Contingency management with stepped care for unhealthy alcohol use among individuals with HIV: Protocol for a randomized controlled trial.

BACKGROUND: Although unhealthy alcohol use is associated with increased morbidity and mortality among people with HIV (PWH), many are ambivalent about engaging in treatment and experience variable responses to treatment. We describe the rationale, aims, and study design for the Financial Incentives, Randomization, with Stepped Treatment (FIRST) Trial, a multi-site randomized controlled efficacy trial. METHODS: PWH in care recruited from clinics across the United States who reported unhealthy alcohol use, had a phosphatidylethanol (PEth) >20 ng/mL, and were not engaged in formal alcohol treatment were randomized to integrated contingency management with stepped care versus treatment as usual. The intervention involved two steps; Step 1: Contingency management (n = 5 sessions) with potential rewards based on 1) short-term abstinence; 2) longer-term abstinence; and 3) completion of healthy activities to promote progress in addressing alcohol consumption or conditions potentially impacted by alcohol; Step 2: Addiction physician management (n = 6 sessions) plus motivational enhancement therapy (n = 4 sessions). Participants' treatment was stepped up at week 12 if they lacked evidence of longer-term abstinence. Primary outcome was abstinence at week 24. Secondary outcomes included alcohol consumption (assessed by TLFB and PEth) and the Veterans Aging Cohort Study (VACS) Index 2.0 scores; exploratory outcomes included progress in addressing medical conditions potentially impacted by alcohol. Protocol adaptations due to the COVID-19 pandemic are described. CONCLUSIONS: The FIRST Trial is anticipated to yield insights on the feasibility and preliminary efficacy of integrated contingency management with stepped care to address unhealthy alcohol use among PWH. CLINICALTRIALS: gov identifier: NCT03089320.

Physician response to COVID-19-driven telehealth flexibility for opioid use disorder.

OBJECTIVES: To learn how preferences and practices regarding telehealth have evolved during the COVID-19 pandemic for physicians who provide opioid use disorder (OUD) treatment. STUDY DESIGN: Publicly registered physicians who provide OUD treatment were surveyed on their current and retrospective use of telehealth and how their perception of telehealth effectiveness and policy preferences have changed during the COVID-19 pandemic as telehealth regulations were loosened throughout the country. METHODS: The primary survey data were collected in July 2020 leveraging administrative contact information for the population of publicly listed buprenorphine-prescribing physicians in the United States. A total of 1141 physicians received the survey and consented to participate. RESULTS: Many surveyed physicians used telehealth for the first time during the early COVID-19 era (29% pre-COVID-19 use rate increased to 66%). Most respondents found telehealth to be more effective than expected (54% vs 16% who found it less effective), 85% were in favor of the temporary telehealth flexibility being permanently extended, and 77% would be likely to use telehealth after the COVID-19 pandemic, regulations permitting. Imputation exercises that leverage the linked survey and administrative data suggest that the findings are unlikely to be driven by nonrandom survey participation. CONCLUSIONS: Physicians were asked about their OUD telehealth policy preferences. Findings suggest that the COVID-19 pandemic increased physician respondent use of telehealth technology, and this has positively shifted their perceptions of effectiveness. Respondents overwhelmingly report interest in post-COVID-19 pandemic telehealth use and support for proposed legislation to loosen telehealth restrictions.

HIV Infection Prevalence Significantly Intersects With COVID-19 Infection At the Area Level: A US County-Level Analysis.

BACKGROUND: Limited empirical evidence exists about the extent to which the current HIV epidemic intersects with COVID-19 infections at the area/geographic level. Moreover, little is known about how demographic, social, economic, behavioral, and clinical determinants are jointly associated with these infectious diseases. SETTING: Contiguous US counties (N = 3108). METHODS: We conducted a cross-sectional analysis and investigated the joint association between new HIV infection prevalence in 2018 and COVID-19 infections (January 22, 2020 and October 7, 2020) and explore the contribution of factors such as income inequality, binge drinking, and socioeconomic deprivation. We used Bayesian multivariate spatial models to estimate the cross-disease correlations between these diseases and identified hotspots, which we defined as a county with a posterior probability greater than 80% of being in the top decile of that disease. RESULTS: New HIV infection prevalence and COVID-19 infection moderately and significantly intersect [spatial correlation = 0.37, 95% credible interval (CrI) = 0.36-0.37]. Seventy-five counties, mostly in the south, were at elevated burden for HIV and COVID-19 infections. Higher income inequality was positively associated with both COVID-19 (relative risk 1.05, 95% CrI = 1.03-1.07) and HIV infection (relative risk = 1.12, 95% CrI = 1.09-1.15). CONCLUSIONS: We found that there is a considerable intersection between the current distribution of HIV burden with COVID-19 infections at the area level. We identified areas that federal funding and vaccination campaigns should prioritize for prevention and care efforts.

Association of Poor Mental-Health Days With COVID-19 Infection Rates in the U.S.

INTRODUCTION: Limited evidence exists about the association between prior prevalence of poor mental health at the area level and subsequent rates of COVID-19 infections. This association was tested using area-level nationwide population data in the U.S. METHODS: A nationwide study including 2,839 U.S. counties was conducted. Poor mental health was the age-adjusted average number of days within the past 30 days that adults reported poor mental health, including depression, stress, and problems with emotions, from the Behavioral Risk Factor Surveillance System. COVID-19 infection rates were cumulative confirmed cases between January 22 and October 7, 2020 per 100,000 people in the general population. Bayesian spatial mixed-effects regression estimated the relationship between COVID-19 infection and poor mental-health days at the county level in 2019 and change in poor mental health between 2010 and 2019, adjusted for several covariates. RESULTS: Poor mental-health days in 2019 were positively associated with higher COVID-19 infection rates (RRR=1.059, 95% credible interval=1.003, 1.117). Change in mental health was not significantly associated with COVID-19. CONCLUSIONS: Prior rates of poor mental health in a county were associated with a higher burden of COVID-19 infection. Interventions that improve well-being and strengthen mental-health systems at the community and other geographic levels are needed to address post-COVID-19 mental health problems.

Naloxone Use by Emergency Medical Services During the COVID-19 Pandemic: A National Survey.

OBJECTIVES: The COVID-19 epidemic in the United States has hit in the midst of the opioid overdose crisis. Emergency medical services (EMS) clinicians may limit their use of intranasal naloxone due to concerns of novel coronavirus infection. We sought to determine changes in overdose events and naloxone administration practices by EMS clinicians. METHODS: Between April 29, 2020 and May 15, 2020, we surveyed directors of EMS fellowship programs across the US about how overdose events and naloxone administration practices had changed in their catchment areas since March 2020. RESULTS: Based on 60 respondents across all regions of the country, one fifth of surveyed communities have experienced an increase in opioid overdoses and events during which naloxone was administered, and 40% have experienced a decrease. The findings varied by region of the country. Eighteen percent of respondents have discouraged or prohibited the use of intranasal naloxone with 10% encouraging the use of intramuscular naloxone. CONCLUSIONS: These findings may provide insight into changes in opioid overdose mortality during this time and assist in future disaster planning.