Isolating the Effect of Covid-19 Related Disruption on Hiv Diagnoses in the Us, 2020

Background: Diagnoses of HIV in the US decreased by 17% in 2020 due to COVID-related disruptions. The extent to which this decrease is attributable to changes in HIV testing versus HIV transmission is unclear. We seek to better understand this issue by analyzing the discrepancy in expected versus observed HIV diagnoses in 2020 among persons who acquired HIV between 2010-2019, as changes in diagnosis patterns in this cohort cannot be attributed to changes in transmission. Method(s): We developed three methods based on the CD4-depletion model to estimate excess missed diagnoses in 2020 among PWH infected from 2010-2019. We stratified the results by transmission group, sex assigned at birth, race/ ethnicity, and region to examine differences by group and confirm the reliability of our estimates. We performed similar analyses projecting new diagnoses in 2019 among PWH infected from 2010-2018 to evaluate the accuracy of our methods against surveillance data. Result(s): There were approximately 3100-3300 fewer diagnoses than expected in 2020 among persons who acquired HIV from 2010-2019. Females (at birth), heterosexuals, persons who inject drugs, and Hispanic/Latino PWH missed diagnoses at higher levels than the overall population. By transmission category, MSM accounted for the highest percentage (61%) of missed diagnoses. Validation and stratification analyses confirmed the accuracy and reliability of our estimates. Conclusion(s): PWH infected from 2010-2019 showed a significant drop in diagnosis rate during 2020, suggesting that changes in testing played a substantial role in the observed decrease in new HIV diagnoses. Levels of missed diagnoses differed substantially across population subgroups. These analyses may be used to inform future estimates of HIV transmission during the COVID-19 pandemic and prioritize populations with increased testing needs.

SARS-CoV-2 INFECTION AMONG PERSONS WHO INJECT DRUGS AND THEIR PARTNERS IN KENYA

Background: Despite increased social vulnerability and barriers to care, there has been a paucity of data on SARS-CoV-2 incidence among key populations in sub-Saharan Africa. We seek to characterize active infections and define transmission dynamics of SARS-CoV-2 among people who inject drugs (PWID) and their sexual and injecting partners from Nairobi and the coastal region in Kenya. Method(s): This was a nested cross-sectional study of SARS-CoV-2 infection from April to July 2021 within a cohort study of assisted partner services for PWID in Kenya. A total of 1000 PWID and their partners (500 living with and 500 living without HIV) were recruited for SARS-CoV-2 antibody testing, of whom 440 were randomly selected to provide self-collected nasal swabs for real-time PCR testing. Whole genome sequencing (WGS) was completed on a limited subset of samples (N=23) with cycle threshold values 32.0. Phylogenetic tree construction and analysis was performed using the Nextstrain pipeline and compared with publicly available SARS-CoV-2 sequences from GenBank. Result(s): A total of 438 (99.5%) participants provided samples for SARS-CoV-2 PCR testing. Median age was 37 (IQR 32-42);128 (29.2%) were female;and 222 (50.7%) were living with HIV. The overall prevalence of SARS-CoV-2 infection identified by RT-PCR was 86 (19.6%). In univariate analyses, there was no increased relative risk of SARSCoV- 2 infection related to positive HIV status, frequenting an injection den, methadone treatment, unstable housing, report of any high-risk exposure, or having a sexual or injecting partner diagnosed with COVID-19 or who died from COVID-19 or flu-like illness. Eight samples were successfully sequenced via WGS and classified as WHO variants of concern: 3 Delta, 3 Alpha, and 2 Beta. Seven were classified into clades predominantly circulating in Kenya during 2021. Notably, two sequences were identical and matched identically to another Kenyan sequence, which is consistent with, though not indictive of, a transmission linkage. Conclusion(s): Overall, the risk of SARS-CoV-2 infection in this population of PWID and their partners was not significantly associated with risk factors related to injection drug use. At a genomic level, the SARS-CoV-2 strains in this study were consistent with contemporary Kenyan lineages circulating during the time and not unique to PWID. Prevention efforts, therefore, must also focus on marginalized groups for control given the substantial amount of mixing that likely occurs between populations.

