Field Testing the "Avoid the Needle" Intervention for Persons at Risk for Transitioning to Injecting Drug Use in Tallinn, Estonia and New York City, USA.

This study aimed to field tested the "Avoid the Needle" (AtN) intervention to reduce transitions from non-injecting to injecting drug use in two different epidemiological settings. Respondent driven sampling was used to recruit current non-injecting drug users (NIDUs) in Tallinn, Estonia in 2018-19 and in New York City (NYC) in 2019-20. Both persons who had never injected and persons who had previously injected but not in the last 6 months were eligible; a structured interview was administered, a blood sample collected, and the intervention administered by trained interventionists. We recruited 19 non-injectors from Tallinn and 140 from NYC. Participants in Tallinn were younger and had begun using drugs at earlier ages than participants in NYC. The primary drugs used in Tallinn were amphetamine, fentanyl, and opioid analgesics, while in NYC they were heroin, cocaine, speedball, and fentanyl. Six-month follow-up data were obtained from 95% of participants in Tallinn. The study was interrupted by COVID-19 lockdown in NYC, but follow-up data were obtained from 59% of participants. There were minimal transitions to injecting: 1/18 in Tallinn and 0/83 in NYC. There were significant declines in the frequencies of using readily injectable drugs (fentanyl, amphetamine, heroin, cocaine) from baseline to follow-up in both sites (Cochran-Armitage tests for trend, χ2 = 21.3, p < 0.001 for New York City; and χ2 = 3.9, p = 0.048 for Tallinn). Reducing transitions into injecting is a potentially very important method for reducing HIV transmission and other harms of drug use. Further investigation and implementation of AtN type interventions is warranted.

Public health interventions, priority populations, and the impact of COVID-19 disruptions on hepatitis C elimination among people who have injected drugs in Montreal (Canada): A modeling study.

BACKGROUND: In Montreal (Canada), high hepatitis C virus (HCV) seroincidence (21 per 100 person-years in 2017) persists among people who have injected drugs (PWID) despite relatively high testing rates and coverage of needle and syringe programs (NSP) and opioid agonist therapy (OAT). We assessed the potential of interventions to achieve HCV elimination (80% incidence reduction and 65% reduction in HCV-related mortality between 2015 and 2030) in the context of COVID-19 disruptions among all PWID and PWID living with HIV. METHODS: Using a dynamic model of HCV-HIV co-transmission, we simulated increases in NSP (from 82% to 95%) and OAT (from 33% to 40%) coverage, HCV testing (every 6 months), or treatment rate (100 per 100 person-years) starting in 2022 among all PWID and PWID living with HIV. We also modeled treatment scale-up among active PWID only (i.e., people who report injecting in the past six months). We reduced intervention levels in 2020-2021 due to COVID-19-related disruptions. Outcomes included HCV incidence, prevalence, and mortality, and proportions of averted chronic HCV infections and deaths. RESULTS: COVID-19-related disruptions could have caused temporary rebounds in HCV transmission. Further increasing NSP/OAT or HCV testing had little impact on incidence. Scaling-up treatment among all PWID achieved incidence and mortality targets among all PWID and PWID living with HIV. Focusing treatment on active PWID could achieve elimination, yet fewer projected deaths were averted (36% versus 48%). CONCLUSIONS: HCV treatment scale-up among all PWID will be required to eliminate HCV in high-incidence and prevalence settings. Achieving elimination by 2030 will entail concerted efforts to restore and enhance pre-pandemic levels of HCV prevention and care.

Hepatitis C Infection and Treatment among Injecting Drug Users Attending General Practice: A Systematic Review and Meta-Analysis.

