Novel Therapeutic and Program-Based Approaches to Opioid Use Disorders.

Opioid use disorder continues to drive overdose deaths in many countries, including the United States. Illicit fentanyl and its analogues have emerged as key contributors to the complications and mortality associated with opioid use disorder. Medications for opioid use disorder treatment, such as methadone and buprenorphine, are safe and substantially reduce opioid use, infectious complications, and mortality risk, but remain underutilized. Polysubstance use and emerging substances such as xylazine and designer benzodiazepines create additional treatment challenges. Recent clinical and policy innovations in treatment delivery, including telemedicine, bridge clinics, and expanded models for accessing methadone have the potential to increase access to life-saving care for people living with opioid use disorder.

Long-term Risk of Serious Infections and Mortality Among Patients Surviving Drug Use-Associated Infective Endocarditis.

Among a statewide cohort of 1874 patients surviving hospitalization for drug use-associated endocarditis during 2017-2020, the 3-year risk of death or future hospitalization was 38% (16% for death before later infection, 14% for recurrent endocarditis, 14% for soft tissue, 9% for bacteremia, 5% for bone/joint, and 4% for spinal infections).

Community-Acquired Staphylococcus aureus Bacteremia Among People Who Inject Drugs: A National Cohort Study in England, 2017-2020.

BACKGROUND: People who inject drugs (PWID) are at increased risk of community-acquired Staphylococcus aureus bacteremia (CA-SAB), but little is known about clinical outcomes of CA-SAB in PWID compared with the wider population of patients with CA-SAB. METHODS: Three national datasets were linked to provide clinical and mortality data on patients hospitalized with CA-SAB in England between 1 January 2017 and 31 December 2020. PWID were identified using the International Classification of Diseases, Tenth Revision code for "mental health and behavioral disorder due to opioid use" (F11). Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) for associations of PWID with 30-day all-cause mortality and 90-day hospital readmission. RESULTS: In 10 045 cases of CA-SAB, 1612 (16.0%) were PWID. Overall, 796 (7.9%) patients died within 30 days of CA-SAB admission and 1189 (11.8%) patients were readmitted to hospital within 90 days of CA-SAB. In those without infective endocarditis, there was strong evidence of lower odds of mortality among PWID compared with non-PWID (aOR, 0.47 [95% confidence interval {CI}: .33-.68]; P < .001), whereas there was no association in CA-SAB case fatality with endocarditis (aOR, 1.40 [95% CI: .87-2.25]; P = .163). PWID were less likely to be readmitted within 90 days of CA-SAB (aOR, 0.79 [95% CI: .65-.95]; P = .011). CONCLUSIONS: In this large cohort study of patients with CA-SAB in England, PWID had lower odds of death in the absence of endocarditis and lower odds of readmission within 90 days compared to non-PWID patients. This study highlights the overrepresentation of PWID among patients with CA-SAB nationally.

Lessons Learned Implementing Syringe Services Programs at Rural Health Departments in Kentucky.

Until recently, most syringe services programs (SSPs) in the United States operated in metropolitan areas. This study explores how SSP implementers at rural health departments in Kentucky secured support for SSP operations. In late 2020, we conducted in-depth, semi-structured interviews with 18 people involved with rural SSP implementation in Kentucky. Participants were asked to reflect on their experiences building support for SSP operations among rural health department staff and community members. Participants reported that attitudes and beliefs about SSP implementation among rural health department staff shifted quickly following engagement in educational activities and interaction with SSP clients. Participants explained that successful SSP implementation at rural health departments required sustained educational activities among community members and authorizing authorities. Future work should explore how rural communities may advocate for low-threshold and evidence-based policies that support the provision of harm reduction services.

Long-acting Injectable PrEP Interest and General PrEP Awareness among People who Inject Drugs in the San Diego-Tijuana Border Metroplex.

