Factors Associated with HIV Testing Among People Who Inject Drugs: Findings from a Multistate Study at the Start of the COVID-19 Pandemic.

Few studies have examined HIV testing among people who inject drugs (PWID) during the COVID-19 pandemic. This study examines factors associated with PWID who have been recently (past six months) tested for HIV during the COVID-19 pandemic. PWID were recruited between August 2020 and January 2021 from 22 drug treatment and harm reduction programs in nine states and the District of Columbia. We used logistic regression to identify correlates of recent HIV testing among PWID (n = 289). Most (52.9%) PWID reported having been recently tested for HIV. Factors associated with recent HIV testing included: having attended college [adjusted odds ratio (aOR) 2.32, 95% confidence interval (95% CI) 1.32-4.10], weekly hunger (aOR 2.08, 95% CI 1.20-3.60), crystal methamphetamine injection (aOR 2.04, 95% CI 1.05-3.97), and non-metropolitan residence (aOR 0.33, 95% CI 0.13, 0.88). Findings suggest HIV testing initiatives should be expanded during times of crisis, such as global pandemics.

Opioid injection-associated bacterial infections in England, 2002-2021: a time series analysis of seasonal variation and the impact of COVID-19.

BACKGROUND: Bacterial infections cause substantial pain and disability among people who inject drugs. We described time trends in hospital admissions for injecting-related infections in England. METHODS: We analysed hospital admissions in England between January 2002 and December 2021. We included patients with infections commonly caused by drug injection, including cutaneous abscesses, cellulitis, endocarditis, or osteomyelitis, and a diagnosis of opioid use disorder. We used Poisson regression to estimate seasonal variation and changes associated with COVID-19 response. RESULTS: There were 92,303 hospital admissions for injection-associated infections between 2002 and 2021. 87% were skin, soft-tissue or vascular infections; 72% of patients were male; and the median age increased from 31 years in 2002 to 42 years in 2021. The rate of admissions reduced from 13.97 per day (95% CI 13.59-14.36) in 2003 to 8.94 (95% CI 8.64-9.25) in 2011, then increased to 18.91 (95% CI 18.46-19.36) in 2019. At the introduction of COVID-19 response in March 2020, the rate of injection-associated infections reduced by 35.3% (95% CI 32.1%-38.4%). Injection-associated infections were also seasonal; the rate was 1.21 (95% CI 1.18-1.24) times higher in July than in February. CONCLUSIONS: This incidence of opioid injection-associated infections varies within years and reduced following COVID-19 response measures. This suggest that social and structural factors such as housing and the degree of social mixing may contribute to the risk of infection, supporting investment in improved social conditions for this population as a means to reduce the burden of injecting-related infections.

Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic.

BACKGROUND: Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises. OBJECTIVE: This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19. METHODS: From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing. RESULTS: One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing. CONCLUSIONS: Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.

Implementation of a nurse-led overdose prevention site in a hospital setting: lessons learned from St. Paul's Hospital, Vancouver, Canada.

OBJECTIVES: In May 2018, St. Paul's Hospital (SPH) in Vancouver (Canada) opened an outdoor peer-led overdose prevention site (OPS) operated in partnership with Vancouver Coastal Health and RainCity Housing. At the end of 2020, the partnered OPS moved to a new location, which created a gap in service for SPH inpatients and outpatients. To address this gap, which was magnified by the COVID-19 pandemic, SPH opened a nurse-led OPS in February 2021. This paper describes the steps leading to the implementation of the nurse-led OPS, its impact, and lessons learned. METHODS: Four steps paved the way for the opening of the OPS: (1) identifying the problem, (2) seeking ethics guidance, (3) adapting policies and practices, and (4) supporting and training staff. RESULTS: The OPS is open between 10:00 and 20:00 and staffed by two nurses per shift. It is accessible to all patients including inpatients, patients in the Emergency Department, and patients attending outpatient services. Between February 1, 2021 and October 23, 2021, the OPS recorded 1612 visits for the purpose of injection, for an average weekly visit number of 42. A total of 46 overdoses were recorded in that 9-month period. Thirty-seven (80%) required administration of naloxone and 12 (26%) required a code blue response. CONCLUSIONS: Due to the unique nature of our OPS, we learned many important lessons in the process leading to the opening of the site and the months that followed. We conclude the paper with lessons learned grouped into six main categories, namely engagement, communication, access, staff education and support, data collection, and safety.

