Contingency Management Interventions for HIV, Tuberculosis, and Hepatitis Control Among Individuals With Substance Use Disorders: A Systematized Review

A novel, multi-component contingency management intervention in the context of a syndemic of drug-related harms in Glasgow, Scotland: First year of the 'WAND' initiative

Background

To address high levels of drug-related harms among people who inject drugs (PWID) in Glasgow, a novel contingency management intervention was developed to engage high-risk PWID with four harm reduction measures (known as the WAND initiative: Wound care, Assessment of injecting, Naloxone, and Dried blood-spot test). Our aims were to assess if WAND engaged and re-engaged high-risk PWID.

Methods

Baseline data of WAND participants (n = 831) from 1st Sept-2020 to 30th Aug-2021 were analysed. For those who took part in the first six months, extent of re-engagement was determined and, among those re-engaged, intervention coverage was compared between baseline and final engagement.

Results

Among those who first engaged in WAND from Sept 2020-Feb 2021 (n = 546), 40 % re-engaged by Aug 2021. Compared to those who engaged once (n = 321), those who re-engaged (n = 215) within one year had higher baseline prevalence of injecting risk behaviours such as injecting daily (56 % vs 64 %, p = 0.032), injecting away from home (42 % vs 52 %, p = 0.0179), injecting cocaine (56 % vs 75 %, p < 0.001), having an SSTI (40 % vs 60 %, p < 0.001), and been prescribed naloxone (57 % vs 72 %, p < 0.001). For those who re-engaged six months to one year after initial engagement (n = 107), there was a significant increase in having a BBV test in the last six months (61 % to 81 %, p = 0.003) and carrying naloxone (22 % to 32 %, p = 0.011).

Conclusion

WAND was able to engage and re-engage large numbers of high-risk PWID with multiple harm reduction initiatives. These findings suggest contingency management could be a useful tool for harm reduction services.

Implementing a pre-exposure prophylaxis (PrEP) promotion intervention among persons who inject drugs: Perspectives from community and research implementation partners

BACKGROUND

Clinical guidelines recommend pre-exposure prophylaxis (PrEP) to prevent HIV among persons who inject drugs (PWID), yet few are reached by this evidence-based intervention. To address this challenge, we are conducting a clinical trial to evaluate the impact of contingency management (CM) with stepped care to PrEP adherence and support services (PASS) among PWID. We sought to elicit perspectives from community- and research-based implementation partners on barriers and facilitators to implementing this intervention package as well as describe perspectives around evidence-based research practices in general.

METHODS

In October 2023, we conducted three focus groups with community-based site staff (n = 8), site leadership (n = 6), and research coordinators (n = 6) involved in delivering and implementing the intervention. The Promoting Action on Research Implementation in Health Service (PARIHS) implementation science framework construct (evidence, context, and facilitation opportunities) informed qualitative data collection and analysis.

RESULTS

Regarding evidence, focus group participants had a mix of previous experience or backgrounds in behavioral and interventional research with pre-existing research experience and embedded research infrastructure described as implementation facilitators. Participants described initially mixed views towards CM but became more positive as participants engaged in trial implementation. Regarding context within the community-based setting, focus group participants acknowledged challenges in promoting PrEP among PWID given competing social needs as well as individual and service priorities. Participants described turnover and burnout among staff delivering the intervention in addition to providing regular day-to-day services as major barriers to implementation. Regarding future intervention facilitation opportunities, participants suggested integrating interventional activities into off-site services like outreach as well as increasing the number of CM sessions. To facilitate site engagement and localized practice improvement, site leadership emphasized the need for consistent research team presence and detailed correspondence of results at the conclusion of research.

CONCLUSION

Focus group participants identified barriers and facilitators to implementing and sustaining CM-based PrEP promotion interventions within community-based settings. Efforts should be made to anticipate and address staff capacity and turnover when implementing HIV prevention interventions within community settings. Additionally, integrating CM-based PrEP promotion programs into off-site services and operations to reach PWID could be an opportunity to increase reach.

Integrated Stepped Alcohol Treatment With Contingency Management for Unhealthy Alcohol Use Among People With HIV: A Randomized Controlled Trial

BACKGROUND

We examined the impact of integrated stepped alcohol treatment with contingency management (ISAT + CM) on alcohol abstinence among people with HIV (PWH) and unhealthy alcohol use.

