Telehealth access and experiences of older adults with HIV during the COVID-19 pandemic: Lessons for the future.

BACKGROUND: Telehealth services are proposed to improve access and retention to care for people with HIV (PWH). Yet the rapid uptake of telehealth services during the COVID-19 pandemic created equity concerns, especially for already vulnerable populations. Older PWH may face a combination of barriers to telehealth but also stand to benefit given social isolation and the need for multimorbidity management. Few studies have focused on this population, and we aimed to assess the telehealth capability and experiences of older PWH at an urban HIV clinic. METHODS: We did this in two ways: (1) we contacted PWH aged ≥65 via telephone about telehealth capabilities and (2) we conducted focus groups with older PWH who transitioned from in-person to virtual classes affiliated with the clinic. RESULTS: Among 179 PWH aged ≥65, 80 answered the telehealth questions. Among those who answered, 91% were male with a mean age of 69 (SD 3.0), and 55% were White. One-third did not have internet access or an email address. A total of 65% had at least one telehealth-capable device but 12.5% of respondents with a device did not know how to use it. Thirteen older PWH participated in focus groups with a mean age of 64 (SD 6.9) and 44% female. Themes were grouped into benefits (social/emotional connection and convenience) and challenges (technological barriers and missed in-person experience). CONCLUSION: Participants preferred in-person classes but felt telehealth was a good alternative for mitigating isolation. Telehealth gave those with mobility and transportation issues improved access to supportive services. As the COVID-19 public health emergency ends, hybrid options should be considered to improve access for older PWH and address social isolation. Ensuring equitable access to devices and digital literacy training will be critical to ensure services can be utilized.

Engagement in HIV care and viral suppression following changes in long-term opioid therapy for treatment for chronic pain.

Chronic pain is common among persons living with HIV and changes in opioid prescribing practices may complicate HIV care management. Using medical record data from a retrospective cohort study conducted January 1, 2012 to June 30, 2019 for 300 publicly insured HIV-positive primary care patients prescribed opioids for chronic non-cancer pain in San Francisco, we examined associations between opioid dose changes and both time to disengagement from HIV care and experiencing virologic failure using logistic regression. Discontinuation of prescribed opioids was associated with increased odds of disengagement in care at 3, 6, and 9 months after discontinuation. There were no associations with virologic failure. Providers and policy makers must weigh impacts on HIV care when implementing necessary changes in opioid prescribing.

Randomized feasibility trial of directly observed versus unobserved hepatitis C treatment with ledipasvir-sofosbuvir among people who inject drugs.

AIMS: The advent of direct-acting antivirals for hepatitis C virus (HCV) and limited effectiveness of prevention have generated interest in "Treatment as Prevention" (TasP), in which those most likely to transmit HCV (i.e. people who inject drugs [PWID]) are treated to reduced secondary transmission. However, there are scant data regarding the feasibility of treating PWID at high risk for secondary transmission or the optimal approach to treatment delivery. METHODS: We conducted a 2:1 randomized trial of modified directly-observed (mDOT) versus unobserved HCV treatment with ledipasvir-sofosbuvir daily for 8 weeks among PWID with 36 weeks of follow-up in San Francisco from 2015-2017. We evaluated recruitment-enrollment, treatment completion, end-of-treatment and 12-week response, and reinfection rate. RESULTS: Of 83 individuals eligible for screening, 72 (87.6%) attended the screening visit, 33 were eligible, and 31 enrolled; mean age was 42 years, 81% were male, 74% white. All but one participant (in the mDOT arm) completed treatment and 89.4% of mDOT and 96.6% of unobserved arm visits were attended. HCV was undetectable for 96.8% (30/31) at end of treatment and 89.7% (26/29) 12 weeks later (1 relapse, 1 reinfection), with no differences by arm. Two additional reinfections were subsequently identified, for a reinfection rate of 16.3 (95% CI 5.3-50.5) per 100 person-years of observation. CONCLUSIONS: It was feasible to recruit active PWID for HCV treatment and achieve high retention, viral response, and satisfaction with either mDOT or unobserved protocols, supporting treatment of PWID at risk of transmitting HCV to others. The reinfection rate suggests we successfully reached a high-risk population and that successful HCV TasP initiatives may aim to be sufficient in scope to significantly lower prevalence in the community. TRIAL REGISTRATION: clinicaltrials.gov NCT02609893.

Behavioral intervention to reduce opioid overdose among high-risk persons with opioid use disorder: A pilot randomized controlled trial.

OBJECTIVE: The United States is amidst an opioid epidemic, including synthetic opioids that may result in rapid death, leaving minimal opportunity for bystander rescue. We pilot tested a behavioral intervention to reduce the occurrence of opioid overdose among opioid dependent persons at high-risk for subsequent overdose. MATERIALS AND METHODS: We conducted a single-blinded randomized-controlled trial of a repeated dose motivational interviewing intervention (REBOOT) to reduce overdose versus treatment as usual, defined as information and referrals, over 16 months at the San Francisco Department of Public Health from 2014-2016. Participants were 18-65 years of age, had opioid use disorder by Structured Clinical Interview, active opioid use, opioid overdose within 5 years, and prior receipt of naloxone kits. The intervention was administered at months 0, 4, 8, and 12, preceded by the assessment which was also administered at month 16. Dual primary outcomes were any overdose event and number of events, collected by computer-assisted personal interview, as well as any fatal overdose events per vital records. RESULTS: A total of 78 persons were screened and 63 enrolled. Mean age was 43 years, 67% were born male, 65% White, 17% African-American, and 14% Latino. Ninety-two percent of visits and 93% of counseling sessions were completed. At baseline, 33.3% of participants had experienced an overdose in the past four months, with a similar mean number of overdoses in both arms (p = 0.95); 29% overdosed during follow-up. By intention-to-treat, participants assigned to REBOOT were less likely to experience any overdose (incidence rate ratio [IRR] 0.62 [95%CI 0.41-0.92, p = 0.019) and experienced fewer overdose events (IRR 0.46, 95%CI 0.24-0.90, p = 0.023), findings that were robust to sensitivity analyses. There were no differences between arms in days of opioid use, substance use treatment, or naloxone carriage. CONCLUSIONS: REBOOT reduced the occurrence of any opioid overdose and the number of overdoses. TRIAL REGISTRATION: clinicaltrials.gov NCT02093559.