Long-acting injectable HIV pre-exposure prophylaxis (LAI-PrEP) could help overcome multilevel challenges to HIV prevention for people who inject drugs (PWID), including those in the binational San Diego-Tijuana metroplex. Yet, general PrEP awareness and interest in LAI-PrEP remain underexplored among PWID. From 2020 to 2021, 562 HIV-negative PWID in San Diego and Tijuana completed surveys assessing general PrEP awareness and interest in oral and LAI-PrEP. Modified Poisson regression examined factors associated with general PrEP awareness. Multinomial logistic regression assessed factors associated with interest in both oral and LAI-PrEP, oral PrEP only, LAI-PrEP only, or neither. General PrEP awareness was low (18%) and associated with experiencing unsheltered homelessness (adjusted prevalence ratio [APR] = 1.50, 95% confidence interval [CI]: 0.96-2.33), past 6-month fentanyl injection (APR = 1.53, 95% CI: 1.04-2.25), and transactional sex (APR = 1.71, 95% CI: 1.06-2.76). Interest in oral PrEP only was most common (44%), followed by LAI-PrEP only (25%) and neither (16%). Compared to the odds of being interested in LAI-PrEP only, the odds of being interested in oral PrEP only were lower among those who were stopped by police (AOR = 0.38, 95% CI: 0.22-0.65), reported past 6-month fentanyl injection (AOR = 0.33, 95% CI: 0.20-0.56), polydrug use (AOR = 0.48, 95% CI: 0.27-0.86), injecting multiple times daily (AOR = 0.26, 95% CI: 0.14-0.46), receptive syringe use (AOR = 0.30, 95% CI: 0.19-0.49), and higher perceived HIV risk (AOR = 0.24, 95% CI: 0.15-0.39). Interest in LAI-PrEP was more common among PWID reporting social and structural factors that could interfere with oral PrEP adherence, suggesting LAI-PrEP implementation could increase PrEP coverage among those most vulnerable to HIV.

Safe Injection Self-Efficacy is Associated with HCV and HIV Seropositivity Among People Who Inject Drugs in the San Diego-Tijuana Border Region.

Safe injection self-efficacy (SISE) is negatively associated with injection risk behaviors among people who inject drugs (PWID) but has not been examined in differing risk environments. We compared responses to a validated SISE scale between PWID in San Diego, California and Tijuana, Mexico, and examine correlates of SISE among PWID in Tijuana. PWID were recruited via street outreach for a longitudinal cohort study from October 2020-September 2021. We compared SISE scale items by city. Due to low variability in SISE scores among San Diego residents, we restricted analysis of factors associated with SISE to Tijuana residents and identified correlates of SISE score levels (low, medium, high) using ordinal logistic regression. Of 474 participants, most were male (74%), Latinx (78%) and Tijuana residents (73%). Mean age was 44. Mean SISE scores among San Diego residents were high (3.46 of 4 maximum) relative to Tijuana residents (mean: 1.93). Among Tijuana residents, White race and having previously resided in San Diego were associated with higher SISE scores. HCV and HIV seropositivity, homelessness, fentanyl use, polysubstance co-injection, and greater injection frequency were associated with lower SISE scores. We found profound inequalities between Tijuana and San Diego SISE, likely attributable to differential risk environments. Associations with fentanyl and polysubstance co-injection, injection frequency, and both HIV and HCV seropositivity suggest that SISE contribute to blood-borne infection transmission risks in Tijuana. SISE reflects an actionable intervention target to reduce injection risk behaviors, but structural interventions are required to change the risk environment.

RESUMEN: La autoeficacia de inyección segura (SISE, por sus siglas en inglés) se asocia negativamente con conductas de riesgo de inyección entre las personas que se inyectan drogas (PWID, por sus siglas en inglés), pero no se ha examinado en diferentes entornos de riesgo. Comparamos las respuestas a una escala validada de SISE entre PWID en San Diego, California, y Tijuana, México, y examinamos los correlatos de SISE entre PWID en Tijuana. Participantes fueron reclutados por medio de alcance callejero para un estudio de cohorte longitudinal entre octubre 2020 ­septiembre de 2021. Comparamos los ítems de la escala SISE por ciudad. Debido a la baja variabilidad en los puntajes SISE entre los residentes de San Diego, restringimos el análisis de factores asociados con SISE a los residentes de Tijuana e identificamos factores correlacionados con niveles de SISE (bajo, medio, alto) mediante regresión logística ordinal. De 474 participantes, la mayoría eran hombres (74%), latinx (78%) y residentes de Tijuana (73%). La edad promedio fue de 44 años. Los puntajes medios de SISE entre los residentes de San Diego fueron altos (3.46 de un máximo de 4) en comparación con los residentes de Tijuana (media: 1.93). Entre los residentes de Tijuana, la raza blanca y haber residido previamente en San Diego se asociaron con puntajes más altos de SISE. La seropositividad para HCV y VIH, la falta de vivienda, el uso de fentanilo, la co-inyección de múltiples sustancias y una mayor frecuencia de inyecciónes se asociaron con puntajes más bajos de SISE. Encontramos profundas desigualdades entre SISE en Tijuana y San Diego, probablemente atribuibles a diferentes entornos de riesgo. Las asociaciones con fentanilo y la co-inyección de múltiples sustancias, la frecuencia de inyección y la seropositividad tanto para VIH como para HCV sugieren que SISE contribuye a los riesgos de transmisión de infecciones transmitidas por la sangre en Tijuana. SISE refleja un objetivo de intervención accionable para reducir las conductas de riesgo de inyección, pero se requieren intervenciones estructurales para cambiar el entorno de riesgo.