SARS-CoV-2 SEROPREVALENCE AMONG PEOPLE WHO INJECT DRUGS IN BALTIMORE

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.

Changes in Service Access among People Who Inject Drugs in Philadelphia, 2018-2022

Background: The COVID-19 pandemic disrupted HIV prevention and treatment services, especially for structurally vulnerable individuals like many people who inject drugs (PWID). We sought to compare present levels of access to these services to their levels before the pandemic. Method(s): We used data from 2018 and 2022 collected through the National HIV Behavioral Surveillance (NHBS) survey among PWID in Philadelphia. Using generalized linear regression models, we estimated the associations between our exposure (year) and self-reported HIV testing, medical care, SSP access, PrEP use, and drug treatment in the year prior to interview. We calculated adjusted prevalence ratios (aPR) using multivariable models adjusted for age, race/ ethnicity, housing stability, and primary injecting drug. Result(s): There were 620 participants in 2018 and 604 in 2022 included in analyses. Compared to the 2018 sample, the 2022 sample was significantly older, non-Hispanic Black, and primarily injected drugs other than heroin. A significantly smaller proportion of participants in 2022 had a recent HIV test (57% vs. 71%), visited a health care provider (77% vs 82%), received sterile needles from an SSP (69% vs 75%), or participated in a drug treatment program (47% vs 54%). Between 2018 and 2022, PrEP awareness increased significantly (39% vs 54%) but PrEP use did not (3% vs 3%). In adjusted models, an 18% decrease in recent HIV testing was observed between 2018 and 2022 (aPR: 0.82;95% CI: 0.70-0.96). Among those who reported a recent HIV test, there was an 18% increase in testing in clinical settings observed between 2018 and 2022 (aPR: 1.18;95% CI: 1.10-1.26). Recent medical care, SSP access, PrEP use, and drug treatment were not associated with year in adjusted models. Conclusion(s): Access to a full range of social services is necessary for Ending the HIV Epidemic. These findings indicate that HIV prevention services, particularly HIV testing, among PWID have not rebound fully from the pandemic. Considering this and ongoing outbreaks of HIV among PWID, public health practitioners should closely monitor HIV testing frequency among PWID and prioritize expanding access to low-barrier HIV prevention and care services, especially in non-clinical settings.

Intervention Efficacy on Covid-19 Testing and Vaccination in People Who Inject Drugs

Background: People who inject drugs (PWID) are vulnerable to SARS-CoV-2 and severe disease but have low rates of COVID-19 testing and vaccination due to multilevel barriers. We partnered with a mobile syringe service program (SSP) in San Diego County, CA, to develop the theory-informed LinkUP intervention to increase COVID-19 testing and vaccination among PWID. Method(s): From March-June 2022, we conducted a pilot randomized controlled trial (RCT;ClinicalTrials.gov #NCT05181657) to assess efficacy of LinkUP vs. a didactic attention-matched control condition in increasing COVID-19 testing uptake and acceptance of vaccination referrals. Based on Social Cognitive Theory, trained, SSP-hired peer counsellors delivered tailored education, motivational interviewing, and problem-solving and planning to the active LinkUP intervention arm. We referred eligible participants (PWID, >=18 years old, San Diego County residents without recent voluntary COVID-19 testing or fully vaccinated status) to mobile SSP sites that had been randomized by week to offer LinkUP or the control condition;all participants were then offered on-site rapid COVID-19 antigen testing and vaccination referrals. Our intent-to-treat analysis used Chi-square tests to compare intervention groups' outcomes and log-binomial regression to estimate preliminary intervention efficacy and explore potential moderation. Result(s): Among 150 participants, median age was 41 years, 33% identified as Latinx and 65% as male, 73% were experiencing homelessness, and 45% had prior mandatory COVID-19 testing. Overall, we only detected one SARS-CoV-2 case. However, more active intervention vs. control participants agreed to COVID-19 testing (77.3% vs. 22.7%;p< .001) and vaccine referrals (32.4% vs. 13.3%;p=0.006). Homelessness moderated intervention effects: LinkUP increased COVID-19 testing uptake more among participants experiencing homelessness (adjusted risk ratio [aRR]: 1.64;95% CI: 1.27-2.12) than those not experiencing homelessness (aRR: 1.25;95% CI: 0.99-1.56). Conclusion(s): Findings from this RCT support the efficacy of LinkUP in increasing COVID-19 testing and acceptance of vaccination referrals among PWID presenting at mobile SSP sites, particularly for those experiencing homelessness. This research underscores the significance of communityacademic partnerships when working with PWID and identifies a promising model that could be adapted to increase access to other underutilized vaccines in this vulnerable population.

