No Patient Left Behind: A Novel Paradigm to Fulfill Hepatitis C Virus Treatment for Rural Patients.

Background: This study evaluates a novel multidisciplinary program providing expanded access to hepatitis C virus (HCV) treatment for rural Appalachian patients in South Carolina. This program identified patients via an opt-out emergency department screening program, and it aimed to achieve HCV cure by using community paramedics (CPs) to link and monitor patients from treatment initiation through 12-week sustained virologic response (SVR). Methods: Patients aged ≥18 years who were HCV RNA positive were eligible for enrollment if they failed to appear for a scheduled HCV appointment or reported barriers to accessing office-based treatment. CPs provided home visits (initial and 4, 12, and 24 weeks) using a mobile Wi-Fi hotspot to support telemedicine appointments (compliant with the Health Insurance Portability and Accountability Act) and perform focused physical assessments, venipuncture, and coordinated home delivery of medications. Statistics described participant characteristics, prevalence of SVR, and patient satisfaction results at 12 weeks posttreatment. Results: Thirty-four patients were eligible for SVR laboratory tests by 31 August 2023; the majority were male (61.7%) and White (64.7%) with an average age of 56 years (SD, 11.7). Twenty-eight (82.4%) completed treatment and achieved 12-week SVR. Six (17.6%) were lost to follow-up. Two-thirds strongly agreed that they were satisfied with the overall care that they received, and half strongly agreed that their overall health had improved. Conclusions: This CP-augmented treatment program demonstrated success curing HCV for rural patients who lacked access to office-based treatment. Other health care systems may consider this novel delivery model to treat hard-to-reach individuals who are HCV positive.

Psychological Distress Mediates the Relationship Between HIV-Related Stigma and Prescription Opioid Misuse Among Chinese People Living with HIV.

Prescription opioid misuse (POM) among people living with HIV (PLWH) is a serious concern due to risks related to dependence and overdose, and PLWH may be at higher risk for POM due to psychosocial stressors including psychological distress. However, scant POM research has examined the role of HIV-related stigma (e.g., internalized stigma, enacted stigma) in POM among PLWH. Guided by minority stress theory, this study examined a hypothesized serial mediation among enacted stigma, internalized stigma, psychological distress, and POM within a sample of Chinese PLWH with pain symptoms enrolled in a wave (between November 2017 and February 2018) of a longitudinal cohort study in Guangxi (n = 116). Models were tested individually for six enacted stigma experiences, controlling for key demographic and health-related variables (e.g., CD4 + count). Results showed HIV-related workplace discrimination was the most common stigma experience (12%,) and 10.3% of PLWH reported POM. Indirect effect analyses showed that internalized stigma was indirectly associated with POM through psychological distress. Internalized stigma and psychological distress mediated the association between workplace discrimination and POM. Family discrimination, gossip, and healthcare discrimination were directly associated with POM. This study suggests that Chinese PLWH may engage in POM to cope with psychological distress that is rooted in HIV-related stigma and highlights the important context of workplace discrimination for PLWH. Implications for interventions to reduce POM among PLWH are discussed.

Overreporting of adherence to hepatitis C direct-acting antiviral therapy and sustained virologic response among people who inject drugs in the HERO study.

BACKGROUND: Self-reported adherence to direct-acting antivirals (DAAs) to treat hepatitis C virus (HCV) among persons who inject drugs (PWID) is often an overreport of objectively measured adherence. The association of such overreporting with sustained virologic response (SVR) is understudied. This study among PWID aimed to determine a threshold of overreporting adherence that optimally predicts lower SVR rates, and to explore correlates of the optimal overreporting threshold. METHODS: This study analyzed per-protocol data of participants with adherence data (N = 493) from the HERO (Hepatitis C Real Options) study. Self-reported and objective adherence to a 12-week DAA regimen were measured using visual analogue scales and electronic blister packs, respectively. The difference (Δ) between self-reported and objectively measured adherence was calculated. We used the Youden index based on receiver operating characteristic (ROC) curve analysis to identify an optimal threshold of overreporting for predicting lower SVR rates. Factors associated with the optimal threshold of overreporting were identified by comparing baseline characteristics between participants at/above versus those below the threshold. RESULTS: The self-reported, objective, and Δ adherence averages were 95.1% (SD = 8.9), 75.9% (SD = 16.3), and 19.2% (SD = 15.2), respectively. The ≥ 25% overreporting threshold was determined to be optimal. The SVR rate was lower for ≥ 25% vs. < 25% overreporting (86.7% vs. 95.8%, p <.001). The factors associated with ≥ 25% Δ adherence were unemployment; higher number of days and times/day of injecting drugs; higher proportion of positive urine drug screening for amphetamine, methamphetamine, and oxycodone, and negative urine screening for THC (tetrahydrocannabinol)/cannabis. CONCLUSIONS: Self-reported DAA adherence was significantly greater than objectively measured adherence among PWID by 19.2%. Having ≥ 25% overreported adherence was associated with optimal prediction of lower SVR rates. PWID with risk factors for high overreporting may need to be more intensively managed to promote actual adherence.

