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BACKGROUND: Disparities persist in testing and treatment for hepatitis C virus (HCV), leaving socially marginalized populations, including people who inject drugs (PWID), less likely to benefit from curative treatment. Linkage services are often insufficient to overcome barriers to navigating the medical system and contextual factors. METHODS: The Youre Empowered for Treatment Initiation (YETI) Partner trial is a single-site randomized controlled trial evaluating the efficacy of a two-session behavioral intervention that engages injecting partners as peer navigators for HCV treatment. We aim to recruit 250 PWID and their primary injecting partners in San Francisco, California, randomizing them 1:1 to either a control or intervention group. The primary outcome is the initiation of HCV treatment, with secondary outcomes including treatment completion and sustained virologic response 12 weeks post-treatment. Data will be collected through questionnaires and electronic health records and analyzed using intention-to-treat and mixed-effects models. DISCUSSION: This trial will provide evidence of a new HCV treatment linkage intervention leveraging the support of primary injecting partners to initiate HCV treatment. If successful, the intervention could inform public health strategies and policies to address HCV in marginalized populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT06179498. Registered on December 22, 2023.

OBJECTIVE: Internally displaced persons (IDPs) can have limited access to HIV and hepatitis C Virus (HCV) treatment and prevention. IDPs comprise > 7% of Georgian population but prevalence and levels of HIV and HCV knowledge in this population remain unknown. We tested 100 IDPs in Georgia for HIV and HCV, many of whom had drug injecting experience, and interviewed them about their migration experience, sexual and drug injecting practices, and HIV/HCV transmission knowledge. RESULTS: The average age of participants was 37.5 years (range 18-63); 31% were women. Almost half (N = 48) of participants reported ever injecting drugs; 17% of those (N = 8) started injecting drugs within the last year. Anti-HCV and HIV prevalence was 11% and 0%, respectively. Fewer people without drug use experience compared to people who inject drugs correctly answered all questions on the HIV knowledge test (13% vs. 35%, p = 0.015) or knew where to get tested for HIV (67% vs 98%, p

BackgroundYoung adult (18-30 years) people who inject drugs (PWID) face high hepatitis C virus (HCV) prevalence. In San Francisco, where >60% of PWID lack stable housing, barriers hinder HCV treatment access. We assessed progress towards the World Health Organization's (WHO) HCV elimination goal of an 80% reduction in incidence over 2015-2030, focusing on young (YPWID) and unstably housed PWID in San Francisco.MethodsWe developed a dynamic HCV transmission model among PWID, parameterized and calibrated using bio-behavioural survey datasets from San Francisco. This included 2018 estimates for the antibody-prevalence among PWID (77%) and care cascade estimates for HCV for YPWID (72% aware of their status and 33% ever initiating treatment). Based on programmatic data, we assumed a 53.8% reduction in testing and 40.7% decrease in treatment from 2020 due to the COVID-19 pandemic, which partially rebounded from April 2021 with testing rates then being 31.1% lower than pre-pandemic rates and treatment numbers being 19.5% lower. We simulated different scenarios of how services changed after the pandemic to project whether elimination goals would be met.ResultsContinuing post-pandemic rates of testing and treatment, the model projects an 83.3% (95% credibility interval [95% CrI]:60.6-96.9%) decrease in incidence among PWID over 2015-2030 to 1.5/100pyrs (95% CrI:0.3-4.4) in 2030. The probability of achieving the elimination goal by 2030 is 62.0%. Among YPWID and unstably housed PWID, the probability of achieving the elimination goal by 2030 is 54.8 and 67.6%, respectively. Importantly, further increasing testing and treatment rates to pre-pandemic levels by 2025 only results in a small increase in the probability (67.5%) of the elimination goal being achieved among all PWID by 2030, while increased coverage of medication for opioid use disorder among YPWID and/or housing interventions results in the probability of achieving elimination increasing to over 75%.ConclusionThe COVID-19 pandemic impeded progress toward achieving HCV elimination. Our findings indicate that existing partial rebounds in HCV testing and treatment may achieve the elimination goal by 2030, with an additional scale-up of interventions aimed at YPWID or unstably housed PWID ensuring San Francisco is likely to achieve elimination by 2030.

BackgroundWe examined HIV prevalence and transmission dynamics among people who inject drugs in the U.S./Mexico border region during the COVID-19 pandemic.MethodsPeople who inject drugs aged ≥18 years from 3 groups were recruited: people who inject drugs who live in San Diego (SD) and engaged in cross-border drug use in Tijuana, Mexico (SD CBDUs), and people who inject drugs in SD and Tijuana (TJ) who did not engage in cross-border drug use (NCBDUs). We computed HIV prevalence at baseline and bivariate incidence-density rates (IR) at 18-month follow-up. Bayesian phylogenetic analysis was used to identify local transmission clusters, estimate their age, and effective reproductive number (Re) over time within the clusters.FindingsAt baseline (n = 612), 26% of participants were female, 9% engaged in sex work, and HIV prevalence was 8% (4% SD CBDU, 4% SD NCBDU, 16% TJ NCBDU). Nine HIV seroconversions occurred over 18 months, IR: 1.357 per 100 person-years (95% CI: 0.470, 2.243); 7 in TJ NCBDU and 2 in SD CBDU. Out of 16 identified phylogenetic clusters, 9 (56%) had sequences from both the U.S. and Mexico (mixed-country). The age of three youngest mixed-country dyads (2018-2021) overlapped with the COVID-related US-Mexico border closure in 2020. One large mixed-country cluster (N = 15) continued to grow during the border closure (Re = 4.8, 95% Highest Posterior Density (HPD) 1.5-9.1) with 47% engaging in sex work.InterpretationAmidst the COVID-19 pandemic and the border closure, cross-border HIV clusters grew. Efforts to end the HIV epidemic in the U.S. should take into account cross-border HIV-1 transmission from Tijuana. Mobile harm reduction services and coordination with municipal HIV programs to initiate anti-retroviral therapy and pre-exposure prophylaxisis are needed to reduce transmission.FundingThis research was supported by the James B. Pendleton Charitable Trust and the San Diego Center for AIDS Research.

