Feasibility of Implementing a Low-Barrier Long-Acting Injectable Antiretroviral Program for HIV Treatment and Prevention for People Experiencing Homelessness.

BACKGROUND: Long-acting (LA) antiretrovirals may provide meaningful benefit to people who use drugs and people experiencing homelessness (PEH) who face disproportionate structural and psychosocial barriers in adhering to daily oral HIV antiretroviral therapy or pre-exposure prophylaxis (PrEP), but their use in these populations has not been studied. SETTING: The Maria X. Martinez Health Resource Center is a low-barrier (eg, no appointment) community-based clinic serving San Francisco PEH. METHODS: A multidisciplinary care model with robust monitoring and outreach support was developed to provide LA antiretroviral therapy (ART) and LA-PrEP to eligible patients experiencing difficulties adhering to oral antiretrovirals. Feasibility was assessed by evaluating the rates of HIV viremia and on-time injections among patients receiving LA antiretrovirals over the first 24 months of program implementation. RESULTS: Between November 2021 and November 2023, 33 patients initiated LA-ART or LA-PrEP (median age, 37 years; 27% transgender/nonbinary; 73% non-White; 27% street homeless; 52% sheltered homeless; 30% with opioid use disorder; 82% with methamphetamine use disorder). Among 18 patients with HIV, 14 initiated LA-ART injections with detectable viremia (median CD4 count, 340 cells/mm 3 ; mean log 10 viral load, 3.53; SD, 1.62), 8 had never previously been virally suppressed, and all but 1 achieved or maintained virologic suppression (mean, 9.67 months; SD, 8.30). Among 15 LA-PrEP patients, all remained HIV negative (mean, 4.73 months; SD, 2.89). Of 224 total injections administered, 8% were delayed >7 days. DISCUSSION: The implementation of LA antiretrovirals is feasible in low-barrier, highly supportive clinical settings serving vulnerable PEH. Expansion of such programs will be critical in ending the HIV epidemic.

Psychedelics in Addiction Treatment-Navigating a Sociopolitical Rift.

This Viewpoint discusses the use of psychedelics in treatment for substance use disorders.

Housing Instability Associated with Return to Stimulant Use among Previously Abstaining Women.

Stimulant use among unstably housed individuals is associated with increased risks of psychiatric co-morbidity, violence, HIV transmission, and overdose. Due to a lack of highly effective treatments, evidence-based policies targeting the prevention of stimulant use disorder are of critical importance. However, little empirical evidence exists on risks associated with initiating or returning to stimulant use among at-risk populations. In a longitudinal cohort of unstably housed women in San Francisco (2016-2019), self-reported data on stimulant use, housing status, and mental health were collected monthly for up to 6 months, and factors associated with initiating stimulants after a period of non-use were identified through logistic regression. Among 245 participants, 42 (17.1%) started using cocaine and 46 (18.8%) started using methamphetamine. In analyses adjusting for demographics and socio-structural exposures over the preceding month, experiencing street homelessness was associated with initiating cocaine use (AOR: 2.10; 95% CI: 1.04, 4.25) and sheltered homelessness with initiating methamphetamine use (AOR: 2.57; 95% CI: 1.37, 4.79). Other factors-including race, income, unmet subsistence needs, mental health, and treatment adherence-did not reach levels of significance, suggesting the paramount importance of policies directed toward improving access to permanent supportive housing to prevent stimulant use among unstably housed women.

Commentary: Evidence-Informed Recommendation to Achieve Approximate Parity in the Allowed Number of Doses for Common Psychedelics.

In recent years, policymakers have proposed and implemented regulatory changes promoting the deprioritization, decriminalization, or state-level legalization of one or more psychedelic substances, usually referencing data from clinical trials as reasons to support liberalizing drug control policies. As psychedelic policies continue to be drafted, personal possession limits may be considered for inclusion in those regulations. If "allowable amount" limits are to be written into law to set personal possession limits, then such amounts should be more consistently related to psychedelic doses found to be safe and efficacious in clinical trials, existing data on moderate-high doses commonly used in various naturalistic settings, and the few studies that estimate psychedelic dose equivalence based on the intensity of subjective effects. In this commentary, we provide an evidence-informed table of typical moderate-high doses for seven commonly used psychedelic substances. These estimates of comparable moderate-high doses can be used to inform "allowable amount" values for psychedelic substances. When such limits are written into legislation, the adoption of evidence-informed comparable limits akin to those presented here would be an important first step toward ensuring greater parity and consistency in drug policy, relative to limits that have little or no scientific basis.

Understanding HIV Pre-Exposure Prophylaxis Questions of U.S. Health Care Providers: Unique Perspectives from the PrEPline Clinical Teleconsultation Service.