BACKGROUND: The care provided in general practice to intravenous drug users (IDUs) with hepatitis C (HCV) extends beyond opioid substitution therapy. An aggregated analysis of HCV service utilization within general practice specifically related to diagnosis and treatment outcomes remains unknown from previous literature. AIMS: This study aims to estimate the prevalence of HCV and analyze data related to the diagnosis and treatment-related outcomes of HCV patients with a history of intravenous drug use in the general practice setting. DESIGN AND SETTING: A systematic review and meta-analysis in general practice. METHODS: This review included studies published in the following databases: EMBASE, PubMed, and Cochrane Central Register of Controlled Trials. Two reviewers independently extracted data in standard forms in Covidence. A meta-analysis was done using a DerSimonian and Laird random-effects model with inverse variance weighting. RESULTS: A total of 20,956 patients from 440 general practices participated in the 18 selected studies. A meta-analysis of 15 studies showed a 46% (95% confidence interval (CI), 26-67%) prevalence rate of hepatitis C amongst IDUs. Genotype information was available in four studies and treatment-related outcomes in 11 studies. Overall, treatment uptake was 9%, with a cure rate of 64% (95% CI, 43-83%). However, relevant information, such as specific treatment regimens, treatment duration and doses, and patient comorbidities, was poorly documented in these studies. CONCLUSION: The prevalence of HCV in IDUs is 46% in general practice. Only ten studies reported HCV-related treatment outcomes; however, the overall uptake rate was below 10%, with a cure rate of 64%. Likewise, the genotypic variants of HCV diagnoses, medication types, and doses were poorly reported, suggesting a need for further research into this aspect of care within this patient group to ensure optimal treatment outcomes.

"You'll come in and dose even in a global pandemic": A qualitative study of adaptive opioid agonist treatment provision during the COVID-19 pandemic.

BACKGROUND: Opioid agonist treatment (OAT) improves multiple health and social outcomes, yet requirements to attend for supervised dosing can be burdensome and stigmatising. The COVID-19 pandemic and associated restrictions threatened continuity of care and the wellbeing of people receiving OAT, risking a parallel health crisis. This study sought to understand how adaptations in the complex system of OAT provision impacted and responded to risk environments of people receiving OAT during the COVID-19 pandemic. METHODS: The analysis draws on semi-structured interviews with 40 people receiving and 29 people providing OAT located across Australia. The study considered the risk environments that produce COVID-19 transmission, treatment (non-)adherence, and adverse events for people receiving OAT. Drawing on theories of risk environments and complex adaptive systems, data were coded and analysed to understand how adaptations to the typically rigid system of OAT provision impacted and responded to risk environments during the COVID-19 pandemic. RESULTS: During COVID-19, the complex system of OAT provision demonstrated possibilities for responsive adaptation to the entangled features of risk environments of people receiving OAT. Structural stigma was evident in the services which stayed rigid during the pandemic, requiring people to attend for daily supervised dosing and risking fracturing therapeutic relationships. In parallel, there were several examples of services developing enabling environments by offering flexible care through increased takeaways, treatment subsidies, and home delivery. CONCLUSIONS: Rigidity in the delivery of OAT has been an impediment to achieving health and wellbeing over past decades. To sustain health-promoting environments for people receiving OAT, the wider impacts of the complex system should be acknowledged beyond narrowly defined outcomes relating solely to the medication. Centring people receiving OAT in their own care plans will ensure adaptations in the complex system of OAT provision are responsive to the individual's risk environment.

Protecting persons at-risk of viral hepatitis and alcohol-related liver disease during the pandemic and beyond: mitigating the impact of Coronavirus disease 2019 on liver health

Background: Treatment seeking for people with alcohol use disorders (AUD), injecting drug use and viral hepatitis is low, and has worsened during the coronavirus disease 2019 (COVID-19) pandemic. Deferring clinical care and increasing drug and alcohol use exacerbate the risks of progression for individuals with chronic liver disease from viral hepatitis and/or alcohol-related liver disease (ALD). We explored the impact COVID-19 epidemic may have on patients with chronic liver disease and suggested mechanisms to protect this at-risk population during and after the pandemic.

Assessment of knowledge and challenges toward the use of subcutaneous self-injecting insulin among diabetes patients during COVID-19 pandemic in Saudi Arabia.

