COVID-19 vaccination uptake and determinants of booster vaccination among persons who inject drugs in New York City.

BACKGROUND: Persons who inject drugs (PWID) may be unengaged with healthcare services and face an elevated risk of severe morbidity and mortality associated with COVID-19 due to chronic diseases and structural inequities. However, data on COVID-19 vaccine uptake, particularly booster vaccination, among PWID are limited. We examined COVID-19 vaccine uptake and factors associated with booster vaccination among PWID in New York City (NYC). METHODS: We recruited PWID using respondent-driven sampling from October 2021 to November 2023 in a survey that included HIV and SARS-CoV-2 antibodies testing. The questionnaire included demographics, COVID-19 vaccination and attitudes, and drug use behaviors. RESULTS: Of 436 PWID, 80% received at least one COVID-19 vaccine dose. Among individuals who received at least one COVID-19 vaccine dose, 95% were fully vaccinated. After excluding participants recruited before booster authorization for general adults started in NYC, and those who had never received an initial vaccination, 41% reported having received a COVID-19 booster vaccine dose. COVID-19 booster vaccination was significantly associated with having a high school diploma or GED (adjusted odds ratio (aOR) 1.93; 95% confidence interval (CI) 1.09, 3.48), ever received the hepatitis A/B vaccine (aOR 2.23; 95% CI 1.27, 3.96), main drug use other than heroin/speedball, fentanyl and stimulants (aOR 14.4; 95% CI 2.32, 280), number of non-fatal overdoses (aOR 0.35; 95% CI 0.16, 0.70), and mean vaccination attitude score (aOR 0.94; 95% CI 0.89, 0.98). CONCLUSIONS: We found a suboptimal level of COVID-19 booster vaccination among PWID, which was consistent with the rates observed in the general population in NYC and the U.S. Community-based interventions are needed to improve COVID-19 booster vaccination access and uptake among PWID. Attitudes towards vaccination were significant predictors of both primary and booster vaccination uptake. Outreach efforts focusing on improving attitudes towards vaccination and educational programs are essential for reducing hesitancy and increasing booster vaccination uptake among PWID.

Hepatitis C treatment outcomes among people who inject drugs experiencing unstable versus stable housing: Systematic review and meta-analysis.

BACKGROUND: The prevalence of hepatitis C virus (HCV) among people who inject drugs (PWID) is between 50-70%. Prior systematic reviews demonstrated that PWID have similar direct acting antiviral treatment outcomes compared to non-PWID; however, reviews have not examined treatment outcomes by housing status. Given the links between housing and health, identifying gaps in HCV treatment can guide future interventions. METHODS: We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched six databases for articles from 2014 onward. Two reviewers conducted title/abstract screenings, full-text review, and data extraction. We extracted effect measures for treatment initiation, adherence, completion, success, and reinfection by housing status. Studies underwent quality and certainty assessments, and we performed meta-analyses as appropriate. RESULTS: Our search yielded 473 studies, eight of which met inclusion criteria. Only the treatment initiation outcome had sufficient measures for meta-analysis. Using a random-effects model, we found those with unstable housing had 0.40 (0.26, 0.62) times the odds of initiating treatment compared to those with stable housing. Other outcomes were not amenable for meta-analysis due to a limited number of studies or differing outcome definitions. CONCLUSIONS: Among PWID, unstable housing appears to be a barrier to HCV treatment initiation; however, the existing data is limited for treatment initiation and the other outcomes we examined. There is a need for more informative studies to better understand HCV treatment among those with unstable housing. Specifically, future studies should better define housing status beyond a binary, static measure to capture the nuances and complexity of housing and its subsequent impact on HCV treatment. Additionally, researchers should meaningfully consider whether the outcome(s) of interest are being accurately measured for individuals experiencing unstable housing.

HIV risk and prevention among clients of a delivery-based harm reduction service during an HIV outbreak among people who use drugs in northern rural Minnesota, USA.