Optimal hepatitis C treatment adherence patterns and sustained virologic response among people who inject drugs: The HERO study.

BACKGROUND & AIMS: Direct-acting antivirals (DAAs) are highly effective for treating HCV infection even among people who inject drugs (PWID). Yet, little is known about patients' adherence patterns and their association with sustained virologic response (SVR) rates. We aimed to summarize various adherence patterns and determine their associations with SVR. METHODS: Electronic blister packs were used to measure daily adherence to once-a-day sofosbuvir/velpatasvir during the 12-week treatment period among active PWIDs. Blister pack data were available for 496 participants who initiated DAAs for whom SVR status was known. Adherence was summarized in multiple patterns, such as total adherent days, consecutive missed days, and early discontinuations. Thresholds for adherence patterns associated with >90% SVR rates were also determined. RESULTS: The overall SVR rate was 92.7%, with a median adherence rate of 75%. All adherence patterns indicating greater adherence were significantly associated with achieving SVR. Participant groups with ≥50% (>42/84) adherent days or <26 consecutive missed days achieved an SVR rate of >90%. Greater total adherent days during 9-12 weeks and no early discontinuation were significantly associated with higher SVR rates only in those with <50% adherence. Participants with first month discontinuation and ≥2 weeks of treatment interruption had low SVR rates, 25% and 85%, respectively. However, greater adherent days were significantly associated with SVR (adjusted odds ratio 1.10; 95% CI 1.04-1.16; p <0.001) even among participants with ≥14 consecutive missed days. CONCLUSIONS: High SVR rates can be achieved in the PWID population despite suboptimal adherence. Encouraging patients to take as much medication as possible, with <2 weeks consecutive missed days and without early discontinuation, was found to be important for achieving SVR. IMPACT AND IMPLICATIONS: People who inject drugs can be cured of HCV in >90% of cases, even with relatively low adherence to direct-acting antivirals, but early discontinuations and long treatment interruptions can significantly reduce the likelihood of achieving cure. Clinicians should encourage people who inject drugs who are living with HCV to adhere daily to direct-acting antivirals as consistently as possible, but if any days are interrupted, to continue and complete treatment. These results from the HERO study are important for patients living with HCV, clinicians, experts writing clinical guidelines, and payers. CLINICAL TRIAL NUMBER: NCT02824640.

Self-reported and measured adherence to hepatitis C direct-acting antiviral therapy and sustained virologic response among people who inject drugs: The HERO study.