METHODS

In this multisite 24-week trial, we randomized PWH reporting untreated unhealthy alcohol use and with phosphatidylethanol (PEth) >20 ng/mL to receive ISAT+CM or treatment as usual (TAU). Intervention : Step 1 : Social worker-delivered CM; Step 2 : Addiction physician management plus motivational enhancement therapy. Participants were advanced to step 2 at week 12 if they lacked evidence of abstinence over the prior 21 days. TAU : Health handout, and for those who met criteria for alcohol use disorder, a referral to substance use treatment. Primary outcome: self-reported abstinence for the past 21 days at week 24.

RESULTS

We enrolled 120 PWH between January 5, 2018, and March 1, 2022. Mean age was 59 years, 96% were men, and 83% were Black. Eight percent were lost to follow-up. In the ISAT+CM group, 87% were advanced to Step 2. The posterior mean proportion of participants with self-reported abstinence at 24 weeks was higher among those randomized to ISAT+CM [posterior mean proportion 9% (95% credible interval [CrI]: 0%-33%)] compared with TAU [posterior mean proportion 0.3% (95% CrI: 0%-4%)] [posterior mean treatment effect 9%, (95% CrI: 0%-32%)], the posterior probability of TAU being superior to ISAT + CM was <0.0001.

DISCUSSION

ISAT + CM delivered in HIV clinics modestly increased self-reported 3-week abstinence among PWH. Our findings indicate a need for more effective treatments to promote abstinence and a potential role for ISAT + CM for reductions in alcohol use.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT03089320).

Optimizing variables for contingency management among infant caregivers using a simulated purchase task

Behavioral economics offers a framework for understanding choice making around public health concerns such as drug use and distracted driving. Such a framework could be beneficial to understanding caregiver choices related to arranging an infant sleep environment. Nonadherence to infant sleep safety guidelines provided by the American Academy of Pediatrics increases the risk of sleep-related infant deaths. The present study adopted a willingness-to-accept purchase task procedure, used in previous research to evaluate variables that predict abstaining from consuming alcohol, to evaluate intention to adhere to recommendations for arranging a safe infant sleep environment. This analysis would inform contingency management incentive scales used to measure caregiver adherence following training caregivers to arrange an infant sleep environment and identify variables that might predict treatment engagement. The results identified incentive sizes, condition duration, and participant variables that predict caregiver adherence. The results can be applied to future investigations that train caregivers to arrange an infant sleep environment.

Readiness to implement contingency management to promote PrEP initiation and adherence among people who inject drugs: results from a multi-site implementation survey

BACKGROUND

Contingency management (CM), an incentive-based intervention to encourage target behaviors, effectively promotes medication adherence. However, efforts to extend CM to HIV pre-exposure prophylaxis (PrEP) have been lacking. As part of a randomized clinical trial to promote HIV Prevention among people who inject drugs (PWID), we examined the readiness of staff in community-based organizations serving PWID to implement CM for PrEP uptake and adherence in this population.

METHODS

From April to August 2022, we conducted a survey of staff from four community-based organizations providing HIV testing, harm reduction, and outreach services in the northeastern United States. We assessed knowledge and attitudes regarding PrEP for PWID on five-point Likert scales (e.g., Poor to Excellent, Not at all to Extremely). Using a modified version of the Contingency Management Beliefs Questionnaire, we assessed the degree to which attitudes about CM for HIV prevention influenced interest in its adoption on a scale from "1-No influence at all" to "5-Very strong influence". We explored endorsement patterns, along with average values of individual items and subscale scores.

RESULTS

Among 271 staff invitations, 123 (45.4%) responded. The majority (88.6%) of respondents reported prior PrEP awareness, with a mean self-rated knowledge of 2.98 out of 5 (SD = 1.1). Attitudes towards PrEP, including its relevance to and importance for clients (both means = 4.3), efficacy (mean = 4.5), and safety (mean = 4.2), were positive. Items related to practicality and confidence in providing PrEP-related care had relatively lower ratings. Respondents endorsed influential generalized (mean = 2.1) and training-related (mean = 2.5) CM implementation barriers less frequently than positive attitudes towards CM (mean = 3.6). Staff favored adding CM to existing services (mean = 3.8), and highly endorsed it as "useful for targeting HIV prevention with PrEP" (mean = 3.7).

