Personal historical perspective of HIV: part 11.

All animal life on earth is thought to have a common origin and have common genetic mechanisms. Evolution has enabled differentiation of species. Pathogens likewise have evolved within various species and mostly come to a settled dynamic equilibrium such that co-existence results (pathogens ideally should not kill their hosts). Problems arise when pathogens jump species because the new host had not developed any resistance. These infections from related species are known as zoonoses. COVID-19 is the latest example of a virus entering another species but HIV (and various strains of influenza) were previous examples. HIV entered the human population from monkeys in Africa. These two papers outline the underlying principle of HIV and the differing epidemiologies in Africa, the USA and in Edinburgh. The underlying immunosuppression of HIV in Africa was initially hidden behind common infections and HIV first came to world awareness in focal areas of the USA as a disease seemingly limited to gay males. The epidemic of intravenous drug abuse in Edinburgh was associated with overlapping epidemics of bloodborne viruses like hepatitis B, hepatitis C and HIV.

HIV and its associated factors among people who inject drugs in Mizoram, Northeast India.

AIM: To estimate the prevalence and associated factors with the human immune-deficiency virus (HIV) among people who inject drugs (PWID) in Mizoram, Northeast India. METHODS: The data source for the analysis was the 2019-2020 Mizoram State AIDS Control Society (MSACS) survey from 2695 PWID registered for the Targeted Intervention (TI) services. Logistic regression analysis was conducted to examine the factors associated with HIV among PWID after adjusting for sociodemographic characteristics, injection, and sexual behaviours. RESULTS: 21.19% of the participants tested positive for HIV and the prevalence of HIV among male and female participants were 19.5% and 38.6%, respectively. Multiple logistic regression analysis revealed that female (AOR 1.74; 95% CI 1.26-2.41), 35 years or older (AOR 1.45; 95% CI 1.06-1.99), married (AOR 1.41; 95% CI1.08-1.83), divorced/separated/widowed (AOR 2.12; 95% CI 1.59-2.82) and sharing of needle/syringe (AOR 1.62; 95% CI 1.30-2.00) were all positively associated with HIV infection. We also found that concomitant alcohol use was reduced by 35% (AOR 0.65; 95% CI 0.51-0.82) among HIV positive PWID, and HIV infection was also reduced by 46% (AOR 0.54; 95% CI 0.44-0.67) among those PWID who use a condom with a regular partner. CONCLUSION: The findings of this study suggested that there is a high prevalence of HIV among PWID with 1 in 5 PWID reported to have HIV. HIV among PWID was significantly higher among those over 35 years of age, females and divorced/separated/widowed participants. Needle/syringe sharing behaviour is an important determinant of HIV infection. The high prevalence of HIV among PWID population is multifactorial. To reduce HIV among PWID in Mizoram, interventions should target those sharing needles/syringes, females, especially those over 35 years of age and unmarried participants.

A new outbreak of HIV infection among people who inject drugs during the COVID-19 pandemic in Greece.

BACKGROUND: Multiple HIV outbreaks have been recorded among people who inject drugs (PWID) since 2010. During an intervention for PWID in 2019-2021 in Thessaloniki, Greece, an increasing number of HIV cases was documented. Here, we provide an analysis of this new outbreak. METHODS: ALEXANDROS was a community-based program and participation included interviewing, rapid HIV/HCV tests, counselling and linkage to care. PWID were recruited through Respondent-Driven Sampling (RDS) in five sampling rounds. Crude and RDS-weighted HIV prevalence estimates were obtained. HIV incidence was estimated from data on 380 initially seronegative PWID with at least two tests. Multivariable Cox proportional hazards model was used to assess risk factors for HIV seroconversion. RESULTS: In total, 1,101 PWID were recruited. At first participation, 53.7% were current PWID, 20.1% homeless, 20.3% on opioid substitution treatment and 4.8% had received syringes in the past 12 months. HIV prevalence (95% CI) was 7.0% (5.6-8.7%) and an increasing trend was observed over 2019-2021 (p = 0.002). Two-thirds of the cases (67.5%) were new diagnoses. HIV incidence was 7.0 new infections/100 person-years (95% CI:4.8-10.2). Homelessness in the past 12 months (HR:2.68; 95% CI:1.24-5.81) and receptive syringe sharing (HR:3.86; 95% CI:1.75-8.51) were independently associated with increased risk of seroconversion. By the end of the program, 67.3% of the newly diagnosed cases initiated antiretroviral treatment. CONCLUSIONS: A new HIV outbreak among PWID was documented in Greece during the COVID-19 pandemic with homelessness and syringe sharing being associated with increased risk of HIV acquisition. Peer-driven programs targeting the population of high-risk underserved PWID can be used to early identify emerging outbreaks and to improve linkage to HIV care.

