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Background: People who inject drugs (PWID) may be at a greater risk of SARS-CoV-2 infection and COVID-19 due to socio-structural inequities, high-risk behaviors and comorbidities;however, PWID have been underrepresented in case-based surveillance due to lower access to testing. We characterize temporal trends and correlates of SARS-CoV-2 seroprevalence among a community-based sample of current and former PWID. Method(s): A cross-sectional study was conducted among participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study-a community-based cohort of adults with a history of injection drug use in Baltimore, Maryland. Participants' first serum sample collected at routine study visits between December 2020 and July 2022 was assayed for antibodies to the nucleocapsid (N) (past infection) and spike-1 (S) (past infection and/or vaccination) proteins using the MSD V-Plex Panel 2 IgG SARS-CoV-2 assay. For each correlate, we estimated adjusted prevalence ratios (PR) via separate Poisson regression models adjusted for calendar time, age, sex and race. Result(s): Of 561 participants, the median age was 59 years (range=28-77), 35% were female, 84% were Black, 36% were living with HIV (97% on ART), and 55% had received >=1 COVID-19 vaccine dose. Overall, anti-N and anti-S prevalence was 26% and 63%, respectively. Prevalence of anti-N increased from 23% to 40% between December 2020-May 2021 and December 2021-July 2022, with greater increases in the prevalence of anti-S from 34% to 86% over the same period (Figure). Being employed (PR=1.53 [95%CI=1.11-2.11]) and never being married (PR=1.40 [0.99-1.99]) were associated with a higher prevalence of anti-N, while female sex (PR=0.75 [0.55-1.02]) and a history of cancer (PR=0.40 [0.17-0.90]) were associated with a lower prevalence of anti-N. Younger age, female sex (PR=0.90 [0.80-1.02]), and homelessness (PR=0.78 [0.60-0.99]) were associated with a lower prevalence of anti-S. Although HIV infection was not associated with anti-N, it was associated with a higher prevalence of anti-S (PR=1.13 [1.02-1.27]). Substance use was not associated with anti-N or anti-S. Conclusion(s): Anti-N and anti-S levels increased over time, suggesting cumulative increases in SARS-CoV-2 incidence of infection and vaccination among PWID;however, disparities in seroprevalence remain. Younger and female PWID and those experiencing homelessness were less likely to be anti-S positive, suggesting programs should aim to improve vaccination coverage in such vulnerable populations.
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Background: Structural barriers to care among people who inject drugs (PWID) raise concerns about disproportionate access to essential services like COVID-19 vaccination. Given the heightened risk of serious complications resulting from SARS-CoV-2 infection, particularly among people living with HIV (PWH) with unsuppressed viral load, its critical to understand the role of HIV care among other factors associated with timely vaccination. We aimed to assess the role of HIV care on COVID-19 vaccination uptake among PWID. Method(s): We included 960 adult PWUD participating in the ALIVE (AIDS Linked to the Intravenous Experience) longitudinal study in Baltimore, Maryland, who were alive and in follow up as of April 2020. We ed COVID-19 vaccination data from electronic medical records linked to participants via the regional health information exchange. We conducted survival analysis to estimate time from broad vaccine eligibility (April 6, 2021) to completion of the COVID-19 vaccination primary series by HIV status (uninfected, virally suppressed PWH [HIV-RNA< 400 copies/mL], unsuppressed PWH [HIV-RNA >400 copies/mL]) and Cox Proportional Hazards regression to adjust for potential confounding by health status and substance use variables. Result(s): Our sample (N=960) was primarily black (77%) and male (65%) with 31% reporting recent injection drug use. Among 265 people living with HIV (PWH) in our sample (27%), 84% were virally suppressed. As of February 22, 2022, 539 (56%) completed the primary series, 131 (14%) received a single dose of mRNA vaccine and 290 (30%) remained unvaccinated. Compared to PWID without HIV, virally suppressed PWH were significantly more likely to complete the primary series (Adjusted Hazard Ratio [AHR]:1.23,95% Confidence Interval [95%CI]:1.07,1.50), while PWH with higher viral loads were less likely (AHR:0.72,95%CI:0.45,1.16). Sensitivity analyses with a subsample restricted to PWH confirmed significant differences in time to vaccination by viral load status (log-rank p-value: 0.016) and modeling with an origin of Dec. 12, 2020, yielded similar adjusted results. Conclusion(s): Among PWID with HIV, viral suppression is associated with quicker vaccination uptake, likely due to HIV care engagement. Alongside interventions targeting social determinants (e.g. low income, homelessness) and substance use behaviors (e.g. active injecting, stimulant use), targeted improvements along the HIV care continuum and other efforts to engage PWID may bolster vaccine uptake. Figure 1. Kaplan-Meier survival curve demonstrating time-to-vaccination (completion of COVID-19 primary series) in weeks by HIV status accounting for viral load (HIV-, HIV+ [VL <= 400 cells/muL], HIV+ [VL > 400 cells/muL]), including results for Log-rank tests for homogeneity among strata (p-value).