Hiv Viral Load and Time-to-Covid-19 Vaccination among People Who Inject Drugs

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).

Methamphetamines and Serious Injection Related Infections: Epidemiology and Outcomes of Alabama's Drug Crisis

Background. The U.S. is facing a steep increase in infectious consequences of intravenous drug use due to the ongoing opioid crisis, surging methamphetamine use, and health care disruptions caused by COVID-19. We hypothesize that the sociodemographic and clinical outcomes of persons who inject drugs (PWID) differ based on their drug of choice (opioids, methamphetamines). Further, we hypothesize that the OUD (opioid use disorder) continuum, including linkage and retention inOUD treatment, will vary depending on co-occurring methamphetamine use. By elucidating differences in these groups, we aim to identify opportunities for interventions along the care continuum. Methods. This is a retrospective study of hospitalized PWID receiving care at the University of Alabama at Birmingham Hospital for a serious injection related infection (SIRI) between 1/11/2016 and 4/24/2021. We queried the EMR for clinical data and health outcomes. We extracted data on substance use disorder(s), treatments, and linkage to care through review of primary and addiction medicine consultation notes. Using statistical measures of association, we compared demographic factors and clinical outcomes among groups;delineating between those with and without methamphetamine use, and without OUD. When appropriate, additional comparisons were made to detect statistical differences between factors and those with and without methamphetamine use. Results. Of 370 PWID, 286 had OUD, 94 had OUD and methamphetamine use, and 84 had another substance use disorder. There were significant differences according to drug use disorder with patients with OUD and meth use being mostly White (99%), 42% female, and younger relative to those who use opioids only. Patient directed discharge was most common among those with OUD plus meth use, but death was highest for those with OUD only. The OUD care continuum was similar and alarming for both groups with many gaps in care. (Table Presented) Conclusion. PWID with SIRI are a diverse group with significant differences based on substance of choice, but all experience suboptimal hospital outcomes. There are opportunities to improve linkage and retention across the care continuum, most noticeably outpatient linkage.

Acceptability and feasibility of long-acting injectable antiretroviral therapy for persons who inject drugs in Vietnam: using the Consolidated Framework on Implementation Research to identify determinants and inform implementation strategies

Background. Long-acting injectable antiretroviral therapy (LAI) is an exciting alternative to daily oral ART. Less frequent dosing afforded by LAI may be especially pertinent for persons who inject drugs (PWID), who experience more HIV-related mortality largely driven by inadequate ART adherence. We used the Consolidated Framework on Implementation Research (CFIR) to characterize determinants of LAI implementation, focusing on use among PWID, in Hanoi, Vietnam. Methods. We conducted in-depth interviews with HIV-infected PWID, ART providers, and policymakers using purposive sampling, recruiting respondents with diverse ART experience from public HIV/ART clinics and national regulatory agencies. Participants were briefed regarding LAI ART, including administration, effectiveness, side effects, and dosing frequency.Datawere coded and analyzed using thematic analysis. Results. We interviewed 19 PWID, 14 providers, and five policymakers (February-November, 2021). We identified recurrent themes in CFIR domains. Intervention(s): All informants were excited about LAI, citing convenience and discrete dosing as major facilitators. Surprisingly, provider concerns, including more frequent clinic visits and injection reactions, were rarely voiced by PWID who described monthly injections as similar to current visit frequency and cited 'high pain tolerance.' Outer: Providers and policymakers were eager to offer patients ART choice but were divided as to if LAI distribution should proceed with sub-population prioritization. Inner: Providers described personnel and clinic logistic concerns but were confident these could be addressed. Individual: Providers were motivated and confident in their ability to deliver LAI. Process: Transitions to new ART and provision of COVID-19 vaccines were frequently invoked by providers and policymakers as interventions informing LAI implementation. Figure Determinants of LAI ART implementation in Vietnam using the domains of the Consolidated Framework on Implementation Research Conclusion. Using CFIR, we identified multiple determinants of LAI implementation in Vietnam. Stakeholders agreed that LAI was feasible and acceptable. Medication tolerance and efficacy concerns highlight the importance of patient and provider education. Areas where stakeholders diverge should be considered in designing LAI implementation strategies.

