Taiwan's national strategies and actions toward HCV elimination before 2025

In 1990, the seroprevalence of antibody against hepatitis C virus (anti- HCV) in Taiwan was first documented to be 0.95% in volunteer blood donors, 90% in hemophiliacs, and 81% in parenteral drug abusers. The risk factors for HCV infection in Taiwan include iatrogenic transmission (medical injection, hemodialysis, acupuncture, and blood transfusion), tattooing, and sexual transmission. The long-term risk of hepatic and non-hepatic diseases has been well-documented by REVEL-HCV study. A national program of antiviral therapy for chronic viral hepatitis was launched in Taiwan in 2003. Mortality rates of end-stage liver diseases decreased continuously from 2000-2003 to 2008-2011 in all age and gender groups. When the World Health Assembly adopted the Global Health Sector Strategy on Viral Hepatitis in 2016, National program to eliminate hepatitis C was very carefully evaluated. It became a consensus to reach the WHO's 2030 goals in 2025. Taiwan Hepatitis C Policy Guideline 2018-2025 was approved and published at the beginning of 2019. There are triple focuses of hepatitis C elimination in Taiwan including (1) therapy spearheads prevention, (2) screening supports therapy, and (3) prevention secures outcome. A total of US$1.7 billion will be allocated from 2017 to 2025 for the elimination of HCV. The coverage of HCV screening and treatment has been increasing significantly since 2017. The HCV screening coverage was almost 100% for dialytic patients, 96% for HIV-infected patients, 65% for patients under opioid substitution treatment, 63% for patients in the pre-end-stage renal disease care program, 57% for patients in the early chronic kidney disease care program, 52% for patients in diabetes care program, 39% for prisoners, and 38% for adults aged 45-79 years old in the general population by April 30, 2020. The budget to cover the cost of DAA increased from US$101 million in 2017 to US$219 million in 2019. The number of chronic hepatitis C patients receiving DAA therapy increased from 9,538 in 2017, 19,549 in 2018, to 45,806 in 2019. However, the number of DAA-treated CHC patients reduced to 36,159 in 2020 and 20,559 in 2021 due to the COVID-19 pandemic. The cure rate based on SVR12 was 96.8% in 2017, 97.4% in 2018, over 98.6% after 2019. It is expected that Taiwan will achieve WHO's HCV elimination goal by 2025.

Mortality among people with HIV in the UK in 2021: findings from the National HIV Mortality Review

Background: The National HIV Mortality Review (NHMR) was launched by UK Health Security Agency (UKHSA) and British HIV Association to better recognise causes of death and preventable death, and to describe end-of-life care, among people with HIV. Method(s): UK HIV services submitted data on all known deaths among people with HIV under their care in 2021 through a secure online form. Cause of death was categorised by an epidemiologist and four clinicians using the Coding Causes of Death in HIV protocol. Result(s): In 2021, 101 services reported 606 deaths among people with HIV to NHMR. In 2019, 74 services reported to the NHMR while 121 reported in 2020. Median age at death was 58 [interquartile range (IQR): 56-59] and most (76%) were male. Death cause was ascertainable for 78% (n=475), with the most common being non-AIDS-related cancers (26%), followed by non-AIDS-defining infections (19%), cardiovascular disease (16%), AIDS (9%), substance misuse (8%), respiratory disease (4%), accident/suicide (3%), liver disease (2%) and other causes (11%). COVID- 19 caused or contributed to 11% of all deaths. Thirtythree people (5%) died within a year of HIV diagnosis, 90% of these were diagnosed late (CD4<350 cells/mm3), 80% very late (CD4<200 cells/mm3), 54% diagnosed with AIDS and 33% had documented missed opportunities for earlier diagnosis. Viral suppression (<200 copies/mL) (87%) and treatment coverage (98%) was high with the median time on treatment 13 years [IQR: 8-20]. Common lifestyle risk factors in the preceding year included smoking (33%;n=179), excessive alcohol use (20%;n=103). Other factors included drug use (non-injecting and injecting) and opioid substitution therapy. Death had been expected for 298 (49%) individuals, of whom 230 had discussed end-of-life care and 108 had a documented advanced end-of-life care plan in place. Conclusion(s): Over half of people living with diagnosed HIV are aged over 50. Most deaths were not AIDS related however, one in eleven people with diagnosed HIV in the UK died from AIDS. Of people that died within a year of diagnosis, one in three had documented missed opportunities for earlier HIV diagnosis.