BACKGROUND: Objective adherence measures, such as electronic blister pack (BP), for direct-acting antivirals (DAAs) for hepatitis C virus (HCV) treatment have high accuracy, but their use is limited in real practice settings. We examined the association of self-reported adherence using a visual analogue scale (VAS) with objective BP adherence and sustained virologic response (SVR) among people who inject drugs. METHODS: We conducted secondary analyses using a subset of participants (N = 493) from the per-protocol sample of the HERO study, a pragmatic randomized trial of HCV treatment interventions that used both VAS and BP to measure adherence to a 12-week sofosbuvir/velpatasvir DAA regimen. Multivariable mixed-effects regression models tested the association of self-report adherence level with longitudinal weekly objective adherence. Multivariable logistic regression tested the association of self-report adherence with SVR. RESULTS: The average VAS and BP adherences were 95.1 % (SD = 8.9 %) and 76.0 % (16.0 %), respectively, and the proportion of the participants achieving SVR was 92.9 %. The estimated adjusted mean objective adherence was significantly different (-16 %; 95 % CI: -22 %, -11 %, p < .001) between participants with 100 % and <80 % VAS adherence. The likelihood of SVR was significantly lower for those with <80 % VAS adherence [adjusted OR = 0.07; 95 % CI: 0.02, 0.24; p < .001] compared to those with 100 %. CONCLUSION: Self-reported adherence overestimated objective adherence. However, higher self-report adherence was significantly associated with higher objective adherence. Also, self-reported adherence ≥80 % was significantly associated with SVR. Thus, the self-report measure has utility as a monitoring tool for adherence during DAA treatment.

Implementation of a mobile health clinic framework for Hepatitis C virus screening and treatment: a descriptive study.

Background: Although treatment for Hepatitis C Virus (HCV) is effective, individuals face access barriers. The utility of mobile health clinics (MHC), effective mechanisms for providing healthcare to underserved populations, is understudied for HCV-related interventions. We aimed to describe implementation of, and factors associated with, screening and treatment via MHCs. Methods: Clemson Rural Health implemented a novel MHC program to reach and treat populations at-risk for HCV with a focus on care for uninsured individuals. We examined HCV screening and treatment initiation/completion indicators between May 2021 and January 2023. Findings: Among 607 individuals screened across 31 locations, 94 (15.5%) tested positive via antibody and viral load testing. Treatment initiation and completion rates were 49.6% and 86.0%, respectively. Among those screened, the majority were male (57.5%), White (61.3%; Black/Hispanic: 28.2%/7.7%), and without personal vehicle as primary transportation mode (54.4%). Injection drug use (IDU) was 27.2% and uninsured rate was 42.8%. Compared to HCV-negative, those infected included more individuals aged 30-44 (52.1% vs. 36.4%, p = 0.023), male (70.2% vs. 55.2%, p = 0.009), White (78.5% vs. 60.2%, p < 0.0001), without personal vehicle (58.5% vs. 43.5%, p = 0.028), IDU (83.7% vs. 21.0%, p < 0.0001), and uninsured (61.2% vs. 48.8%, p = 0.050). Uninsured rates were higher among those initiating compared to not initiating treatment (74.5% vs. 45.3%, p = 0.004). Interpretation: The MHC framework successfully reaching its target population: at-risk individuals with access barriers to healthcare. The high HCV screening and treatment initiation/completion rates demonstrate the utility of MHCs as effective and acceptable intervention settings among historically difficult-to-treat populations. Funding: Gilead Sciences, Inc., and SC Center for Rural and Primary Healthcare.

Effectiveness of Transitional Care Program among High-Risk Discharged Patients: A Quasi-Experimental Study on Saving Costs, Post-Discharge Readmissions and Emergency Department Visits.

Transitional care programs (TCPs), where hospital care team members repeatedly follow up with discharged patients, aim to reduce post-discharge hospital or emergency department (ED) utilization and healthcare costs. We examined the effectiveness of TCPs at reducing healthcare costs, hospital readmissions, and ED visits. Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) program adjudicated claims files and electronic health records from Greenville Memorial Hospital, Greenville, SC, were accessed. Data on post-discharge 30- and 90-day ED visits and readmissions, total costs, and episodes with costs over BPCI target prices were extracted from November 2017 to July 2020 and compared between the "TCP-Graduates" (N = 85) and "Did Not Graduate" (DNG) (N = 1310) groups. As compared to the DNG group, the TCP-Graduates group had significantly fewer 30-day (7.1% vs. 14.9%, p = 0.046) and 90-day (15.5% vs. 26.3%, p = 0.025) readmissions, episodes with total costs over target prices (25.9% vs. 36.6%, p = 0.031), and lower total cost/episode (USD 22,439 vs. USD 28,633, p = 0.018), but differences in 30-day (9.4% vs. 11.2%, p = 0.607) and 90-day (20.0% vs. 21.9%, p = 0.680) ED visits were not significant. TCP was associated with reduced post-discharge hospital readmissions, total care costs, and episodes exceeding target prices. Further studies with rigorous designs and individual-level data should test these findings.