BACKGROUND: Since 2019, multiple HIV outbreaks occurred among people who inject drugs (PWID) in Minnesota. Syringe service programs (SSPs) are evidence-based programs that reduce the spread of HIV. We conducted an assessment of characteristics and HIV risk and prevention among clients of a delivery-based SSP near an HIV outbreak in rural, northern Minnesota. METHODS: In the fall of 2021, we conducted a cross-sectional survey of clients of a mobile SSP based in Duluth, Minnesota. Survey topics included demographics, drug use, sexual behavior, HIV testing history, and HIV status. We conducted descriptive analyses and used univariate logistic regression to identify correlates of syringe sharing. The analysis was limited to PWID in the last six months. RESULTS: A total of 125 people were surveyed; 77 (62%) were PWID in the last six months. Among these participants, 52% were female and 50% were homeless. Thirty-two percent reported sharing syringes and 45% reported sharing injecting equipment. Approximately one-half (49%) of participants had been tested for HIV in the past year, and none reported being HIV-positive. Individuals reported low condom usage (88% never used), and 23% of participants reported engaging in some form of transactional sex in the last six months. Incarceration in the last year was associated with sharing syringes (odds ratio = 1.4, 95% confidence interval 1.1-1.8). CONCLUSION: HIV risk was high among PWID receiving services at this SSP. These data highlight a rural SSP that is engaged with people at risk for HIV and needs additional support to expand harm reduction services.

Non-fatal drug overdose among persons who inject drugs during first two years of the COVID-19 pandemic in New York City: Prevalence, risk factors.

Background: We examined non-fatal drug overdoses during the COVID-19 pandemic among persons who inject drugs (PWID) in New York City (NYC). Methods: We recruited 275 PWID through respondent driven sampling and staff outreach from Oct. 2021-Sept. 2022 and enrolled in a cross-sectional survey. Information was collected on demographics, drug use behaviors, overdose experiences, substance use treatment history and strategies for coping with overdose threat. We compared PWID who did and did not experience non-fatal overdoses during lifetime and during the COVID-19 pandemic. Results: Participants were 71% male, and the mean age was 49 (SD 10). Heroin was the most frequently reported drug used (79%), 82% were fentanyl positive at enrollment urinalysis, 60% had overdosed in their lifetime and 34% had overdosed during the COVID-19 pandemic. In multivariable logistic regression, having previous overdosed, having a received a psychiatric diagnosis, and having a regular group of injectors were independently associated with experiencing an overdose during the pandemic. Overdose during the pandemic was unexpectedly high (approximately 30%) among persons reporting less than daily use of their main drug. Among PWID, 95% reported practicing at least one and 75% at least two overdose coping strategies. Practicing the different strategies, however, was generally not associated with a lower probability of experiencing an overdose. Conclusions: There has been a high rate of non-fatal overdoses among PWID in NYC during the pandemic. Fentanyl is almost ubiquitous in the drug supply in the city. PWID coping strategies are not yet providing strong protective effects against non-fatal overdose.

Understanding intentionality of fentanyl use and drug overdose risk: Findings from a mixed methods study of people who inject drugs in New York City.

BACKGROUND: As the proportion of drug overdose deaths involving fentanyl continues to increase in the US, monitoring exposure to and possible changes in intention to use fentanyl among people who use drugs (PWUD) is of great public health importance. This mixed methods study examines intentionality of fentanyl use among persons who inject drugs (PWID) in New York City during a period of unprecedently high rates of drug overdose mortality. METHODS: Between October 2021 and December 2022, N = 313 PWID were enrolled in a cross-sectional study that included a survey and urine toxicology screening. A subset of N = 162 PWID also participated in an in-depth interview (IDI) examining drug use patterns, including fentanyl use and experiences with drug overdose. RESULTS: 83% of PWID were urine-toxicology positive for fentanyl, though only 18% reported recent intentional fentanyl use. Intentionality of fentanyl use was associated with being younger, white, increased drug use frequency, recent overdose (OD), recent stimulant use, among other characteristics. Qualitative findings suggest PWID tolerance to fentanyl may be increasing, which could result in an increased preference for fentanyl. Concern about overdose was common with nearly all PWID using overdose prevention strategies to avoid it. CONCLUSION: The findings from this study demonstrate a high prevalence of fentanyl use among PWID in NYC, despite an expressed preference for heroin. Our results suggest that the pervasiveness of fentanyl may be increasing fentanyl use and tolerance, which may contribute to an increased risk for drug overdose. Expanding access to existing evidence-based interventions such as naloxone and medications for opioid use disorder is necessary to reduce overdose mortality. Further, exploring the implementation of additional novel strategies to reduce the risk of drug overdose should be considered, including other forms of opioid maintenance treatment and expansion and government support for overdose prevention centers.