Social support network factors associated with verbal fluency among vulnerable persons living with HIV.

Vulnerable persons living with HIV (PLWH) are at high risk of cognitive impairment and challenges accessing quality social support in later life. Impaired verbal fluency (VF), a cognitive domain linked to HIV, could impede social support associated with health and well-being for already vulnerable PLWH. We examined the structure of social support, using latent class analysis, and the associations among quantity, specific forms and quality of social support and VF among PLWH. Participants enrolled in the BEACON study (n = 383) completed the Controlled Oral Word Association test (COWAT) and a social support network inventory. Latent class analysis with count variables was used to determine the number of classes of PLWH based on their social network characteristics. The majority of PLWH were male (61.4%) and African American (85.9%). Two distinct latent classes, with a major distinction in the number of network members who were female, knew participants' HIV status and HIV medication usage. Fewer support network members (ß = -.13, p < 0.01), greater negative interactions (ß = -.16, p < 0.01), and less positive interactions with network members (ß = .15, p < 0.05) were significantly associated with lower COWAT scores. Comprehensive screening of high-risk PLWH and early intervention with those with cognitive impairment are important for addressing social support needs.

Broadening and strengthening the health providers caring for patients with chronic hepatitis C may improve continuity of care.

BACKGROUND: Direct-acting antiviral (DAA) therapies for hepatitis C virus infection (HCV) lead to excellent rates of sustained virological response (SVR). However, loss to follow-up (LTFU) for SVR testing remains a challenge. We examine factors associated with LTFU in a real-world setting. METHODS: Adults who received DAA therapy for HCV in one of 26 centers across Australia during 2016-2021 were followed up for 2 years. Data sources included the patient medical records and the national Pharmaceutical and Medicare Benefits Schemes. Linkage to Medicare provided utilization data of other health-care providers and re-treatment with DAAs. LTFU was defined as no clinic attendance for SVR testing by at least 52 weeks after DAA treatment commencement. Multivariable logistic regression assessed factors associated with LTFU. RESULTS: In 3619 patients included in the study (mean age 52.0 years; SD = 10.5), 33.6% had cirrhosis (69.4% Child-Pugh class B/C), and 19.3% had HCV treatment prior to the DAA era. Five hundred and fifteen patients (14.2%) were LTFU. HCV treatment initiation in 2017 or later (adj-OR = 2.82, 95% confidence interval [CI] 2.25-3.54), younger age (adj-OR = 2.63, 95% CI 1.80-3.84), Indigenous identification (adj-OR = 1.99, 95% CI 1.23-3.21), current injection drug use or opioid replacement therapy (adj-OR = 1.66, 95% CI 1.25-2.20), depression treatment (adj-OR = 1.49, 95% CI 1.17-1.90), and male gender (adj-OR = 1.31, 95% CI 1.04-1.66) were associated with LTFU. CONCLUSIONS: These findings stress the importance of strengthening the network of providers caring for patients with HCV. In particular, services targeting vulnerable groups of patients such as First Nations Peoples, youth health, and those with addiction and mental health disorders should be equipped to treat HCV.

HIV knowledge, self-perception of HIV risk, and sexual risk behaviors among male Tajik labor migrants who inject drugs in Moscow.