Shame and stigma in association with the HCV cascade to cure among people who inject drugs.

BACKGROUND: Psycho-social experiences including shame and experienced and internalized stigma have been associated with substance use, HCV infection, and reluctance to disclose HCV status and pursue treatment. These psycho-social barriers have been examined independently for many chronic diseases, including HCV, but to our knowledge have not been quantitatively explored in a large multi-site US-based sample of people who inject drugs (PWID) in HCV treatment. METHODS: We examine baseline relationships with HCV-stigma and engagement across the HCV treatment cascade as well as baseline and longitudinal relationships between shame and engagement across the HCV treatment cascade including treatment initiation, adherence, completion, and sustained virologic response (SVR) among a multi-site sample of PWID with HCV, where N=755 were randomized to the pragmatic trial comparing HCV treatment outcomes in modified directly observed treatment (mDOT) or patient navigation, and N=623 initiated treatment. RESULTS: While cross-sectional assessments of shame and HCV-stigma were not associated with engagement across the HCV treatment cascade, those whose shame scores decreased compared to those who reported consistently high and increasing levels of shame were significantly more likely to complete HCV treatment (aOR=5.29; 95%CI: 1.56,18.00) and achieve SVR (aOR=6.32; 95%CI: 1.61, 24.87). CONCLUSION: Results underscore the relationships between lower levels of shame and health-related behavior and treatment outcomes among PWID and suggest SVR achievement may contribute to reductions in shame or that reductions in shame may contribute to continued treatment and thus SVR.

Preliminary Evidence of the Association between Time on Buprenorphine and Cognitive Performance among Individuals with Opioid Use Disorder Maintained on Buprenorphine: A Pilot Study.

People on buprenorphine maintenance treatment (BMT) commonly present cognitive deficits that have been associated with illicit drug use and dropout from buprenorphine treatment. This study has compared cognitive responses to the Stroop Task and the Continuous Performance Task (CPT) among individuals on BMT, with recent drug use, and healthy controls and explored the associations between cognitive responses and drug use, craving, and buprenorphine use among participants on BMT. The participants were 16 individuals on BMT and 23 healthy controls. All participants completed a 60 min laboratory session in which they completed the Stroop Task and the CPT, a saliva drug test, a brief clinical history that collected substance-use- and treatment-related information, and the Opioid Craving Scale. The results showed that the BMT participants presented more commission errors (MBMT participants = 2.49; Mhealthy controls = 1.38; p = 0.048) and longer reaction times (MBMT participants = 798.09; Mhealthy controls = 699.09; p = 0.047) in the Stroop Task than did the healthy controls. More days on buprenorphine were negatively associated with reaction time in the CPT (-0.52) and the number of commission errors (-0.53), simple reaction time (-0.54), and reaction time correct (-0.57) in the Stroop Task. Neither drug use nor craving was significantly associated with the results for the cognitive tasks. Relative to the control participants, the BMT individuals performed worse in terms of longer reaction times and more commission errors in the Stroop Task. Within the BMT participants, longer times on buprenorphine were associated with better cognitive results in terms of faster reaction times for both tasks and lower commission errors for the Stroop Task.

Substance use, psychiatric symptoms, personal mastery, and social support among COVID-19 long haulers: A compensatory model.

BACKGROUND: Substance use has become a critical health concern during the COVID-19 pandemic, and emerging attention has been paid to people with the persistent symptoms of COVID-19 (COVID-19 long haulers) due to their high vulnerability. However, scant research has investigated their substance use and relevant psychosocial factors. The current study was to (1) examine substance use behaviors (i.e., legal drug use, illicit drug use, and non-medical use of prescription drugs); and (2) assessed their associations with psychiatric symptoms (i.e., depression, anxiety, and post-traumatic stress disorder) and psychosocial factors (i.e., personal mastery and social support) among COVID-19 long haulers. METHODS: In January-March 2022, 460 COVID-19 long haulers (50% female), with an average age of 32, completed online surveys regarding their demographics, substance use, psychiatric symptoms, and psychosocial factors. RESULTS: In the past three months, the most commonly used or non-medically used substances were tobacco (82%) for legal drugs, cocaine (53%) for illicit drugs, and prescription opioids (67%) for prescription drugs. Structural equation modeling suggested that psychiatric symptoms were positively associated with substance use behaviors (ßs = 0.38 to .68, ps < 0.001), while psychosocial factors were negatively associated with substance use behaviors (ßs = -0.61 to -0.43, ps < 0.001). CONCLUSION: Substance use is common in COVID-19 long haulers and psychiatric symptoms are the risk factors. Personal mastery and social support appear to offer protection offsetting the psychiatric influences. Substance use prevention and mental health services for COVID-19 long haulers should attend to personal mastery and social support.