Global epidemiology of abortion among female sex workers: a systematic review, meta-analysis, and meta-regression.

PURPOSE: Despite the evidence of a high rate of unintended pregnancy, there remains limited information about the prevalence and experiences of abortion among female sex workers (FSWs). In response, we aimed to summarize the available evidence on abortion among FSWs. METHODS: We searched Medline, Embase, PsycINFO, CINAHL, Scopus, and Web of Science from inception to January 29, 2023 . We pooled data from the included studies using random-effects meta-analyses. We also grouped countries for the legality of elective abortion stratified by the United Nations database on abortion laws and policies. RESULTS: We identified 60 eligible studies from 2031 potentially eligible records. The pooled lifetime prevalence of at least one and multiple induced abortions was 37.7% (95% confidence interval, 31.8-43.7) and 21.7% (14.9-29.2), respectively. Among FSWs recruited in countries where elective abortion is illegal, at least one induced abortion prevalence was 35.1% (28.1-42.4), and multiple induced abortion prevalence was 23.1% (12.4-35.9). In countries where elective abortion is legal, at least one induced abortion prevalence was 44.6% (34.8-54.6), and multiple induced abortion prevalence was 19.9% (11.9-29.3). Among FSWs experiencing abortion, self-managed abortion prevalence was estimated at 32.8% (23.6-42.7) overall, 42.8% (37.2-48.5) for countries where elective abortion is illegal, and 15.6% (3.9-32.7) for countries that legally allow elective abortion. CONCLUSIONS: Induced abortion is prevalent among FSWs, highlighting the need for interventions to increase access to effective contraception and safe abortion care. While induced abortion prevalence did not significantly differ across the legal grounds for abortion, self-managed abortion prevalence was higher in countries where elective abortion was illegal, highlighting the urgent need for accessible abortion services for FSWs in criminalized settings. Moving forward necessitates implementing and evaluating culturally acceptable models of safe abortion and post-abortion care for FSWs to increase access to the full spectrum of sexual and reproductive health services.

Field Testing the "Avoid the Needle" Intervention for Persons at Risk for Transitioning to Injecting Drug Use in Tallinn, Estonia and New York City, USA.

This study aimed to field tested the "Avoid the Needle" (AtN) intervention to reduce transitions from non-injecting to injecting drug use in two different epidemiological settings. Respondent driven sampling was used to recruit current non-injecting drug users (NIDUs) in Tallinn, Estonia in 2018-19 and in New York City (NYC) in 2019-20. Both persons who had never injected and persons who had previously injected but not in the last 6 months were eligible; a structured interview was administered, a blood sample collected, and the intervention administered by trained interventionists. We recruited 19 non-injectors from Tallinn and 140 from NYC. Participants in Tallinn were younger and had begun using drugs at earlier ages than participants in NYC. The primary drugs used in Tallinn were amphetamine, fentanyl, and opioid analgesics, while in NYC they were heroin, cocaine, speedball, and fentanyl. Six-month follow-up data were obtained from 95% of participants in Tallinn. The study was interrupted by COVID-19 lockdown in NYC, but follow-up data were obtained from 59% of participants. There were minimal transitions to injecting: 1/18 in Tallinn and 0/83 in NYC. There were significant declines in the frequencies of using readily injectable drugs (fentanyl, amphetamine, heroin, cocaine) from baseline to follow-up in both sites (Cochran-Armitage tests for trend, χ2 = 21.3, p < 0.001 for New York City; and χ2 = 3.9, p = 0.048 for Tallinn). Reducing transitions into injecting is a potentially very important method for reducing HIV transmission and other harms of drug use. Further investigation and implementation of AtN type interventions is warranted.

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.

Modeling HIV transmission among persons who inject drugs (PWID) at the "End of the HIV Epidemic" and during the COVID-19 pandemic.