Regional Buvidal Care Pathway for Northern Ireland

Introduction: Due to an increase in heroin use and subsequent high demand for treatment services, community pharmacies are nearing saturation for opioid supervision services for patients on buprenorphine. The Covid-19 pandemic exacerbated this issue, highlighting the need for alternative forms of opioid substitution therapy (OST). Buvidal is a long-acting injectable form of buprenorphine for the treatment of opioid dependence. It comes in two formulations - weekly or monthly subcutaneous injection. The availability and use of Buvidal would help to reduce pressure on community pharmacy and provide an alternative treatment option to assist patients in their recovery journey. Aim(s): To provide safe and consistent service for the administration of Buvidal across Northern Ireland (NI). Objective(s): The development of a regional pathway to provide a framework to: ** Better support clinicians to initiate and use Buvidal safely and effectively. ** To ensure adequate physical health checks are carried out at initiation. ** To improve documentation. ** To ensure equitable care for all patients prescribed Buvidal across Northern Ireland. Method(s): ** Mental Health Pharmacists from each trust in NI met to determine the feasibility of introducing Buvidal . ** The group met with the Department of Health regarding the CD regulatory requirements in outpatient settings. ** The group met with the Health and Social Care Board (HSCB) to secure funding for Buvidal ** A regional pathway and kardex were developed to ensure consistency of prescribing across trusts. ** The pathway was shared with the addiction teams and prison services across NI for agreement. ** Adjustments were made and the pathway was piloted in different regions. Result(s): ** An agreed regional pathway for Buvidal developed. ** A regional kardex for Buvidal was developed. ** Funding was approved for each trust. ** A mixture of stock orders and individual patient prescriptions are used for the ordering of Buvidal across trusts. ** An electronic care record alert was developed for all forms of OST. ** Feedback was requested from those prescribed Buvidal and of those who responded 95% stated their life has improved on Buvidal and would recommend it to a friend. Discussion(s): Following initial reluctance for the need of a regional pathway and kardex it has now been established ensuring consistency across all trusts with regards to prescribing, baseline tests and advice a patient receives prior to the commencement of Buvidal . Staff have fed back that Buvidal use has been a positive service development and particularly beneficial for chaotic patients who struggled to go to the community pharmacy each day. They find the assessment page useful but the kardex can cumbersome at initiation and as such work is ongoing to streamline this. Conclusion(s): Buvidal is now prescribed across NI providing an alternative form of OST to patients. The regional mental health pharmacist group played a strategic role in developing this new service. This has exposed the addictions teams to the potential a pharmacist can play within their team resulting in the recruitment of addictions pharmacists in some trusts. The initial forecasted numbers were quickly exceeded resulting in ongoing service expansion. Consideration is now being given to the administration of Buvidal by community pharmacies in NI. The OST alert now available on NIECR improves communication at interfaces to highlight those patients prescribed OST.

Increase of overdose and deaths related to methadone during COVID-19 epidemic

Introduction: Following COVID-19 epidemic, a reinforced monitoring has been set up by the French addictovigilance network from March 16th to June 30th, 2020 due to the risk of overdoses increase (changes in health organization and rules for renewing prescriptions;risk of higher drugs consumption due to stress). Methadone was the first substance reported. In this context, a specific study has been managed in order to analyze overdoses in 2020 compared to 2019. Material and methods: Overdoses and deaths related to methadone and reported in the French pharmacovigilance database in 2019 and 2020 were analyzed. Results: A total of 332 cases were analyzed (193 occurred in 2019 and 139 in 2020). First, this study revealed a time lag between the date of reports and the date of occurrence in particularly in deaths (77% of deaths occurring in 2019 were reported in 2020). In this context, we have taken into account only cases that occurred and reported the same year. Secondly, there were more cases in 2020 compared to 2019: 1.2 times more overdoses (98 versus 79) and 2.2 times more deaths (41 versus 19). In 2020, a greater number of cases were observed in April and May for overdoses and in May for deaths. Overdoses and deaths occurred during occasional methadone use and also in subjects with opioid substitution therapy and resulted from different factors: overconsumption, multiple drug use with depressants drugs or cocaine, injection, consumption for sedative, recreational purposes or voluntary drug poisoning. There was low mention of "take home" naloxone use and methadone was obtained from prescription, street market or from entourage. Discussion/Conclusion: All these data show an increase of morbidity and mortality related to methadone during COVID-19 epidemic. In this context, the French addictovigilance network has disseminated several information on methadone overdose risk.

