Engagement in Maximally-Assisted Therapy and Adherence to Antiretroviral Therapy Among a Cohort of Indigenous People Who Use Illicit Drugs

Substance Use and Mental Health Comorbidities and Receipt of Specialty Care Among Patients Enrolled in a Low-Barrier HIV Clinic

Low-barrier care is one model of a differentiated service delivery approach for people with HIV (PWH) who are not engaged in conventionally-organized HIV care. Although psychiatric and substance use disorders are common among patients in low-barrier clinics, approaches to behavioral health service delivery within this context have not been well-described. We conducted a descriptive analysis using retrospective review of medical records to evaluate substance use and psychiatric comorbidities and receipt of behavioral health services among patients in the Max Clinic in Seattle, Washington. Among 227 patients enrolled from 2015 to mid-2020, most had a history of hazardous substance use (85%), a psychiatric diagnosis (69%) or unstable housing (69%) documented in the medical record. Less than half of patients referred for depression treatment (33%) or for opioid use disorder treatment (40%) completed even one specialty care visit. More effective approaches are needed to engage patients in behavioral health services within the context of low-barrier HIV care.

Acceptability and Feasibility of a Mobile Phone Application to Support HIV Pre-exposure Prophylaxis Among Women with Opioid Use Disorder

Despite evidence supporting HIV pre-exposure prophylaxis (PrEP) effectiveness, very few women with opioid use disorder (OUD) take PrEP. Interventions that improve medication assisted treatment (MAT) uptake and adherence may also be beneficial for PrEP. The reSET-O mobile phone app is a component of the evidence-based Therapeutic Education System, which improves retention and abstinence for people with OUD. To better understand use of this mobile health tool as a support for PrEP among women with OUD, pre-implementation contextual inquiry is needed. Therefore, we set out to assess target user characteristics, implementation barriers, feasibility, and acceptability of reSET-O. We recruited women with OUD receiving care from a community-based organization in Philadelphia to complete semi-structured interviews. All participants were prescribed reSET-O. We interviewed 20 participants (average age 37 years; 70% white, 15% Hispanic, 5% Black) from 5/2021 to 2/2022. We used an integrated analysis approach combining modified grounded theory and implementation science constructs. Half reported recent injection drug use, and 6 were taking buprenorphine. Mental health symptoms were common, and half described engaging in transactional sex. The majority expressed strong interest in PrEP. Participants reported the app would be highly acceptable for PrEP and MAT adherence support, but only two redeemed the prescription. The most common barriers included phone and internet access. Our findings highlight potential implementation challenges for the use of such an app to support PrEP use in this population. Poor uptake of the app at follow-up indicates that initial prescription redemption is a major barrier to reSET-O implementation.

Implementation of Low-Barrier Human Immunodeficiency Virus Care: Lessons Learned From the Max Clinic in Seattle

Low-barrier care (LBC) for people with human immunodeficiency virus (HIV) is a differentiated service delivery strategy to engage people in HIV treatment who are not well-engaged in conventionally organized HIV medical care. The LBC approach is flexible, but experience suggests that the intervention has distinct core components. This review summarizes our experience implementing one model of LBC, the Max Clinic in Seattle; describes the core components of the intervention; and presents a framework for implementing low-barrier HIV care with the goal of providing a practical guide for clinical and public health leaders seeking to implement a new LBC program. A systematic approach to addressing key factors during LBC implementation can support practitioners to design an LBC approach that fits the local context while maintaining essential elements of the intervention.

Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada

We investigated associations between (1) housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

Methadone maintenance therapy service components linked to improvements in HIV care cascade outcomes: A systematic review of trials and observational studies

BACKGROUND

The beneficial links between engagement in methadone maintenance therapy (MMT) and HIV treatment outcomes have been extensively described. Nevertheless, people who use drugs (PWUD) continue to experience suboptimal HIV treatment outcomes. In this systematic review, we sought to identify components of MMT service provision that are associated with improvements in HIV care outcomes across the HIV care cascade.

METHODS

We searched for peer-reviewed studies in online databases. To be eligible for inclusion in this review, studies must have involved a population or sub-population of PWUD engaged in MMT; report improved uptake of HIV testing, exposure to ART, or HIV-1 RNA plasma viral load suppression; provide details on MMT services; and be published in English between 1 January 2006 until 31 December 2018.

RESULTS

Out of the 5594 identified records, 22 studies were eligible for this systematic review. Components of MMT services associated with HIV care cascade outcomes described in the studies were classified in three categories of care models: 1) standard MMT care with adequate doses, 2) standard MMT care and alongside additional medical component(s), and 3) standard MMT care, additional medical component(s) as well as informational or instrumental social support.

CONCLUSION

The few studies identified reflect a scarcity of evidence on the role of social support to increase the benefits of MMT for PWUD who are living with HIV. Further research is needed to assess the role of medical and social service components in MMT care delivery in advancing PWUD along the HIV care cascade.

Adherence among HIV-positive injection drug users undergoing methadone treatment in Taiwan

AIMS

The study aims were to investigate adherence to methadone maintenance treatment (MMT) and to identify associated clinical factors in patients who inject drugs diagnosed with human immunodeficiency virus (HIV) infection in Taiwan.

METHODS

Data were from the National Health Surveillance System on HIV and the National Drug Treatment System on MMT. HIV-positive people who inject drugs (HIVPWID) were defined as the study population. Information obtained included age, sex, education, marital status, employment, methadone dose, and date of diagnosis of HIV infection. Adherence was defined as taking methadone for the past 90, 180 and 365 days, then categorized as high (> 90%), moderate (51 to 90%), or low (<=50%) adherent respectively.

RESULTS

Of 1641 HIVPWID registered in the datasets from 2007 to 2012, 961 (58.56%) had received MMT. For HIVPWID evaluated at 90 days (n = 951), 271 (28.5%), 382 (40.2%), and 298 (31.3%) were classified as high, moderate, and low adherent respectively. For HIVPWID evaluated at 180 days (n = 936), 190 (20.3%), 349 (37.3%), and 397 (42.4%) were classified as high, moderate, and low adherent respectively. For HIVPWID evaluated at 365 days (n = 919), 133 (14.5%), 271 (29.5%), and 515 (56.0%) were classified as high, moderate, and low adherent respectively. After controlling for sociodemographics, results showed that methadone dose, location of MMT clinic, and date of HIV diagnosis were significantly associated with MMT adherence.

CONCLUSIONS

Study findings underscore the importance to MMT adherence of methadone dosage, early diagnosis of patient's HIV infection, and area of patient residence.