CONCLUSIONS

Respondents generally supported the use of CM to promote HIV prevention among PWID and favored adding it to their existing services. Though respondents understood the value of both PrEP and CM to support HIV prevention activities, findings corroborate research citing relative lack of knowledge and confidence regarding PrEP management among clients, potentially detracting from implementation readiness.

TRIAL REGISTRATION NUMBER

NCT04738825.

Continuous care engagement in clinical practice: perspectives on selected current strategies for people with HIV in the United States

INTRODUCTION

Modern antiretroviral therapy is associated with reduced rates of HIV-related morbidity and mortality. HIV viral suppression and retention in care are critically important outcomes requiring successful continuous patient engagement. However, barriers to such engagement are complex and require innovative solutions.

AREAS COVERED

A multistakeholder group of experts comprising clinicians and service delivery researchers assembled to clarify what constitutes engagement in HIV care and identify overarching themes that inform strategies in this field. This article captures this expert opinion and adds relevant literature on selected current best practices.

EXPERT OPINION

The multistakeholder group felt strongly that a better understanding of the facilitators of continuous care engagement was critical. Unlike 'retention in care,' 'engagement in care' for an individual is nuanced, flexible, evolves and requires ongoing communication between patients, providers, and other key stakeholders. The following approaches highlight care engagement strategies at different stakeholder levels: 1) patient-level: personalized care and incentivization; 2) clinic-level: wraparound, co-localized, patient-centered low-barrier care, a diverse multidisciplinary team, patient support networks, and expanded use of telemedicine; 3) healthcare system-level: utilization of external partnerships. We propose a series of diverse and complementary approaches based on a more nuanced understanding of the qualitative aspects of engagement in care.

Impact of the COVID-19 Pandemic on HIV Test Uptake Among People Who Inject Drugs in the Context of an HIV Outbreak

Glasgow, Scotland's largest city, has been experiencing an HIV outbreak among people who inject drugs (PWID) since 2015. A key focus of the public health response has been to increase HIV testing among those at risk of infection. Our aim was to assess the impact of COVID-19 on HIV testing among PWID in Glasgow. HIV test uptake in the last 12 months was quantified among: (1) PWID recruited in six Needle Exchange Surveillance Initiative (NESI) surveys (n = 6110); linked laboratory data for (2) people prescribed opioid agonist therapy (OAT) (n = 14,527) and (3) people hospitalised for an injecting-related hospital admission (IRHA) (n = 12,621) across four time periods: pre-outbreak (2010-2014); early-outbreak (2015-2016); ongoing-outbreak (2017-2019); and COVID-19 (2020-June 21). From the pre to ongoing period, HIV testing increased: the highest among people recruited in NESI (from 28% to 56%) and on OAT (from 17% to 54%) while the lowest was among people with an IRHA (from 15% to 42%). From the ongoing to the COVID-19 period, HIV testing decreased markedly among people prescribed OAT, from 54% to 37% (aOR 0.50, 95% CI 0.48-0.53), but increased marginally among people with an IRHA from 42% to 47% (aOR 1.19, 95% CI 1.08-1.31). In conclusion, progress in increasing testing in response to the HIV outbreak has been eroded by COVID-19. Adoption of a linked data approach could be warranted in other settings to inform efforts to eliminate HIV transmission.

The IMPACT (Infection Management Plus Addiction Care Together) Pilot: A Case Series of Combined Contingency Management for Substance Use Disorders and Antibiotic Adherence in the Hospital Setting

OBJECTIVES

Psychostimulant-related mortality is rising alongside increasing substance use-related hospitalizations, which are commonly complicated by patient-directed (or "against medical advice") discharges. Contingency management (CM) is an underused evidence-based treatment for substance use disorders with proven efficacy to support medication adherence. Our objective was to describe feasibility and preliminary effectiveness of a novel CM intervention incentivizing both drug use reduction and antibiotic adherence in the hospital setting.

METHODS

We conducted a pilot intervention of twice weekly CM for stimulant and/or opioid use disorder and antibiotic adherence conducted on inpatient wards and/or an embedded skilled nursing facility in an urban public hospital. Based on point-of-care urine drug test results and objective antibiotic adherence review, participants earned increasing opportunities to receive incentives. We measured feasibility via number of visits attempted and cost of gift cards dispensed. We evaluated effectiveness via antibiotic completion, discharge type, and participant perception of intervention effectiveness collected via structured survey.