Inpatient Low-dose Transitions From Full Agonist Opioids Including Methadone Onto Long-acting Depot Buprenorphine: Case Series From a Multicenter Clinical Trial.

OBJECTIVES: Persons with opioid use disorder (OUD) suffer disproportionately from morbidity and mortality related to serious addiction-related infections requiring hospitalization. Long-acting buprenorphine (LAB) is an underused medication for OUD that may facilitate linkage to care and treatment retention when administered before hospital discharge. Transition onto buprenorphine in the inpatient setting is often complicated by pain, active infection management, potential surgical interventions, and risk of opioid withdrawal in transition from full agonists to a partial agonist. METHODS: The COMMIT Trial is a randomized controlled trial evaluating LAB administered by infectious disease physicians and hospitalists compared with treatment as usual for persons with OUD hospitalized with infections. We report a case series of participants on full agonist opioids including methadone who were transitioned to sublingual buprenorphine using low-dose ( microdosing ) strategies followed by LAB injection. RESULTS: Seven participants with current opioid use disorder and life-threatening infections, all with significant concurrent pain and many requiring surgical intervention, underwent low-dose transitions starting at buccal buprenorphine doses ranging from 225 µg to 300 µg 3 times a day on the first day. All were well tolerated with average time to LAB injection of 7.5 days (range, 5-10 days). CONCLUSIONS: Inpatient low-dose buprenorphine transition from full agonist opioids including methadone onto LAB is feasible even in those with complex hospitalizations for concurrent infections and/or surgery. This strategy facilitates dosing of LAB before hospital discharge when risk of opioid relapse and overdose are significant.

Injecting practices during and after hepatitis C treatment and associations with not achieving cure among persons who inject drugs.

BACKGROUND: Persons who inject drugs (PWID) are a key population for hepatitis C virus (HCV) treatment. Study aims were to describe injection practices of PWID during HCV treatment with direct-acting antivirals (DAAs) and assess whether injection practices were associated with not achieving a sustained virologic response (SVR). METHODS: Secondary analysis of the HERO Study (ClinicalTrials.gov, NCT02824640), a pragmatic randomized trial in 8 U.S. states to evaluate the effectiveness of HCV care models among active PWID seen in opioid treatment programs and community clinics. Frequency, sharing and reuse of injecting equipment were assessed at baseline, end-of-treatment (EOT) and quarterly visits up to 60 weeks post-treatment. Generalized Estimating Equations logistic regression models with linear spline were used to compare trends in injecting behaviors during vs. post-treatment. Multivariable logistic regression models explored associations between injecting behaviors during treatment and lack of SVR. RESULTS: Among 501 participants, 27% were female, 35% were non-white, mean age was 44 (SD 11.5) years and nearly half (49%) were unhoused. At baseline, 41% reported receptive sharing of injecting equipment, declining to 16% at EOT visit. Receptive sharing of cookers, rinses, or needles/syringes during treatment was associated with a nearly 5-fold increase in not achieving SVR (adjusted odds ratio (aOR)=4.83; 95% CI: 2.26, 10.28) as was reuse of one's own needles/syringes (aOR=2.37; 95% CI: 1.11, 4.92). CONCLUSIONS: PWID in the HERO study adopted safer injecting behaviors during DAA treatment; receptive sharing of injecting equipment and reuse of one's own equipment during treatment were associated with not achieving cure.