BACKGROUND: The COVID-19 pandemic has revolutionized the delivery of chronic health care. For diabetic patients, maintaining regular contact with healthcare providers and visiting healthcare centers are crucial to patients' overall ability to control their glycemic status. OBJECTIVE: To assess patients' knowledge regarding the use of insulin injection devices and the challenges these patients face in obtaining medical advice, as well as to suggest alternative solutions for addressing these challenges among diabetic patients self-administering their injections during the COVID-19 pandemic. METHODOLOGY: An observational cross-sectional study was conducted among a sample population (N = 178) of diabetic patients attending Security Forces Hospital-Riyadh, Saudi Arabia, from which the Institutional Review Board (IRB) was granted. Data was collected using a self-administered questionnaire, which was distributed from August to September 2020. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) program (version 21). Significant P-value = < 0.05. RESULTS: The majority of patients had good knowledge and practice explained with values 73.6% of total papulation. Sixty-four percent of patients with type 1 diabetes and 59% of patients with type 2 diabetes reported experiencing moderately severe challenges obtaining counseling. There was no correlation between severity of disease and knowledge levels (p-value = 0.36). The most appropriate means of obtaining counseling was determined to be conversations with healthcare providers; this strategy received an overall average score of 4.9 ± 0.4 (p-value < 0.0001). CONCLUSION: Regardless of whether knowledge is high among patients with diabetes, continuous support and counseling from healthcare providers is critical. The creation of innovative approaches to facilitate communication between diabetes patients and healthcare providers is recommended for continued patient care during the COVID-19 pandemic.

Association between social vulnerability and rates of HIV diagnoses among black adults, by selected characteristics and region of residence - United States, 2018

During 2018, Black or African American (Black) persons accounted for 43% of all new diagnoses of HIV infection in the United States (1). The annual diagnosis rate (39.2 per 100,000 persons) among Black persons was four times the rate among all other racial/ethnic groups combined, indicating a profound disparity in HIV diagnoses (1,2). Community-level social and structural factors, such as social vulnerability, might help explain the higher rate of HIV diagnoses among Black persons. Social vulnerability refers to the potential negative health effects on communities caused by external stresses (3). CDC used National HIV Surveillance System (NHSS)* and Social Vulnerability Index (SVI) data to examine the association between diagnosed HIV infections and social vulnerability among Black adults aged 18 years. Black adults in communities in the highest quartile of SVI were 1.5 times (rate ratio [RR] = 1.5;95% CI = 1.4-1.6) as likely to receive a diagnosis of HIV infection as were those in communities in the lowest quartile. Because of a history of racial discrimination and residential segregation, some Black persons in the United States reside in communities with the highest social vulnerability (4,5), and this finding is associated with experiencing increased risk for HIV infection. The development and prioritization of interventions that address social determinants of health (i.e., the conditions in which persons are born, grow, live, work, and age), are critical to address the higher risk for HIV infection among Black adults living in communities with high levels of social vulnerability. Such interventions might help prevent HIV transmission and reduce disparities among Black adults. Data on diagnoses of HIV infection among Black adults and reported to CDC through December 2019 were obtained from NHSS. Cases were geocoded to the U.S. Census Bureau tract level based on a person's residential address at the time of diagnosis. Census tract level social vulnerability data were obtained from the 2018 CDC SVI, which was developed to identify communities with the most potential needs (i.e., highest social vulnerability), before, during, and after public health events. Scores for overall SVI were generated using 15 population-based measures.. and were presented as percentile rankings by census tract, with higher scores indicating more vulnerability. SVI scores ranged from 0 to 1 and were categorized as quartiles based on their distribution among all U.S. Census tracts. NHSS data for Black adults with HIV diagnosed during 2018 were linked with SVI data. Data were analyzed by sex at birth with stratifications by age group and region of residence.. at time of diagnosis to assess differences in HIV diagnosis rates by SVI quartile. HIV diagnosis rates were calculated per 100,000 persons. RRs with 95% CIs were calculated comparing communities with the lowest SVI scores (Quartile 1) to those with the highest scores (Quartile 4) by sex at birth for age group and region of residence. Rates were considered significantly different if the 95% CIs of RRs excluded 1. Differences in numbers of diagnoses across the quartiles were analyzed by sex at birth and transmission category (i.e., male-to-male sexual contact, injection drug use, and heterosexual contact.) Rates and RRs were not calculated for transmission categories because of lack of population data. Data were statistically adjusted using multiple imputation techniques to account for missing HIV transmission categories (6). Analyses were conducted using SAS software (version 9.4;SAS Institute, Inc). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.**Among the 13,807 diagnoses of HIV infection among Black adults in 2018, the number and percentage of diagnoses by SVI quartile was 1,045 (7.6%) in Quartile 1;1,881 (13.6%) in Quartile 2;3,423 (24.8%) in Quartile 3;and 7,205 (52.2%) in Quartile 4 (Table);SVI scores were missing for 253 persons (1.8%). Black adults in Quartile 4 (rate = 52.1) were 1.5 times (RR = 1.5) as likely to