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BACKGROUND: Data from the COVID-19 pandemic describes increases in drug use and related harms, especially fatal overdose. However, evidence is needed to better understand the pathways from pandemic-related factors to substance use behaviours. Thus, we investigated stockpiling drugs among people who use drugs (PWUD) in five cities in the United States and Canada. METHODS: We used data from two waves of interviews among participants in nine prospective cohorts to estimate the prevalence and correlates of stockpiling drugs in the previous month. Longitudinal correlates were identified using bivariate and multivariate generalized linear mixed-effects modeling analyses. RESULTS: From May 2020 to February 2021, we recruited 1873 individuals who completed 2242 interviews, of whom 217 (11.6%) reported stockpiling drugs in the last month at baseline. In the multivariate model, stockpiling drugs was significantly and positively associated with reporting being greatly impacted by COVID-19 (Adjusted Odds Ratio [AOR]= 1.21, 95% CI: 1.09-1.45), and at least daily use of methamphetamine (AOR = 4.67, 95% CI: 2.75-7.94) in the past month. CONCLUSIONS: We observed that approximately one-in-ten participants reported stocking up on drugs during the COVID-19 pandemic. This behaviour was associated with important drug-related risk factors including high-intensity methamphetamine use. While these correlations need further inquiry, it is possible that addressing the impact of COVID-19 on vulnerable PWUD could help limit drug stockpiling, which may lower rates of high-intensity stimulant use.
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Background: The number of undiagnosed persons globally remains a barrier to achieving UNAIDS 95-95-95 goals. While nearly 80% are aware of their status, there is much variability by age and geography. Many of those undiagnosed are not engaging in traditional HIV services and do not visit physical locations;novel strategies are needed to overcome structural barriers. We implemented an online, HIV self-testing (HIVST) service for vulnerable populations in India. Methods: An integrated web-based platform for HIVST www.safezindagi. net/selftesting was implemented across 24 Indian states in July 2021. Virtual outreach workers (vORWs) contacted clients on dating apps and social media platforms, provided counseling, and directed interested clients to HIVST via a platform that allowed for home delivery or pick up at a community site. HIVST could be assisted or unassisted with pre/post-test counseling from vORWS. Linkage to confirmatory testing/ART and PrEP was provided as needed. Descriptive statistics were used to characterize outcomes. Results: Between June 30-October 21, 2021, 2,234 clients registered and 1,356 (61%) clients ordered an HIVST kit. Median age of the 1,356 clients was 27 years;74% were male and 66% self-identified as MSM. Ten percent self-identified as transgender. In the prior 6 months, 67% reported condomless sex, 51% multiple partners, 13% transactional sex, 7% STIs, and 4% injection drug use. 1,190 clients (88%) received their kits within 3 days;44% used a courier service and 56% picked up from a community site. Of 1,070 (90%) results uploaded, 43 (4%) were positive with geographical variability (5 states had >4% positivity). The median age of the positive clients was 30 years and 74% were male. Of importance, 65% reported condomless sex with multiple partners in prior 6 months and none were previously tested for HIV. 19 (44%) were linked to confirmatory testing of whom 16 (84%) were confirmed positive and 14 (88%) initiated ART at public centers (see Figure). Conclusion: These data highlight the role of an HIVST platform to reach first time test-takers in a population with high risk behaviors and identified HIV burden >16 times the general population. With increasing online engagement and uptake of telemedicine globally, as well as continuing disruptions due to COVID-19, HIVST offers a critical approach to reach high-risk individuals, identify PLHIV, and link them to care and treatment.