Differences in the delivery of medications for opioid use disorder during hospitalization by racial categories: A retrospective cohort analysis.

Background: As the drug-related overdose crisis and COVID-19 pandemic continue, communities need increased access to medications for opioid use disorder (MOUD) (i.e., buprenorphine and methadone). Disparities in the type of MOUD prescribed or administered by racial and ethnic categories are well described in the outpatient clinical environment. It is unknown, however, if these disparities persist when MOUD is provided in acute care hospitals. Methods: This study assessed differences in the delivery of buprenorphine versus methadone during acute medical or surgical hospitalizations for veterans with opioid use disorder (OUD) by racial categories (Black Non-Hispanic or Latino vs. White Non-Hispanic or Latino). Data were obtained retrospectively from the Veterans Health Administration (VHA) for federal fiscal year 2017. We built logistic regression models, adjusted for individual and hospital-related covariates, and calculated the predicted probabilities of MOUD delivery by racial categories. Results: The study cohort (n = 1,313 unique patients; N = 107 VHA hospitals) had a mean age of 57 (range 23 to 87 years), was predominantly male (96%), and composed entirely of Black (29%) or White (71%) patients. White patients were 11% more likely than Black patients to receive buprenorphine than methadone during hospitalization (p = 0.010; 95% CI: 2.7%, 20.0%). Among patients on MOUD prior to hospitalization, White patients were 21% more likely than Black patients to receive buprenorphine (p = 0.000; 95% CI: 9.8%, 31.5%). Among patients newly initiated on MOUD during hospitalization, there were no differences by racial categories. Conclusion: We observed disparities in the delivery of buprenorphine versus methadone during hospitalization by racial categories. The observed differences in hospital-based MOUD delivery may be influenced by MOUD received prior to hospitalization within the racialized outpatient addiction treatment system. The VHA and health systems more broadly must address all aspects of racism that contribute to inequitable MOUD access throughout all clinical contexts.

Patient satisfaction with telemedicine in addictions

Telemedicine refers to providing healthcare from one site to another remote site, through information technologies, and has been advocated by the World Health Organisation. Telemedicine has been found to be cost-effective, reducing travel and improving satisfaction as compared to face-to-face appointments. Methods. We assessed patient satisfaction with a new Telemedicine in Addictions service as part of a feasibility randomised controlled trial of telemedicine versus face-to-face consultations (ISRCTN36756455), with addiction specialist prescribers, pre-COVID19. Opioid dependent patients prescribed opioid replacement treatment attending an outreach clinic were recruited. Telemedicine participants completed the NHS Friends and Family Test (FFT) after each consultation. We completed qualitative analysis of the free text responses. Results. Thirty Friends and Family Tests were completed, of which all participants were ‘extremely likely’ (n=19;67%) or ‘likely’ (n=11;37%) to recommend Telemedicine. Qualitative analysis themes for recommending telemedicine were ‘convenience’, ‘less travel’, ‘supportive staff’ and ‘listened to’. Patients said that everything went well, including communication. Conclusions. Our study found that patients recommend telemedicine because of convenience, less travel, good communication and supportive staff, showing this is acceptable to patients. Due to the COVID-19 pandemic, this technology will be essential for continued access to addiction services.

COVID 19 and the Opioid Epidemic: An Analysis of Clinical Outcomes During COVID 19.