The 2010 HIV Outbreak Among People Who Inject Drugs in Athens, Greece Could Have Been Prevented If the 2009 Undetected HCV Outbreak Had Been Detected. What Would Have Been the Savings If There Was an Outbreak Detection System?

Objectives: Wars, pandemics, and disasters that cause societal instability are referred to as "Big Events" and have been associated with outbreaks of infectious diseases. At the initiation of the 2008 severe economic recession in Greece (the last Big-Event before the pandemic), a hepatitis C virus (HCV) outbreak emerged among people who inject drugs (PWID) in 2009, which was the root of the 2010 Human Immunodeficiency Virus (HIV) outbreak. The HCV-outbreak was not detected, while that of HIV was identified in mid-2011. Given that HCV and HIV share common transmission routes, the HIV-interventions directly reduced the HIV-incidence by 78% and indirectly HCV-incidence by 64.8%. This study aims to assess what would have been the course of the two outbreaks, and their economic consequences if the 2009 HCV-outbreak had been timely detected. Method(s): A published, stochastic, dynamic model was used to simulate HCV and HIV transmission among PWID (Gountas et al. IJDP 2020, Gountas et al. PLOS 2021). The model was calibrated to reproduce the observed epidemiological parameters among PWID of Athens, Greece. The time-horizon of the analysis was 2002-2019 to capture second-order transmission effects. Result(s): Under the status-quo scenario, the cumulative HCV and HIV cases were 6480 (95% CrI: 6000, 6900) and 1360 (95% CrI: 400, 2600), respectively. If the HCV outbreak had been detected and integrated interventions had been initiated in 2009 or 2010, 440 and 970 new HCV cases and 740 and 1110 new HIV cases could have been averted by 2019, respectively. Concerning the costs of treating the new cases for both diseases, the existence of an efficient notification system would have saved 40.9-65.8 million by 2019. Conclusion(s): An accurate automated outbreak detection system among PWID is a cost-saving investment. During the COVID-19 pandemic, which is the current Big Event, HIV/HCV surveillance should be more intense to timely detect new outbreaks. Copyright © 2022

Progress Towards Hcv Elimination in the Country of Georgia: Insights from Modelling and National Survey

Background: A national serosurvey in 2015 found the country of Georgia had high hepatitis C virus (HCV) prevalence, with 5.4% of adults (~150,000 people) chronically infected. In April 2015, Georgia launched a national program to eliminate HCV infection (reduce prevalence by 90%). We developed an HCV transmission model to capture current and historical dynamics of HCV infection in Georgia, and project long-term impact of the elimination program. A follow-up serosurvey in 2021 provided data used to validate the model and update impact projections. Method(s): The original model was calibrated to the 2015 serosurvey and surveys among people who inject drugs (PWID), accounting for age, sex, PWID status, and liver disease state. We compare model projected prevalence overall and by age group, sex, and among ever injected drugs to 2021 serosurvey prevalence, and weight the parameter sets to match the serosurvey results. We used logistic regression to assess which input parameters or model characteristics affect fit. We used program data on 77,168 persons treated May 2015-February 2022 to estimate current incidence of HCV infection, cases and deaths averted. We project the impact of reductions in treatment rates during the COVID-19 epidemic. Result(s): The original modelled adult hepatitis C prevalence for 2021 (2.7%, 1.9-3.5%) was higher than the observed serosurvey prevalence (1.8%, 1.3-2.4%);across all groups uncertainty bounds overlap. Parameter sets that fit the 2021 serosurvey data suggest the model overestimated the initial burden of infection. Weighted Hepatitis C incidence in March 2022 is estimated to be 0.05 (95% credible interval (CrI) 0.03-0.11) per 100 person-years in general population, and 1.14 (0.08-6.4) per 100 person-years in PWID, a 60% decrease since 2015. As of March 2022, 9,186 (5,396-16,720) infections and 842 (489-1324) deaths have been averted, with benefit accumulating to 26,154 (15,850-47,627) infections and 3,971 (2,516-5,536) deaths averted if tracked to 2030. Treatment numbers went from 996/ month in 2019 to 406/month March 2020-February 2022 during the COVID-19 pandemic, resulting in 14,127 fewer treatments, 471 (242-817) fewer infections averted by March 2022. At 406 treatments/month, elimination can be reached in 2031. Conclusion(s): HCV prevalence reduction due to treatment and prevention interventions was greater than originally projected, but treatment numbers must still increase in order to reach HCV elimination by 2030.