We examined changes in the proportion of people with human immunodeficiency virus (PWH) with virologic suppression (VS) in a multisite US cohort before and since the coronavirus disease 2019 (COVID-19) pandemic. Overall, prior gains in VS slowed during COVID-19, with disproportionate impacts on Black PWH and PWH who inject drugs.

We assessed the uptake of COVID-19 vaccination in a community-recruited sample of people who inject drugs (PWID) in San Francisco in 2022. Overall, 72.4% (95% CI 64.6–80.3) were vaccinated for COVID-19. Independent predictors of vaccination were age 65 years and older (adjusted odds ratio [AOR] 9.7, 95% CI 2.2–28.7) and ever testing positive for COVID-19 (AOR 2.0, 95% CI 1.2–3.5). Homelessness was associated with lower COVID-19 vaccination (AOR 0.5, 95% CI 0.3–0.8). Our study underscores the urgent need for targeted interventions to address unique challenges faced by PWID in accessing COVID-19 vaccination, particularly for those experiencing homelessness and who are younger. [ABSTRACT FROM AUTHOR]

Background: Intersectional stigma of drug-use and HIV hinders provision and utilization of HIV prevention services for people who inject drugs (PWID), particularly within rural US communities. Resilience and coping may be critical for PWID to counter pervasive stigma. Methods: Between October 2021 and July 2022, 35 in-depth interviews were conducted in Appalachian Ohio to understand the intersection of drug-use and HIV prevention stigma and how resilience and coping processes are displayed, shared, and enacted. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted, guided by Harper et al.'s four key resilience processes: (a) engaging in health-promoting cognitive processes, (b) enacting in health behavioral practices, (c) exchanging social support, and (d) empowering other PWID to engage in health behavior practices. Results: Resilience processes aligned with the Harper framework with additional coping processes identified, including anticipation strategies and maladaptive coping. Empowering other PWID emerged as a prominent resiliency process, often supported by systems of support like syringe service programs (SSPs), which provided resources and helped reduce stigma. However, bidirectional social support was constrained, as PWID frequently acted as providers of resources and referrals for peers despite limited knowledge of HIV prevention strategies and feeling unsupported themselves. Anticipation strategies were employed to manage anticipated stigma, including accessing support or, conversely, avoiding healthcare and refraining from disclosing drug use. Maladaptive coping included behaviors such as social isolation and self-administered medical care, highlighting critical gaps in opportunities to foster resilience. Conclusions: Findings highlight that empowering peers and anticipation strategies can be key resilience processes, while maladaptive coping and limited bidirectional social support underscore the need for resilience-building and stigma-reduction interventions. Tailored systems of support for PWID in rural communities are critical to fostering adaptive coping and enhancing engagement with HIV prevention services. [ABSTRACT FROM AUTHOR]

Background: Hospitalizations for bacterial infections are often difficult for people who inject drugs (PWID) and healthcare workers, in part due to biases and stigma associated with substance use, patients' competing needs, such as pain and withdrawal management, and strict antibiotic treatment protocols. In recent years, peer navigators have been introduced as a strategy to reduce stigma and bridge the gap between patients and healthcare workers, but little is known about their involvement in hospitalization settings. The aim of this study was to assess the value of adding a peer navigator program and to evaluate the elements that key stakeholders identified as essential for the program to be successful. Methods: This was a qualitative study using focus groups. The interview guide was collaboratively developed by ethicists, physicians, and a person with lived experience and validated with a PWID and a community worker. Three two-hour focus groups were conducted in February 2022 with PWID, community organizations and healthcare workers. Descriptive and interpretive thematic analyses were carried out. Results: Nineteen people (5 PWID, 6 community organization workers, 8 healthcare workers) participated in the focus groups. The final coding strategy involved 4 main themes: challenges in current care, positive aspects of current care, aspirations for quality care, the contribution of peer navigators as a solution to current challenges and the realization of aspirations. Improvements in the quality of care should focus on an approach centered on patients' values and aspirations; improving the current hospital environment, particularly in terms of training and communication; and encouraging collaborative partnerships with all parties involved. The integration of peer navigators seems to be a promising strategy for improving communication and trust and, consequently, to facilitate shared decision-making and adapted care. Conclusions: Our study showed that any innovative model should be centered on patients' needs and values and therefore co-constructed with them and other parties involved, notably the community organizations offering services to these patients. The inclusion of well-trained and well-supported peer navigators has the potential to improve care and work toward achieving aspirations of quality care. [ABSTRACT FROM AUTHOR]

Background: Hepatitis C virus (HCV) infection remains a public health threat. Although therapy with direct-acting antivirals made its elimination possible, major challenges remain in treating vulnerable populations, such as people who inject drugs (PWID) enrolled in low-threshold programmes (LTPs). This study analysed the outcome of HCV management focused on HCV reinfection in a specifically designed model-of-care (MoC) for PWID in Slovenia, where treatment is prescribed without limitations, though only by specialist physicians. Methods: All HCV antibody (anti-HCV) positive users of a MoC, combining HCV management at Clinic for Infectious Diseases at the University Medical Centre in Ljubljana and LTP for PWID in 100 km distanced civil society organisation (CSO) Svit Koper, between January 2017 to December 2022, were included. The MoC enabled regular transportation of PWID between LTP and the Clinic, where specifically assigned services for individually tailored HCV management in cooperation with CSO were available. Data on participants´ demographic, epidemiological, and clinical characteristics were collected partly retrospectively and prospectively, with a particular focus on HCV treatment outcome and reinfection status, and analysed accordingly. Results: The study included 49 anti-HCV positive PWID with a mean age of 38.7 (standard deviation (SD) = 7.6) years at first visit. The majority was male (40/49, 81.6%); 16/49 (32.7%) experienced previous incarceration, 14/49 (28.6%) were experiencing homelessness, and 42/49 (85.7%) were receiving opioid agonist therapy. A total of 42/49 (83.7%) were HCV RNA-positive. Of them 36/42 (85.7%) started HCV treatment at a mean age of 42.7 (SD = 5.7) years and 33/36 (91.7%) completed treatment. Six (14.3%) HCV RNA-positive PWID died. Among 28/33 (84.9%) who achieved a sustained virological response 12 weeks post treatment, 6/28 (21.4%) presented with reinfection. The HCV reinfection rate was 13.3 per 100 – PY (95% confidence interval (CI) [6.0, 29.7]), the rate of positive HCV RNA re-test was 12.2 per 100 – PY (95%CI [7.7–16.7]), while hazard of reinfection in our cohort increased with time, with the estimated reinfection probability exceeding 0.5 at 4 years. Conclusions: In marginalised population of PWID attending LTP, a sustainable HCV RNA re-screening and follow-up after HCV cure are necessary, as the risk of reinfection remains high. [ABSTRACT FROM AUTHOR]