BACKGROUND: We explore injecting risk and HIV incidence among PWID in New York City (NYC), from 2012 to 2019, when incidence was extremely low, <0.1/100 person-years at risk, and during disruption of prevention services due to the COVID-19 pandemic. METHODS: We developed an Agent-Based model (ABM) to simulate sharing injecting equipment and measure HIV incidence in NYC. The model was adapted from a previous ABM model developed to compare HIV transmission with "high" versus "low" dead space syringes. Data for applying the model to NYC during the period of very low HIV incidence was taken from the "Risk Factors" study, a long-running study of participants entering substance use treatment in NYC. Injecting risk behavior had not been eliminated in this population, with approximately 15 % reported recent syringe sharing. Data for possible transmission during COVID-19 disruption was taken from previous HIV outbreaks and early studies of the pandemic in NYC. RESULTS: The modeled incidence rates fell within the 95 % confidence bounds of all of the empirically observed incidence rates, without any additional calibration of the model. Potential COVID-19 disruptions increased the probability of an outbreak from 0.03 to 0.25. CONCLUSIONS: The primary factors in the very low HIV incidence were the extremely small numbers of PWID likely to transmit HIV and that most sharing occurs within small, relatively stable, mostly seroconcordant groups. Containing an HIV outbreak among PWID during a continuing pandemic would be quite difficult. Pre-pandemic levels of HIV prevention services should be restored as quickly as feasible.

Recurrent Injecting Drug Use as a Mediator between Psychiatric Disorder and Non-Fatal Overdose.

BACKGROUND: Unintentional drug overdose has increased markedly in the United States. Studies document an association between psychiatric disorder and unintentional overdose; we extend this research through a preliminary test of a causal model of recurrent injection drug use mediating this relationship. METHODS: In a cross-sectional study of 241 adults in New York City with a possible current substance use disorder, we conducted conventional and Imai's mediation analyses to examine if psychiatric disorder is associated with increased prevalence of ever overdosing and if recurrent injection drug use mediates this association. Our cross-sectional data permit the first step of assessing causal models: testing if statistical associations are consistent with the model. RESULTS: Fifty-eight percent of the sample endorsed previous psychiatric disorder diagnosis and 35.7% reported ever overdosing. Imai's mediation analysis showed that, adjusting for covariates, the total association between psychiatric diagnosis and ever overdosing (adjusted prevalence difference [aPD] = 0.16, 95% CI 0.04-0.28) was composed of a direct effect (aPD = 0.09, 95% CI -0.03 - 0.21, p = 0.136) and an indirect effect (aPD = 0.07, 95% CI 0.02-0.13). Recurrent injecting drug use contributed to 42% (ratio of indirect effect to total effect; 95% CI 12 - 100%, p = 0.02) of the association between psychiatric diagnosis and ever overdosing. Conventional mediation analysis produced similar results. CONCLUSIONS: Our results provide a warrant for taking the necessary next step for assessing a causal model using longitudinal data, potentially providing a strong rationale for intervening on psychiatric disorders to stem overdose.

Thick trust, thin trust, social capital, and health outcomes among trans women of color in New York City.

Introduction: Many trans women of color communities experience high HIV seroprevalence, extreme poverty, high rates of victimization and substance use, and poor mental health. Greater knowledge of trans women of color social capital may contribute toward more effective services for this marginalized population. Methods: These data come from a mixed-methods study that examined trans/gender-variant people of color who attended transgender support groups at harm reduction programs in NYC. The study was conducted from 2011 to 12, total N = 34. The qualitative portion was derived from six focus group interviews. Results: Two support groups stood out as exhibiting very strong alternative kinship structures. One group was comprised of immigrant trans Latinas, and the other group were trans women of African descent living with HIV. Both groups demonstrated ample cultivation of "trust capital" in the form of "thick trust" (bonding capital) and "thin trust" (bridging/linking capital) both inside and outside/beyond the support groups. Thick trust included the cultivation of intimacy, support in primary romantic relationships, and community leadership. Thin trust included networking with a variety of organizations, increased educational opportunities, and cultural production. Discussion: Participants "opened up to social capital" through the process of trusting as a series of (1) risks; (2) vulnerabilities; and (3) reciprocities. A solid foundation of thick trust resulted in a social, psychological, and emotional "base." Upon this foundation, thin trust was operationalized resulting in positive material, economic, and quality-of-life outcomes, leading to an expanded space of capabilities.

Is your syringe services program cost-saving to society? A methodological case study.