Association between Initial Opioid Prescription and Patient Pain with Continued Opioid Use among Opioid-Naïve Patients Undergoing Elective Surgery in a Large American Health System.

There is growing concern about the over-prescription of opioids and the risks of long-term use. This study examined the relationship between initial need (pre-operative, post-operative, and discharge pain) and dosage of opioids in the first prescription after surgery with continued opioid use through opioid refills over 12 months, while considering patient-level characteristics. A total of 9262 opioid-naïve patients underwent elective surgery, 7219 of whom were prescribed opioids following surgery. The results showed that 17% of patients received at least one opioid refill within one year post-surgery. Higher initial opioid doses, measured in morphine milligram equivalent (MME), were associated with a greater likelihood of continued use. Patients receiving a dose greater than 90 MME were 1.57 times more likely to receive a refill compared to those receiving less than 90 MME (95% confidence interval: 1.30-1.90, p < 0.001). Additionally, patients who experienced pain before or after surgery were more likely to receive opioid refills. Those experiencing moderate or severe pain were 1.66 times more likely to receive a refill (95% confidence interval: 1.45-1.91, p < 0.001). The findings highlight the need to consider surgery-related factors when prescribing opioids and the importance of developing strategies to balance the optimization of pain management with the risk of opioid-related harms.

Harm reduction and recovery services support (HRRSS) to mitigate the opioid overdose epidemic in a rural community.

BACKGROUND: Rural areas in the United States (US) are ravaged by the opioid overdose epidemic. Oconee County, an entirely rural county in northwest South Carolina, is likewise severely affected. Lack of harm reduction and recovery resources (e.g., social capital) that could mitigate the worst outcomes may be exacerbating the problem. We aimed to identify demographic and other factors associated with support for harm reduction and recovery services in the community. METHODS: The Oconee County Opioid Response Taskforce conducted a 46-item survey targeting a general population between May and June in 2022, which was mainly distributed through social media networks. The survey included demographic factors and assessed attitudes and beliefs toward individuals with opioid use disorder (OUD) and medications for OUD, and support for harm reduction and recovery services, such as syringe services programs and safe consumption sites. We developed a Harm Reduction and Recovery Support Score (HRRSS), a composite score of nine items ranging from 0 to 9 to measure level of support for placement of naloxone in public places and harm reduction and recovery service sites. Primary statistical analysis using general linear regression models tested significance of differences in HRRSS between groups defined by item responses adjusting for demographic factors. RESULTS: There were 338 survey responses: 67.5% were females, 52.1% were 55 years old or older, 87.3% were Whites, 83.1% were non-Hispanic, 53.0% were employed, and 53.8% had household income greater than US$50,000. The overall HRRSS was relatively low at a mean of 4.1 (SD = 2.3). Younger and employed respondents had significantly greater HRRSS. Among nine significant factors associated with HRRSS after adjusting for demographic factors, agreement that OUD is a disease had the greatest adjusted mean difference in HRSSS (adjusted diff = 1.22, 95% CI=(0.64, 1.80), p < 0.001), followed by effectiveness of medications for OUD (adjusted diff = 1.11, 95%CI=(0.50, 1.71), p < 0.001). CONCLUSIONS: Low HRRSS indicates low levels of acceptance of harm reduction potentially impacting both intangible and tangible social capital as it relates to mitigation of the opioid overdose epidemic. Increasing community awareness of the disease model of OUD and the effectiveness of medications for OUD, especially among older and unemployed populations, could be a step toward improving community uptake of the harm reduction and recovery service resources critical to individual recovery efforts.

Development and initial findings from the Peer Recovery Coach (PRC) checklist: a new tool to assess the nature of peer recovery coaching service delivery.