COVID-19 vaccination and HIV transmission among persons who inject drugs during the first two years of the COVID-19 pandemic in New York City.

BACKGROUND: To examine COVID-19 vaccination and HIV transmission among persons who inject drugs (PWID) during the COVID-19 pandemic (2020-2022) in New York City (NYC). METHODS: Two hundred and seventy five PWID were recruited from October 2021 to September 2022. A structured questionnaire was used to measure demographics, drug use behaviors, overdose experiences, substance use treatment history, COVID-19 infection, vaccination, and attitudes. Serum samples were collected for HIV, HCV, and SARS-CoV-2 (COVID-19) antibody testing. RESULTS: Participants were: 71% male, the mean age was 49 (SD 11), 81% reported at least one COVID-19 immunization, 76% were fully vaccinated and 64% of the unvaccinated had antibodies for COVID-19. Self-reported injection risk behaviors were very low. HIV seroprevalence was 7%. Eighty-nine percent of the HIV seropositive respondents reported knowing they were HIV seropositive and being on antiretroviral therapy prior to the COVID-19 pandemic. There were two likely seroconversions in 518.83 person-years at risk from the March 2020 start of the pandemic to the times of interviews, for an estimated incidence rate of 0.39/100 person-years, 95% Poisson CI 0.05-1.39/100 person-years. CONCLUSIONS: There is concern that the COVID-19 pandemic disruptions to HIV prevention services and the psychological stress of the pandemic may lead to increased risk behavior and increased HIV transmission. These data indicate adaptive/resilient behaviors in both obtaining COVID-19 vaccination and maintaining a low rate of HIV transmission among this sample of PWID during the first two years of the COVID-19 pandemic in NYC.

The impacts of COVID-19 on structural inequities faced by people living with HIV who inject drugs: A qualitative study in St. Petersburg, Russia.

BACKGROUND: People who inject drugs (PWID) living with HIV may be disproportionately impacted by pandemic restrictions. This study qualitatively explored the impacts of the SARS-CoV-2 pandemic on PWID with HIV in St. Petersburg, Russia. METHODS: In March and April 2021, we conducted remote, semi-structured interviews with PWID with HIV, health care providers, and harm reductionists. RESULTS: We interviewed 25 PWID with HIV (aged 28-56 years, 46% female) and 11 providers. The pandemic exacerbated economic and psychological challenges experienced by PWID with HIV. Simultaneously, barriers to HIV care access, ART prescription refill and dispensing and police violence, which hindered the health and safety of PWID with HIV, were themselves hindered from normal operations by the pandemic, significantly reducing these burdens. CONCLUSION: Pandemic responses should account for the unique vulnerabilities of PWID with HIV to avoid worsening the structural violence they already experience. Wherever the pandemic decreased structural barriers, such as institutional, administrative, and bureaucratic challenges and state violence enacted by police and other elements of the criminal justice system, such changes should be protected.

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

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

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

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

SARS-CoV-2 antibody prevalence, correlates, and access to harm reduction services among people who inject drugs living with and without HIV and their partners in Kenya.

BACKGROUND: In sub-Saharan Africa many people who inject drugs (PWID) are living with undiagnosed or untreated HIV and experience high levels of poverty and conditions that can contribute to worse outcomes from SARS-CoV-2 infection. Identifying the burden of SARS-CoV-2 infection in marginalized populations like PWID may contribute to controlling the pandemic. METHODS: This is a nested cross-sectional study within an ongoing cohort study that recruits PWID living with HIV and their injecting and/or sexual partners at needle and syringe program sites and methadone clinics in Kenya. 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 were collected on HIV status, antiretroviral therapy and methadone adherence. We used logistic regression to identify factors associated with antibody positivity and descriptive statistics to report SARS-CoV-2 antibody prevalence. RESULTS: One thousand participants were enrolled 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: 30, 42). SARS-CoV-2 antibody positivity was found in 309 (30.9%) participants. Disruption in obtaining methadone service was reported by 106 (24.3%) of the participants. Men were significantly less likely than women to have SARS-CoV-2 antibodies (adjusted odds ratio [aOR] = 0.68, 95% confidence interval [CI] 0.51, 0.95; p < 0.01) Participants who reported a sexual or injecting partner diagnosed with SARS-CoV-2 were twofold more likely to have SARS-CoV-2 antibodies detected (aOR = 2.21, 95% CI 1.06, 4.58; p < 0.032). Living with HIV was not associated with presence of SARS-CoV-2 antibodies. CONCLUSION: The seroprevalence of SARS-CoV-2 of 30.9% in this cohort suggests high transmission rates within this population. SARS-CoV-2 seroprevalence was similar for people living with and without HIV. A large portion of this population was noted to have had disruption in access to harm reduction services.

