National HIV and HCV Screening Rates for Hospitalized People who Use Drugs Are Suboptimal and Heterogeneous Across 11 US Hospitals.

Background: To end the HIV and hepatitis C virus (HCV) epidemics, people who use drugs (PWUD) need more opportunities for testing. While inpatient hospitalizations are an essential opportunity to test people who use drugs (PWUD) for HIV and HCV, there is limited research on rates of inpatient testing for HIV and HCV among PWUD. Methods: Eleven hospital sites were included in the study. Each site created a cohort of inpatient encounters associated with injection drug use. From these cohorts, we collected data on HCV and HIV testing rates and HIV testing consent policies from 65 276 PWUD hospitalizations. Results: Hospitals had average screening rates of 40% for HIV and 32% for HCV, with widespread heterogeneity in screening rates across facilities. State consent laws and opt-out testing policies were not associated with statistically significant differences in HIV screening rates. On average, hospitals that reflexed HCV viral load testing on HCV antibody testing did not have statistically significant differences in HCV viral load testing rates. We found suboptimal testing rates during inpatient encounters for PWUD. As treatment (HIV) and cure (HCV) are necessary to end these epidemics, we need to prioritize understanding and overcoming barriers to testing.

Everything but the Kitchen Sink: An Analysis of Bacterial and Chemical Contaminants Found in Syringe Residue From People Who Inject Drugs.

Background: People who inject drugs (PWID) are at high risk of severe wounds, invasive infections, and overdoses. To date, there are few data on the bacterial and chemical contaminants PWID are exposed to when using illicitly manufactured fentanyls and stimulants. Methods: Previously used injection drug use equipment was recovered in St Louis, Missouri, by harm reduction organizations over a 12-month period. Syringe residue was analyzed for bacterial contaminants by routine culturing followed by whole genome sequencing of single bacterial isolates. Chemical adulterants in syringe residue were identified by liquid chromatography-mass spectrometry. Results: Bacteria were cultured from 58.75% of 160 syringes analyzed. Polymicrobial growth was common and was observed in 23.75% of samples. Bacillus cereus was the most common pathogen present and was observed in 20.6% of syringe residues, followed closely by Staphylococcus aureus at 18.8%. One hundred syringes underwent mass spectrometry, which demonstrated that chemical adulterants were common and included caffeine, diphenhydramine, lidocaine, quinine, and xylazine. Conclusions: Analysis of syringe residue from discarded drug use equipment demonstrates both chemical and biological contaminants, including medically important pathogens and adulterants.

Drug preparation, injection-related infections, and harm reduction practices among a national sample of individuals entering treatment for opioid use disorder.

BACKGROUND: The rise in injection drug use in the USA has led to an increase in injection site infections. We performed a national survey of people who use drugs to evaluate common drug use preparation, harm reduction practices, and experiences with injection site infections. METHODS: A survey was disseminated to members of the Survey of Key Informants' Patients Program from 2021 to 2022 and distributed to patients 18 years or older newly entering one of 68 substance use disorder treatment programs across the USA with a primary diagnosis of an opioid use disorder. Participants were surveyed about practices when preparing and using drugs, along with self-reported infections and drug use complications. RESULTS: 1289 participants responded to the survey. Sexually transmitted infections were common, with 37.6% reporting ever having had any sexually transmitted infection. Injection-associated infections had affected 63.4% of participants who had ever used injection drugs. Many respondents reported not seeking professional medical assistance for infection management, including 29% draining abscesses without seeking medical care and 22.8% obtaining antibiotics through non-healthcare sources. Non-sterile injection practices included sharing needles with others who were febrile or ill (18%), using needles previously used to drain wounds/abscesses (9.9%) for subsequent injection drug use, and licking needles (21.2%). CONCLUSION: Patients entering treatment for opioid use disorder reported a high burden of infectious diseases. A number of easily-modifiable high risk behaviors for developing injection-related infections were identified. Efforts are needed to disseminate targeted harm reduction education to PWID on how to reduce their risks for injection-related infections.

Hepatitis C and obstetrical morbidity in a substance use disorder clinic: a role for telemedicine?