Background: Tapentadol is a dual action opioid analgesic with emerging data on abuse and diversion. Aim: This study describes tapentadol abuse, clinical presentation, and treatment patterns. Methods: We reviewed patients seeking help for tapentadol use (2017–2023) at a South Indian tertiary hospital. We collected data on sociodemographics, clinical profiles, and treatment, including buprenorphine dose and dose limiting side effects. Results: Of 933 opioid use disorder cases, 228 involved tapentadol. Most (89%) initiated opioid use with tapentadol, and 93% injected dissolved tablets. 80% were diagnosed with opioid dependence. Over half required inpatient treatment. 75% received buprenorphine, but tolerability was poor. The median first day dose was 0.8 mg (IQR = 0.4–2), and the maintenance dose was 4 mg (IQR = 2–8), with nausea being the main side effect. Conclusion: We can conclude that Tapentadol is prone to abuse and dependence. These patients have poor buprenorphine tolerability and receive low maintenance doses. Further research is needed on effective opioid agonist treatment for tapentadol dependence. [ABSTRACT FROM AUTHOR]

Sexual and/or injecting partners of people who inject drugs (PWID) may have an elevated risk of HIV infection either from sharing a transmission network or an epidemiological environment. We estimated the degree of similarity between HIV and hepatitis C (HCV) sequences from PWID and their partners to assess whether partner-based recruitment identifies sexual or injecting partners within transmission networks. We used assisted partner services (APS) to recruit sexual and injecting partners of PWID living with HIV in Kenya and evaluated trends in the TN93 distances (an adjusted measure of sequence similarity) of the HIV-1 and HCV sequences from partner pairs. Of 135 unique pairs identified, 2 sexual, 2 injecting, and 3 unique sexual and injecting partner pairs had HIV sequences within a TN93 distance of 0.045, and 4 unique partner pairs had HCV sequences with distances <0.015. Sexual but not injecting partner pairs had HIV sequences with significantly smaller distances than non-partners, on average, but injecting partner pairs did have significantly smaller HCV-4a patristic distances than non-partners. APS recruitment partly reflects the HIV transmission network among sexual, but not injecting, partners of PWID. The relationship between the injecting partner recruitment and molecular networks is stronger for HCV than HIV and may reflect some recent parenteral HCV transmission. Our results show the importance of continued focus on reducing sexual HIV transmission among PWID and on education and services to address HCV transmission through needle- and/or equipment-sharing. [ABSTRACT FROM AUTHOR]

Background and objective: This study aims to understand the reasons people avoid or delay HCV treatment and identify potential pathways that can increase the uptake of HCV treatment from a health systems perspective. Methods: Semi-structured interviews with 15 participants who were HCV positive and had a history of active or recent injecting drug use were conducted. Thematic and framework analyses based on an integrated framework by Høj and colleagues were used to identify barriers and opportunities to HCV treatment. Results: The study identified barriers and enablers to HCV treatment at individual, socio-structural, and system levels. Competing priorities, unstable housing, and stigma were barriers, while engagement in opioid agonist therapy and peer support were enablers. Misinformation, limited OAT prescribers, and gaps in care coordination, especially within the prison system, were identified as missed opportunities at the system level, while organizational support and respectful relationships with service providers were key to engagement. Conclusions: Person-centered care addressing the specific needs of PWID, such as housing, and drug and alcohol treatment, should be enhanced, and HCV care embedded within these services. Strengthening care pathways, especially within and between prisons and other primary care services, is urgently needed. [ABSTRACT FROM AUTHOR]

Background: Disparities persist in testing and treatment for hepatitis C virus (HCV), leaving socially marginalized populations, including people who inject drugs (PWID), less likely to benefit from curative treatment. Linkage services are often insufficient to overcome barriers to navigating the medical system and contextual factors. Methods: The You're Empowered for Treatment Initiation (YETI) Partner trial is a single-site randomized controlled trial evaluating the efficacy of a two-session behavioral intervention that engages injecting partners as peer navigators for HCV treatment. We aim to recruit 250 PWID and their primary injecting partners in San Francisco, California, randomizing them 1:1 to either a control or intervention group. The primary outcome is the initiation of HCV treatment, with secondary outcomes including treatment completion and sustained virologic response 12 weeks post-treatment. Data will be collected through questionnaires and electronic health records and analyzed using intention-to-treat and mixed-effects models. Discussion: This trial will provide evidence of a new HCV treatment linkage intervention leveraging the support of primary injecting partners to initiate HCV treatment. If successful, the intervention could inform public health strategies and policies to address HCV in marginalized populations. Trial registration: ClinicalTrials.gov NCT06179498. Registered on December 22, 2023. [ABSTRACT FROM AUTHOR]

People with HIV (PWH) who inject drugs (PWID) face many barriers to ART adherence. Kazakhstan has one of the fastest growing HIV epidemics in the world, primarily fueled by injection drug use, yet ART adherence among PWID is low. Social support can help address these barriers, but ART adherence among PWID is rarely examined within the relationship context. We conducted interviews with 20 PWID with HIV and 18 of their intimate partners and performed a qualitative dyad analysis to examine ART adherence factors. The results indicated many barriers and facilitators of ART adherence at the individual level (e.g., substance use), interpersonal level (e.g., social support) and structural level (e.g., stigma, transportation). Reported adherence barriers and facilitators had high congruence between dyad members; however, some notable differences were found between dyads. Compared to PWH, partners without HIV had a lack of awareness about the role of stigma in impeding ART adherence. Different manifestations of social support to facilitate ART adherence were noted between seroconcordant dyads (e.g., taking pills together, attending appointments together) and serodiscordant dyads (e.g., reminders to take pills, providing babysitting to enable attendance at doctor appointments). Future research and programs may benefit from integrating dyad approaches into ART adherence interventions. [ABSTRACT FROM AUTHOR]