Background: Peer recovery coaching is recovery support service for Substance Use Disorder (SUD) that emphasizes shared lived experience and social support. Though a promising intervention for SUD, differences in the roles, responsibilities, and operationalization of peer recovery coaching across studies make objective implementation and evaluation of this service a challenge.Objective: This study sought to develop a tool to better guide and operationalize peer recovery coaching service delivery. This study describes the initial development, acceptability, feasibility, and validity of this tool: The PRC Checklist.Methods: The PRC Checklist was conceptualized and operationalized by drawing from social support theory and recovery capital research. The PRC Checklist was utilized by PRCs in a pilot randomized controlled trial to demonstrate feasibility and acceptability. To further validate the PRC Checklist, recovery coaches (N = 16; 56% female) were recruited to complete a survey about their responsibilities and their perspectives on the content and potential utility of the PRC Checklist.Results: The PRC checklist used in the pilot study delineates personalized from generalized support and tracks 25 specific activities across three domains of support (i.e. socioemotional, informational, and instrumental). PRCs in the pilot study were able to use the PRC Checklist in all in-person initial baseline encounters and 96.4% of follow-up encounters. Qualitative information collected during project meetings was generally positive but also identified potential limitations to its use. All PRCs surveyed reported that they agreed that the PRC Checklist was helpful, encompassed the services they provided, represented a good idea, provided meaningful information, and would be easy to use. All five of the most common activities PRCs engaged in were reflected in the PRC Checklist.Conclusion: Capturing both personal and generalized support provided by PRCs, this work suggests that the PRC Checklist captures key activities engaged in and is a helpful tool for use in healthcare settings.

Missed opportunities for diagnosis of HIV in the emergency department using non-risk-based testing strategy.

Objectives: The objective of this study was to identify the number of missed opportunities (MO) for human immunodeficiency virus (HIV) diagnoses within our emergency departments (EDs) and assess any significant associated patient characteristics. Following current Centers for Disease Control guidelines, an opt-out HIV screening program was implemented in 2 of 7 EDs within a large Southern healthcare system. This study sought to differentiate the risk of MO in opt-out compared to clinician-initiated, risk-based ED screening protocols. Methods: A retrospective analysis was conducted from August 2019 to March 2022 of adult patients (≥18 years old) screened for HIV, comparing the ED screening method and characterization of all MOs. MO was defined as any ED visit, before HIV seropositivity, that included sexually transmitted infection screening and/or treatment with no HIV screening. Two EDs implemented generalized opt-out screening for all adult patients (>18 years old); whereas, the remaining 5 sites relied on clinician-initiated screening. Patient characteristics associated with an MO were evaluated by χ2, t tests, and multivariable logistic regression. Results: In total, 19,423 patients were screened for HIV, 142 of who tested positive. Of the 142 HIV-positive individuals, 12 (8.5%) had 1 MO and 3 of 12 (25%) had 2. The proportion of patients with a MO was significantly higher at clinician-initiated EDs as compared opt-out EDs (41.7% vs 13.9%, P = 0.01). After adjusting for demographics, individuals seen at clinician-initiated EDs were more likely to have a MO compared opt-out EDs (adjusted odds ratio, 4.64; 95% confidence interval, 1.18-18.27; P = 0.02). Conclusion: This novel study highlights the success and overall high positivity (0.7%) of an ED-based opt-out screening program. Taken together, the implementation of generalized opt-out screening within a large Southern healthcare system can rapidly increase overall screening, uncover a surprisingly high positivity rate, and decrease MOs for HIV diagnosis.

Evaluation of Policies Limiting Opioid Exposure on Opioid Prescribing and Patient Pain in Opioid-Naive Patients Undergoing Elective Surgery in a Large American Health System.

OBJECTIVES: Overprescribing to opioid-naive surgical patients substantially contributes to opioid use disorders, which have become increasingly prevalent. Opioid stewardship programs (OSPs) within healthcare settings provide an avenue for introducing interventions to regulate prescribing. This study examined the association of OSP policies limiting exposure on changes in surgery-related opioid prescriptions and patient pain. METHODS: We evaluated policies implemented by an OSP in a large American healthcare system between 2016 and 2018: nonopioid medication during surgery, decrease of available opioid dosage vials in operating rooms, standardization of opioid in-patient practices through electronic health record alerts, and limit to postsurgery opioid supply. Generalized linear mixed effects models examined the association of interventions with outcome changes in 9262 opioid-naive patients undergoing elective surgery. Outcomes were discharge pain, morphine milligram equivalent in the first prescription postsurgery, and opioid prescription refills. RESULTS: Decreases in all prescription outcomes and discharge pain were observed following onset of OSP interventions ( P 's < 0.001). Among individual policies, standardization of in-patient prescribing practices was associated with the strongest decrease in prescribed morphine milligram equivalent. Importantly, there was no evidence of an increase in discharge pain related to any intervention. CONCLUSIONS: This study promotes the potential of OSP formation and policies to reduce opioid prescribing without compromising patient pain. The most effective policy, standardization of in-patient prescribing practices through alerts, suggests that reminding prescribers to re-evaluate the patient's need is effective in changing behavior. The findings offer considerations for OSP formation and policy implementation across health systems to improve quality and safety in opioid prescribing.