BACKGROUND: Hepatitis C infection often co-occurs with substance use disorders in pregnancy. Accessing hepatitis C treatment is challenging because of loss to follow-up in the postpartum period, attributable to social and financial barriers to care. Telemedicine has been explored as a means of increasing routine postpartum care, but the potential impact on retention in and completion of care for postpartum hepatitis C has not been assessed. OBJECTIVE: This study aimed to evaluate the impact of hepatitis C on obstetrical morbidity in a substance use disorder-specific prenatal clinic, and the effect of Infectious Disease telemedicine consultation on subsequent treatment delivery. STUDY DESIGN: We performed a retrospective cohort study of all patients in our substance use disorder prenatal clinic from June 2018 to February 2023. Telemedicine consults for hepatitis C diagnoses began in March 2020 and included electronic chart review by Infectious Disease when patients were unable to be seen. Our primary outcome was composite obstetrical morbidity (preterm birth, preeclampsia, fetal growth restriction, fetal anomaly, abruption, postpartum hemorrhage, or chorioamnionitis) compared between patients with and without active hepatitis C. We additionally evaluated rates of completed referral and initiation of hepatitis C treatment before and after implementation of telemedicine consult. RESULTS: A total of 224 patients were included. Of the 222 patients who underwent screening, 71 (32%) were positive for active hepatitis C. Compared with patients without hepatitis C, a higher proportion of patients with hepatitis C were White (80% vs 58%; P=.02), had a history of amphetamine use (61% vs 32%; P<.01), injection drug use (72% vs 38%; P<.01), or overdose (56% vs 29%; P<.01), and were on methadone (37% vs 18%; P<.01). There was no difference in the primary outcome of composite obstetrical morbidity. The rate of hepatitis C diagnosis was not statistically significantly different between the pre- and posttelemedicine cohorts (N=29 [41%], N=42 [27%]), and demographics of hepatitis C virus-positive patients were similar, with most being unemployed, single, and publicly insured. A lower proportion of patients in the posttelemedicine group reported heroin use compared with the pretelemedicine cohort (62% vs 90%; P=.013). After implementation of telemedicine, patients were more likely to attend the visit (19% vs 44%; P=.03), and positive patients were much more likely to receive treatment (14% vs 57%; P<.01); 100% of visits in the posttelemedicine group occurred via telemedicine. There were 7 patients who were prescribed treatment by their obstetrician after chart review by Infectious Disease. CONCLUSION: Patients with and without hepatitis C had similar maternal and neonatal outcomes, with multiple indicators of social and financial vulnerability. Telemedicine Infectious Disease consult was associated with increased follow-up and hepatitis C treatment, and obstetricians were able to directly prescribe. Because patients with substance use disorders and hepatitis C may have increased barriers to care, telemedicine may represent an opportunity for intervention.

Harm Reduction: A Missing Piece to the Holistic Care of Patients Who Inject Drugs.

Background: The rise in injection drug use (IDU) has led to an increase in drug-related infections. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We attempted to evaluate the harm reduction counseling that infectious diseases physicians provide to PWID presenting with infections. Methods: An electronic survey was distributed to physician members of the Emerging Infections Network to inquire about practices used when caring for patients with IDU-related infections. Results: In total, 534 ID physicians responded to the survey. Of those, 375 (70%) reported routinely caring for PWID. Most respondents report screening for human immunodeficiency virus (HIV) and viral hepatitis (98%) and discussing the risk of these infections (87%); 63% prescribe immunization against viral hepatitis, and 45% discuss HIV preexposure prophylaxis (PrEP). However, 55% of respondents (n = 205) reported not counseling patients on safer injection strategies. Common reasons for not counseling included limited time and a desire to emphasize antibiotic therapy/medical issues (62%), lack of training (55%), and believing that it would be better addressed by other services (47%). Among respondents who reported counseling PWID, most recommended abstinence from IDU (72%), handwashing and skin cleansing before injection (62%), and safe disposal of needles/drug equipment used before admission (54%). Conclusions: Almost all ID physicians report screening PWID for HIV and viral hepatitis and discussing the risks of these infections. Despite frequently encountering PWID, fewer than half of ID physicians provide safer injection advice. Opportunities exist to standardize harm reduction education, emphasizing safer injection practices in conjunction with other strategies to prevent infections (eg, HIV PrEP or hepatitis A virus/hepatitis B virus vaccination).

'Don't judge me 'til you walk through my shoes': A qualitative investigation of the experiences of women living with HIV.