Introduction: The World Health Organization (WHO) has established objectives for eradicating the hepatitis C virus (HCV). People who inject drugs (PWID), a major driver of HCV transmission, are an essential part of China's hepatitis C elimination program. This study aimed to estimate the requisite screening and antiviral treatment levels to achieve these goals among people who inject drugs in China and identify the most cost-effective strategy. Methods: This study utilized models based on dynamic social networks to simulate HCV transmission and disease progression among people who inject drugs in China, incorporating a cost-effectiveness analysis from a healthcare perspective. Results: To achieve the WHO targets, a minimum screening and treatment rate of 10% is required to meet the mortality goal, while a 25% rate is necessary for the incidence goal. The most cost-effective strategy includes a 25% screening rate and a 95% treatment rate. Compared to no intervention, this approach significantly reduces costs by − $85,873.38 (95% CI − $94,311.16 to − $77,435.59) and adds 24.66 (95% CI 23.68 to – 25.64) quality-adjusted life years. The intervention is dominant, with a cost-effectiveness ratio of − $3482.29 (95% CI − $3982.73 to − $3020.11) per quality-adjusted life year. Conclusion: Achieving the WHO's hepatitis C virus elimination targets among people who inject drugs in China is feasible and cost-saving. [ABSTRACT FROM AUTHOR]

Islatravir is a nucleoside reverse transcriptase translocation inhibitor in development for the treatment of HIV‐1. People living with HIV‐1 receiving methadone maintenance therapy may benefit from islatravir. This study was designed to evaluate single‐dose islatravir on steady‐state methadone pharmacokinetics. A nonrandomized, open‐label study (NCT04568603) was conducted and included adult participants receiving methadone therapy. Participants received their standard methadone therapy and a single oral dose of islatravir 60 mg concomitantly. Blood samples were collected to determine methadone and islatravir pharmacokinetics. Fourteen participants aged 26‐63 years were enrolled; 13 completed the study. The geometric mean ratios for methadone area under the concentration‐time curve from time 0 to 24 hours (AUC0‐24), maximum plasma concentration (Cmax), and concentration at 24 hours (C24) were 1.03, 1.01, and 1.07, respectively. Similar effects were seen for the R‐ and S‐enantiomer of methadone (R‐methadone: AUC0‐24, 1.03; Cmax, 1.02; and C24, 1.06; S‐methadone: AUC0‐24, 1.03; Cmax, 1.01; and C24, 1.08). For islatravir, based on a comparison with historical data, the geometric mean ratios for AUC0‐inf and Cmax were 1.18 and 0.86, respectively. Coadministration of a single dose of islatravir and methadone was generally well tolerated. Single‐dose islatravir did not affect steady‐state methadone pharmacokinetics in a clinically meaningful way. [ABSTRACT FROM AUTHOR]

We examined the role of network communication about HIV-related topics in mediating the efficacy of a social network intervention on HIV seroconversion among people who inject drugs (PWID) in Ukraine, where Eastern Europe's second-largest HIV epidemic is concentrated among PWID. We used randomized controlled trial data from 1200 HIV-negative PWID (Ukraine; 2010–2012) in an inverse-odds weighted analysis to examine mediation by network communication. Network communication mediated 24 % (95 % CI= 19.22–29.38) of the intervention's effect. Integrating training to support network communication about additional HIV prevention resources could enhance the impact of social network HIV prevention interventions among PWID. • We assessed a mechanism through which a social network intervention reduced HIV seroconversion among PWID. • Network communication about HIV risk reduction mediated 24 % of the intervention's effect. • Our findings support increasing communication about HIV risk reduction in social networks of PWID. • Leveraging existing social networks could impact HIV harm reduction among PWID. [ABSTRACT FROM AUTHOR]

BACKGROUND: Opioid Agonist Treatment (OAT) combines opioid agonist medications with counseling and therapy for a whole-patient approach to treating opioid use disorder. The war in Ukraine threatened the continuity of care and well-being of individuals receiving OAT. This study aimed to capture patients experiences accessing OAT during the war in Ukraine to provide insights that can inform and improve the programs that serve them. METHODS: In October - November 2022, we conducted semi-structured interviews with 17 OAT patients who are peer advocates in the Ukrainian Patient Network VOLNA. All interviews were conducted virtually via Zoom, recorded, and transcribed. Through thematic analysis, we generated codes from the transcripts, iteratively using both inductive and deductive approaches. RESULTS: The qualitative interviews revealed four themes: 1) medication, focusing on concerns about availability, dosage, and quality of OAT; 2) patient barriers, discussing access challenges for specific patient groups, such as refugees or patients living under the occupation; 3) clinic-level challenges, involving dosing adequacy, treatment continuity, patient volume, and clinician stigma, and 4) regulatory inflexibility, describing uneven implementation of regulations and increased policing to receive OAT during the war. CONCLUSION: Our study emphasizes the importance of adapting OAT programs in Ukraine to better serve vulnerable patients affected by the war. The Russian invasion has severely disrupted OAT provision, increasing the risks of opioid withdrawal, overdose, and diversion. By understanding patients experiences, treatment preferences, and barriers to care, OAT programs can provide continuity of care to those in need.

