ABSTRACT
Background. Since the onset of the COVID-19 pandemic, opioid-related overdose deaths have increased. Buprenorphine, a medication for opioid use disorder (OUD), is safe and effective but is underutilized and requires qualifying physicians to obtain a waiver. Infectious diseases (ID) physicians are uniquely positioned to treat OUD, as persons with OUD may present with infectious complications from injection drug use. We sought to understand the proportion and distribution of ID physicians with waivers in the United States (US). Methods. This was a cross-sectional study merging data from the Centers for Medicare & Medicaid Services and the Drug Enforcement Agency Substance Abuse and Mental Health Services Agency. Our primary outcome was proportion of ID physicians who possess buprenorphine waivers. We used multivariable regression models to identify individual and county-level characteristics associated with buprenorphine waiver possession. We used geospatial analysis to describe county-level distribution of buprenorphine-waivered ID physicians. Results. Among 6439 ID physicians in the US, 170 (2.6%) possessed buprenorphine waivers. Overall, 57.2% of ID physicians were male with a median 23 (IQR 15-33) years since medical school. Most (97.3%) practiced in metropolitan counties. In multivariable analysis, medical school graduation beyond 20 years was associated with lower odds of waiver possession compared to those graduating within 20 years (OR 0.59, 95% CI 0.43-0.80). ID physicians practicing in counties with median income > 50,000/year and in counties with higher proportion of uninsured residents also had lower odds of having a waiver (OR 0.58, 95% CI 0.35-0.97;OR 0.93, 95% CI 0.90-0.97). Among counties with at least one ID physician (n=519), 86.6% had no buprenorphine-waivered ID physicians (Figure 1). Figure 1 County-Level Distribution of Infectious Diseases Physicians with Buprenorphine Waivers Conclusion. Fewer than 3% of ID physicians in the US have obtained waivers to prescribe buprenorphine, highlighting missed opportunities to treat individuals with OUD, especially in rural America. Education on OUD management should be integrated into ID continuing medical education, and policies are urgently needed to expand buprenorphine access to persons without insurance.
ABSTRACT
Background: The contributions of non-AIDS comorbidities and HIV-related factors to coronavirus disease 2019 (COVID-19) outcomes among persons with HIV (PWH) remain unclear. We aimed to identify risk factors for COVID-19 hospitalization among PWH. Methods: We evaluated all adult (≥18 years) PWH with a positive SARS-CoV-2 PCR evaluated in a public safety-net hospital system, a Ryan White-funded HIV clinic and a Veterans Affairs medical center in Atlanta, GA between March 1, 2020 and November 15, 2020. Demographic and clinical characteristics and COVID-19 disease outcomes were ascertained by medical record abstraction. We performed multivariable logistic regression to determine associations with COVID-19 hospitalization. Results: 180 patients (mean age 49 years, 78% male, 78% Black, 14% Latinx) were included. 97% were on antiretroviral therapy (ART), 91% had HIV-1 RNA <200 copies/ml, and mean CD4 count was 527 cells/mm3. 60 patients (33%) were hospitalized, 28 (47%) required supplemental oxygen. Overall mortality rate among PWH was 1.63%;mortality among hospitalized PWH was 5%. 130 patients (72%) had at least 1 non-AIDS comorbidity;22% had >4 comorbidities (hypertension, dyslipidemia, obesity and diabetes were most prevalent). In univariable models, age, hypertension, dyslipidemia, diabetes, heart disease, and chronic kidney disease were associated with hospitalization. HIV characteristics including CD4 count, viral load, and ART use were not associated with hospitalization. After adjusting for those baseline characteristicsassociated with hospitalization, only age [aOR(95%CI) 1.073 (1.036-1.110), p<0.0001] and diabetes mellitus [aOR(95%CI) 2.653 (1.027-6.853), p=0.0439] were associated with hospitalization. In a multivariable model adjusting only for age, comorbidity count was associated with a 25% increased risk for hospitalization [aOR(95% CI) 1.245 (1.013-1.531), p=0.0375];and having ≥4 comorbidities was associated with a 2.8-fold increased risk of hospitalization compared with 0-1 comorbidities [aOR(95% CI) 2.848 (1.174-6.910), p=0.0240] (Figure). In age-adjusted analyses restricted to CD4 <200 cells/mm3 or HIV-1 RNA >200 copies/mL, HIV-related factors were not associated with hospitalization. Conclusion: In a cohort of PWH with well-controlled HIV and COVID-19, age and non-AIDS comorbidities, but not HIV-related factors, were associated with hospitalization for COVID-19. Further research into causes of severe COVID-19 among PWH is warranted. (Figure Presented).