Background and Objectives: Here we aimed to characterize clinical outcomes in those receiving treatment at a Veterans Health Administration (VHA) methadone maintenance treatment program (MMT) during the COVID 19 pandemic in which SAMSHA regulations for MMTs were changed to provide a greater number of methadone allotments and decreased clinic-visit frequency. Methods: We report results of a single-site, pre-post cohort study of urine drug screen data 3 months before and after an increase in allotments of take-home medication from the methadone clinic. One hundred twenty-nine patients met inclusion criteria for this study. The study was reviewed by the NYHHS IRB committee and granted final approval by the Research and Development Committee. Results: The sample was predominately male, average age 66years and average years in most recent treatment is 4.1 years. No statistical significance was found between period 1 and period 2 in the positive test detection for nonprescribed opiates, methadone and illicit substances (P > .05), number of new medical illnesses or overdoses. We controlled for participant age, substance use disorder diagnosis, psychiatric disorder diagnosis, and number of years in treatment. Discussion/Conclusions: The results of the study illustrate the relative safety of the changes made at this particular MMT during the pandemic. Additionally, there was continued adherence to methadone treatment with minimal change in illicit substance use during period 1 and period 2. Scientific Significance: To these authors' knowledge this paper is one of the first to examine clinical outcomes in those with opioid addiction prescribed methadone from MMTs during the COVID 19 pandemic.

Opioid agonist treatment and patient outcomes during the COVID-19 pandemic in south east Sydney, Australia.

INTRODUCTION: In early 2020, many services modified their delivery of opioid treatment in response to the COVID-19 pandemic, to limit viral spread and maintain treatment continuity. We describe the changes to treatment and preliminary analysis of the association with patients' substance use and well-being. METHODS: A pre-post comparison of treatment conditions and patient self-reported outcomes using data extracted from electronic medical records in the 5 months before (December 2019-April 2020) and after (May 2020-September 2020) changes were implemented in three public treatment services in South Eastern Sydney Local Health District. RESULTS: Data are available for 429/460 (93%) patients. Few (21, 5%) dropped out of treatment. In the 'post' period there was significantly more use of depot buprenorphine (12-24%), access to any take-away doses (TAD; 24-69%), access to ≥6 TAD per week (7-31%), pharmacy dosing (24-52%) and telehealth services. There were significant reductions in average opioid and benzodiazepine use, increases in cannabis use, with limited group changes in social conditions, or quality of life, psychological and physical health. At an individual level, 22% of patients reported increases in their use of either alcohol, opioids, benzodiazepines or stimulants of ≥4 days in the past 4 weeks. Regression analysis indicates increases in substance use were associated with higher levels of supervised dosing. DISCUSSION AND CONCLUSIONS: These preliminary findings suggest that the modified model of care continued to provide safe and effective treatment, during the pandemic. Notably, there was no association between more TAD and significant increases in substance use. Limitations are discussed and further evaluation is needed.

A cross-section observational study on the seroprevalence of antibodies to COVID-19 in patients receiving opiate agonist treatment.

INTRODUCTION: The HSE National Drug Treatment Centre is an inner city drug treatment centre in Dublin which provides opiate agonist treatment (OAT) to approximately 565 patients, many of whom have complex care needs. OBJECTIVE: This study was conducted to determine seropositivity to the COVID-19 virus in patients attending NDTC, and to establish if patients tested had any clinical symptoms of this disease since March 2020. METHOD: All patients attending for OAT were invited to participate and 103/565 patients agreed. The patients were tested for the presence of serum antibodies to COVID-19 in a single sample collected over a 4-month period (July-October 2020). A questionnaire was administered at the same time as sample taking. RESULTS: Results showed that the majority of patient samples (100; 97%) tested were negative for the presence of antibodies to COVID-19. There were only two confirmed positive results (1.9%) and one equivocal result (1%). None of the approximately 565 attendees at the HSE NDTC presented with serious illness indicative of COVID-19 throughout the three waves of the pandemic, nor were any deaths due to COVID-19 reported. CONCLUSION: These findings indicate (a) possible low level of exposure to COVID-19 among this patient cohort or (b) that those patients who have been exposed have not developed or maintained detectable antibody levels, nor developed symptoms of the disease. Public health measures could explain the low level of COVID-19 in this cohort. The findings are also consistent with the possibility of a protective effect of OAT medications on development of the disease.

A health crisis within a health crisis: Opioid access in the COVID-19 pandemic.