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Background: While the diversity in SARS-CoV-2 transmission across geographies and risk groups is well recognized, there has been limited investigation into spatial heterogeneity at a local scale, that is variability across a single city. Identifying patterns and factors associated with spatial variability requires population representative samples which are challenging to obtain but critical for mitigation strategies including vaccine distribution. Methods: From Jan to May 2021, we sampled 4,828 participants from 2,723 unique households across 100 spatial locations in Chennai, India using a probability proportional to population density sampling approach. All participants provided a blood sample and underwent a household and individual survey. 4,712 samples were tested for antibodies to the Spike protein (anti-Spike IgG) by the Abbott ARCHITECT. SARS-CoV-2 prevalence by spatial location was plotted using splines estimated by generalized additive models. Associations between seroprevalence and spatial attributes (zone, population density), study characteristics (date of sampling), household and individual-level covariates were estimated using Bayesian mixed effects logistic regression accounting for clustering within households and locations. Results: The median age was 38 and 49% self-identified as female. Overall, anti-S IgG prevalence was 61.9% (95% confidence interval [CI]: 60.5-63.3%) but ranged from 41.5% to 73.1% across the 12 zones. Splines indicated statistically significant variation in seroprevalence across the city (Panel A). Mixed effects regression including location and household effects indicated 31% of variance was attributable to location. In adjusted analysis, seroprevalence was significantly associated with population density (OR=1.46 per 100 people/100 sq meter [95%CI: 1.08-1.97];Panel B), age (OR=1.004 [95%CI: 1.0002-1.005]), having an air conditioner (OR=0.65 [95%CI: 0.43-0.98]) and sample timing but not with household crowding (OR=0.97 per person/room [95%CI: 0.75-1.26];Panel C). Significant spatial variation across locations remained after adjustment for these variables, accounting for 28% of variance. Conclusion: We observed substantial spatial heterogeneity of SARS-CoV-2 burden in this high prevalence setting not fully explained by individual, household or population factors. Such local variability in prevalence has implications not only for transmission but for scale-up of vaccines which remain in limited supply in low-and middle-income countries.