How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States.

BACKGROUND: Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois. METHODS: Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses. RESULTS: We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care. CONCLUSION: The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.

Dependence-Robust Confidence Intervalsfor Capture-Recapture Surveys

Capture-recapture (CRC) surveys are used to estimate the size of a population whose members cannot be enumerated directly. CRC surveys have been used to estimate the number of Coronavirus Disease 2019 (COVID-19) infections, people who use drugs, sex workers, conflict casualties, and trafficking victims. When k-capture samples are obtained, counts of unit captures in subsets of samples are represented naturally by a 2k contingency table in which one element-the number of individuals appearing in none of the samples-remains unobserved. In the absence of additional assumptions, the population size is not identifiable (i.e., point identified). Stringent assumptions about the dependence between samples are often used to achieve point identification. However, real-world CRC surveys often use convenience samples in which the assumed dependence cannot be guaranteed, and population size estimates under these assumptions may lack empirical credibility. In this work, we apply the theory of partial identification to show that weak assumptions or qualitative knowledge about the nature of dependence between samples can be used to characterize a nontrivial confidence set for the true population size. We construct confidence sets under bounds on pairwise capture probabilities using two methods: test inversion bootstrap confidence intervals and profile likelihood confidence intervals. Simulation results demonstrate well-calibrated confidence sets for each method. In an extensive real-world study, we apply the new methodology to the problem of using heterogeneous survey data to estimate the number of people who inject drugs in Brussels, Belgium.

Safety in Solitude? Competing Risks and Drivers of Solitary Drug Use among Women who Inject Drugs and Implications for Overdose Detection.

BACKGROUND AND AIMS: Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID). DESIGN: A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews. SETTING: Baltimore City, Maryland, USA. PARTICIPANTS: Twenty-seven WWID, (mean age: 39 years, 67% White, 74% injected drugs daily) recruited via outreach and street intercept (April-September 2021). MEASUREMENTS: Interviews explored the physical (i.e., indoor/private, outdoor/public) and social (i.e., alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone. FINDINGS: Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs, and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ("spotting"), and using drugs in public spaces. CONCLUSIONS: Women who inject drugs appear to engage frequently in solitary drug use due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Hepatitis C microelimination among people living with HIV in Taiwan.

To reach the WHO target of hepatitis C virus (HCV) elimination by 2025, Taiwan started to implement free-of-charge direct-acting antiviral (DAA) treatment programme in 2017. Evaluating the progress of HCV microelimination among people living with HIV (PLWH) is a critical step to identify the barriers to HCV elimination. PLWH seeking care at a major hospital designated for HIV care in Taiwan between January 2011 and December 2021 were retrospectively included. For PLWH with HCV-seropositive or HCV seroconversion during the study period, serial HCV RNA testing was performed using archived samples to confirm the presence of HCV viremia and estimate the prevalence and incidence of HCV viremia. Overall, 4199 PLWH contributed to a total of 27,258.75 person-years of follow-up (PYFU). With the reimbursement of DAAs and improvement of access to treatments, the prevalence of HCV viremia has declined from its peak of 6.21% (95% CI, 5.39-7.12%) in 2018 to 2.09% (95% CI, 1.60-2.77%) in 2021 (decline by 66.4% [95% CI, 55.4-74.7%]); the incidence has declined from 25.94 per 1000 PYFU (95% CI, 20.44-32.47) in 2019 to 12.15% per 1000 PYFU (95% CI, 8.14-17.44) (decline by 53.2% [95% CI, 27.3-70.6%]). However, the proportion of HCV reinfections continued to increase and accounted for 82.8% of incident HCV infections in 2021. We observed significant declines of HCV viremia among PLWH with the expansion of the DAA treatment programme in Taiwan. Further improvement of the access to DAA retreatments is warranted to achieve the goal of HCV microelimination.

The impact of the COVID-19 pandemic on people who inject drugs accessing harm reduction services in an rural American state.