The novel coronavirus has thrown large sections of our healthcare system into disarray, with providers overburdened by record breaking number of hospitalizations and deaths. The U.S., in particular, has remained the nation with one of the fastest growing case counts in the world. As a consequence, many other critical healthcare needs have not received the necessary resources or consideration. This commentary draws attention to substance use and opioid access during the ongoing crisis, given the potential for breakdowns in treatment access for addiction, the growing concern of mental health comorbidities, and the lack of access for those who require opioids for adequate pain management. Further, the commentary will offer policy and practice recommendations that may be implemented to provide more equitable distribution of care.

Leveraging pharmacists to maintain and extend buprenorphine supply for opioid use disorder amid COVID-19 pandemic.

PURPOSE: Strategies for deploying clinical pharmacists to increase access to buprenorphine in inpatient, outpatient and transitional care, and community practice settings are described. SUMMARY: Access to medications for opioid use disorder (MOUD) is essential, but patients face many barriers when pursuing treatment and MOUD. The coronavirus disease 2019 (COVID-19) pandemic has compounded the opioid crisis and worsened outcomes by introducing new barriers to MOUD access. Many strategies to ensure continued access to MOUD have been described, but the role of leveraging pharmacists during the opioid/COVID-19 syndemic to improve medication access and outcomes remains underappreciated. Pharmacists, while both qualified and capable of liberalizing access to all forms of MOUD, may have the strongest impact by increasing access to buprenorphine. Herein, we present progressive strategies to maintain and extend buprenorphine access for patients with OUD through deployment of clinical pharmacists, particularly in the context of the COVID-19 pandemic, during which access may be further restricted. CONCLUSION: Leveraging pharmacists to extend access to MOUD, particularly buprenorphine, remains an underutilized strategy that should be implemented, particularly during the concurrent COVID-19 global pandemic.

Sharp decline in hospital and emergency department initiated buprenorphine for opioid use disorder during COVID-19 state of emergency in California.

The California Bridge Program supports expansion of medications for opioid use disorder (MOUD) in emergency departments (EDs) and hospital inpatient units across the state. Here, we describe the change in activity before and after the coronavirus disease 2019 (COVID-19) California statewide shutdown. Of the 70 participating hospitals regionally distributed across California, 52 report MOUD-related activity monthly. We analyzed data on outcomes of OUD care and treatment: identification of OUD, acceptance of referral, receipt of buprenorphine prescription, administration of buprenorphine, and follow-up linkage to outpatient OUD treatment, from May 2019 to April 2020. In estimating the expected number of patients who met each outcome in April 2020, we found decreases in the expected to observed number of patients across all outcomes (all p-values<0.002): 37% (from 1053 to 667) decrease in the number of patients identified with OUD, 34% (from 632 to 420) decrease in the number of patients who accepted a referral, 48% (from 521 to 272) decrease in the number of patients who were prescribed buprenorphine, 53% (from 501 to 234) decrease in the number of patients who were administered buprenorphine, and 33% (from 416 to 277) decrease in the number of patients who attended at least one follow-up visit for addiction treatment. The COVID-19 California statewide shutdown was associated with an abrupt and large decrease in the progress toward expanded access to OUD treatment.

COVID-19 and Substance Use Disorder: Study Protocol for the International Society of Addiction Medicine Practice and Policy Interest Group Global Survey.

INTRODUCTION: As one of the major health problems in the present century, the COVID-19 pandemic affected all parts of the global communities and the health of substance users are potentially at a greater risk of harm. This global study has been designed and conducted by the International Society of Addiction Medicine Practice and Policy Interest Group (ISAM-PPIG) to understand better the health related issues of people with Substance Use Disorders (SUD) as well as responses of the relevant health care systems during the pandemic. METHODS: This is a cross-sectional study using convenient sampling. The data gathering was carried out with two follow-up stages each two months apart through an online conducted survey prepared using Google platform. The survey started by emergence of COVID-19 as a pandemic in March 2020 and respondents were followed till September 2020 when most of the initial lockdowns by most countries are supposed to be reopened. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. The results will be published in relevant peer reviewing journals and communicated with different international stakeholders.