Patient and stakeholder perspectives on impacts of the COVID-19 pandemic on HIV and mental health care delivery in South Africa.

BACKGROUND: The COVID-19 pandemic had a global impact on health systems and the delivery of health services, including for chronic conditions such as HIV. In South Africa, impacts on HIV services have widely been quantitatively described. Across different health settings, patients have also qualitatively described numerous negative impacts to their HIV care. However, patient perspectives on COVID-19 impacts to HIV care in South Africa, the largest HIV care system in the world, have been little explored to date. METHODS: We conducted 29 semi-structured individual interviews with people living with HIV (n = 24) and providers (n = 5) in Cape Town, South Africa. RESULTS: While most patient participants reported continued access to HIV treatment during the pandemic, many described perceiving that the quality of their care declined. Increased structural barriers were described as one contributing factor to this change. Additionally, patients described that reduced privacy in clinical interactions was a key factor negatively influencing their experience of receiving care. CONCLUSION: Findings underscore the importance of ensuring patient privacy for HIV services even during the rearrangement of services in emergencies. It is also important to continue developing models to integrate community mental health services within HIV care delivery in South Africa.

Patient experiences of COVID-19-induced changes to methadone treatment in a large community-based opioid treatment program in Baltimore.

INTRODUCTION: Following the March 2020 federal declaration of a COVID-19 public health emergency, in line with recommendations for social distancing and decreased congregation, federal agencies issued sweeping regulation changes to facilitate access to medications for opioid use disorder (MOUD) treatment. These changes allowed patients new to treatment to receive multiple days of take-home medications (THM) and to use remote technology for treatment encounters-allowances that previously had been reserved exclusively for "stable" patients who met minimum adherence and time-in-treatment criteria. The impact of these changes on low-income, minoritized patients (frequently the largest recipients of opioid treatment program [OTP]-based addiction care), however, is not well characterized. We aimed to explore the experiences of patients who were enrolled in treatment prior to COVID-19 OTP regulation changes, with the goal of understanding patients' perceptions of the impact of these changes on treatment. METHODS: This study included semistructured, qualitative interviews with 28 patients. We used a purposeful sampling method to recruit individuals who were active in treatment just before COVID-19-related policy changes went into effect, and who were still in treatment several months later. To ensure a diverse array of perspectives, we interviewed individuals who either had or had not experienced challenges with methadone medication adherence from 3/24/21 to 6/8/21, approximately 12-15 months following the onset of COVID-19. Interviews were transcribed and coded using thematic analysis. RESULTS: Participants were majority male (57 %), Black/African American (57 %), with a mean age of 50.1 (SD = 9.3). Fifty percent received THM prior to COVID-19, which increased to 93 % during the pandemic. COVID-19 program changes had mixed effects on treatment and recovery experiences. Themes identified convenience, safety, and employment as reasons for preferring THM. Challenges included difficulty with managing/storing medications, experiencing isolation, and concern about relapse. Furthermore, some participants reported that telebehavioral health encounters felt less personal. CONCLUSIONS: Policymakers should consider patients' perspectives to foster a more patient-centered approach to methadone dosing that is safe, flexible, and accommodating to a diverse array of patients' needs. Additionally, technical support should be provided to OTPs to ensure interpersonal connections are maintained in the patient-provider relationship beyond the pandemic.

"How can I hug someone now [over the phone]?": Impacts of COVID-19 on peer recovery specialists and clients in substance use treatment.

INTRODUCTION: The COVID-19 pandemic has disproportionately affected underserved, low-income, ethnoracial minority communities, as well as those with substance use disorders (SUDs). The workforce of peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, has rapidly expanded in response to a shortage of access to substance use treatment, particularly for those from underserved communities. As PRSs are likely serving individuals disproportionately affected by the pandemic, it is important to understand how COVID-19 has affected the PRS role and the individuals with SUD who they are supporting. METHOD: This study aimed to examine: (1) the impact of COVID-19 on the PRS role and experience, (2) the impact of COVID-19 on clients in or seeking SUD treatment, (3) facilitators for clients engaging in treatment and adapting to new changes, and (4) sustainability of new treatment methods post-pandemic. RESULTS: Findings suggest that PRSs have had to adapt their role and responsibilities to meet changing client needs; however, PRS strengths, such as their shared experience and expertise navigating treatment barriers, make them uniquely suited to assist clients during the pandemic. The study identified various barriers and facilitators to clients seeking treatment or living with SUD, such as the loss of interpersonal connection. PRSs also identified some drawbacks to utilizing telehealth, but identified this as a potentially sustainable approach to delivering care after the pandemic. CONCLUSION: Future research could explore how challenges to fulfilling the PRS role, as well as adaptations to overcome these challenges, have changed over time.