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Background: People who use unregulated drugs (PWUD) in Canada and the United States (US) are contending with the intersection of two simultaneous health crises: the COVID-19 pandemic and the longstanding drug poisoning crisis. However, the possible contributions of COVID-related factors to increases in overdoses during the pandemic are not well understood. Our study objectives were to assess the prevalence of non-fatal overdose and identify factors associated with overdose among participants in nine prospective cohorts of PWUD in urban centers in Canada (Vancouver, BC) and the US (Baltimore, MD;Miami, FL;Chicago, IL;Los Angeles, CA) during the COVID-19 pandemic. We further sought to examine the prevalence of and identify factors associated with reporting being highly impacted day-to-day by COVID-19. Methods: Data were derived from the nine cohorts in the NIDA-funded C3PNO consortium between May, 2020 and April, 2021. Multivariable logistic regression was used to identify factors associated with nonfatal overdose and day-to-day impact among participants who had used unregulated drugs in the past month. Results: Among 885 participants, 253 (28.6%) were female and 41 (4.6%) had reported experiencing a non-fatal overdose. Most of the sample reported being worried and approximately half reported being highly impacted day-to-day by the pandemic. In multivariable analyses, individuals who had experienced an overdose were more likely to be female (Adjusted Odds Ratio [AOR]=2.18;95% Confidence Interval [CI]:1.10-4.30);unstably housed/homeless (AOR = 2.16;95% CI: 1.11-4.26);engaged in medications for opioid use disorder (MOUD) (AOR = 2.45;95% CI: 1.19-4.97);and highly impacted day-to-day by COVID-19 (AOR = 2.42;95% CI: 1.22-5.10). In a second multivariable model, highly-impacted individuals were more likely to report higher levels of COVID-related worry (AOR = 1.30;95% CI: 1.23-1.37) and stocking up on drugs (AOR = 1.59, 95% CI: 1.09-2.32) due to the pandemic. Conclusion: Our findings indicate a need for a multi-level approach involving the spectrum of care services to meet the elevated risks of overdose in the context of the dual crises, particularly among women, those unstably housed/homeless and those who reported being highly impacted day-to-day by the pandemic. Efforts to prevent overdose, however, should prioritize addressing the root causes of the drug poisoning crisis, such as the continuous exposure to toxic and contaminated unregulated drug supplies among PWUD.
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Background: The COVID-19 pandemic disrupted the normal delivery of HIV care, altered social support networks, and caused economic insecurity. People with HIV (PWH) are vulnerable to such disruptions, particularly if they have a history of substance use. We describe engagement in care and adherence to antiretroviral therapy (ART) for PWH during the pandemic. Methods: From May 2020 to February 2021, 773 PWH enrolled in 6 existing cohorts completed 1495 surveys about substance use and engagement in HIV care during the COVID-19 pandemic. We described the prevalence and correlates of having missed a visit with an HIV provider in the past month and having missed a dose of ART in the past week. Results: Thirteen percent of people missed an HIV visit in the past month. Missing a visit was associated with unstable housing, food insecurity, anxiety, low resiliency, disruptions to mental health care, and substance use including cigarette smoking, hazardous alcohol use, cocaine, and cannabis use. Nineteen percent of people reported missing at least one dose of ART in the week prior to their survey. Missing a dose of ART was associated with being a man, low resiliency, disruptions to mental health care, cigarette smoking, hazardous alcohol use, cocaine, and cannabis use, and experiencing disruptions to substance use treatment. Conclusion: Social determinants of health, substance use, and disruptions to mental health and substance use treatment were associated with poorer engagement in HIV care. Close attention to continuity of care during times of social disruption is especially critical for PWH.
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Background: With global vaccine scale-up, the utility of the more stable anti-S IgG assay in seroprevalence studies is limited. P population prevalence estimates of anti-N IgG SARS-CoV-2 using alternate targets (eg, anti-N IgG) will be critical for monitoring cumulative SARS-CoV-2 incidence., We demonstrate the utility of a Bayesian approach that accounts for heterogeneities in SARS-CoV-2 seroresponse (eg, must consider mild infections and/or antibody waning) to ensure anti-N IgG prevalence is not underestimated and correlates not misinterpreted. Methods: We sampled 4,828 participants from 2,723 households across 100 unique geospatial locations in Chennai, India, from Jan-May, 2021 when <1% of the general population was vaccinated. All samples were tested for SARS-CoV-2 IgG antibodies to S and N using the Abbott ARCHITECT. We calculated prevalence using manufacturer cut-offs and applied a Bayesian mixture model. In the mixture model, individuals were assigned a probability of being seropositive or seronegative based on their normalized index value, accounting for differential immune response by age and antibody waning. Regression analyses to identify correlates of infection defined seropositivity by manufacturer cut-offs and the mixture model. Results: The raw SARS-CoV-2 seroprevalence using IgG to S (cutoff=50) and N (cutoff=1.4) were 61.9% (95% confidence interval [CI]: 60.5-63.3%) and 13.7% (CI: 12.8-14.7%), respectively with a correlation of 0.33. With the mixture model, anti-N IgG prevalence was 65.4% (95% credible interval [CrI]: 61.8-68.9). Correlates of anti-N IgG positivity differed qualitatively by the two approaches (Table). Using the manufacturer cut-off, income loss during the pandemic, household crowding and lack of air conditioning were associated with significantly lower anti-N prevalence. By contrast, in the mixture model, many measures of lower socioeconomic status were associated with higher prevalence, associations that were comparable when anti-S was the outcome. The age pattern differed between approaches: the mixture model identified that individuals aged >50 had the lowest seroprevalence, but the highest immune response to infection. Conclusion: With global vaccine scale-up, population prevalence estimates of anti-N IgG will be critical for monitoring cumulative SARS-CoV-2 incidence. We demonstrate the utility of a Bayesian approach that accounts for heterogeneities in SARS-CoV-2 seroresponse to improve accuracy of anti-N IgG prevalence estimates and associated correlates.