Unionstagung der Schweizerischen Gesellschaften fur Gefasskrankheiten Gemeinsam mit der Schweizerischen Gesellschaft fur Ultraschall in der Medizin Sektion Gefasse

The proceedings contain 57 papers. The topics discussed include: percutaneous angioplasty and stenting in patients with upper extremity peripheral artery disease (PAD);molecular atlas of the human brain vasculature across development, adulthood and disease at the single-cell level;enoxaparin for symptomatic outpatients with COVID-19: 90-day results from the randomized, open-label, parallel-group, multicenter, phase III OVID trial;quality of warfarin anticoagulation in adults with short bowel syndrome on home parenteral nutrition;mortality rate related to peripheral artery disease: a retrospective analysis of epidemiological data (years 20082019);development and implementation of an ambulatory integrated care pathway tool for peripheral artery disease patients: the vascular passport from knowledge to awareness;late outcomes after fixed-dose ultrasound-assisted catheter-directed thrombolysis for acute pulmonary embolism: single-center experience at a university hospital;and venous thromboembolism and its clinical sequelae in intravenous drug users: systematic review and meta-analysis.

MYSTERIOUSLY PUFFY EXTREMITIES: AN UNINTENDED CONSEQUENCE OF IV DRUG ABUSE

CASE: A previously healthy, 27-year-old Caucasian male presented with erythema and edema in his extremities. He endorsed multiple years of injecting heroin into numerous areas from his chest to his toes, including both upper extremities. The patient was seen six months ago at local urgent care for swelling of both of his dorsal feet and a small abscess with surrounding cellulitis of the right hand. He was given a dose of Ceftriaxone and a 2-week course of Augmentin, which he completed with moderate improvement. A month prior to his presentation, he reported that this swelling started asymmetrically;it started in his legs, then in his right arm, and then in his left arm. He denied any discharge from any site on his skin. He last injected heroin the morning of his admission. He denied fever, shortness of breath, pleuritic chest pain, orthopnea, dyspnea on exertion, and any urinary symptoms. On presentation, he was afebrile and saturated 98% on room air. His extremities were warm, normal capillary refill, and distal pulses were strong and symmetric. There were also pitting edema in the right hand with associated volar erythema, pitting edema in the right foot, and left-hand edema with a punctate area around the mid-arch with associated tenderness to palpation without overlying redness, crepitus, or fluctuance. Blood cell count revealed mild leukocytosis to 12.0. CMP was unremarkable. While the infectious disease team was consulted for further evaluation, he was started on cefazolin 1g for 10 days. The urine drug screen was positive for benzodiazepines, THC, cocaine, and opiates. HIV negative, Covid negative, and blood cultures showed no growth. Histoplasma/ Blastomyces urine antigens were negative. Urinalysis without evidence of proteinuria, and transaminases were within the normal limit. Ultrasound showed occlusive cephalic vein thrombosis in the right upper extremities. Cefazolin was discontinued. Based on the presentation, the history, and the evaluation, it was concluded to be Puffy Hand Syndrome. IMPACT/DISCUSSION: Puffy hand syndrome is a form of lymphedema caused via the sclerosing nature of intravenously administered drugs, which our patient extensively utilized. Described by Abeles in 1965 as seen in New York prisoners, it affects between 7 to 16% of intravenous drug users. Its pathology is suspected to be caused due to a combination of lymphatic and venous insufficiency. Differential diagnosis of this syndrome involves identification of infection alongside cardiac or renal insufficiency, and edematous scleroderma. Treatment is mostly symptomatic. Patients are advised to stop IV drug use. Long-term use of low-stretch bandages and compression may be useful in decreasing the puffiness of the extremities. CONCLUSION: With the quality of care for drug addicts being a critical area of interest, this case displays a common drug abuse complication clinicians raise awareness for. This observation presents an opportunity to identify a possible drug abuser and intervene accordingly.

