Behavioral Risk Factors for HIV Infection in Hospitalized Persons Who Co-use Stimulants and Opioids

Drug use and harm reduction practices of applicants to a public health vending machine service in Clark County, NV, 2021-2023

BACKGROUND

In 2017, Clark County, NV, implemented Public Health Vending Machines (PHVMs), an innovative approach to the dispensation of harm reduction supplies to persons who inject drugs (PWID), including sterile equipment and naloxone. Administrative data associated with PHVM operations can be valuable for understanding drug use behaviors among PWID. The current study examines the demographics and drug use profiles of PHVM registrants who completed the harm reduction survey between January 2021 to June 2023 with comparison to nation-wide trends.

METHODS

All registration forms for PHVM services in Clark County, NV, between 1/1/2021-6/30/2022 with a completed harm reduction survey were included for analysis. Descriptive statistics were used to characterize differences in applicant demographics as well as self-reported injection and non-injection drug use, risk behaviors, and interest in harm reduction services. Logistic regression models tested the association between types of injection drug use and overdose and risk behaviors.

RESULTS

A total of 637 PHVM applications with completed survey data were included for analysis. Respondents were an average of 36.1 ± 10.2 years old, 56.3% male sex, and 63.6% non-Hispanic White with 85.1% reporting injection drug use (IDU). Notably, greater proportions of respondents with histories of IDU also indicated non-injection drug administration, such as smoking and snorting. In the 3 months prior to registration, the majority of IDU respondents reported high risk drug use behaviors, including daily use, multiple injections per day, and opioid and stimulant co-use. Fentanyl was suspected in 62.1% of overdoses in the last 3 months. Compared to PWID using stimulants only, respondents with opioid and stimulant co-use had a higher likelihood of overdose (aOR 4.51; 95% CI 2.05, 11.1; p < 0.001) and re-using injection supplies (aOR 2.14; 95% CI 1.33, 3.48; p = 0.002). More opioid and stimulant co-use respondents were interested in treatment/detox and obtaining naloxone than those without co-use.

CONCLUSIONS

The demographics and drug use behaviors of the PHVM PWID are consistent with contemporaneous county and nation-wide. As the overdose crisis evolves, PHVM could be pivotal tools in the early detection of new risks to facilitate timely adaptation of harm reduction strategies to improve morbidity and mortality.

Comparing the brief Holistic Health for HIV (3H+) to the Holistic Health Recovery Program (HHRP+) among people with HIV and opioid use disorder: Results from a randomized, controlled non-inferiority trial

Few evidence-based interventions have been widely adopted in common clinical settings, particularly for opioid-dependent people with HIV (PWH) seeking drug treatment. We developed a brief evidence-based intervention, Holistic Health for HIV (3H+), specifically for ease of implementation and integration within drug treatment settings. In this study, we compared 3H+ to the gold standard, Holistic Health Recovery Program (HHRP+) using a non-inferiority trial. Between 2012 and 2017, 106 participants were randomly assigned to either the brief 3H+ intervention or the gold standard HHRP+. HIV treatment (ART adherence, viral suppression) and risk behaviors (sharing injection equipment, condom use) were compared between the two arms at baseline, end-of-intervention (EOI-12 weeks) and at follow-up (24 weeks). Average treatment effect was calculated based on the difference-in-difference (DID) estimator and a non-parametric bootstrap was used to assess non-inferiority. At the 12-week EOI point, 3H+ was found to be non-inferior to HHRP+ with respect to multiple outcomes: percent sharing syringes and needles (DID:1.4, 95%CI [-18.6,21.5], p<0.01) and attainment of high ART adherence (DID: 9.7, 95%CI: [-13.1, 32.2], p = 0.04). At the 24-week EOI point, 3H+ was found to be non-inferior to HHRP+ with respect to percent sharing syringes and needles (DID: 8.9, [-10.1, 28.30], p = 0.04) and attainment of viral suppression (DID: 18.9, 95% CI:[-7.1, 42.0], p = 0.01). For other indicators, such as consistent condom use, the hypothesis test for non-inferiority was inconclusive at the 12-week EOI (DID: -20.2, 95%CI [-48.9-10.7], p = 0.51). For HIV treatment as prevention to be effective, PWH need to achieve viral suppression. In the absence of this success, they must reduce HIV risk behaviors. The finding that 3H+ was non-inferior to HHRP+ suggests that brief behavioral interventions can be deployed in real world settings to help more efficiently achieve Ending the HIV Epidemic goals.

Racial and Ethnic Disparities in HIV Testing in People Who Use Drugs Admitted to a Tertiary Care Hospital

Ending the HIV epidemic requires increased testing, diagnosis, and linkage to care. In the past 10 years, rates of HIV have increased among people with substance use disorder (SUD). HIV testing is recommended during hospitalization. Despite rising rates of infections and recommendations, HIV testing remains suboptimal. This study sought to detect differences in HIV testing by race and ethnicity in people who use drugs (PWUD) admitted to Tufts Medical Center (TuftsMC). This study is a retrospective review of hospitalized PWUD admitted from January 1, 2017 to December 31, 2020. PWUD were identified through toxicology results, medication prescribed for SUD, and nursing intake questions. The primary outcome of interest was whether an HIV test was ordered during hospitalization. The indicator of interest was race and ethnicity. Of 13,486 PWUD admitted to TuftsMC, only 10% had an HIV test ordered. Compared with White patients, Black patients [adjusted odds ratio (AOR): 0.69, 95% confidence interval (CI) (0.59-0.83)] and Hispanic patients [AOR: 0.68, 95% CI (0.55-0.84)] had decreased odds of receiving an HIV test. Our report is the first to show racial and ethnic differences in HIV testing ordering for hospitalized PWUD. Without access to harm reduction tools and expanded systems-based testing strategies, the HIV epidemic will continue and disproportionately impact minoritized communities.