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Background: The COVID-19 pandemic and associated lockdowns threaten to diminish gains made with respect to HIV epidemic control. The impacts are likely to be most profound among marginalized key populations in resource-limited settings. Methods: Beginning in 2013, we initiated integrated care centers (ICCs) targeting PWID and MSM;ICCs are currently active in 16 Indian cities (8 PWID, 8 MSM) providing core and population-focused HIV services, including HIV counseling/testing, STI testing, and linkage to/monitoring of ART from government facilities. To understand the pandemic's impact on service access, we compared service utilization among ICC clients early in the pandemic (March-July 2020) to pre-pandemic (Jan-Feb 2020) levels. Specifically, we assessed: 1) numbers of clients accessing HIV testing and STI screening as well as new HIV diagnoses, and 2) for HIV-infected clients on ART in December 2019, the medication possession ratio (MPR). The MPR is the percentage of days in a month that a client had an available dose of ART based on the client's government ART book. Results: Overall, 14,415 clients visited an ICC from Jan-July 2020. Compared to pre-pandemic levels, the total number of clients receiving services at the ICC began declining in March and dropped to ∼25% normal capacity in May and only returned to ∼35% capacity by July. HIV testing declined by 88% beginning in mid-March (PWID 90%, MSM 84%) followed by a modest increase in April/ May, but levels did not return to pre-pandemic levels (Figure panel A);a similar pattern was seen for STI testing. HIV diagnoses had a sharp decline in March/ April with no significant rebound to pre-pandemic levels by July;among MSM there was only one new diagnosis in all of April-July, compared to ∼30 each month in January and February. Compared to February, the median MPR in April declined by nearly 60% for PWID (from an MPR of 97% to 40%) and by 20% for MSM (100% to 80%). The MPR continued to fall for PWID reaching a nadir of 16% in July;by contrast the MPR climbed back to near pre-pandemic levels for MSM by July (Figure panel B). Conclusion: The COVID-19 pandemic has led to significant decreases in use of HIV-related services among key populations in India. PWID have fared substantially worse than MSM in both preventive and treatment services. This presents an opportunity for increased transmission and incidence among groups that are already disproportionately impacted by the HIV epidemic.