BACKGROUND: As many as 2.4 million Americans are affected by chronic Hepatitis C Virus (HCV) in the United States.In 2018, the estimated number of adults with a history of HCV infection in San Diego County was 55,354 (95% CI: 25,411-93,329). This corresponded to a seroprevalence of 2.1% (95% CI: 2.1-3.4%). One-third of infections were among PWID. Published research has demonstrated that direct-acting antivirals (DAAs) have high efficacy and can now be used by primary care providers to treat HCV. In addition, limited evidence exists to support the effectiveness of simplified algorithms in clinical trial and real-world settings. Even with expanded access to HCV treatment in primary care settings, there are still groups, especially people who inject drugs (PWID) and people experiencing homelessness, who experience treatment disparities due to access and treatment barriers. The current study extends the simplified algorithm with a streetside one-stop-shop approach with integrated care (including the offer of buprenorphine prescriptions and abscess care) using a mobile clinic situated adjacent to a syringe service program serving many homeless populations. Rates of HCV treatment initiation and retention will be compared between patients offered HCV care in a mobile clinic adjacent to a syringe services program (SSP) and homeless encampment versus those who are linked to a community clinics current practice of usual care, which includes comprehensive patient navigation. METHODS: A quasi-experimental, prospective, interventional, comparative effectiveness trial with allocation of approximately 200 patients who inject drugs and have chronic HCV to the simplified care pathway (intervention group) or the usual care pathway (control group). Block randomization will be performed with a 1:1 randomization. DISCUSSION: Previous research has demonstrated acceptable outcomes for patients treated using simplified algorithms for DAAs and point-of-care testing in mobile medical clinics; however, there are opportunities to explore how these new, innovative systems of care impact treatment initiation rates or other HCV care cascade outcomes among PWID. TRIAL REGISTRATION: We have registered our study with ClinicalTrials.gov, a resource of the United States National Library of Medicine. This database contains research studies from United States and other countries around the world. Our study has not been previously published. The ClinicalTrials.gov registration identifier is NCT04741750.

In 2020, the Eliminate Hepatitis C Initiative in the county of San Diego (COSD) was launched, a private-public joint endeavor between the COSD and the American Liver Foundation. We use epidemic modeling to assess whether the COSD is on track to reach its elimination targets (80% reduction in incidence, 65% reduction in hepatitis C virus (HCV)-related mortality by 2030 compared to 2015) and what intervention scale-up may be required. We adapted a previously developed dynamic, deterministic model of HCV transmission and disease progression among adults in the COSD, stratified by risk, age, gender, and human immunodeficiency virus (HIV) status. The model is calibrated to detailed historical epidemiological data on HCV burden, treatment, and mortality in the COSD. We project HCV infections and mortality under status quo HCV treatment (65%/year among people coinfected with HCV and HIV, 0-5%/year among others) and determine what treatment scale-up among those without HIV is required to achieve HCV elimination, with or without concomitant reductions in injection transmission risk from 2024 onward. We project an increase in new HCV infections in the COSD to 2213 [95% C.I.: 1069-3763] in 2030, a mean 91% relative increase between 2015 and 2030. HCV-related deaths are expected to decrease to 246 [95% C.I.: 180-295] in 2030, a mean relative decrease of 14% compared to 2015. The incidence elimination target could be achieved through increasing HCV treatment among those without HIV to a mean of 60%/year, similar to the level achieved among people coinfected with HCV and HIV. Combination interventions reduce the treatment needed; if injecting risk is reduced by 25%, then treating 48%/year could achieve elimination. The COSD is likely not on track to reach the incidence or mortality targets, but achieving the incidence target is possible if treatment rates overall are scaled-up to rates that have been achieved among people coinfected with HCV and HIV. Elimination is achievable but requires committed funding and expansion of comprehensive testing, linkage, and treatment programs alongside harm reduction initiatives.

BackgroundPeople who use drugs (PWUD) experience elevated HIV risk and numerous barriers to facility-based HIV testing. HIV self-testing (HIVST) could circumvent many of those barriers and is acceptable among PWUD, yet HIVST implementation for PWUD is limited. Service providers' perspectives on specific HIVST delivery strategies could help increase availability for PWUD.MethodsFrom April-November 2021, we interviewed 16 health, harm reduction, and social service providers working with PWUD in San Diego, CA. Interviews and rapid thematic analysis explored perspectives on HIVST's utility and appropriateness, as well as the feasibility of and anticipated challenges with specific HIVST delivery strategies, including peer or secondary distribution.ResultsParticipants viewed HIV as a significant threat to PWUD health and confirmed the presence of numerous barriers to local facility-based HIV testing. Participants viewed HIVST as a promising and potentially empowering solution. Based on community familiarity with secondary distribution of harm reduction supplies (i.e., naloxone) and information, participants viewed secondary distribution of HIVST kits as an appropriate and feasible strategy for increasing the reach of HIVST, but also described potential barriers (e.g., engaging socially disconnected individuals, ensuring linkages to services following HIVST) and provided suggestions for alternative HIVST kit delivery models (e.g., harm reduction vending machines).ConclusionsService providers viewed secondary distribution of HIVST kits among PWUD as promising, appropriate, and feasible, yet specialized efforts may be needed to reach the most marginalized individuals and ensure consistent provision of educational information and referral supports that maximize the impact of this approach.

BackgroundHIV self-testing (HIVST) could increase HIV testing access among people who inject drugs (PWID), and secondary distribution (i.e., peer-delivery) of HIVST kits in PWID social networks could further expand coverage. We assessed willingness to use and distribute HIVST kits among PWID in the San Diego-Tijuana border region.MethodsFrom 2020 to 2021, HIV-negative PWID in San Diego, USA, and Tijuana, Mexico, completed surveys and provided data on individual (N = 539) and social network (N = 366) characteristics. We used modified Poisson regression to examine the effects of individual and social network characteristics on willingness to use and distribute HIVST kits.ResultsMost participants were willing to use (81%) and distribute (81%) HIVST kits. At the individual level, prior HIV testing was positively associated with willingness to use (adjusted prevalence ratio [aPR] = 1.24, 95% confidence interval [CI] 1.10-1.40) and distribute (aPR = 1.27, 95% CI 1.12-1.43) HIVST kits, while perceiving oneself to be at higher HIV risk than others was negatively associated with willingness to use HIVST kits (aPR = 0.83, 95% CI 0.74-0.93). At the network level, willingness to distribute HIVST kits was positively associated with network size (aPR = 1.04 per member, 95% CI 1.01-1.08) and greater proportions of one's network encouraging them to use drugs (aPR = 1.29, 95% CI 1.16-1.44) and having a history of homelessness (aPR = 1.51, 95% CI 1.31-1.74) or detention/arrest (aPR = 1.57, 95% CI 1.36-1.82), and negatively associated with a greater proportion of one's network including "very close" persons (aPR = 0.80, 95% CI 0.69-0.94).ConclusionsWe found high potential for HIVST kits and their secondary distribution to increase HIV testing among PWID who face the greatest barriers to facility-based testing.