BACKGROUND: The impact of public health policies during the COVID-19 pandemic on people who inject drugs (PWID) has varied across regions. In other countries, recent research has shown that PWID access to harm reduction services, despite rapid adaptations, has been negatively impacted. Our study describes these impacts in a rural state. METHODS: We conducted semi-structured interviews with PWID, community partners, and healthcare providers in the rural state of Maine (USA). We explored how changes made during the pandemic impacted access to harm reduction services, including basic services (i.e., shelter), syringe service programs, safe drug supply, low barrier treatment, and peer support. Interviews were analyzed using the framework method to apply Penchansky's model of access, with Saurman's modification, which includes six dimensions of access-accessibility, availability, acceptability, affordability, accommodation, awareness. RESULTS: We interviewed thirty-six stakeholders (N = 9 community partners, N = 9 healthcare providers, N = 18 PWID). Policies such as mobile outreach expansion, mail delivery of equipment, and relaxed telemedicine regulations facilitated accessibility to syringe service programs and low barrier buprenorphine treatment. Public health policies, such as social distancing and screening policies, reduced contact, which subsequently reduced acceptability and awareness of many services. Elimination of the one-for-one needle exchange in some areas increased, acceptability (i.e., perception of service), and affordability for PWID. However, some areas actually began enforcing a one-for-one needle exchange policy, which reduced affordability, acceptability, and awareness of services. CONCLUSIONS: Changes resulting from the COVID-19 pandemic have impacted all dimensions of access to harm reduction services among PWID. While some barriers to harm reduction services were unavoidable during the pandemic, we found that specific policy decisions mitigated service barriers, while other policies exacerbated them. Relaxing needle exchange policies were particularly helpful in facilitating access to harm reduction services by giving community organizations flexibility to adapt to the evolving needs of PWID. These results can inform policies and service delivery to optimally mitigate the negative impacts on PWID during, and beyond, the pandemic.

COVID-19 Vaccine Hesitancy and Vaccination Status in a Community-Based Cohort of People Who Inject Drugs in Baltimore, Maryland, March-June 2021.

OBJECTIVE: People who inject drugs are a population who are often unengaged with health care services. The objective of this study was to characterize COVID-19 vaccine hesitancy and uptake in a community-based sample of people who inject drugs in Baltimore, Maryland. METHODS: The ALIVE study (AIDS Linked to the IntraVenous Experience) in Baltimore is a community-based cohort study of people with a history of injection drug use. From March 2 through June 28, 2021, 346 ALIVE participants completed a survey on substance use, structural determinants of health, and COVID-19 vaccine hesitancy. The exposure of interest was COVID-19 vaccine hesitancy, and the primary outcome was vaccination status as of June 30, 2021. We extracted data on the dates of vaccination from electronic medical records linked to study participants. RESULTS: The median age of the sample was 60 years; most participants were male (66%) and non-Hispanic Black (87%). Most (55%) trusted the COVID-19 vaccine, and 68% had received ≥1 dose. After age standardization, survey participants were more likely than the Maryland general population to be unvaccinated (prevalence ratio = 1.20; 95% CI, 0.97-1.49; P = .10). Participants who somewhat trusted or did not trust the COVID-19 vaccine had 6-fold higher odds of being unvaccinated than participants who trusted the vaccine (odds ratio = 6.30; 95% CI, 3.74-10.60). CONCLUSION: Uptake of COVID-19 vaccine among people with a history of injection drug use was high. Attitudes and knowledge about vaccination were important predictors of vaccine uptake. Education and outreach efforts could be effective in reducing hesitancy and increasing vaccination in substance-using populations.

Factors associated with self-reported avoidance of harm reduction services during the COVID-19 pandemic by people who use drugs in five cities in the United States and Canada.

BACKGROUND: This study examines individual-level factors associated with avoiding two important health services for people who use drugs-medications for treatment of opioid use disorder and syringe service programs-during the first year of the COVID-19 pandemic. METHODS: Data come from two subsamples of people who use drugs who were active participants in one of nine cohort studies in Vancouver, British Columbia; Baltimore, Maryland; Los Angeles, California; Chicago, Illinois; and Miami, Florida. Participants were interviewed remotely about COVID-19-associated disruptions to healthcare. We estimated the association of demographic, social, and health factors with each outcome using logistic regression among 702 participants (medication analysis) and 304 participants (syringe service analysis.) Analyses were repeated, stratified by city of residence, to examine geographic variation in risk. RESULTS: There were large differences between cities in the prevalence of avoiding picking up medications for opioid use disorder, with almost no avoidance in Vancouver (3%) and nearly universal avoidance in Los Angeles, Chicago, and Miami (>90%). After accounting for between-city differences, no individual factors were associated with avoiding picking up medications. The only factor significantly associated with avoiding syringe service programs was higher levels of self-reported worry about COVID-19. CONCLUSION: During the first year of the COVID-19 pandemic, geographic differences in service and policy contexts likely influenced avoidance of health and harm reduction services by people who use drugs in the United States and Canada more than individual differences between people.