Introduction: Fewer than a quarter of people considered to have factors associated with HIV acquisition are prescribed pre-exposure prophylaxis (PrEP) in the United States. Prior studies demonstrate disparities in provider comfort and knowledge regarding PrEP, suggesting a need for provider capacity building to support widespread PrEP availability. This study examined real-world PrEP clinical questions/cases from providers to a teleconsultation service to identify knowledge gaps and improve PrEP-related training materials and clinical guidelines. Methods: The National Clinician Consultation Center (NCCC) PrEPline provides educational teleconsultation services on clinical decision-making related to PrEP for U.S. health care providers. The NCCC PrEP consultation data collected between 2017 and 2020 were reviewed and systematically categorized by clinical topics, subtopics, and complexity levels (low, moderate, and high). Results: Within the study period, the PrEPline provided 1,754 teleconsultations. More than three quarters came from advanced practice nurses and physicians. The topics of questions commonly focused on medication-based HIV prevention strategies (22.7%), PrEP laboratory ordering/monitoring (17.4%), and side effects and contraindications (14.6%). The majority of teleconsultations (57.9%) involved sharing information that was directly available/addressed in the Centers for Disease Control and Prevention (CDC) 2017 PrEP Guidelines (i.e., low complexity). Discussion: The low frequency of consultations from nonphysician and non-nurse practitioner providers may suggest a need for increased training and collaborative opportunities for other types of providers. The high percentage of low-complexity inquiries may reveal a desire for capacity-building materials specifically designed for practicing providers (e.g., abridged versions of guidelines). This study may inform future research, best clinical practices, and aid in the development of training materials to increase providers' HIV prevention comfort and knowledge.

Infectious Diseases Learning Unit: Understanding Advances in the Treatment of Latent Tuberculosis Infection Among People With Human Immunodeficiency Virus.

Tuberculosis (TB) remains the leading cause of death among people with human immunodeficiency virus (PWH). The diagnosis of latent TB infection (LTBI) and treatment with TB preventative therapy (TPT) can reduce morbidity and mortality in this population. Historically, isoniazid has been recommended for TPT in PWH due to the absence of drug-drug interactions with most antiretroviral therapy (ART). However, newer rifamycin-based regimens are safer, shorter in duration, associated with improved adherence, and may be as or more effective than isoniazid TPT. Current guidelines have significant heterogeneity in their recommendations for TPT regimens and acceptability of drug interactions with modern ART. In this Infectious Diseases learning unit, we review common questions on diagnosis, treatment, and drug interactions related to the management of LTBI among PWH.

COVID-19: A catalyst for change in telehealth service delivery for opioid use disorder management.

BACKGROUND: COVID-19 has exacerbated income inequality, structural racism, and social isolation-issues that drive addiction and have previously manifested in the epidemic of opioid-associated overdose. The co-existence of these epidemics has necessitated care practice changes, including the use of telehealth-based encounters for the diagnosis and management of opioid use disorder (OUD). METHODS: We describe the development of the "Addiction Telehealth Program" (ATP), a telephone-based program to reduce treatment access barriers for people with substance use disorders staying at San Francisco's COVID-19 Isolation and Quarantine (I&Q) sites. Telehealth encounters were documented in the electronic medical record and an internal tracking system for the San Francisco Department of Public Health (SFDPH) COVID-19 Containment Response. Descriptive statistics were collected on a case series of patients initiated on buprenorphine at I&Q sites and indicators of feasibility were measured. RESULTS: Between April 10 and May 25, 2020, ATP consulted on the management of opioid, alcohol, GHB, marijuana, and stimulant use for 59 I&Q site guests. Twelve patients were identified with untreated OUD and newly prescribed buprenorphine. Of these, all were marginally housed, 67% were Black, and 58% had never previously been prescribed medications for OUD. Four self-directed early discharge from I&Q-1 prior to and 3 after initiating buprenorphine. Of the remaining 8 patients, 7 reported continuing to take buprenorphine at the time of I&Q discharge and 1 discontinued. No patients started on buprenorphine sustained significant adverse effects, required emergency care, or experienced overdose. CONCLUSIONS: ATP demonstrates the feasibility of telephone-based management of OUD among a highly marginalized patient population in San Francisco and supports the implementation of similar programs in areas of the U.S. where access to addiction treatment is limited. Legal changes permitting the prescribing of buprenorphine via telehealth without the requirement of an in-person visit should persist beyond the COVID-19 public health emergency.

Development and Validation of HIV-ASSIST, an Online, Educational, Clinical Decision Support Tool to Guide Patient-Centered ARV Regimen Selection.