PrEP disclosure and discussions within social networks of people who inject drugs experiencing homelessness: a brief report.

BACKGROUND: In the context of increasing injection-related HIV outbreaks across the United States, particularly among people who inject drugs (PWID) experiencing homelessness, there is an urgent need to expand access to pre-exposure prophylaxis (PrEP) for HIV prevention. Peer-based interventions for PrEP could be helpful for promoting PrEP uptake, yet the social experiences of using PrEP among PWID experiencing homelessness have not been thoroughly explored. METHODS: To better understand social experiences surrounding PrEP use among PWID experiencing homelessness, we conducted qualitative interviews from March-December 2020 with current and former PrEP patients of an innovative, low-threshold program implemented by Boston Health Care for the Homeless Program (BHCHP) in Boston, MA. Thematic analysis of coded interview data explored participants' perspectives and experiences with PrEP disclosure and discussions within their social networks. RESULTS: Among interviews with 21 participants, we identified the following four interrelated aspects of their social experiences using PrEP: (1) participants' were aware of increasing HIV transmission within their social networks, which motivated their PrEP use and disclosure; (2)  participants generally avoided disclosing their PrEP use within public spaces or casual conversations; (3)  participants expressed greater willingness to discuss PrEP with their close social contacts; and (4)  some participants self-identified as leaders or expressed interest in leading the dissemination of PrEP information within their social networks. CONCLUSIONS: Findings highlight the significance of PrEP disclosure and discussions within the social networks of PWID experiencing homelessness, suggesting a need for continued social network and intervention research-particularly to establish the feasibility and acceptability of peer-based interventions for promoting PrEP-with this marginalized population.

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.

The moderating role of resilience in the relationship between experiences of COVID-19 response-related discrimination and disinformation among people who inject drugs.

BACKGROUND: Due to the persistence of COVID-19, it remains important to measure and examine potential barriers to COVID-19 prevention and treatment to avert additional loss of life, particularly among stigmatized populations, such as people who inject drugs (PWID), who are at high risk for contracting and spreading SARS-CoV-2. We assessed the psychometrics of a novel COVID-19 response-related discrimination scale among PWID, and characterized associations between COVID-19 response-related discrimination, resilience to adversity, and endorsement of COVID-19 disinformation. METHODS: We assessed internal reliability, structural validity and construct validity of a 4-item COVID-19 response-related discrimination scale among PWID living in San Diego County, completing interviewer-administered surveys between October 2020 and September 2021. Using negative binomial regression, we assessed the relationship between COVID-19 response-related discrimination and disinformation and the potential moderating role of resilience. RESULTS: Of 381 PWID, mean age was 42.6 years and the majority were male (75.6 %) and Hispanic (61.9 %). The COVID-19 response-related discrimination scale had modest reliability (α = 0.66, ω = 0.66) as a single construct with acceptable construct validity (all p ≤ 0.05). Among 216 PWID who completed supplemental surveys, a significant association between COVID-19 response-related discrimination and COVID-19 disinformation was observed, which was moderated by resilience (p = 0.044). Specifically, among PWID with high levels of resilience, endorsement of COVID-19 disinformation significantly increased as exposure to COVID-19 response-related discrimination increased (p = 0.011). CONCLUSIONS: These findings suggest that intervening on COVID-19 response-related discrimination may offset the negative outcomes associated with COVID-19 disinformation.

How has the COVID-19 epidemic affected the risk behaviors of people who inject drugs in a city with high harm reduction service coverage in Vietnam? A qualitative investigation.