BACKGROUND: While there is a general acceptance among public health officials and policy-makers that syringe services programs can be effective in reducing HIV transmission among persons who inject drugs, local syringe services programs are often asked to provide economic justifications for their activities. A cost-effectiveness study, estimating the cost of preventing one HIV infection, would be the preferred methods for addressing this economic question, but few local syringe services programs have the needed data, staff and epidemiologic modeling resources needed for a cost-effectiveness study. We present a method for estimating a threshold value for the number of HIV infections prevented above which the program will be cost-saving to society. An intervention is considered "cost-saving" when it leads to a desirable health outcome a lower cost than the alternative. METHODS: The research literature on the effectiveness of syringe services programs in controlling HIV transmission among persons who inject drugs and guidelines for syringe services program that are "functioning very well" were used to estimate the cost-saving threshold at which a syringe services program becomes cost-saving through preventing HIV infections versus lifetime treatment of HIV. Three steps are involved: (1) determining if HIV transmission in the local persons who inject drugs (PWID) population is being controlled, (2) determining if the local syringe services program is functioning very well, and then (3) dividing the annual budget of the syringe services program by the lifetime cost of treating a single HIV infection. RESULTS: A syringe services program in an area with controlled HIV transmission (with HIV incidence of 1/100 person-years or less), functioning very well (with high syringe coverage, linkages to other services, and monitoring the local drug use situation), and an annual budget of $500,000 would need to prevent only 3 new HIV infections per year to be cost-saving. CONCLUSIONS: Given the high costs of treating HIV infections, syringe services programs that are operating according to very good practices ("functioning very well") and in communities in which HIV transmission is being controlled among persons who inject drugs, will almost certainly be cost-saving to society.

Hepatitis C incidence and prevalence among Puerto Rican people who use drugs in New York City.

Background: Hepatitis C virus (HCV) infection is associated with substantial morbidity and mortality among people who use drugs (PWUD). Health disparities related to race/ethnicity and immigration status also increase the risk of HCV infection and decrease the probability of linkage to care. Effective, curative treatment is now available for HCV infection and, alongside prevention, may eliminate HCV epidemics. Methods: We examined HCV incidence, prevalence and associated risk factors among 5459 Puerto Rican (both PR-born and U.S.-born) and non-Puerto Rican (only U.S.-born) entrants to Mount Sinai Beth Israel drug treatment programs in New York City, from August 2005 to January 2018, to assess the need for HCV screening, prevention and treatment in this population. Results: HCV incidence and prevalence among Puerto Rican PWUD was significantly greater than the non-Puerto Ricans PWUD. Among people who inject drugs (PWID), there was no difference in injection risk behaviours by ethnicity/birth place. Conclusions: Findings suggest HCV treatment is a necessary component of a strategy to eliminate HCV epidemics among PWUD. Findings also underline the interconnectedness of epidemics across regions, such that to eliminate the HCV epidemic in one location may depend on eliminating the HCV epidemics in other locations.

Prescription opiate analgesics, heroin, HIV and HCV among persons who inject drugs in New York City, 2016-2018.

OBJECTIVES: Assess relationships among non-medical use of prescription opioid analgesics (POAs), heroin use, and HIV and hepatitis C (HCV) infection among persons who inject drugs (PWID) in New York City, 2016-2018. METHODS: PWID (N = 134) were recruited from Mount Sinai Beth Israel drug treatment programs. HIV seropositive persons were oversampled. A questionnaire was administered, and serum samples were collected for HIV and HCV testing. Analyses were stratified by HIV serostatus and compared those who had used POAs to those who had not used POAs. RESULTS: Among the participants, 97% reported injecting heroin, 44% reported injecting cocaine, and 47% reported smoking crack cocaine in the 6 months prior to the interview. There were 66% who reported oral non-medical use of POAs, with 42% using oral POAs in the previous 6 months. There was a clear historical pattern in median year of first injection for different groups: HIV seropositive persons (1985), HIV seronegative persons who never used POAs (1999), and HIV seronegative persons who used POAs (2009). By the time of interview (2016-2018), however, almost all participants (97%) reported injecting heroin. All PWID who reported using POAs also reported injecting heroin. CONCLUSIONS: Non-medical POA use among PWID was very common and should not be considered a separate drug use epidemic, but as an additional component of the continuing heroin/poly-drug use epidemic, itself a part of the syndemic of opioid use, stimulant use, overdose, HCV and HIV occurring in New York City.