Patient-Reported Outcomes During and After Hepatitis C Virus Direct-Acting Antiviral Treatment Among People Who Inject Drugs.

OBJECTIVES: People who inject drugs (PWID) are at a high risk of hepatitis C virus (HCV) infection. HCV cure is associated with improved patient-reported outcomes (PROs), but there are little data among PWID. This study aimed to assess the change in PROs during and after HCV direct-acting antiviral (DAA) treatment. METHODS: This analysis used data from 2 clinical trials of DAA treatment in PWID. PROs assessed included health-related quality of life, social functioning, psychological distress, housing, and employment. Generalized estimating equations and group-based trajectory modeling were used to assess changes in PROs over time. RESULTS: No significant changes in the 3-level version of EQ-5D scores, EQ visual analogue scale scores, social functioning, psychological distress, and housing were observed over the 108-week study period. There was a significant increase in the proportion of participants employed (18% [95% confidence interval (CI) 12%-23%] at baseline to 28% [95% CI 19%-36%] at the end of the study). Participants were more likely to be employed at 24 weeks and 108 weeks after commencing treatment. Having stable housing increased the odds of being employed (odds ratio 1.70; 95% CI 1.00-2.90). The group-based trajectory modeling demonstrated that most outcomes remained stable during and after DAA treatment. CONCLUSIONS: Although no significant improvement was identified in health-related quality of life after HCV DAA treatment, there was a modest but significant increase in employment during study follow-up. The study findings support the need for multifaceted models of HCV care for PWID addressing a range of issues beyond HCV treatment to improve quality of life.

COVID-19 Testing Practices, Preventive Behaviors, and Factors Associated With Test Positivity: Population-Based Statewide Survey Study.

BACKGROUND: The COVID-19 pandemic has challenged public health efforts globally. Timely population-based surveillance is crucial to support public health programs and policies to limit the spread of COVID-19. The South Carolina (SC) Sampling and Testing Representative Outreach for Novel Coronavirus Guidance (SC STRONG) statewide initiative was established to estimate population-level prevalence and immunity and characterize the transmission dynamics of SARS-CoV-2 using community testing and online surveys. OBJECTIVE: This paper aimed to leverage the survey data collected as part of the initiative to understand risk perceptions, testing practices, and preventive behaviors and identify risk factors for COVID-19 test positivity in SC over time. METHODS: Probability proportionate to size cluster random sampling was used to select SC residents to participate in testing for COVID-19 infection and antibodies and to complete an online survey. This paper focuses on data from the online surveys completed between November 2020 and June 2021. Descriptive statistics were used to describe risk perceptions, attitudes and behaviors, and associated changes over time. Univariate and multivariate logistic regression models were used to identify factors associated with self-reported COVID-19 test positivity. RESULTS: Among the 7170 online survey respondents, 58.7% (4213/7170) self-reported ever testing for COVID-19. The most commonly cited barriers to testing were inconvenient dates, time, and location, as well as discomfort. Overall, 18.7% (790/7170) of respondents reported a history of COVID-19 test positivity. Multivariate logistic regression results indicated that individuals who were aged 50 years or older, self-identified as Black/African American, were obese, and were employed as frontline health care workers or nursing home staff were more likely to self-report COVID-19 test positivity. By contrast, there was a decreased likelihood of test positivity among respondents who were concerned about the burden of COVID-19 in their community and about being infected. CONCLUSIONS: Strategies to remove testing barriers should be implemented to improve access. Our findings provide insights on statewide testing patterns, adoption of prevention behaviors, and risk factors for infection and may inform public health strategies to curb transmission.