Evolutions and characteristics of new HIV diagnoses among people who inject drugs in France between 2004 and 2019. (S..ropositivit.. au VIH: diagnostic, pr..vention et v..cu au temps de la Covid-19.) [French]

Based on data from mandatory HIV declarations in France, this article presents the characteristics of new HIV diagnoses among people who inject drugs (PWID), by their birthplace, for the period 2016-2019, and the evolutions of these characteristics since the 2004-2007 period. For 2016-2019, PWID represented 0.8% of all new HIV diagnoses declared, a decreased percentage compared to 2004-2007 (1.7%). The main evolutions observed are an increasing trend of PWID aged 50 years or over, an increase of unemployed PWID, a sharp rise in PWID from Eastern Europe and a decrease in those born in France, as well as an improvement in the early diagnosis indicator for PWID born in France that was not observed for those born abroad. Almost three-quarters of PWID had never been tested before their diagnosis. The rising proportion of unemployed PWID probably reflects worsened levels of precarity. The very high proportion of PWID never tested before the HIV diagnosis indicates that part of this population remains distant from the health system. These conclusions show the need to enhance targeted screening and support policies for PWID and migrants.

HIV/AIDS infection in Italy up to December 31, 2020

Data on new HIV diagnoses have a national coverage since 2012. Data reported in 2020 have been affected by the COVID-19 pandemic. In 2020, 1,303 new HIV diagnoses were reported, with an incidence of 2.2 per 100,000 residents. In 2020, HIV incidence in Italy was lower compared to that reported in the European Union (3.3 new diagnoses per 100,000). Since 2018, an evident decrease in the number of new HIV diagnoses is observed, with no relevant differences by transmission mode. In 2020, heterosexual transmission accounted for 42% (25% in males, 17% in females) of reported cases, sex between men accounted for 46%, and injecting drug use accounted for 3%. Data on AIDS cases are collected since 1982. In 2020, 352 AIDS cases were reported, with an incidence of 0.7 per 100,000 residents;80% of these individuals discovered being HIV-infected in the six months prior to AIDS diagnosis.

Living Under Coronavirus and Injecting Drugs in Bristol (LUCID-B): A qualitative study of experiences of COVID-19 among people who inject drugs.