Progress towards HCV elimination in the country of Georgia: insights from modelling and national survey

Background and aims: A national serosurvey in 2015 found the country of Georgia had high hepatitis C virus (HCV) prevalence, with 5.4% of adults (∼150, 000 people) chronically infected. In April 2015, Georgia launched a national program to eliminate HCV infection (reduce prevalence by 90%). We developed an HCV transmission model to capture current and historical dynamics of HCV infection in Georgia, and project long-term impact of the elimination program. A follow-up serosurvey in 2021 provided data which was used to validate the model and update impact projections. Method: The original model was calibrated to the 2015 serosurvey and surveys among people who inject drugs (PWID), accounting for age, sex, PWID status, and liver disease state. We compare model projected prevalence overall and by age group, sex, and among ever injected drugs to 2021 serosurvey prevalence, and filter the original 532 parameter sets to match the serosurvey results.We used logistic regression to assess which input parameters or model characteristics affect fit.We used program data on 77,168 persons treated May 2015- February 2022 to estimate current incidence of HCV infection, cases and deaths averted.We project the impact of reductions in treatment rates that occurred in during the COVID-19 epidemic. Results: The original modelled adult hepatitis C prevalence for 2021 (2.7%, 1.9–3.5%) was higher than the observed serosurvey prevalence (1.8%, 1.3–2.4%);across all groups uncertainty bounds overlap. Only 14% of 532 model runs fit within the 95% confidence interval of all hepatitis C prevalence estimates;32% fit overall, 28% fit in females, 43% fit in males, 85% fit in ever-injected drugs. Runs that fit the 2021 serosurvey data tend to have lower total population and lower general population hepatitis C incidence, suggesting the model overestimated the initial burden of infection. After filtering, modelled hepatitis C adult prevalence is slightly higher than the observed prevalence (2.1%, 1.6–2.4%). Hepatitis C incidence in March 2022 is estimated to be 0.05 (95% credible interval (CrI) 0.03–0.11) per 100 person-years in general population, and 1.14 (0.08–6.4) per 100 person-years in PWID, a 60% decrease since 2015. As of March 2022, 9, 186 (5, 396–16, 720) infections and 842 (489–1324) deaths have been averted, with benefit accumulating to 26, 154 (15, 850–47, 627) infections and 3, 971 (2, 516–5, 536) deaths averted if tracked to 2030. Treatment numbers went from 996/month in 2019 to 406/month March 2020-March 2022 during the COVID-19 pandemic, resulting in 14, 127 fewer treatments, 471 (242–817) fewer infections averted by March 2022. At 406 treatments/month, elimination can be reached in 2031.(Figure Presented)Conclusion: HCV prevalence reduction due to treatment and prevention interventions was greater than originally projected, but treatment numbers must still increase in order to reach HCV elimination by 2030

A novel hepatitis C intervention in Denmark to test and treat people who inject drugs