RESULTS

Of 13 participants enrolled, most had opioid use disorder (fentanyl in 10/13) and stimulant use disorder (methamphetamine in 7/13). Almost all were receiving treatment for osteomyelitis and/or endocarditis (12/13). Feasibility challenges included competing demands of acute care with variable range of completed visits per participant (1-12 visits). Despite this, antibiotic completion was high (92%, 12/13 participants) with only two patient-directed discharges. Participants described CM as very effective in aiding infection treatment but had greater variability in beliefs regarding CM facilitation of reduced drug use.

CONCLUSIONS

Providing CM in the hospital setting may represent an effective approach to improving health outcomes by increasing antibiotic adherence and addressing substance use.

Can Contingency Management Solve the Problem of Adherence to Antiretroviral Therapy in Drug-Dependent Individuals?

Drug misuse among people living with HIV (human immunodeficiency virus) is associated with higher mortality. It is a frequently observed reason for treatment abandonment, with people who misuse drugs showing a 10 to 25 times higher risk of HIV than the general population. The authors conducted a systematic review and meta-analysis to assess the efficacy of contingency management (CM) to improve adherence to antiretroviral therapy in people living with HIV and substance use disorder (SUD). The inclusion criteria consisted of studies written in English, Italian, Spanish, German, and French; studies conducted with humans; and clinical trials that combined SUD treatment with CM for people living with HIV. Two hundred twenty-two articles were identified, five met all inclusion criteria, and three provided enough data to perform the meta-analysis. We considered treatment adherence by measuring the increase in the CD4 count as our primary outcome. We found a significant increase in treatment adherence in the patient group compared with the control groups during the intervention phase. Positive findings did not persist after the cessation of the incentives. The meta-analysis showed that the intervention improved patient adherence by 2.69 (95% confidence interval: [0.08, 0.51]; p = .007) compared with the control group during the intervention period. All short-term CM studies converged on a positive result for adherence to antiretroviral therapy.

Promoting HIV care continuum outcomes among people who use drugs and alcohol: a systematic review of randomized trials evaluating behavioral HIV care interventions published from 2011 to 2023

BACKGROUND

Substance use remains a robust predictor of HIV infection and a serious impediment to HIV care continuum progression for people living with HIV. The primary research question of this systematic review is focused on understanding the extent to which behavioral HIV care interventions have been efficacious in helping people who live with HIV and who use substances along the HIV care continuum.

METHODS

Using PubMed and ProQuest databases, we performed a systematic review of randomized trials of behavioral HIV care continuum interventions among people who use substances published from 2011 to August 2023, since the beginning of the treatment-as-prevention era.

RESULTS

We identified 11 studies (total participants: N = 5635), ten intentionally targeting substance-using populations. Four studies involved samples using ≥ 1 substance (e.g., alcohol, opioids, stimulants, marijuana); four involved injection drug use; one involved methamphetamine use; and one involved alcohol use. One study targeted a population with incidental substance use (i.e., alcohol, injection drug use, non-injection drug use reported in most participants). Each study defined one or more HIV care outcomes of interest. Viral suppression was an outcome targeted in 9/11 studies, followed by uptake of antiretroviral therapy (ART; 7/11), ART adherence (6/11), retention in care (5/11), and linkage to care (3/11). While most (nine) of the studies found significant effects on at least one HIV care outcome, findings were mostly mixed. Mediated (2/11) and moderated (2/11) effects were minimally examined.

CONCLUSIONS

The results from this systematic review demonstrate mixed findings concerning the efficacy of previous HIV care interventions to improve HIV care continuum outcomes among people who use substances. However, heterogeneity of study components (e.g., diversity of substances used/assessed, self-report vs. objective measures, attrition) prevent broad deductions or conclusions about the amenability of specific substance-using populations to HIV care intervention. More coordinated, comprehensive, and targeted efforts are needed to promote and disentangle intervention effects on HIV care continuum outcomes among substance-using populations.