Mobile Telemedicine for Buprenorphine Treatment in Rural Populations With Opioid Use Disorder.

Importance: The demand for medications for opioid use disorder (MOUD) in rural US counties far outweighs their availability. Novel approaches to extend treatment capacity include telemedicine (TM) and mobile treatment on demand; however, their combined use has not been reported or evaluated. Objective: To evaluate the use of a TM mobile treatment unit (TM-MTU) to improve access to MOUD for individuals living in an underserved rural area. Design, Setting, and Participants: This quality improvement study evaluated data collected from adult outpatients with a diagnosis of OUD enrolled in the TM-MTU initiative from February 2019 (program inception) to June 2020. Program staff traveled to rural areas in a modified recreational vehicle equipped with medical, videoconferencing, and data collection devices. Patients were virtually connected with physicians based more than 70 miles (112 km) away. Data analysis was performed from June to October 2020. Intervention: Patients received buprenorphine prescriptions after initial teleconsultation and follow-up visits from a study physician specialized in addiction psychiatry and medicine. Main Outcomes and Measures: The primary outcome was 3-month treatment retention, and the secondary outcome was opioid-positive urine screens. Exploratory outcomes included use of other drugs and patients' travel distance to treatment. Results: A total of 118 patients were enrolled in treatment, of whom 94 were seen for follow-up treatment predominantly (at least 2 of 3 visits [>50%]) on the TM-MTU; only those 94 patients' data are considered in all analyses. The mean (SD) age of patients was 36.53 (9.78) years, 59 (62.77%) were men, 71 (75.53%) identified as White, and 90 (95.74%) were of non-Hispanic ethnicity. Fifty-five patients (58.51%) were retained in treatment by 3 months (90 days) after baseline. Opioid use was reduced by 32.84% at 3 months, compared with baseline, and was negatively associated with treatment duration (F = 12.69; P = .001). In addition, compared with the nearest brick-and-mortar treatment location, TM-MTU treatment was a mean of 6.52 miles (range, 0.10-58.70 miles) (10.43 km; range, 0.16-93.92 km) and a mean of 10 minutes (range, 1-49 minutes) closer for patients. Conclusions and Relevance: These data demonstrate the feasibility of combining TM with mobile treatment, with outcomes (retention and opioid use) similar to those obtained from office-based TM MOUD programs. By implementing a traveling virtual platform, this clinical paradigm not only helps fill the void of rural MOUD practitioners but also facilitates access to underserved populations who are less likely to reach traditional medical settings, with critical relevance in the context of the COVID-19 pandemic.

"I have to be around people that are doing what I'm doing": The importance of expanding the peer recovery coach role in treatment of opioid use disorder in the face of COVID-19 health disparities.

The COVID-19 pandemic and ongoing opioid epidemic are causing notable morbidity and mortality among low-income and minority populations. Peer recovery coaches (PRCs), people with lived experience of substance use and recovery, are uniquely positioned to support underserved, minority individuals who face the greatest barriers to care. This commentary combines research and clinical perspectives to describe the potential role of PRCs in reaching and supporting particularly vulnerable populations in the setting of substantial changes in the opioid use disorder (OUD) recovery landscape during COVID-19. During this time, PRCs can provide guidance from their own experience navigating changes to routines and social support systems, reduce social isolation, build trust and buy-in, and support engagement in care. Specific barriers include access to technology and underlying distrust of public and medical authorities. This article highlights the importance of expanding the reach of the PRC workforce as well as supporting their specific needs at this time to combat the intersecting devastation of two epidemics.