Background and aims: Providing testing and treatment for hepatitis C (HCV) for people who inject drugs (PWID) is critical in eliminating HCV, but reaching this population with traditional healthcare services can be challenging. Combining point-of-care (PoC) testing with peer support and counselling is a model of care (MoC) that can be effective for PWID. This study aims to investigate if a peer-led mobile van equipped with rapid PoC tests for HCV antibodies (Ab) and RNA could simplify testing and link PWID to care and treatment. Method: In Copenhagen, Denmark, a peer-led mobile service providing counselling, Ab testing (In-Tec™) and linkage to standard of care was equipped with a PoC HCV-RNA finger-prick test (Xpert HCV Viral Load Finger-Stick Point-of-Care Assay, Cepheid). Eligible HCV-RNA+ individuals were offered assisted referral to a fast-track hospital clinic for evaluation and treatment, with peer support available if needed. Results: From 1 May 2019 to 25 October 2021, 1013 people were tested for HCV-RNA and 10.2% (n = 103) were positive. Nine additional individuals with HCV infection contacted the service to be linked to care. Of the 112 individuals with chronic HCV infection, 72.3% (n = 81) were evaluated for treatment at the hospital clinic, of whom86.4% (n = 70) initiated direct-acting antiviral therapy and 3.7% (n = 3) are waiting to initiate treatment. Major reasons for not being evaluated for treatment included being undocumented (38.7%;n = 12) and being lost to follow-up (32.3%;n = 10). Among those who initiated treatment, 20.0% (n = 14) were connected to drug addiction treatment services. The peer-led service assisted all treated with communication with the hospital nurse, collection of treatment medicine and accompaniment to follow-up visits. Conclusion: We found that a peer-led mobile PoC service is an MoC that can engage PWID in HCV testing and link them to treatment, even during the COVID-19 pandemic. We identified being an undocumented migrant as a major cause for not accessing care. This poses a challenge for HCVelimination in Denmark due to the risk of onward transmission. Next steps include engaging with health authorities to provide care for these migrants.

CRYPTIC PREGNANCY, SYPHILIS AND CONSTITUTIONAL SYMPTOMS IN AN IV DRUG USER DURING THE COVID-19 OUTBREAK

Background Infective endocarditis (IE) during pregnancy is rare and is associated with high maternal and fetal morbidity and mortality. We report the case of a 30-year-old patient with IE who was incidentally found to be 24 weeks pregnant during the COVID outbreak. We also reviewed the relevant literature. Case An active intravenous drug user presented with a 2-week history of constitutional symptoms (myalgias, fever) and lower back pain during the COVID outbreak. Initial investigations revealed bilateral consolidations on chest X-ray. After she tested negative for COVID-19, CT chest showed septic pulmonary emboli and grew MSSA on blood cultures. An echocardiogram revealed a large (1.6 × 1.0 cm) mass attached to the tricuspid valve suggestive of IE with severe tricuspid regurgitation. She was also incidentally found to be 24 weeks pregnant (G1P0) and positive for syphilis. Viable intrauterine pregnancy was confirmed at 25 weeks on an ultrasound. She was treated with 5-weeks course of IV flucloxacillin, however a repeat echocardiogram demonstrated an increase in vegetation size (> 3 cm). As her vegetation size had increased, a surgical opinion for IE was sought. Cardiac operation under cardiopulmonary bypass in a pregnant woman is associated with high maternal and fetal morbidity and mortality. She was managed conservatively with oral antibiotics, regular echocardiographic and obstetrics reviews and delivered a healthy baby at 37 weeks following induction of labour. Conclusions: The review of literature confirms that if IE in pregnancy is diagnosed early, an uncomplicated outcome is possible with a multidisciplinary team approach.