Background: People who inject drugs (PWID) are especially vulnerable to harms from opioid use disorder (OUD). Medications for OUD (MOUD) effectively reduce overdose and infectious disease transmission risks. Objective: We investigate whether state Medicaid coverage for methadone and buprenorphine is related to past-year MOUD use among PWID using cross-sectional, multilevel analyses with individual-level data on PWID from the Centers for Disease Control and Prevention's 2018 National HIV Behavioral Surveillance. The sample included 8,142 PWID aged 18-64 who reported daily opioid use from 22 U.S. metropolitan areas. Our outcome was any self-reported MOUD use in the past 12 months. Exposures were state Medicaid coverage and prior authorization requirements for methadone and buprenorphine. We interacted these exposures with PWID race/ethnicity, insurance status, and spatial access to treatment and harm reduction resources. Results: Compared with PWID in states without Medicaid methadone coverage, odds of past-year MOUD use were 73% (p<0.05) higher among PWID in states with methadone coverage requiring prior authorization and 80% (p<0.05) higher among PWID in states with coverage without prior authorization. Insured PWID were twice as likely to report MOUD use than uninsured PWID, with no statistically significant differences between Medicaid versus other insurance. Medicaid prior authorization requirements for buprenorphine were not significantly associated with MOUD use. Non-Hispanic Black PWID were significantly less likely to use MOUD than non-Hispanic White and Hispanic PWID. Conclusions: State Medicaid methadone coverage was strongly associated with higher odds that PWID utilized MOUD, suggesting that expanding methadone insurance coverage could improve MOUD treatment in a vulnerable population. [ABSTRACT FROM AUTHOR]

Abstract Background We aimed to identify motivators for people who inject drugs to pursue treatment for hepatitis C virus (HCV) infection and uncover opportunities that could make treatment more appealing. Methods Between November 2023 and January 2024, we conducted semi-structured interviews with 15 HCV RNA-positive individuals with a history of injecting drug use and self-reported as either untreated or treated but delayed treatment for more than 6 months. Thematic and framework data analysis was employed and interpreted using the Capability, Opportunity and Motivation (COM-B) framework of behaviour change. Results The findings suggest that a combination of stability through secure housing, mental readiness and overcoming drug dependence supported by OAT (Capability), accessible and convenient healthcare like mobile outreach services coupled with financial incentives (Opportunity), and supportive relationships (Motivation) could serve to help people who inject drugs take up HCV treatment. Conclusion Alcohol and other drug and primary care services for people who use drugs should adopt person-centred approaches and recognise the gradual nature of behavioural change to foster empathy and supportive relationships to promote engagement in HCV care. Additionally, integrating HCV treatment with mobile outreach services and providing practical assistance, such as housing and financial incentives, are critical to ensuring that individuals remain engaged in HCV care.

Abstract Background People who inject drugs (PWID) are at high risk of blood-borne infections, and injection drug use contributes significantly to hepatitis C virus (HCV) transmission. The WHO has therefore set targets of reducing HCV incidence and prevalence among PWID and increasing treatment coverage to eliminate HCV by 2030. The DRUCK study (2011–2014) found high HCV prevalence and low treatment coverage among PWID in Germany. To assess progress in the elimination of HCV among PWID, we conducted a cross-sectional study in two German federal states that piloted a future monitoring. Methods PWID aged 16 + who injected drugs (previous 12 months) were recruited in low-threshold drug services and opioid agonist treatment (OAT) practices in Berlin and Bavaria between June 2021 and April 2022. Participants completed a questionnaire on sociodemographics, behaviours and access to care, and were tested for hepatitis B virus (HBV) and HCV, and HIV. Data was analysed regarding HCV prevalence, history of treatment, and risk and prevention behaviours. Results were compared with the DRUCK study. Results A total of 588 PWID, with a median age of 39 (range: 17–66) years and 68% (399/587) male, were included in the analysis. Of the participants, 61% (353/574) reported receiving OAT and 14% (66/469) recent use of shared needles/syringes during the last 30 days. History of imprisonment was reported by 77% (444/577) and history of homelessness by 75% (428/569) of participants. Among anti-HCV positive participants, viraemic HCV infections decreased by 44% from 66% (904/1361) in 2011–2014 to 37% (160/432) in 2021–2022, while those with cleared HCV infection and treatment history increased from 20% (266/1361) to 34% (148/432). Conclusions Despite a decrease since 2011–2014, viraemic HCV prevalence among PWID in Germany remains high, and treatment coverage is still insufficient. To achieve the WHO targets, universal health coverage and targeted integrated testing and treatment for PWID are needed. PWID receiving OAT and people in prison should be offered testing and treatment at any contact with the medical system. A nationwide monitoring system will help assess successes and remaining gaps, and track progress towards elimination of HCV among PWID in Germany.