BACKGROUND: The interplay of human immunodeficiency virus (HIV) knowledge and self-perception of risk for HIV among people who inject drugs is complex and understudied, especially among temporary migrant workers who inject drugs (MWID) while in a host country. In Russia, Tajik migrants make up the largest proportion of Moscow's foreign labor. Yet, HIV knowledge and self-perceived risk in association with sexual risk behavior among male Tajik MWID in Moscow remains unknown. OBJECTIVE: This research examines knowledge about HIV transmission, self-perception of HIV risk, and key psychosocial factors that possibly contribute to sexual risk behaviors among male Tajik labor MWID living in Moscow. METHODS: Structured interviews were conducted with 420 male Tajik labor MWID. Modified Poisson regression models investigated possible associations between major risk factors and HIV sexual risk behavior. RESULTS: Of the 420 MWID, 255 men (61%) reported sexual activity in the last 30 days. Level of HIV knowledge was not associated in either direction with condom use or risky sexual partnering, as measured by sex with multiple partners or female sex workers (FSW). Lower self-perceived HIV risk was associated with a greater likelihood of sex with multiple partners (aPR: 1.79, 95% CI: 1.34, 2.40) and FSW (aPR: 1.28, 95% CI: 1.04, 1.59), but was not associated with condom use. Police-enacted stigma was associated with sex with multiple partners (aPR: 1.22, 95% CI: 1.01, 1.49) and FSW (aPR: 1.32, 95% CI: 1.13, 1.54). While depression and lower levels of loneliness were associated with condomless sex (aPR: 1.14, 95% CI: 1.05, 1.24; aPR: 0.79, 95% CI: 0.68, 0.92, respectively), only depression was associated with condomless sex with FSW (aPR: 1.26, 95% CI: 1.03, 1.54). CONCLUSIONS: HIV prevention programing for male Tajik MWID must go beyond solely educating about factors associated with HIV transmission to include increased awareness of personal risk based on engaging in these behaviors. Additionally, psychological services to counter depression and police-enacted stigma are needed.

Unmet needs and harm reduction preferences of syringe services program participants: differences by co-use of illicit opioids and methamphetamine.

BACKGROUND: The current fourth wave of the United States opioid overdose epidemic is characterized by the co-use of opioids and stimulants, including illicit opioids and methamphetamine. The co-use of these two drugs, known as "goofballing," is associated with higher risk for several adverse outcomes, including more frequent injections, greater health risks, and higher morbidity. Considering these differences, this unique subpopulation of people who inject drugs (PWID) may also have unique unmet needs and harm reduction preferences. METHODS: We collected self-reported data from participants (N = 50) of a syringe services program (SSP), including basic needs and harm reduction preferences. Using bivariate analyses, we examined differences between SSP participants who do and do not co-use illicit opioids and methamphetamine. Co-use was defined as reporting the use of both drugs, which may or may not have been used simultaneously. RESULTS: In the overall sample, the mean level of need was highest for bus passes or other transportation, a person who can help you get the services you need, medication for opioid use disorder, and a job or job training. Additionally, all participants reported being either interested or very interested in fentanyl test strips, safe consumption sites, delivery of syringe service supplies, and delivery of naloxone. Those who endorsed co-use had a greater need for food, healthcare, substance use disorder treatment, a support person to help them access needed services, and bus passes or transportation. CONCLUSIONS: Unmet needs were prevalent, and the desire for more harm reduction services was high among these PWID. Results also suggest people who co-use illicit opioids and methamphetamine may have the greatest unmet needs and desire for additional harm reduction services.

A confirmed case of xylazine-induced skin ulcers in a person who injects drugs in Miami, Florida, USA.

BACKGROUND: Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the illicit drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who use drugs (PWUD). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida. CASE PRESENTATION: A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at a Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits were informed by best clinical judgement due to lack of formal guidelines at the time. Wound outcomes are unknown as the patient has not returned to clinic. CONCLUSIONS: Many PWUD at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system due to stigma. There is an urgent need for access to XTS for PWUD and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.

Association of spatial proximity to fixed-site syringe services programs with HCV serostatus and injection equipment sharing practices among people who inject drugs in rural New England, United States.