INTRODUCTION: The COVID-19 outbreak disproportionally affects vulnerable populations including people who inject drugs (PWID). Social distancing and stay-at-home orders might result in a lack of access to medical and social services, poorer mental health, and financial precariousness, and thus, increases in HIV and HCV risk behaviors. This article explores how the HIV/HCV risk behaviors of PWID in Haiphong, a city with high harm reduction service coverage in Vietnam, changed during the early phase of the COVID-19 pandemic, and what shaped such changes, using the risk environment framework. METHOD: We conducted three focus group discussions with peer outreach workers in May 2020 at the very end of the first lockdown, and 30 in-depth interviews with PWID between September and October 2020, after the second wave of infection in Vietnam. Discussions and interviews centered on the impact of the COVID-19 pandemic on their lives, and how their drug use and sexual behaviors changed as a result of the pandemic. RESULTS: The national shutdown of nonessential businesses due to the COVID-19 epidemic caused substantial economic challenges to participants, who mostly were in a precarious financial situation before the start of the epidemic. Unsafe injection is no longer an issue among our sample of PWID in Haiphong thanks to a combination of different factors, including high awareness of injection-related HIV/HCV risk and the availability of methadone treatment. However, group methamphetamine use as a means to cope with the boredom and stress related to COVID-19 was common during the lockdown. Sharing of smoking equipment was a standard practice. Female sex workers, especially those who were active heroin users, suffered most from COVID-related financial pressure and may have engaged in unsafe sex. CONCLUSION: While unsafe drug injection might no longer be an issue, group methamphetamine use and unsafe sex were the two most worrisome HIV/HCV risk behaviors of PWID in Haiphong during the social distancing and lockdown periods. These elevated risks could continue beyond the enforced lockdown periods, given PWID in general, and PWID who are also sex workers in particular, have been disproportionately affected during the global crisis.

Isolating the Effect of COVID-19-Related Disruptions on HIV Diagnoses in the United States in 2020.

BACKGROUND: Diagnoses of HIV in the United States 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 and 2019 because changes in diagnosis patterns in this cohort cannot be attributed to changes in transmission. METHODS: We developed 3 methods based on the CD4-depletion model to estimate excess missed diagnoses in 2020 among persons with HIV (PWH) infected from 2010 to 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 diagnoses in 2019 among PWH infected from 2010 to 2018 to evaluate the accuracy of our methods against surveillance data. RESULTS: There were approximately 3100-3300 (approximately 18%) fewer diagnoses than expected in 2020 among PWH infected from 2010 to 2019. Females (at birth), heterosexuals, persons who inject drugs, and Hispanic/Latino PWH missed diagnoses at higher levels than the overall population. Validation and stratification analyses confirmed the accuracy and reliability of our estimates. CONCLUSIONS: The substantial drop in number of previously infected PWH diagnosed in 2020 suggests that changes in testing played a substantial role in the observed decrease. Levels of missed diagnoses differed substantially across population subgroups. Increasing testing efforts and innovative strategies to reach undiagnosed PWH are needed to offset this diagnosis gap. These analyses may be used to inform future estimates of HIV transmission during the COVID-19 pandemic.

Using nominal group technique to identify barriers and facilitators to preventing HIV using combination same-day pre-exposure prophylaxis and medications for opioid use disorder.

BACKGROUND: Preventing HIV transmission among people who inject drugs (PWID) is a key element of the US Ending the HIV Epidemic strategy and includes both pre-exposure prophylaxis (PrEP) and medications for opioid use disorder (MOUD). While both lead to decreases in HIV transmission, MOUD has other social and health benefits; meanwhile, PrEP has additional HIV prevention advantages from sexual risk and the injection of stimulants. However, these medications are often prescribed in different settings and require multiple visits before initiation. Strategies to integrate these services (i.e., co-prescription) and offer same-day prescriptions may reduce demands on patients who could benefit from them. METHODS: Nominal group technique, a consensus method that rapidly generates and ranks responses, was used to ascertain barriers and solutions for same-day delivery of PrEP and MOUD as an integrated approach among PWID (n = 14) and clinical (n = 9) stakeholders. The qualitative portion of the discussion generated themes for analysis, and the ranks of the proposed barriers and solutions to the program are presented. RESULTS: The top three barriers among PWID to getting a same-day prescription for both PrEP and MOUD were (1) instability of insurance (e.g., insurance lapses); (2) access to a local prescriber; and (3) client-level implementation factors, such as lack of personal motivation. Among clinical stakeholders, the three greatest challenges were (1) time constraints on providers; (2) logistics (e.g., coordination between providers and labs); and (3) availability of providers who can prescribe both medications. Potential solutions identified by both stakeholders included pharmacy delivery of the medications, coordinated care between providers and health care systems (e.g., case management), and efficiencies in clinical care (e.g., clinical checklists), among others. CONCLUSIONS: Implementing and sustaining a combined PrEP and MOUD strategy will require co-training providers on both medications while creating efficiencies in systems of care and innovations that encourage and retain PWID in care. Pilot testing the co-prescribing of PrEP and MOUD with quality performance improvement is a step toward new practice models.