BACKGROUND: Multiple antiretroviral (ARV) regimens are effective at achieving HIV viral suppression, but differ in pill burden, side effects, barriers to resistance, and impact on comorbidities. Current guidelines advocate for an individualized approach to ARV regimen selection, but synthesizing these modifying factors is complex and time-consuming. METHODS: We describe the development of HIV-ASSIST (https://www.hivassist.com), a free, online decision support tool for ARV selection and HIV education. HIV-ASSIST ranks potential ARV options for any given patient scenario using a composite objective of achieving viral suppression while maximizing tolerability and adherence. We used a multiple-criteria decision analysis framework to construct mathematical algorithms and synthesize various patient-specific (eg, comorbidities and treatment history) and virus-specific (eg, HIV mutations) attributes. We then conducted a validation study to evaluate HIV-ASSIST with prescribing practices of experienced HIV providers at 4 large academic centers. We report on concordance of provider ARV selections with the 5 top-ranked HIV-ASSIST regimens for 10 diverse hypothetical patient-case scenarios. RESULTS: In the validation cohort of 17 experienced HIV providers, we found 99% concordance between HIV-ASSIST recommendations and provider ARV selections for 4 case-scenarios of ARV-naive patients. Among 6 cases of ARV-experienced patients (3 with and 3 without viremia), there was 84% and 88% concordance, respectively. Among 3 cases of ARV-experienced patients with viremia, providers reported 20 different ARV selections, suggesting substantial heterogeneity in ARV preferences in clinical practice. CONCLUSIONS: HIV-ASSIST is a novel patient-centric educational decision support tool that provides ARV recommendations concordant with experienced HIV providers for a diverse set of patient scenarios.

Immunogenicity and Safety of the Measles Vaccine in HIV-Infected Children: An Updated Systematic Review.

Children infected with human immunodeficiency virus (HIV) are at increased risk of measles morbidity and mortality. We searched abstracts from the PubMed, Embase, and Latin American and Caribbean Center on Health Sciences Information databases for articles published from the earliest date available through September 26, 2017. The primary outcome of interest was serological responses to measles vaccine, stratified by HIV infection status. A total of 2,858 potentially eligible articles were identified, and the final review included 12 studies published between 1992 and 2013, 9 of which reported data on vaccine safety. The studies we included represented 3,573 children, of whom at least 335 were infected with HIV, 788 were HIV-exposed but not infected, and 1,478 were unexposed to HIV. Four of the 12 studies found statistically significant reductions in seropositivity among HIV-infected children compared with HIV-uninfected children within 4 months of vaccination (prevalence ratio range, 0.44-0.70), and forest plots provided visual trends of decreasing immunity over time among HIV-infected children in 2 additional studies. No vaccine-related deaths or serious adverse events were reported. This updated review demonstrated limitations of the existing published literature but supported evidence of reduced immunogenicity of measles vaccine among HIV-infected children, supporting the World Health Organization recommendation to revaccinate HIV-infected children against measles following immune reconstitution with combination antiretroviral therapy.

Three Years Post-Affordable Care Act Sexually Transmitted Disease Clinics Remain Critical Among Vulnerable Populations.

INTRODUCTION: The purpose of the study is to examine whether demand for publicly funded sexually transmitted disease clinics changed after Affordable Care Act implementation. METHODS: The percentages of total incident sexually transmitted infections in Baltimore City that occurred at publicly funded sexually transmitted disease clinics were compared between the 3 years prior to and following the 2014 Medicaid and private insurance expansions. Risk factors associated with diagnosis at sexually transmitted disease clinics were identified using log binomial regression. Statistical analyses were conducted in May 2017. RESULTS: Post-Affordable Care Act, the relative proportion of total sexually transmitted infection diagnoses increased among private and hospital-affiliated clinics, remained unchanged at sexually transmitted disease clinics, and decreased at federally qualified health centers and other publicly funded programs (p<0.001). Multivariable analysis controlling for age, sex, race, and ethnicity showed an overall decline in the risk of diagnosis at sexually transmitted disease clinics post-Affordable Care Act compared with prior (adjusted relative risk=0.92, 95% CI=0.89, 0.96), but the risk among black and Latino men aged <25 years persisted (relative risk=1.03, 95% CI=0.96, 1.10). CONCLUSIONS: The Affordable Care Act increased access to traditional health care, reducing burden on publicly funded programs. However, demand for sexually transmitted disease clinics remains substantial among priority patients. In the healthcare reform era, sexually transmitted disease clinic funding remains critical.

Continued Importance of Sexually Transmitted Disease Clinics in the Era of the Affordable Care Act.

INTRODUCTION: Following the 2014 expansions of Medicaid and private health insurance through the Affordable Care Act, municipal sexually transmitted disease (STD) clinics-which have historically served predominantly uninsured patients-have been threatened with budget cuts nationwide. This study was conducted to evaluate the impact of the insurance expansions on the demand for STD clinic services. METHODS: The proportion of total incident sexually transmitted infections in Baltimore City that were diagnosed at STD clinics was compared between 2013 and 2014, and a multivariate analysis was conducted to determine factors associated with diagnosis at an STD clinic. Analyses were conducted in July 2015. RESULTS: There was no change in the overall proportion of sexually transmitted infection diagnoses made at STD clinics from 2013 to 2014 (relative rate, 1.03; 95% CI=0.95, 1.11). Hispanic ethnicity, black race, male sex, and age >24 years were associated with an increased likelihood of STD clinic utilization (p<0.0001). CONCLUSIONS: Despite the Affordable Care Act's insurance expansion measures, the demand for STD clinics remained stable. These safety net clinics serve patients likely to face barriers to accessing traditional health care and their preservation should remain a priority.