BACKGROUND: Hepatitis C virus (HCV) disproportionately affects rural communities, where health services are geographically dispersed. It remains unknown whether proximity to a syringe services program (SSP) is associated with HCV infection among rural people who inject drugs (PWID). METHODS: Data are from a cross-sectional sample of adults who reported injecting drugs in the past 30 days recruited from rural counties in New Hampshire, Vermont, and Massachusetts (2018-2019). We calculated the road network distance between each participant's address and the nearest fixed-site SSP, categorized as ≤ 1 mile, 1-3 miles, 3-10 miles, and > 10 miles. Staff performed HCV antibody tests and a survey assessed past 30-day injection equipment sharing practices: borrowing used syringes, borrowing other used injection equipment, and backloading. Mixed effects modified Poisson regression estimated prevalence ratios (aPR) and 95% confidence intervals (95% CI). Analyses were also stratified by means of transportation. RESULTS: Among 330 PWID, 25% lived ≤ 1 mile of the nearest SSP, 17% lived 1-3 miles of an SSP, 12% lived 3-10 miles of an SSP, and 46% lived > 10 miles from an SSP. In multivariable models, compared to PWID who lived within 1 mile of an SSP, those who lived 3 to 10 miles away had a higher prevalence of HCV seropositivity (aPR: 1.25, 95% CI 1.06-1.46), borrowing other used injection equipment (aPR: 1.23, 95% CI 1.04-1.46), and backloading (aPR: 1.48, 95% CI 1.17-1.88). Similar results were observed for PWID living > 10 miles from an SSP: aPR [HCV]: 1.19, 95% CI 1.01-1.40; aPR [borrowing other used equipment]:1.45, 95% CI 1.29-1.63; and aPR [backloading]: 1.59, 95% CI 1.13-2.24. Associations between living 1 to 3 miles of an SSP and each outcome did not reach statistical significance. When stratified by means of transportation, associations between distance to SSP and each outcome (except borrowing other used injection equipment) were only observed among PWID who traveled by other means (versus traveled by automobile). CONCLUSIONS: Among PWID in rural New England, living farther from a fixed-site SSP was associated with a higher prevalence of HCV seropositivity, borrowing other used injection equipment, and backloading, reinforcing the need to increase SSP accessibility in rural areas. Means of transportation may modify this relationship.

"Make yourself un-NIMBY-able": stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America.

BACKGROUND: Overdose prevention centers (OPCs), also known as supervised injection facilities and safe consumption sites, are evidenced-based interventions for preventing overdose deaths and drug-related morbidities. The pathways to legalizing OPCs in the USA have confronted multiple social, political, and legal obstacles. We conducted a multi-site, qualitative study to explore heterogeneities in these pathways in four jurisdictions, as well as to understand stakeholder perspectives on valuable strategies for galvanizing political and public support for OPCs. METHODS: From July 2022 to February 2023, we conducted 17 semi-structured, in-depth interviews with OPC policymakers, service providers, advocates, and researchers from California, New York City, Philadelphia, and Rhode Island, where efforts have been undertaken to authorize OPCs. Using inductive thematic analysis, we identified and compared contextually relevant, salient approaches for increasing support for OPCs. RESULTS: Participants described several strategies clustering around five distinct domains: (1) embedding OPC advocacy into broader overdose prevention coalitions to shape policy dialogs; (2) building rapport with a plurality of powerbrokers (e.g., lawmakers, health departments, law enforcement) who could amplify the impact of OPC advocacy; (3) emphasizing specific benefits of OPCs to different audiences in different contexts; (4) leveraging relationships with frontline workers (e.g., emergency medicine and substance use treatment providers) to challenge OPC opposition, including 'NIMBY-ism,' and misinformation; and (5) prioritizing transparency in OPC decision-making to foster public trust. CONCLUSION: While tailored to the specific socio-political context of each locality, multiple OPC advocacy strategies have been deployed to cultivate support for OPCs in the USA. Advocacy strategies that are multi-pronged, leverage partnerships with stakeholders at multiple levels, and tailor communications to different audiences and settings could yield the greatest impact in increasing support for, and diffusing opposition to, future OPC implementation.

3D Cinematic rendering for evaluating femoral pseudoaneurysms in injection drug users.

The inguinal region, specifically the femoral vasculature, is a commonly used site of injection for intravenous drug users (IVDU). Repeated puncture of the vessel wall results in breakdown and subsequent arterial pseudoaneurysm- dilatations or outpouching of blood vessels, which, if left untreated, can result in fatal complications such as rupture with hemorrhage, sepsis, or even limb loss. The current modalities for arterial pseudoaneurysms include Doppler ultrasound and computed tomography (CT) angiography, both of which play important roles in management and surgical planning. However, 3D cinematic rendering (CR), a novel CT post-processing technique, offers timely, highly detailed photorealistic images that more clearly display the relation of anatomical structures, allowing for greater diagnostic confidence and precise surgical planning, particularly useful in the emergency setting. In this pictorial review, we demonstrate role of 3D CR in diagnosis and management of femoral pseudoaneurysms in IVDU through 9 illustrative cases.