The effects of COVID-19 on New York State's Drug User Health Hubs and syringe service programs: a qualitative study.

BACKGROUND: Syringe service programs (SSPs) deliver critical harm reduction services to people who inject drugs (PWID). Some SSPs in New York State received enhanced funding to provide additional services to combat opioid overdose fatalities. These SSPs, known as Drug User Health Hubs, provide buprenorphine for the treatment of opioid use disorder and other health-related services in addition to their syringe services. While the COVID-19 pandemic posed widespread challenges to the delivery of health services nationwide, the effect of the pandemic on SSPs uniquely impacts PWID. This study examines the impact of COVID-19 on service delivery of Drug User Health Hubs and stand-alone SSPs in New York State. METHODS: Between July 2020 and September 2020, we performed eleven semi-structured virtual interviews with staff from three Health Hub SSPs and three stand-alone SSPs. The interviews explored the effect of the COVID-19 pandemic on SSPs and their clients as well as the changes implemented in response. Interviews were recorded and transcribed. We performed content analysis to identify emerging themes from the data. RESULTS: Due to the COVID-19 pandemic, some SSPs temporarily shut down while others limited their hours of operation. SSPs modified their service delivery to maintain syringe services and naloxone distribution over other services such as STI and HCV testing. They virtualized components of their services, including telemedicine for the provision of buprenorphine. While SSPs found virtualization to be important for maintaining their services, it negatively impacted the intimate nature of client interactions. Participants also described the impact of the pandemic on the well-being of PWID, including isolation, worsened mental health challenges, and increased drug overdoses. CONCLUSIONS: In response to the COVID-19 pandemic, SSPs demonstrated innovation, adaptability, and togetherness. Despite the challenges posed by the pandemic, SSPs continued to be key players in maintaining access to sterile supplies, buprenorphine, and other services for PWID. In addition to adapting to COVID-19 restrictions, they also responded to the dynamic needs of their clients. Sustainable funding and recognition of the critical role of SSPs in supporting PWID can help to improve outcomes for PWID.

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.

The impact of COVID-19 on people who inject drugs in New York City: increased risk and decreased access to services.

BACKGROUND: While people who inject drugs (PWID) are vulnerable to the adverse outcomes of events like COVID-19, little is known regarding the impact of the current pandemic on PWID. We examine how COVID-19 has affected PWID in New York City across four domains: substance use, risk behaviors, mental health, and service utilization. METHODS: As part of a randomized trial to improve access to HCV treatment for PWID, we recruited 165 participants. Eligibility criteria included detectable HCV RNA and recent drug injection. The present cross-sectional analysis is based on a subsample of 106 participants. We compared responses between two separate samples: 60 participants interviewed prior to the pandemic (pre-COVID-19 sample) and 46 participants interviewed during the pandemic (COVID-19 sample). We also assessed differences by study group [accessible care (AC) and usual care (UC)]. RESULTS: Compared to the pre-COVID-19 sample, those interviewed during COVID-19 reported higher levels of mental health issues, syringe reuse, and alcohol consumption and greater reductions in syringe-service programs and buprenorphine utilization. In the analysis conducted by study group, the UC group reported significantly higher injection risk behaviors and lower access to buprenorphine treatment during COVID-19, while during the same period, the AC group reported lower levels of substance use and injection risk behaviors. CONCLUSION: The current study provides insight on how COVID-19 has negatively affected PWID. Placing dispensing machines of harm-reduction supplies in communities where PWID live and increasing secondary exchange, mobile services, and mail delivery of supplies may help maintain access to lifesaving supplies during big events, such as COVID-19. Trial registration ClinicalTrials.gov NCT03214679. Registered July 11 2017. https://clinicaltrials.gov/ct2/show/NCT03214679 .