Factors associated with perceived decline in the quality of drugs during the COVID-19 pandemic: Evidence from community-recruited cohorts of people who use drugs in Vancouver, Canada.

OBJECTIVES: Driven by an increasingly toxic drug supply, drug toxicity deaths in the United States and Canada have risen to unprecedented levels during the COVID-19 pandemic. This study aimed to characterize the prevalence of and the factors associated with a perceived decline in the quality of drugs during the COVID-19 pandemic among community-recruited cohorts of PWUD in Vancouver, Canada. METHODS: Data collection took place between July and November 2020. In adherence with COVID-19 safety protocols, questionnaires were administered by interviewers through remote means (e.g., phone or videoconference). Using multivariable logistic regression, we characterized the prevalence of and factors associated with a perceived decline in drug quality during the start of the COVID-19 pandemic in Vancouver, Canada. RESULTS: Of the 738 individuals included in this analysis, 272 (36.9%) reported that the quality of drugs declined during the COVID-19 pandemic. In multivariable analysis, perceived decline in the quality of drugs was significantly associated with: recent non-fatal overdose (adjusted odds ratio [AOR]=2.01, 95% Confidence Interval [CI]: 1.29-3.15), at least weekly injection drug use (AOR=1.94, 95% CI: 1.40-2.71), at least weekly crack use (AOR=1.61, 95%CI: 1.10-2.36), and at least weekly crystal methamphetamine use (AOR=1.46, 95%CI: 1.03-2.08). DISCUSSION: Over a third of PWUD perceived that the quality of drugs declined during the COVID-19 pandemic and these individuals were significantly more likely to report experiencing a recent non-fatal overdose, engaging in frequent injection drug and stimulant use. Study findings indicate the need for interventions to address the toxic drug supply, including providing a regulated supply.

Epidemiology of infective endocarditis: novel aspects in the twenty-first century.

INTRODUCTION: The epidemiology of infective endocarditis (IE) in this millennium has changed with emergence of new risk factors and reemergence of others. This, coupled with modifications in national guidelines in the setting of a pandemic, prompted an address of the topic. AREAS COVERED: Our goal is to provide a contemporary review of IE epidemiology considering changing incidence of rheumatic heart disease (RHD), cardiac device implantation, and injection drug use (IDU), with SARS-CoV-2 pandemic as the backdrop. METHODS: PubMed and Google Scholar were used to identify studies of interest. EXPERT OPINION: Our experience over the past two decades verifies the notion that there is not one 'textbook' profile of IE. Multiple factors have dramatically impacted IE epidemiology, and these factors differ, based, in part on geography. RHD has declined in many areas of the world, whereas implanted cardiovascular devices-related IE has grown exponentially. Perhaps the most influential, at least in areas of the United States, is injection drug use complicating the opioid epidemic. Healthy younger individuals contracting a potentially life-threatening infection has been tragic. In the past year, epidemiological changes due to the COVID-19 pandemic have also occurred. No doubt, changes will characterize IE in the future and serial review of the topic is warranted.

HIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in Maryland.

Drug overdose remains a leading cause of death in the US, with growing rates attributable to illicit fentanyl use. Recent HIV outbreaks among people who inject drugs (PWID) and service disruptions from COVID-19 have renewed concerns on HIV resurgence. We examined the relationship between fentanyl use and three injection-related HIV risk behaviors among PWID in Baltimore City (BC) and Anne Arundel Country (AAC), Maryland. PWID (N = 283) were recruited to the study through targeted sampling at street-based locations in BC and AAC from July 2018 to March 2020. Receptive syringe sharing (RSS) [adjusted odds ratio (AOR): 2.8, 95% confidence interval (CI): 1.2-6.3] and daily injecting (AOR: 1.9, 95% CI: 1.0-3.6) were associated with injecting fentanyl and cocaine together. Fentanyl availability and COVID-19 bring new HIV prevention challenges, particularly among those who inject fentanyl with cocaine, highlighting the importance to expand and sustain harm reduction, prevention, and treatment services for PWID to reduce HIV and overdose burden.