OBJECTIVE: Women living with the human immunodeficiency virus (HIV) are less of a focus in the HIV literature, which tends to focus on the HIV experiences of men who have sex with men (MSMs). Hence, we conducted a qualitative study that examined: (a) the type of stigma and discrimination that women living with HIV experience related to their HIV status, (b) the source of this stigma and discrimination, (c) their responses related to this stigma and discrimination, and (d) the ways in which women living with HIV cope with these experiences of stigma and discrimination. DESIGN: Participants consisted of 14 self-identified women living with HIV that were recruited at a community organization in the Southern United States that provides services to individuals living with HIV. The participants ranged in age from 27 to 65 (M = 47.92, SD = 13.08). The sample primarily identified as Black (N = 12), followed by White (N = 1) and Multiracial (N = 1). Most women were cisgender (N = 13) with one woman identifying as transgender (N = 1). RESULTS: Fourteen women participated in one of two focus groups (seven in each focus group), which were audio recorded and transcribed. We identified 24 categories across five domains (Stigma and Discrimination, Source of Stigma and Discrimination, Response to Stigma and Discrimination, Coping with Stigma and Discrimination, and Support). CONCLUSIONS: This study identified that women living with HIV experience stigma and discrimination in a multitude of ways from different sources. Moreover, women with HIV responded to and coped in negative and positive ways. Multidimensional approaches including personal and community education may help alleviate the stigma and discrimination faced by women living with HIV.

Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics.

Importance: US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown. Objective: To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids. Design, Setting, and Participants: In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort. Main Outcomes and Measures: Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs). Results: The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000. Conclusions and Relevance: This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.

Outcomes of Partial Oral Antibiotic Treatment for Complicated Staphylococcus aureus Bacteremia in People Who Inject Drugs.

BACKGROUND: Staphylococcus aureus represents the leading cause of complicated bloodstream infections among persons who inject drugs (PWID). Standard of care (SOC) intravenous (IV) antibiotics result in high rates of treatment success but are not feasible for some PWID. Transition to oral antibiotics may represent an alternative treatment option. METHODS: We evaluated all adult patients with a history of injection drug use hospitalized from January 2016 through December 2021 with complicated S. aureus bloodstream infections, including infective endocarditis, epidural abscess, vertebral osteomyelitis, and septic arthritis. Patients were compared by antibiotic treatment (standard of care intravenous [SOC IV] antibiotics, incomplete IV therapy, or transition from initial IV to partial oral) using the primary composite endpoint of death or readmission from microbiologic failure within 90 days of discharge. RESULTS: Patients who received oral antibiotics after an incomplete IV antibiotic course were significantly less likely to experience microbiologic failure or death than patients discharged without oral antibiotics (P < .001). There was no significant difference in microbiologic failure rates when comparing patients who were discharged on partial oral antibiotics after receiving at least 10 days of IV antibiotics with SOC regimens (P > .9). CONCLUSIONS: Discharge of PWID with partially treated complicated S. aureus bacteremias without oral antibiotics results in high rates of morbidity and should be avoided. For PWID hospitalized with complicated S. aureus bacteremias who have received at least 10 days of effective IV antibiotic therapy after clearance of bacteremia, transition to oral antibiotics with outpatient support represents a potential alternative if the patient does not desire SOC IV antibiotic therapy.

Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association.

BACKGROUND: The American Heart Association has sponsored both guidelines and scientific statements that address the diagnosis, management, and prevention of infective endocarditis. As a result of the unprecedented and increasing incidence of infective endocarditis cases among people who inject drugs, the American Heart Association sponsored this original scientific statement. It provides a more in-depth focus on the management of infective endocarditis among this unique population than what has been provided in prior American Heart Association infective endocarditis-related documents. METHODS: A writing group was named and consisted of recognized experts in the fields of infectious diseases, cardiology, addiction medicine, and cardiovascular surgery in October 2021. A literature search was conducted in Embase on November 19, 2021, and multiple terms were used, with 1345 English-language articles identified after removal of duplicates. CONCLUSIONS: Management of infective endocarditis in people who inject drugs is complex and requires a unique approach in all aspects of care. Clinicians must appreciate that it requires involvement of a variety of specialists and that consultation by addiction-trained clinicians is as important as that of more traditional members of the endocarditis team to improve infective endocarditis outcomes. Preventive measures are critical in people who inject drugs and are cured of an initial bout of infective endocarditis because they remain at extremely high risk for subsequent bouts of infective endocarditis, regardless of whether injection drug use is continued.