Abstract Background Oral Pre-exposure prophylaxis (PrEP) is effective in preventing HIV transmission. However, despite high rates of HIV risk behaviors among people who inject drugs (PWID), this population remains underserved by current HIV prevention efforts in the United States. To address this challenge, we conducted an in-depth exploration of perspectives on using oral PrEP among PWID engaged in the HIV Prevention Trials Network (HPTN) 094 INTEGRA Study. Methods Guided by the Practical, Robust, Implementation, and Sustainability Model (PRISM), our qualitative study drew on semi-structured interviews conducted as part of the embedded implementation science evaluation of HPTN 094 INTEGRA. Seventy-seven PWID participants from five sites across New York City, Houston, Los Angeles, Philadelphia, and Washington DC were interviewed to assess intervention delivery, care access, and engagement sustainability. Audio files were transcribed verbatim and analyzed via an inductive and deductive thematic approach. Results Most participants (n = 46, 59.7%) discussed oral PrEP during their interview, though not directly prompted. Participants discussing PrEP had a mean age of 41.6 years and were predominantly white (54.3%) and cisgender men (60.9%). Among these, 15 participants described using PrEP. All participants had facilitated access to oral PrEP. Yet, the choice to use PrEP was influenced by personal risk perceptions, (mis)information about PrEP, and external factors (i.e. housing, financial security), which, for some, limited the autonomy to use PrEP. Two key themes emerged among participants using PrEP: ease of access and perceptions of high HIV risk. Those not using PrEP described two themes: low risk perception and prioritizing more urgent needs. Among participants not using PrEP a subgroup commonly described ambivalent interest, PrEP knowledge gaps, and PrEP readiness (i.e., contemplation). Conclusions Qualitative findings highlight that facilitated PrEP access was insufficient to motivate use for many participants. Rather, PrEP decision-making process (i.e., choice) was linked to risk perception and individuals’ capability to leverage PrEP as a resource based on their circumstances (i.e., autonomy). Participants’ descriptions of the centrality of choice and autonomy for PrEP use underscore that ease of access is a necessary pre-condition, but person-centered interventions should also address housing, financial stability, and urgent medical conditions to promote PrEP utilization among PWID. Clinical trial registration NCT04804027.

Abstract Background With the advent of direct acting antivirals (DAAs) the World Health Organisation (WHO) adopted global strategy to eliminate hepatitis C virus (HCV) infection by 2030. In Europe, people who inject drugs (PWID) account for the majority of new cases, however testing and treatment remain suboptimal. The aim was to monitor progress in HCV policy and cascade-of-care for PWID, led by the civil society organisations (CSO) that provide harm reduction services for PWID across Europe. Methods In period 2020–2023, CSOs representing focal points of Correlation-European Harm Reduction Network were annually invited to complete online questionnaire on use/impact of HCV test-and-treat guidelines for PWID, availability/functioning of continuum-of-care, and role/limitations of harm reduction services for PWID. A retrospective longitudinal analysis of responses to questions answered each year by the same respondents was performed, and a comparison among the studied years was made. Results Twenty-five CSOs from cities in 25 European countries were included and responded to 25 questions. Between 2020 and 2023, there was positive trend in number of HCV treatment guidelines, separate guidelines for PWID, and their positive impact on acess to testing/treatment (24/25, 5/25, and 16/25 in 2023, respectively). DAAs were available in all countries, predominantly prescribed by specialist physicians only (slight increase at primary care), with restrictions including active drug use, stage of liver fibrosis or/and reimbursement policies (2/25, 4/25, and 3/25 in 2023, respectively). A decrease in HCV testing sites was noted. Treatment was consistently most common at clinical settings, however an increase outside the specialist settings was detected, particularly in prisons (12/25 and 15/25 in 2020–2021, respectively). Comparing 2022–2023, number of HCV-testing services increased in many cities with positive dynamic in nearly all the settings; increase in treatment at harm reduction services/community centres was noted (6/25 to 8/25, respectively). Between 2020 and 2023 the frequency of various limitations to CSOs addressing HCV was oscillating, presenting an increase between 2022 and 2023 (9/25 to 14/25, respectively). Conclusion The overall progress towards WHO HCV elimination goals across Europe remains insufficient, most probably also due to the influence of Covid-19 pandemic. Further improvements are needed, also by including CSOs for PWID in continuum-of-care services, and in monitoring progress.

Abstract Background People who use drugs (PWUD) are at increased risk for blood-borne viruses, including hepatitis B (HBV) and delta (HDV). Despite the public health threats both viruses present, awareness remains low among at-risk communities and providers who serve them. This study assessed barriers to HBV and HDV prevention, diagnosis, and linkage to care, evaluated existing levels of knowledge, and identified educational needs and preferences among both PWUD and service providers. Methods For this mixed-methods study, data were collected through an anonymous online provider-focused survey, and interviews with PWUD, non-medical staff, and healthcare providers at a harm reduction organization in Philadelphia, PA, USA. Convenience sampling was used for recruitment of both key informants and survey respondents. Survey respondents were categorized according to their type of practice. For the interviews, a codebook was created for qualitative analysis. Data were subsequently organized into thematic categories. Results The top provider-related barriers limiting HBV screening were identified as confusion about insurance coverage (48%) and competing priorities (45%). Barriers to vaccination included patient hesitancy (52%) and challenges with administering multiple doses (39%). Respondents indicated low knowledge of HDV tests (62%) and cited guideline complexity (31%) as barriers to HDV testing. HBV and HDV awareness within the community and among staff was poor. Findings demonstrated that stigma related to drug use and harm reduction posed a significant barrier to care. Participants recommended awareness campaigns tailored for the PWUD community that are non-stigmatizing and non-judgmental, clear, factual, digestible, and interactive, with empowering steps to protect health. Conclusion This study identified major gaps in HBV and HDV service delivery for PWUD, including poor basic knowledge, the need to address this through culturally appropriate, non-stigmatizing and tailored educational programming, and challenges with access to vaccination and testing. Continued initiatives are needed to close disparities, and to continue to provide financial and political support for harm reduction organizations, a frequently cited facilitator of healthcare access for PWUD. Significant efforts are essential to address lack of vaccination, testing, and linkage to care, and to improve health outcomes among PWUD.

Abstract Background Hepatitis C virus (HCV) reinfection following successful treatment threatens the achievement of HCV elimination. The primary aim of this study is to assess reinfection rate three years after sustained virologic response (SVR) in people who inject drugs (PWID) that are on opioid agonist treatment (OAT) who underwent anti-HCV treatment with interferon-free regimens. Methods Observational, non-interventional, prospective, descriptive study carried out in Spanish tertiary public hospitals between 2017 and 2022. Participants comprised 186 adult HCV infected individuals, 85.5% males with a mean age (Standard Deviation, SD) of 50.1 (5.9). All were enrolled in an OAT program at baseline and had attained SVR 12 weeks after therapy completion with an interferon-free treatment. Baseline data were abstracted from medical chart information collected through the routine clinical practice. Results The overall rate of HCV reinfection three years after SVR12 among PWID was 1.2 new cases per 100 person-years of follow-up at a median of 15.9 months. In the subgroup analyses, those with injection drug practice and without a stable housing had higher reinfection rates. Conclusion Although PWID in OAT present a low rate of reinfection by HCV after successful treatment, a closer monitoring in the first year and strengthening inter-consultations with services responsible for monitoring addiction in these patients will be crucial to reduce risky behaviors avoiding HCV reinfection.