Baltimore oral epidemiology, disease effects, and HIV evaluation study (BEEHIVE) study protocol: a prospective cohort study.

BACKGROUND: As antiretroviral therapy has become widely available and highly effective, HIV has evolved to a manageable, chronic disease. Despite this health advancement, people living with HIV (PLWH) are at an increased risk for age-related non-communicable diseases (NCDs) compared to HIV-uninfected individuals. Similarly, PLWH are at an increased risk for selected oral diseases. PLWH with a history of injecting drugs experience an even greater burden of disease than their counterparts. The overall objective of the Baltimore Oral Epidemiology, Disease Effects, and HIV Evaluation (BEEHIVE) study is to determine the combined effects of HIV infection and NCDs on oral health status. The specific aims of the study are to: (1) determine to what extent HIV status influences access to and utilization of oral health care services; (2) determine to what extent HIV status affects self-reported and clinical oral health status; (3) determine to what extent HIV status influences the progression of periodontitis; and (4) determine to what extent HIV status impacts the periodontitis-associated oral microbiome signature. METHODS: The BEEHIVE study uses a prospective cohort study design to collect data from participants at baseline and at a 24-month follow-up visit. Data are collected through questionnaire assessments, clinical examinations, and evaluation of oral microbiological samples to determine the drivers of oral disease among a high-risk population of PLWH with a history of injection drug use and prevalent comorbid NCDs. The established AIDS Linked to the Intravenous Experience (ALIVE) cohort serves as the source of participants for the BEEHIVE Study. DISCUSSION: Upon completion of the BEEHIVE study, the knowledge gained will be important in informing future clinical and preventive interventions that can be implemented into medical and dental practice to ultimately help eliminate long-standing oral health inequities that PLWH experience.

HCV Microelimination for High-risk Special Populations.

The World Health Organization has set tremendous goals to eliminate viral hepatitis by 2030. However, most countries are currently off the track for achieving these goals. Microelimination is a more effective and practical approach that breaks down national elimination targets into goals for smaller and more manageable key populations. These key populations share the characteristics of being highly prevalent for and vulnerable to hepatitis C virus (HCV) infection. Microelimination allows for identifying HCV-infected people and linking them to care more cost-effectively and efficiently. In this review, we discuss the current obstacles to and progress in HCV microelimination in special populations, including uremic patients undergoing hemodialysis, people who inject drugs, incarcerated people, people living in hyperendemic areas, men who have sex with men with or without human immunodeficiency virus (HIV) infection, transgender and gender-diverse populations, and sex workers. Scaling up testing and treatment uptake to achieve HCV microelimination may facilitate global HCV elimination by 2030.

Estimated Number of People Who Inject Drugs in the United States.

BACKGROUND: Public health data signal increases in the number of people who inject drugs (PWID) in the United States during the past decade. An updated PWID population size estimate is critical for informing interventions and policies aiming to reduce injection-associated infections and overdose, as well as to provide a baseline for assessments of pandemic-related changes in injection drug use. METHODS: We used a modified multiplier approach to estimate the number of adults who injected drugs in the United States in 2018. We deduced the estimated number of nonfatal overdose events among PWID from 2 of our previously published estimates: the number of injection-involved overdose deaths and the meta-analyzed ratio of nonfatal to fatal overdose. The number of nonfatal overdose events was divided by prevalence of nonfatal overdose among current PWID for a population size estimate. RESULTS: There were an estimated 3 694 500 (95% confidence interval [CI], 1 872 700-7 273 300) PWID in the United States in 2018, representing 1.46% (95% CI, .74-2.87) of the adult population. The estimated prevalence of injection drug use was highest among males (2.1%; 95% CI, 1.1-4.2), non-Hispanic Whites (1.8%; 95% CI, .9-3.6), and adults aged 18-39 years (1.8%; 95% CI, .9-3.6). CONCLUSIONS: Using transparent, replicable methods and largely publicly available data, we provide the first update to the number of people who inject drugs in the United States in nearly 10 years. Findings suggest the population size of PWID has substantially grown in the past decade and that prevention services for PWID should be proportionally increased.

Patterns of Infectious Disease Associated With Injection Drug Use in Massachusetts.