Injection and Heterosexual Risk Behaviors for HIV Infection Among Non-gay Identifying Men Who Have Sex with Men and Women.

Non-gay identifying men who have sex with men and women (MSMW) are an important subgroup of men who have sex with men (MSM) and have been underrepresented in studies of MSM that only use gay venues to draw their samples. We assessed heterosexual and drug use risks of MSMW who use drugs in a sample of male entrants to the Mount Sinai Beth Israel drug treatment programs from 2005 to 2018. Blood samples were collected and tested for HIV and HSV-2 infections. Among HIV seronegative participants, MSMW had significantly greater odds of sharing used needles with others, and reporting unprotected sex with female casual partners and female commercial sex partners, compared to their counterparts who reported sex with women exclusively (MSWE). Although not recruited from gay venues, MSMW had a significantly higher HIV prevalence than MSWE (23% vs. 10%, p < 0.001). Interventions that are specifically tailored to HIV prevention among MSMW are needed to ameliorate the prevalence of HIV risks and infection.

Alternative kinship structures, resilience and social support among immigrant trans Latinas in the USA.

Latinas comprise the largest racial/ethnic group of trans women (male-to-female transgender people) in New York City, where HIV seroprevalence among trans Latinas has been found to be as high as 49%. Despite this population's high risk of HIV, little is known about resilience among trans Latinas that may provide protective health factors. Six focus groups and one in-depth interview were conducted with 34 low-income trans/gender-variant people of colour who attended transgender support groups at harm reduction programmes in New York City. This paper reports on data from 13 participants who identified as immigrant trans Latinas. Focus groups were coded and analysed using thematic qualitative methods. The majority of immigrants were undocumented but reported having robust social support. Unique characteristics of immigrant trans Latinas included alternative kinship structures and sources of income. Social creativity was used to develop achievable ways in which to improve their health outcomes. Resilience was evident in informal kinship dynamics, formal support groups, gender-transition, educational access and skills training and substance use reduction. Individual-level resilience increased as a result of strong community-level resilience.

Heterosexual male and female disparities in HIV infection at the end of an epidemic: HIV infection among persons who inject drugs in New York City, 2001-2005 and 2011-2015.

BACKGROUND: We examined whether sex disparities (heterosexual male:female) in HIV infection continue to persist at the "end of the HIV epidemic" among persons who inject drugs (PWID) in New York City (NYC). An "end of the epidemic" was operationally defined as 1) prevalence of untreated HIV infection <5%, and 2) estimated HIV incidence <0.5/100 person-years. METHODS: PWID were recruited from persons entering substance use treatment programs at Mount Sinai Beth Israel in 2001-2005 and 2011-2015. A structured interview was administered, and HIV and HSV-2 testing was conducted. Incidence was estimated using newly diagnosed cases of HIV. Disparity analyses compared prevalence of HIV, of untreated HIV, HIV risk behaviors, and estimated HIV incidence. RESULTS: By 2011-2015, both heterosexual male and female PWID met the two criteria for an "end of the epidemic," and there were no significant differences in the prevalence of untreated HIV infection. A large sex difference remained in estimated HIV incidence. In 2013-2015, estimated HIV incidence was 2.8/10,000 PY for males and 7.1/10,000 PY for females. Females had greater risk for HIV on several factors. CONCLUSION: While NYC has reached an "end of the epidemic" for both heterosexual male and female PWID, sex disparities persist, particularly differences in HIV incidence. Eliminating the sex disparities may require a greater focus on factors associated with sexual transmission.

Cost-effectiveness of hepatitis C screening and treatment linkage intervention in US methadone maintenance treatment programs.