Abstract Background Addiction medicine providers have a key role in HIV prevention amidst rising HIV incidence in persons who inject drugs (PWID). Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are vastly underutilized in this population. Inpatient hospitalization represents a potential touchpoint for initiation of HIV prophylaxis, though little research explores the role of addiction providers. Here we describe rates of PrEP/PEP delivery to hospitalized PWID seen by an Addiction Consult Service (ACS) at an urban, essential hospital. Methods We performed a cross-sectional study of hospitalized patients who were seen by the ACS from January 1, 2020 to December 31, 2022 and had plausible injection drug use. We calculated the proportion of patients who received a new prescription for PrEP/PEP at discharge. We used descriptive statistics to characterize demographics, substance use, reason for admission, and indications for PrEP/PEP. Secondarily, we calculated the monthly proportion of all patients discharged from the hospital with PrEP/PEP who were seen by the ACS compared to those not seen by the ACS. Results The average monthly proportion of ACS consults with plausible injection drug use who received PrEP/PEP was 6.4%. This increased from 4.2% in 2020 to 7.5% in 2022. Those seen by the ACS who received PrEP/PEP had high rates of opioid use disorder (97.5%), stimulant use disorder (77.8%), and homelessness (58.1%); over half were admitted for an injection-related infection. The indications for PrEP/PEP were injection drug use only (70.6%), followed by combined injection and sexual risk (20.2%); 71.9% of prescriptions were for PrEP and 28.1% for PEP. Overall, the ACS was involved in 83.9% of hospital-wide discharges with PrEP/PEP prescriptions (n = 242). Conclusions PWID who were seen by the ACS received PrEP/PEP prescriptions at rates exceeding national averages. The ACS was also involved with the care of the majority of admitted patients who received PrEP/PEP at discharge. While PrEP/PEP use for PWID remains low, the inpatient ACS represents a key resource to improve uptake by leveraging the reachable moment of an inpatient hospitalization.

Abstract Background While people with substance use disorders, including people who inject drugs (PWID), experience increased risk for COVID-19 infection and adverse outcomes, COVID-19 vaccination rates among PWID are consistently lower than those observed in the general population. Offering COVID-19 vaccines at syringe services programs (SSPs) has been proposed as a critical strategy to increase vaccine uptake among this population. We explored the experiences of frontline staff at an SSP in Miami, Florida implementing onsite COVID-19 vaccines. Methods Between June and July 2022, we conducted in-depth semi-structured interviews with 17 staff members of an SSP in Miami, Florida. Data collection and codebook thematic analysis of transcribed interviews were guided by the Consolidated Framework for Implementation Research (CFIR). Results Facilitators and barriers of COVID-19 vaccine implementation at the SSP aligned with all major CFIR domains. Key facilitators included the SSP’s established partnership with the local health department for vaccine distribution, its existing funding sources which could be leveraged for vaccine-related expenses, consensus among staff about the need for new strategies to increase vaccine uptake among PWID, and PWID’s trust in the SSP. Major—but largely modifiable—barriers included lack of participant compensation, limited internal collaboration and communication regarding the vaccine initiative beyond implementation leads and innovation deliverers due to competing priorities and segmented roles and responsibilities, and insufficient involvement of the most participant-facing staff (i.e., the SSP’s peer navigators and outreach workers). Conclusions Implementing onsite COVID-19 vaccines was perceived as feasible and acceptable by frontline staff at the SSP, however contextual factors impeded optimal implementation. Multilevel strategies, such as participant compensation for vaccine completion and internal educational meetings with staff to improve vaccine implementation and reach, are required. As a trusted source of preventative services for PWID, SSPs are an underutilized venue for increasing vaccine uptake among this population, and findings from this study could inform the expansion of low-barrier vaccine services at SSPs nationwide.

Abstract Background Besides the high prevalence of HIV and HCV infections, people who inject drugs (PWID) have a cumulative risk of acquiring skin and soft tissue infections (SSTI) from, among other things, social precariousness, homelessness/unstable housing, and unhygienic injecting practices. We propose to evaluate whether a two-component educational hand hygiene intervention which combines training in hand-washing with the supply of a single-use alcohol-based hand rub, called MONO-RUB, is effective in reducing injection-related abscesses in the PWID population. Specifically, we shall implement a nationwide, two-arm, multi-centre, cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of this intervention in PWID. Methods HAWA is a community-based participatory research study to be conducted in 22 harm reduction centres (HR) in France (not yet recruiting); the latter will be randomised into two clusters: centres providing standard HR services and the intervention (i.e., intervention group) and those providing standard HR services only (i.e., control group). After randomization, each cluster will include 220 PWID, with an inclusion period of 12 months and an individual follow-up period of 6 months. For each participant, we will collect data at M0, M3 and M6 from photos of injection sites on the participant’s body, a face-to-face injection-related SSTI questionnaire, and a CATI questionnaire. The primary outcome is the reduction in abscess prevalence between M0 and M6, which will be compared between the control and intervention arms, and measured from observed (photographs) and self-declared (SSTI questionnaire) data. We will also assess the cost-effectiveness of the intervention. Discussion The HAWA trial will be the first cluster randomized controlled trial to improve hand hygiene among PWID with a view to reducing SSTI. If effective and cost-effective, the intervention combined with the distribution of MONO-RUBs (or a similar cleaning product) may prove to be an important HR tool, helping to reduce the enormous burden of infection-related deaths and diseases in PWID. Trial Registration NCT06131788, received on 2 January 2024.