PROPORTION of PLWH NOT VACCINATED for COVID-19 in ITALY and PREDICTORS

Background: The vaccination campaign against COVID-19 has a substantial beneficial public health impact, but vaccine hesitancy or issues to the access to vaccine could undermine the efforts made. We aim to determine the proportion of people living with HIV (PLWH) not vaccinated for COVID-19 in a cohort of PLWH in Italy and identify predictors of missing vaccination. Methods: Cross sectional study conducted in the Icona network. All PLWH of the centers participating the study with at least 1 follow-up in 2020-2021 were included. Their vaccination status for COVID-19 has been evaluated till 08Oct2021, before entering in the 3rd booster dose campaign for fragile populations in Italy. Data on vaccination status have been collected by medical records and/or administrative databases. Descriptive statistics, crude and adjusted logistic regression models for identifying predictors of not being vaccinated (0 doses received) were used. Results: Vaccination status has been assessed for 3,242 subjects from 17 centers of the cohort. 319/3,242 resulted still not vaccinated (9.8%) and 2,923 received at least one dose (90.2%). The full cycle has been completed by 2,732 subjects (85.5%). 89.1% of PLWH received a mRNA vaccine, 6.6% a viral vector and 4.3% unknown. Characteristics of patients according to being vaccinated or not are shown in Table 1A. In the adjusted logistic regressions, PLWH who did not receive the vaccine were more frequently younger (per 10 years younger AOR=1.22, 95%CI 1.07-1.38), and current/ex injecting drug users (IDU) (AOR=1.61, 95%CI 1.01-2.57), while having a current HIV-RNA < 50 copies mL (AOR=0.62, 95%CI 0.44-0.89), no previous diagnosis of COVID-19 (AOR=0.52, 95%CI 0.30-0.92) and being MSM (AOR=0.63, 95%CI 0.46-0.86) had lower risk to miss vaccination. Conclusion: The acceptance and uptake of vaccine among PLWH has been high, with a proportion of patients who completed the full vaccination cycle higher than targeted general population in Italy (85.5% vs 78.3% at W40-2021). Access to vaccination has been favourable for PLWH but some challenges remain for IDU/ex-IDU PLWH. The vaccination hesitancy lasts in younger population. MSMs seem to have a stronger attitude to protection, whereas patients with unsuppressed HIV-RNA could have a lower compliance reflected also in a lower COVID-19 vaccine uptake. Some selection bias on the population in analysis cannot be ruled out. These findings could help to develop interventions for increasing vaccination uptake for PLWH in future.

SARS-CoV-2 ANTIBODY CORRELATES among PWID LIVING with and WITHOUT HIV in KENYA

Background: In sub-Saharan Africa many persons who inject drugs (PWID) are living with undiagnosed or untreated HIV and experience high levels of poverty, housing instability, and co morbid conditions that contribute to worse outcomes from SARS-CoV-2. We sought to determine SARS-CoV-2 antibody prevalence and risk factors for PWID and their sexual and injecting partners in Kenya. Identifying the burden of infection in marginalized populations like PWID may contribute to controlling the pandemic in LMIC Methods: In a nested cross-sectional study, we recruited PWID living with HIV and their injecting and/or sexual partners in Nairobi, Kilifi, and Mombasa counties at needle and syringe programs (NSP). Blood samples were collected from consenting participants at enrollment to determine SARS-CoV-2 antibodies using a Platellia BioRad SARS-CoV-2 total antibody enzyme-linked immunosorbent assay. Baseline data was collected on HIV status, antiretroviral therapy (ART) and methadone adherence. Logistic regression was used to identify factors associated with antibody positivity Results: In total,1000 participants were enrolled in the study between April and July 2021, of whom 323 (32.3%) were women and 677 (67.7%) were men. Median age of participants was 36 years (Interquartile range [IQR]: 30, 42). SARS-CoV-2 positivity was reported in 309 (30.9%) of the participants. Of the participants who tested positive for SARS-CoV-2 antibodies, 39.5% did not report any symptoms at any time during the last 3 months. Men were significantly less likely than women to have SARS-CoV-2 antibodies (Odds ratio [OR] 0.70, 95% confidence interval [CI] 0.52, 0.94;p<0.016). Participants from the Coast region had lower odds of SARS-CoV-2 antibody positivity compared to the Nairobi region (OR 0.72, 95% CI, 0.54, 0.95;p<0.019) and participants who had a sexual or injecting partner diagnosed with COVID-19 were more likely to have SARS-CoV-2 antibodies detected (OR 2.12, 95% CI 1.02, 4.39;p<0.042). Living with HIV was not significantly associated with presence of SARS-CoV-2 antibodies Conclusion: SARS-CoV-2 antibody was detected in 30.9% of participants in this cohort of PWID and their partners, suggesting high transmission rates within this key population. SARS-CoV-2 seroprevalence was similar for people living with and without HIV;no increase in risk was found for those living with HIV. This cohort represents an at-risk population that should be considered for COVID-19 vaccination, surveillance and other targeted public health measures.