BACKGROUND: Since 2014, multiple outbreaks of human immunodeficiency virus (HIV) among people who inject drugs have occurred across the United States along with hepatitis C virus (HCV), skin and soft tissue infections (SSTIs), and infective endocarditis (IE), creating a converging public health crisis. METHODS: We analyzed the temporal patterns of infectious disease and overdose using a hierarchical Bayesian distributed lag logistic regression model examining the probability that a given geographic area experienced at least 1 HIV case in a given month as a function of the counts/rates of overdose, HCV, SSTI, and IE and associated medical procedures at different lagged time periods. RESULTS: Current-month HIV is associated with increasing HCV cases, abscess incision and drainage, and SSTI cases, in distinct temporal patterns. For example, 1 additional HCV case occurring 5 and 7 months previously is associated with a 4% increase in the odds of observing at least 1 current-month HIV case in a given locale (odds ratios, 1.04 [90% credible interval {CrI}: 1.01-1.10] and 1.04 [90% CrI: 1.00-1.09]). No such associations were observed for echocardiograms, IE, or overdose. CONCLUSIONS: Lagged associations in other infections preceding rises in current-month HIV counts cannot be described as predictive of HIV outbreaks but may point toward newly discovered epidemics of injection drug use and associated clinical sequalae, prompting clinicians to screen patients more carefully for substance use disorder and associated infections.

Opioid Injection-Associated Bacterial Infections in England, 2002-2021: A Time Series Analysis of Seasonal Variation and the Impact of Coronavirus Disease 2019.

BACKGROUND: Bacterial infections cause substantial pain and disability among people who inject drugs. We described time trends in hospital admissions for injecting-related infections in England. METHODS: We analyzed hospital admissions in England between January 2002 and December 2021. We included patients with infections commonly caused by drug injection, including cutaneous abscesses, cellulitis, endocarditis, or osteomyelitis, and a diagnosis of opioid use disorder. We used Poisson regression to estimate seasonal variation and changes associated with coronavirus disease 2019 (COVID-19) response. RESULTS: There were 92 303 hospital admissions for injection-associated infections between 2002 and 2021. Eighty-seven percent were skin, soft-tissue, or vascular infections; 72% of patients were male; and the median age increased from 31 years in 2002 to 42 years in 2021. The rate of admissions reduced from 13.97 per day (95% confidence interval [CI], 13.59-14.36) in 2003 to 8.94 (95% CI, 8.64-9.25) in 2011, then increased to 18.91 (95% CI, 18.46-19.36) in 2019. At the introduction of COVID-19 response in March 2020, the rate of injection-associated infections reduced by 35.3% (95% CI, 32.1-38.4). Injection-associated infections were also seasonal; the rate was 1.21 (95% CI, 1.18-1.24) times higher in July than in February. CONCLUSIONS: This incidence of opioid injection-associated infections varies within years and reduced following COVID-19 response measures. This suggests that social and structural factors such as housing and the degree of social mixing may contribute to the risk of infection, supporting investment in improved social conditions for this population as a means to reduce the burden of injecting-related infections.

Inpatient Hepatitis C Treatment Coordination and Initiation for Patients Who Inject Drugs.

BACKGROUND: With hepatitis C (HCV) incidence rising due to injection drug use, people who inject drugs (PWID) are a priority population for direct-acting antivirals (DAA). However, significant barriers exist. At our institution, hospitalized PWID were screened for HCV but not effectively linked to care. AIM: To improve retention in HCV care among hospitalized PWID. SETTING: Quaternary academic center in the Southeast US from August 2021 through August 2022. PARTICIPANTS: Hospitalized PWID with HCV. PROGRAM DESCRIPTION: E-consultation-prompted care coordination and HCV treatment with outpatient telehealth. PROGRAM EVALUATION: Care cascades were constructed to assess retention and HCV treatment, with the primary outcome defined as DAA completion or sustained virologic response after week 4. Of 28 patients, 11 started DAAs inpatient, 8 initiated outpatient, and 9 were lost to follow-up or transferred care. Overall, 82% were linked to care and 52% completed treatment. For inpatient initiators, 73% achieved the outcome. Of non-inpatient initiators, 71% were linked to care, 53% started treatment, and 36% achieved the outcome. DISCUSSION: Inpatient HCV treatment coordination, including DAA initiation, and telehealth follow-up, was feasible and highly effective for hospitalized PWID. Future steps should address barriers to inpatient DAA treatment and expand this model to other similar patient populations.