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Background: Routine HIV testing for partners and children of PLHIV (e.g., index testing) is a key component of HIV prevention. Anecdotal information suggests that the COVID-19 pandemic's lockdowns and subsequent economic and mobility restrictions have impacted HIV testing programs;however, there is limited empirical data demonstrating this. Methods: Beginning in Oct 2019, we initiated index testing services in 5 high HIV prevalence districts in two Indian states (Maharashtra and Andhra Pradesh) at 55 sites (48 facility-based/7 community-based) to elicit and test contacts (spouses, sexual/needle-sharing partners, children) of known PLHIV. To assess the pandemic's impact on index testing outcomes among contacts, we compared outcomes in a pre-pandemic period (Jan-Mar 2020) to two post-pandemic periods: 1) a lockdown period (Apr-June 2020), and 2) a postlockdown period when restrictions were eased (July-Sept 2020). Specifically, we compared the index testing cascade: number of contacts tested, number of contacts testing HIV+, proportion testing HIV+, and proportion initiating ART, by period and setting (facility vs. community-based). Results: In the pre-pandemic period, 3,191 contacts of 2,258 PLHIV were tested, among whom 859 tested HIV+ (27% positivity). By comparison, in the lockdown period, the number of contacts tested decreased by 84% (rate ratio [RR], 0.16;p<0.001) but positivity increased to 40%. Increases in the number tested were seen post-lockdown, but remained below pre-pandemic levels (RR, 0.54, p<0.001;Panel A). Overall, the pandemic's impact was more severe in facility vs. community sites (Panel B). By Sept 2020, the number of contacts testing positive returned to near pre-pandemic levels in community sites but remained <50% in facility sites. The proportion of newly diagnosed contacts who initiated treatment increased from 81% pre-pandemic to 88% in the lockdown and post-lockdown periods (p<0.01). The median time from diagnosis to ART initiation was 8 days pre-pandemic and during the lockdown, but reduced to 4 days post-lockdown. Conclusion: The pandemic resulted in significant declines in the testing of contacts of PLHIV and new HIV diagnoses, however linkage to ART among those newly diagnosed remained high. Our findings suggest that expansion of community-based service sites and/or incorporating strategies such as HIV self-testing may be needed to regain and maintain progress towards UNAIDS 95-95-95 goals, given the ongoing impacts of COVID-19.
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Background: Rapid detection and isolation of SARS-CoV-2 infections is critical to mitigate the pandemic;however, testing access across the US has been uneven and data on barriers to testing are limited. Methods: We conducted serial cross-sectional assessments of experiences around SARS-CoV-2 PCR testing in Florida, Illinois, and Maryland. We sampled ∼1000/state using an online survey from Jul 15-31 and Sep 16-Oct 15, 2020, with additional waves planned at 6-8 week intervals. At the time of surveys, there were no systematic differences in testing availability (public, private and free testing options) across these states. Participants were recruited using on online panel;demographic targets were provided to match age, sex, race/ethnicity and income distributions of each state. Participants were ≥18 years, provided consent, and resided in the study state. The survey covered demographics, symptoms, and PCR testing in the prior 2 weeks. Results: Of 3,058 persons surveyed most recently (Sep 16-Oct 15), 316 (10%) reported wanting/needing a test in the prior two weeks. Median age of participants wanting/needing a test was 36 years and 46% were female;47% self-identified as White and 57% reported working outside home. Of 316 who wanted/needed a test in the prior 2 weeks, 53% were able to get tested, of whom, 94% received results, with no significant differences by state (Figure);this was not substantially different from the proportion able to get tested in July (51%). Among those wanting/needing a test, getting tested was significantly less common among men (aOR: 0.46) and those reporting black race (aOR: 0.53) and more common in those reporting recent travel (aOR: 3.35;all p<0.05). The primary reasons for testing were desire to know status (35%) and symptoms (28%). Among those tested, 53% had to wait ≥8 days to get a result from the time they wanted/needed a test. Of those tested, 71% reported quarantining while awaiting results. An additional 146 who wanted/needed a test did not get tested;the main reasons for not testing in this group were not knowing where to go (36%) and distance/waiting time (33%);an additional 21% reported fear of being tested. Conclusion: These data reflecting similar testing barriers across three US states underscore the importance of a unified national strategy with clear messaging on who, where, when, and how to get a test, as well as improved turn-aroundtimes. As demand rises borrowing strategies from HIV such as self-testing could help overcome logistical barriers.