Protectoras/uso terapéutico , Trastornos Relacionados con Sustancias/complicaciones , Carga Viral/efectos de los fármacosRESUMEN
PURPOSE: The purpose of the study was to estimate the effect of exposure to neighborhood poverty in adolescence on HIV/STI prevalence in early adulthood. METHODS: Longitudinal data from three waves of the National Longitudinal Study of Adolescent to Adult Health were analyzed. The primary exposure was living in a high- versus medium/low-poverty neighborhood during wave I. The outcome was having a sexually transmitted infection (STI) or receiving a HIV/STI diagnosis in the past 12 months at wave III. Covariates included sociodemographic, behavioral, and mental health-related factors. Inverse probability weighted marginal structural models were used to estimate neighborhood poverty-based differences in HIV/STI prevalence. RESULTS: The analytic sample comprised 8232 National Longitudinal Study of Adolescent to Adult Health participants. Of these, 16% and 84% resided in high- and medium/low-poverty neighborhoods, respectively. Eleven percent currently had an STI or HIV/STI diagnosis within the prior 12 months. Accounting for measured potential sources of confounding and selection bias, the HIV/STI prevalence difference (95% confidence limits) for those who grew up in high- versus medium/low-poverty neighborhoods was 0.015 (-0.015, 0.045). CONCLUSIONS: Strong evidence for neighborhood poverty-based differences in HIV/STI prevalence was not observed. Researchers should continue to investigate the effect of neighborhood-level socioeconomic position measures and, if warranted, identify etiologically relevant exposure periods.
Asunto(s)
Infecciones por VIH/epidemiología , Disparidades en el Estado de Salud , Pobreza/estadística & datos numéricos , Características de la Residencia , Determinantes Sociales de la Salud , Adolescente , Adulto , Femenino , Humanos , Estudios Longitudinales , Masculino , Áreas de Pobreza , Prevalencia , Factores Socioeconómicos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Incarceration and HIV disproportionately impact African American communities. The mass incarceration of African American men is hypothesized to increase HIV acquisition risk for African American women. Interventions optimizing HIV care engagement and minimizing sexual risk behaviors for men living with HIV post-incarceration may decrease HIV incidence. METHODS: Using an agent-based model, we simulated a sexual and injection drug using network representing the African American population of Philadelphia. We compared intervention strategies for men living with HIV post-incarceration by the number of averted HIV transmissions to women within the community. Three interventions were evaluated: a 90-90-90 scenario scaling up HIV testing, ART provision, and ART adherence; a behavioral intervention decreasing sexual risk behaviors; and a combination intervention involving both. RESULTS: The status quo scenario projected 2,836 HIV transmissions to women over twenty years. HIV transmissions to women decreased by 29% with the 90-90-90 intervention, 23% with the behavioral intervention, and 37% with both. The number of men living with HIV receiving the intervention needed in order to prevent a single HIV transmission ranged between 6 and 10. CONCLUSION: Interventions to improve care engagement and decrease sexual risk behaviors post-incarceration for men living with HIV have the potential to decrease HIV incidence within African American heterosexual networks.
Asunto(s)
Negro o Afroamericano , Control de Enfermedades Transmisibles/métodos , Infecciones por VIH/prevención & control , Infecciones por VIH/transmisión , Prisioneros , Algoritmos , Terapia Antirretroviral Altamente Activa , Simulación por Computador , Condones , Femenino , Infecciones por VIH/etnología , Humanos , Incidencia , Masculino , Modelos Teóricos , Philadelphia/epidemiología , Asunción de Riesgos , Procesos Estocásticos , Abuso de Sustancias por Vía Intravenosa/complicaciones , Análisis de Sistemas , Sexo InseguroRESUMEN
A previously published study reported the seemingly paradoxical finding that men who have sex with men status was strongly protective and recent sexual abstinence strongly deleterious in relation to mortality prognosis. We explain why these results are entirely logical and that the counterintuitive direction of the effects derives from the comparison group implied by the study design.
Asunto(s)
Cannabis , Infecciones por VIH , Minorías Sexuales y de Género , Homosexualidad Masculina , Humanos , Masculino , Pronóstico , Factores de RiesgoRESUMEN
BACKGROUND: The United States has the highest incarceration rate in the world. Incarceration can increase HIV risk behaviors for individuals involved with the criminal justice system and may be a driver of HIV acquisition within the community. METHODS: We used an agent-based model to simulate HIV transmission in a sexual-contact network representing heterosexual African American men and women in Philadelphia to identify factors influencing the impact of male mass incarceration on HIV acquisition in women. The model was calibrated using surveillance data and assumed incarceration increased the number of sexual contacts and decreased HIV care engagement for men post-release. Incarceration of a partner increased the number of sexual contacts for women. We compared a counterfactual scenario with no incarceration to scenarios varying key parameters to determine what factors drove HIV acquisition in women. RESULTS: Setting the duration of male high-risk sexual behavior to two years post-release increased the number of HIV transmissions to women by more than 20%. Decreasing post-release HIV care engagement and increasing HIV acquisition risk attributable to sexually transmitted infections (STIs) also increased the number of HIV transmissions to women. Changing the duration of risk behavior for women, the proportion of women engaging in higher risk behavior, and the relative risk of incarceration for HIV-infected men had minimal impact. CONCLUSION: The mass incarceration of African American men can increase HIV acquisition in African American women on a population-level through factors including post-release high-risk behaviors, disruption of HIV care engagement among formerly incarcerated men, and increased STI prevalence. These findings suggest that the most influential points of intervention may be programs seeking to reduce male risk behaviors and promote HIV care engagement post-release, as well as STI testing and treatment programs for recently incarcerated men, as well as women with incarcerated partners.
Asunto(s)
Negro o Afroamericano/psicología , Infecciones por VIH/etnología , Prisioneros/estadística & datos numéricos , Asunción de Riesgos , Conducta Sexual/etnología , Adulto , Negro o Afroamericano/estadística & datos numéricos , Femenino , Infecciones por VIH/terapia , Heterosexualidad/etnología , Heterosexualidad/psicología , Heterosexualidad/estadística & datos numéricos , Humanos , Masculino , Philadelphia/epidemiología , Prevalencia , Factores de Riesgo , Conducta Sexual/psicología , Parejas Sexuales , Enfermedades de Transmisión Sexual/etnología , Análisis de SistemasRESUMEN
In the original publication of the article, the given and family name of the third author was not correct. The name has been corrected with this erratum.