Experiences Using a Multidisciplinary Model for Treating Injection Drug Use Associated Infections: A Qualitative Study.

Background: Over the past two decades, the United States has experienced a dramatic increase in the rate of injection drug use, injection associated infections, and overdose mortality. A hospital-based program for treating opioid use disorder in people who inject drugs presenting with invasive infections was initiated at an academic tertiary care center in 2020. The goal of this program was to improve care outcomes, enhance patient experiences, and facilitate transition from the hospital to longer term addiction care. The purpose of this study was to interview two cohorts of patients, those admitted before vs. after initiation of this program, to understand the program's impact on care from the patient's perspective and explore ways in which the program could be improved. Methods: Thirty patients admitted to the hospital with infectious complications of injection drug use were interviewed using a semi-structured format. Interviews were transcribed and coded. Emergent themes were reported. Limited descriptive statistics were reported based on chart review. Results: Thirty interviews were completed; 16 participants were part of the program (admitted after program implementation) while 14 were not participants (admitted prior to implementation). Common themes associated with hospitalization included inadequate pain control, access to medications for opioid use disorder (MOUD), loss of freedom, stigma from healthcare personnel, and benefits of having an interprofessional team. Participants in the program were more likely to report adequate pain control and access to MOUD and many cited benefits from receiving care from an interprofessional team. Conclusions: Patients with opioid use disorder admitted with injection related infections reported improved experiences when receiving care from an interprofessional team focused on their addiction. However, perceived stigma from healthcare personnel and loss of freedom related to hospitalization were continued barriers to care before and after implementation of this program.

The Cumulative Influence of Perceived Discrimination, Stress, and Coping Responses on Symptoms of Depression Among Young African American Mothers.

BACKGROUND: African American women have an elevated risk for experiencing depressive symptoms, and discrimination, stress, and coping contribute to symptoms of depression. AIMS: We aimed to examine the associations between discrimination, stress, and coping on symptoms of depression among young African American mothers. METHODS: In this retrospective study, we utilized a hierarchical linear regression to explore the effects of perceived racial discrimination, stress, and general and discrimination-related coping responses on depressive symptoms in a sample of African American mothers (N = 250). The data were drawn from the Intergenerational Impact of Genetic and Psychological Factors on Blood Pressure study (InterGEN), a study conducted between 2014 and 2019 and based in Connecticut. RESULTS: After accounting for maternal age, level of education, and income, greater perceived racial discrimination (p = .03), higher levels of stress (p < .001), greater engagement in avoidance coping (p < .001), and use of passive coping responses to discrimination (p = .04) were uniquely associated with increased depressive symptoms. Other forms of coping, specifically, problem-solving and support seeking, did not appear to influence depressive symptoms in this sample. CONCLUSION: The findings highlight the negative impact of discrimination, heightened stress, and maladaptive coping on the emotional health of young African American mothers.

Career practitioners' response to career development concerns in the time of COVID-19.

The COVID-19 pandemic has had a world-wide impact on all areas of individuals' health, including physical, psychological, financial, familial, social, and vocational. In the United States, the unemployment rate rose from 3.5% (5.8 million) to 13.3% (21 million) in May 2020 before dropping to 7.9% in October 2020. Cognitive information processing (CIP)is one career theory that addresses career needs of clients and society. In this article, we examine the impact of COVID-19 on mental health and wellness, highlight differences for marginalized groups, and demonstrate how CIP theoretical elements may have been impacted by COVID-19, and provide strategies enhancing client growth in these domains during a time when largescale social and physical distancing is recommended. The CIP-based differentiated service delivery model is also described as a means for extending and providing access to career services.

Efficacy of Continuous Performance Testing in Adult ADHD in a Clinical Sample Using QbTest.

OBJECTIVE: Continuous performance tests are widely used to aid diagnostic decision making and measure symptom reduction in adult ADHD clinical populations. The diagnostic accuracy of the Quantified Behavior Test plus (QbTest+), developed to identify ADHD populations as an objective measure of ADHD symptoms, was explored. METHODS: The utility of the QbTest+ was investigated in a clinical cohort of 69 adult patients referred to a specialist ADHD clinic in the UK. RESULTS: Scores from the QbTest+ failed to differentiate between patients diagnosed with ADHD and those who did not receive a diagnosis after full clinical assessment. CONCLUSIONS: Based on our findings, we recommend clinicians are cautious when interpreting results of the QbTest+ in clinical populations. This study highlights the need for investigation into the lack of validation of commonly used objective measures in ADHD populations.

Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use-Associated Infective Endocarditis.

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 $416 570 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 $412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163 370 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.

Patients With Serious Injection Drug Use-Related Infections who Experience Patient-Directed Discharges on Oral Antibiotics Have High Rates of Antibiotic Adherence but Require Multidisciplinary Outpatient Support for Retention in Care.

BACKGROUND: Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). Outcomes and adherence to oral antibiotics for PWID with patient-directed discharge (PDD) remain understudied. METHODS: We conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge or immediately after discharge through an infectious diseases telemedicine clinic. Additional support services included health coaches, a therapist, a case manager, free clinic follow-up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow-up were compared between PWID with PDD on oral antibiotics and those who completed intravenous (IV) antibiotics using an as-treated approach. RESULTS: Of 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%), while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups (P = .819). For PWID with a PDD on oral antibiotics, 7.6% had documented nonadherence to antibiotics, 67% had documented adherence, and 23% were lost to follow-up. Factors protective against readmission included antibiotic and MOUD adherence, engagement with support team, and clinic follow-up. CONCLUSIONS: PWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics.

Low Knowledge of HIV PrEP Within a Midwestern US Cohort of Persons who Inject Drugs.

We interviewed persons who inject drugs (PWID) to understand perceptions of pre-exposure prophylaxis (PrEP) to prevent HIV infection. Knowledge of PrEP was poor. Patients felt that PrEP was for sexual intercourse rather than injection drug use, and PWID managed on medications for opioid use disorder felt that they had no need for PrEP.

Barriers to Care Experienced by Patients Who Inject Drugs During the COVID-19 Pandemic: A Qualitative Analysis.

OBJECTIVES: To identify the barriers to accessing health care and social services faced by people who inject drugs (PWID) during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This report is a sub-analysis of a larger qualitative study. Semi-structured interviews were conducted with PWID admitted to an academic medical center from 2017 to 2020 for an invasive injection-related infection. Standard qualitative analysis techniques, consisting of both inductive and deductive approaches, were used to identify and characterize the effects of COVID-19 on participants. RESULTS: Among the 30 PWID interview participants, 14 reported barriers to accessing health and addiction services due to COVID-19. As facilities decreased appointment availability or transitioned to telemedicine, PWID reported being unable to access services. Social distancing led to isolation or loneliness during hospital stays and in the community. Recovery meetings and support groups, critical to addiction recovery, were particularly affected. Other participants reported that uncertainty and fear of contracting the virus generated changes in behavior that led them to avoid seeking services. CONCLUSIONS: COVID-19 has disrupted health systems and social services, leading PWID to experience unprecedented barriers to accessing and maintaining health and addiction services in both inpatient and outpatient settings. Opioid use disorder management must be understood as a holistic process, and a multidisciplinary approach to ensuring comprehensive care, even in the midst of this pandemic, is needed.

Infectious Complications of Injection Drug Use.

The opioid overdose epidemic is one of the leading causes of death in adults. Its devastating effects have included not only a burgeoning overdose crisis but also multiple converging infectious diseases epidemics. The use of both opioids and other substances through intravenous (IV) administration places individuals at increased risks of infectious diseases ranging from invasive bacterial and fungal infections to human immunodeficiency virus (HIV) and viral hepatitis. In 2012, there were 530,000 opioid use disorder (OUD)-related hospitalizations in the United States (US), with $700 million in costs associated with OUD-related infections. The scale of the crisis has continued to increase since that time, with hospitalizations for injection drug use-related infective endocarditis (IDU-IE) increasing by as much as 12-fold from 2010 to 2015. Deaths from IDU-IE alone are estimated to result in over 7,260,000 years of potential life lost over the next 10 years. There have been high-profile injection-related HIV outbreaks, and injection drug use (IDU) is now the most common risk factor for hepatitis C virus (HCV). As this epidemic continues to grow, clinicians in all aspects of medical care are increasingly confronted with infectious complications of IDU. This review will describe the pathogenesis, clinical syndromes, epidemiology, and models of treatment for common infectious complications among persons who inject drugs (PWIDs).