HIV Exposure Prophylaxis Delivery in a Low-barrier Substance Use Disorder Bridge Clinic during a Local HIV Outbreak at the Onset of the COVID-19 Pandemic.

OBJECTIVES: People who inject drugs (PWID) may experience high human immunodeficiency virus (HIV) risk and inadequate access to biomedical HIV prevention. Emerging data support integrating HIV post-exposure and pre-exposure prophylaxis (PEP, PrEP) into services already accessed by PWID. We describe PEP/PrEP eligibility and receipt in a low-barrier substance use disorder bridge clinic located in an area experiencing an HIV outbreak among PWID at the onset of the COVID-19 pandemic. METHODS: Retrospective chart review of new patients at a substance use disorder bridge clinic in Boston, MA (January 15, 2020-May 15, 2020) to determine rates of PEP/PrEP eligibility and prescribing. RESULTS: Among 204 unique HIV-negative patients, 85.7% were assessed for injection-related and 23.0% for sexual HIV risk behaviors. Overall, 55/204 (27.0%) met CDC criteria for HIV exposure prophylaxis, including 7/204 (3.4%) for PEP and 48/204 (23.5%) for PrEP. Four of 7 PEP-eligible patients were offered PEP and all 4 were prescribed PEP. Thirty-two of 48 PrEP eligible patients were offered PrEP, and 7/48 (14.6%) were prescribed PrEP. Additionally, 6 PWID were offered PrEP who lacked formal CDC criteria. CONCLUSIONS: Bridge clinics patients have high rates of PEP/PrEP eligibility. The majority of patients with identified eligibility were offered PEP/PrEP, suggesting that upstream interventions that increase HIV risk assessment may support programs in initiating PEP/PrEP care. Additional work is needed to understand why patients declined PEP/PrEP. PrEP offers to PWID who did not meet CDC criteria also suggested provider concern regarding the sensitivity of CDC criteria among PWID. Overall, bridge clinics offer a potential opportunity to increase biomedical HIV prevention service delivery.

Measuring progress towards reaching zero new HIV acquisitions among key populations in Québec (Canada) using routine surveillance data: a mathematical modelling study.

INTRODUCTION: Men who have sex with men (MSM) and people who inject drugs (PWID) are disproportionately impacted by the HIV epidemic in Canada. Having the second-highest provincial diagnosis rate, an improved understanding of the epidemic among these populations in Québec could aid ongoing elimination efforts. We estimated HIV incidence and other epidemic indicators among MSM and PWID in Montréal and across Québec using a back-calculation model synthesizing surveillance data. METHODS: We developed a deterministic, compartmental mathematical model stratified by age, HIV status and disease progression, and clinical care stages. Using AIDS and HIV diagnoses data, including self-reported time since the last negative test and laboratory results of CD4 cell count at diagnosis, we estimated HIV incidence in each population over 1975-2020 by modelling a cubic M-spline. The prevalence, undiagnosed fraction, fraction diagnosed that started antiretroviral treatment (ART) and median time to diagnosis were also estimated. Since the COVID-19 pandemic disrupted testing, we excluded 2020 data and explored this in sensitivity analyses. RESULTS: HIV incidence in all populations peaked early in the epidemic. In 2020, an estimated 97 (95% CrI: 33-227) and 266 (95% CrI: 103-508) HIV acquisitions occurred among MSM in Montréal and Québec, respectively. Among PWID, we estimated 2 (95% CrI: 0-14) and 6 (95% CrI: 1-26) HIV acquisitions in those same regions. With 2020 data, unless testing rates were reduced by 50%, these estimates decreased, except among Québec PWID, whose increased. Among all, the median time to diagnosis shortened to <2 years before 2020 and the undiagnosed fraction decreased to <10%. This fraction was higher in younger MSM, with 22% of 15-24 year-olds living with HIV in Montréal (95% CrI: 9-39%) and 31% in Québec (95% CrI: 17-48%) undiagnosed by 2020 year-end. Finally, ART access neared 100% in all diagnosed populations. CONCLUSIONS: HIV incidence has drastically decreased in MSM and PWID across Québec, alongside significant improvements in diagnosis and treatment coverage-and the 2013 introduction of pre-exposure prophylaxis. Despite this, HIV transmission continued. Effective efforts to halt this transmission and rapidly diagnose people who acquired HIV, especially among younger MSM, are needed to achieve elimination. Further, as the impacts of the COVID-19 pandemic on HIV transmission are understood, increased efforts may be needed to overcome these.