BACKGROUND: We evaluated the cost-effectiveness of a hepatitis C (HCV) screening and active linkage to care intervention in US methadone maintenance treatment (MMT) patients using data from a randomized trial conducted in New York City and San Francisco. METHODS: We used a decision analytic model to compare 1) no intervention; 2) HCV screening and education (control); and 3) HCV screening, education, and care coordination (active linkage intervention). We also explored an alternative strategy wherein HCV/HIV co-infected participants linked elsewhere. Trial data include population characteristics (67% male, mean age 48, 58% HCV infected) and linkage rates. Data from published sources include treatment efficacy and HCV re-infection risk. We projected quality-adjusted life years (QALYs) and lifetime medical costs using an established model of HCV (HEP-CE). Incremental cost-effectiveness ratios (ICERs) are in 2015 US$/QALY discounted 3% annually. RESULTS: The control strategy resulted in a projected 35% linking to care within 6 months and 31% achieving sustained virologic response (SVR). The intervention resulted in 60% linking and 54% achieving SVR with an ICER of $24,600/QALY compared to no intervention from the healthcare sector perspective and was a more efficient use of resources than the control strategy. The intervention had an ICER of $76,500/QALY compared to the alternative strategy. From a societal perspective, the intervention had a net monetary benefit of $511,000-$975,600. CONCLUSIONS: HCV care coordination interventions that include screening, education and active linkage to care in MMT settings are likely cost-effective at a conventional $100,000/QALY threshold for both HCV mono-infected and HIV co-infected patients.

Racial/Ethnic Disparities at the End of an HIV Epidemic: Persons Who Inject Drugs in New York City, 2011-2015.

OBJECTIVES: To examine whether racial/ethnic disparities persist at the "end of the HIV epidemic" (prevalence of untreated HIV infection < 5%; HIV incidence < 0.5 per 100 person-years) among persons who inject drugs (PWID) in New York City. METHODS: We recruited 2404 PWID entering New York City substance use treatment in 2001 to 2005 and 2011 to 2015. We conducted a structured interview, and testing for HIV and herpes simplex virus 2 (HSV-2; a biomarker for high sexual risk). We estimated incidence by using newly diagnosed cases of HIV. Disparity analyses compared HIV, untreated HIV, HIV-HSV-2 coinfection, HIV monoinfection, and estimated HIV incidence among Whites, African Americans, and Latinos. RESULTS: By 2011 to 2015, Whites, African Americans, and Latino/as met both criteria of our operational "end-of-the-epidemic" definition. All comparisons that included HIV-HSV-2-coinfected persons had statistically significant higher rates of HIV among racial/ethnic minorities. No comparisons limited to HIV monoinfected persons were significant. CONCLUSIONS: "End-of-the-epidemic" criteria were met among White, African American, and Latino/a PWID in New York City, but elimination of disparities may require a greater focus on PWID with high sexual risk.

Risk factors for hepatitis C seropositivity among young people who inject drugs in New York City: Implications for prevention.

BACKGROUND: Hepatitis C virus (HCV) infection remains a significant problem in the United States, with people who inject drugs (PWID) disproportionately afflicted. Over the last decade rates of heroin use have more than doubled, with young persons (18-25 years) demonstrating the largest increase. METHODS: We conducted a cross-sectional study in New York City from 2005 to 2012 among young people who injected illicit drugs, and were age 18 to 35 or had injected drugs for ≤5 years, to examine potentially modifiable factors associated with HCV among young adults who began injecting during the era of syringe services. RESULTS: Among 714 participants, the median age was 24 years; the median duration of drug injection was 5 years; 31% were women; 75% identified as white; 69% reported being homeless; and 48% [95% CI 44-52] had HCV antibodies. Factors associated with HCV included older age (adjusted odds ratio [AOR], 1.99 [1.52-2.63]; p<0.001), longer duration of injection drug use (AOR, 1.68 [1.39-2.02]; p<0.001),more frequent injection (AOR, 1.26 [1.09-1.45]; p = 0.001), using a used syringe with more individuals (AOR, 1.26 [1.10-1.46]; p = 0.001), less confidence in remaining uninfected (AOR, 1.32 [1.07-1.63]; p<0.001), injecting primarily in public or outdoors spaces (AOR, 1.90 [1.33-2.72]; p<0.001), and arrest for carrying syringes (AOR, 3.17 [1.95-5.17]; p<0.001). CONCLUSIONS: Despite the availability of harm reduction services, the seroprevalence of HCV in young PWID in New York City remained high and constant during 2005-2012. Age and several injection behaviors conferred independent risk. Individuals were somewhat aware of their own risk. Public and outdoor injection and arrest for possession of a syringe are risk factors for HCV that can be modified through structural interventions.