BACKGROUND: People who inject drugs (PWID) are a high-risk group for COVID-19 transmission and serious health consequences. Restrictions imposed in the UK in response to the pandemic led to rapid health and housing service alterations. We aimed to examine PWID experiences of: 1) challenges relating to the COVID-19 public health measures; 2) changes to opioid substitution therapy (OST) and harm reduction services; and 3) perceived effects of COVID-19 on drug use patterns and risk behaviour. METHODS: Telephone semi-structured interviews were conducted with 28 PWID in Bristol, Southwest of England. Analysis followed a reflexive thematic analysis. RESULTS: Concern about COVID-19 and adherence to public health guidance varied. Efforts made by services to continue providing support during the pandemic were appreciated and some changes were preferred, such as less frequent OST collection, relaxation of supervised consumption and needle and syringe programmes (NSP) home delivery. However, remote forms of contact were highlighted as less beneficial and more difficult to engage with than in-person contact. Public health guidance advising people to 'stay home' led to increased isolation, boredom, and time to ruminate which impacted negatively on mental health. Lockdown restrictions directly impacted on sources of income and routine. Changes in drug use were explained as a consequence of isolation and fewer interactions with peers, problems accessing drugs, reduced drug purity and reduced financial resources. CONCLUSION: This study captures the significant impacts and challenges of the COVID-19 pandemic on the lives of PWID. While rapid adaptations to service delivery to help mitigate the risks of COVID-19 were appreciated and some changes such as relaxation of supervised daily OST consumption were viewed positively, barriers to access need further attention. Going forwards there may be opportunities to harness the positive aspects of some changes to services.

Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia.

The COVID-19 crisis has had profound impacts on health service provision, particularly those providing client facing services. Supervised injecting facilities and drug consumption rooms across the world have been particularly challenged during the pandemic, as have their client group-people who consume drugs. Several services across Europe and North America closed due to difficulties complying with physical distancing requirements. In contrast, the two supervised injecting facilities in Australia (the Uniting Medically Supervised Injecting Centre-MSIC-in Sydney and the North Richmond Community Health Medically Supervised Injecting Room-MSIR-in Melbourne) remained open (as at the time of writing-December 2020). Both services have implemented a comprehensive range of strategies to continue providing safer injecting spaces as well as communicating crucial health information and facilitating access to ancillary services (such as accommodation) and drug treatment for their clients. This paper documents these strategies and the challenges both services are facing during the pandemic. Remaining open poses potential risks relating to COVID-19 transmission for both staff and clients. However, given the harms associated with closing these services, which include the potential loss of life from injecting in unsafe/unsupervised environments, the public and individual health benefits of remaining open are greater. Both services are deemed 'essential health services', and their continued operation has important benefits for people who inject drugs in Sydney and Melbourne.

A rapid review of the impacts of "Big Events " on risks, harms, and service delivery among people who use drugs: Implications for responding to COVID-19.

BACKGROUND: "Big Events" are major disruptions to physical, political, and economic environments that can influence vulnerability to drug-related harms. We reviewed the impacts of Big Events with relevance to the COVID-19 pandemic on drug-related risk and harms and access to drug treatment and harm reduction services. METHODS: We conducted a rapid review of quantitative, qualitative, and mixed methods literature relating to the following Big Events: respiratory infection pandemics, natural disasters, financial crises, and heroin shortages. Included studies reported data on changes to risks, harms, and/or service provisioning for people who use illicit drugs (other than cannabis) in the context of these Big Events. Searches were conducted in PubMed in May 2020, and two reviewers screened studies for inclusion. Peer-reviewed studies published in English or French were included. We used a narrative synthesis approach and mapped risk pathways identified in the literature. RESULTS: No studies reporting on respiratory infection pandemics were identified. Twelve studies reporting on natural disaster outcomes noted marked disruption to drug markets, increased violence and risk of drug-related harm, and significant barriers to service provision caused by infrastructure damage. Five studies of the 2008 global financial crisis indicated increases in the frequency of drug use and associated harms as incomes and service funding declined. Finally, 17 studies of heroin shortages noted increases in heroin price and adulteration, potentiating drug substitutions and risk behaviors, as well as growing demand for drug treatment. CONCLUSION: Current evidence reveals numerous risk pathways and service impacts emanating from Big Events. Risk pathway maps derived from this literature provide groundwork for future research and policy analyses, including in the context of the COVID-19 pandemic. In light of the findings, we recommend responding to the pandemic with legislative and financial support for the flexible delivery of harm reduction services, opioid agonist treatment, and mental health care.

COVID-19 and the health of people who use drugs: What is and what could be?

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting 'complex adaptive systems': that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.