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.

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

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

MAINTAINED ACCESS to PREVENTION & CARE for PWID DESPITE COVID-19 in HAIPHONG, VIETNAM

Background: Haiphong is a Vietnamese city of 2 million people and a historic hotspot for HIV and drug use. The DRIVE community research program recently demonstrated the end of the HIV epidemic among PWID in the city, with an incidence of 0.085/100PY, and a substantial decrease in HCV incidence in the past 5 years. After the emergence of COVID-19, a one-month strict lockdown was imposed in April 2020 in Vietnam, followed by lighter social distancing restrictions over the year. We investigated whether those measures affected PWID in terms of risk behaviors and access to prevention and care. Methods: Participants were PWID that had been enrolled in a respondent-driven sampling (RDS) survey as part of DRIVE in the last quarter of 2019. They were recalled and interviewed in the last quarter of 2020 by peer educators on their socioeconomic situation, drug use and sexual behaviors, relations to methadone maintenance treatment (MMT) and ART services. They were tested for drugs and methadone in the urine, and for HIV, HCV, and HIV plasma viral load when HIV(+). Changes following the restrictions were assessed by comparing these "after" data to the "before" data collected one year earlier during the RDS survey. In-depth interviews were conducted with 30 participants including 5 female sex workers (FSW). Results: 780 PWID were enrolled. Their mean age was 44 years and 94% were male. 56% were still actively injecting (100% heroin) at the time of the interview;their monthly consumption had decreased from 24 to 17 days on average. The main source of syringes remained pharmacies for 83% before, during and after the lockdown. The proportion of PWID still engaging in sharing decreased from 6.0 to 1.5%. No change in the frequency of condom use was reported. The proportion of PWID on MMT increased from 68.7 to 75.3%. There was no alteration in the HIV cascade of care that was still above 90/90/90. No HIV seroconversion was observed, and HCV incidence remained stable (2.6/100PY, 95%CI: 0.7-6.7). 53% reported a monthly income of less than 130 USD "after" compared to only 9% "before". One FSW reported accepting unsafe sex during the lockdown due to financial pressure. Conclusion: Six months after the beginning of COVID-19-related restrictions, access to harm reduction materials and care services for PWID was maintained and no increase in the number of new HIV or HCV infections was observed. However, this period was a major financial challenge, especially for FSW that were more likely to engage in risky sexual behaviors.

P.0615 Biopsychosocial effect of the Covid-19 pandemic in patients under medication-assisted treatment with methadone and buprenorphine

Introduction: The Covid-19 pandemic is a global threat to public health, mainly affecting vulnerable groups, such as the elderly, chronically ill patients, or patients with substance use disorders (SUD) [1]. Prolonged use results in neurobiological changes in the cerebral area, activating the "reward system," leading to development of drug-seeking behaviors and upregulating proinflammatory cytokines, as well as growth factors [2,3]. The immune system's response inducing Covid-19 virus even to moderate symptoms by adapting the immunomodulation, seems to lead to an inflammatory process, especially in patients with pre-existing production of inflammatory agents, such as patients with SUD [4]. Objective: The investigation of biopsychosocial responses of the Covid-19 pandemic in patients under medication-assisted treatment (MAT) with methadone and buprenorphine and their correlation to biological factors. Material and Methods: 64 patients with Covid-19 were included in the study sample, 26 (40.6%) under methadone administration and 38 (59.4%) under buprenorphine ones. The Control group consisted of patients with SUD that had not been infected by the virus and Covid-19 patients without previous history of substance use. Blood samples were obtained in both groups to determine C-reactive protein (CRP), cortisol, IFNa1, IFNa2, IFNγ, IL-1a, IL-1β, IL-5, IL-6, IL-8, IL-10, IL-18, MCP-1, TNF-a, but in patients with Covid-19, blood samples were obtained at the first, seventh and sixteenth day after infection. The sample with SUD had completed a structured questionnaire (Medication-Assisted Treatment Questionnaire Covid-19 – MATQ/Covid-19) about Covid-19 effect in terms of medications’ administration (methadone and buprenorphine) and psychosocial life. Statistical significance was ascertained by t-tests, ANOVA and Pearson's x2 test as appropriate. Results: Reduced management of medications at take-home doses (p<0.05) and physical dysfunctions (p<0.05) were observed in both groups with SUD. Regarding the patients under methadone treatment, social isolation (p<0.05) and the need for psychosocial support from the therapeutic programs (p<0.001) were found increased. According to the results, the values of cortisol, IL-1a, IL-1b, IL-8 and MCP-1 were significantly elevated (p<0.05) in the study sample compared to the control group. Furthermore, biological factors on the 7th and 16th day after Covid-19 infection (cortisol, IL-1b, IL-8, TNF-a, MCP-1, IL-6) in methadone administration were significantly increased (p<0.05) while greater values of CRP (p<0.05) on the first and seventh day were observed in the buprenorphine group. In respect of the findings, the IL-8 and MCP-1 were significantly increased in the methadone group compared to the buprenorphine group. Moreover, increased values of IL-8 and MCP-1 positively were correlated with the need for psychosocial support, drug-seeking behavior and relapse. Conclusions: In conclusion, the Covid-19 virus negatively influences the immune system in patients under substitution treatment. Although methadone and buprenorphine are key substances as MAT, they seem able to exacerbate the dysregulated cellular functions due to the Covid-19 virus and, thus, lead progressively in drug-seeking behaviors and relapsing disorders. No conflict of interest

Use of an electronic pillbox to increase number of methadone take-home doses during the COVID-19 pandemic.

This study describes use of the commercially available Medminder electronic pillbox at a community substance use disorder treatment program to safely increase the number of methadone take-home doses administered during the COVID-19 pandemic. The pillbox contains 28 cells that lock independently and can be opened only during preprogrammed time windows. This study provided patients (n = 42) deemed vulnerable to take-home mismanagement or more severe symptoms from COVID-19 infection the pillbox and observed them for 11 weeks. A telephone support line was staffed daily to manage technical issues. Overall, patients received about 14 more take-home doses per month after receiving the pillbox. Most medication was dispensed within scheduled windows. The study observed few incidents of suspected tampering, though five patients had their pillbox rescinded to allow more intensive on-site clinical monitoring. The study supports use of an electronic pillbox with a telephone support line to help vulnerable patients to better observe stay-at-home guidelines during the COVID-19 pandemic. The pillbox may offer public health and clinical benefits that extend beyond the pandemic by increasing program treatment capacity and patient satisfaction.