Behavior change, health, and health disparities 2023: Contingency management for treating substance use disorders and promoting health in vulnerable populations

This Special Issue (SI) of Preventive Medicine is the 10th in a series on behavior change, health, and health disparities. This issue focuses on Contingency Management (CM), a highly efficacious behavior-change intervention for substance use disorders (SUDs) and other behavioral health conditions wherein patients receive material incentives (e.g., vouchers exchangeable for retail items) contingent on objectively verified behavior change. Despite substantial support for its efficacy, CM remains largely unavailable in U.S. community SUD treatment facilities and other healthcare settings. This is especially concerning regarding stimulant use disorder for which CM is the only reliably efficacious intervention in controlled studies and yet is unavailable to the vast majority of those in need. This SI details recent promising developments in efforts to surmount longstanding implementation obstacles while also detailing other promising advances from meta-analyses and controlled trials examining CM's efficacy in treating other difficult-to-treat problems including smoking among pregnant women and mothers of young children as well among those as those experiencing homelessness and alcohol use disorder, the promise of digital CM, and a potential new application in promoting adherence with SUD medications.

Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT

Background

Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed.

Objectives

To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption.

Design

Multicentre, three-arm, parallel-group, randomised controlled clinical trial.

Setting

Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands).

Participants

Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate.

Interventions

(1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation.

Main outcome measures

Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule.

Results

Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported.

Limitations

The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted.

Conclusions

Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate.

Future work

Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence.

Trial registration

This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.

Perspectives on contingency management for alcohol use and alcohol-associated conditions among people in care with HIV

BACKGROUND

Contingency management (CM) is an evidence-based approach for reducing alcohol use; however, its implementation into routine HIV primary care-based settings has been limited. We evaluated perspectives on implementing CM to address unhealthy alcohol use and associated conditions for people with HIV in primary care settings.

METHODS

From May 2021 to August 2021, we conducted two focus groups with staff involved in delivering the intervention (n = 5 Social Workers and n = 4 Research Coordinators) and individual interviews (n = 13) with a subset of participants involved in the multi-site Financial Incentives, Randomization, and Stepped Treatment (FIRST) trial. Qualitative data collection and analyses were informed by the Promoting Action on Research Implementation in Health Service (PARIHS) implementation science framework, including evidence (perception of CM), context (HIV primary care clinic and CM procedures), and facilitation (feasibility outside the research setting).

RESULTS

Several major themes were identified. Regarding the evidence, participants lacked prior experience with CM, but the intervention was well received and, by some, perceived to lead to lasting behavior change. Regarding the clinical context for the reward schedule, the use of biochemical testing, specifically fingerstick phosphatidylethanol testing, and the reward process were perceived to be engaging and gratifying for both staff and patients. Participants indicated that the intervention was enhanced by its co-location within the HIV clinic. Regarding facilitation, participants suggested addressing the intervention's feasibility for non-research use, simplifying the reward structure, and rewarding non-abstinence in alcohol use.

CONCLUSIONS

Among patients and staff involved in a clinical trial, CM was viewed as a helpful, positive, and feasible approach to addressing unhealthy alcohol use and related conditions. To enhance implementation, future efforts may consider simplified approaches to the reward structure and expanding rewards to non-abstinent reductions in alcohol consumption.

Contingency management with stepped care for unhealthy alcohol use among individuals with HIV: Protocol for a randomized controlled trial

BACKGROUND

Although unhealthy alcohol use is associated with increased morbidity and mortality among people with HIV (PWH), many are ambivalent about engaging in treatment and experience variable responses to treatment. We describe the rationale, aims, and study design for the Financial Incentives, Randomization, with Stepped Treatment (FIRST) Trial, a multi-site randomized controlled efficacy trial.

METHODS

PWH in care recruited from clinics across the United States who reported unhealthy alcohol use, had a phosphatidylethanol (PEth) >20 ng/mL, and were not engaged in formal alcohol treatment were randomized to integrated contingency management with stepped care versus treatment as usual. The intervention involved two steps; Step 1: Contingency management (n = 5 sessions) with potential rewards based on 1) short-term abstinence; 2) longer-term abstinence; and 3) completion of healthy activities to promote progress in addressing alcohol consumption or conditions potentially impacted by alcohol; Step 2: Addiction physician management (n = 6 sessions) plus motivational enhancement therapy (n = 4 sessions). Participants' treatment was stepped up at week 12 if they lacked evidence of longer-term abstinence. Primary outcome was abstinence at week 24. Secondary outcomes included alcohol consumption (assessed by TLFB and PEth) and the Veterans Aging Cohort Study (VACS) Index 2.0 scores; exploratory outcomes included progress in addressing medical conditions potentially impacted by alcohol. Protocol adaptations due to the COVID-19 pandemic are described.

CONCLUSIONS

The FIRST Trial is anticipated to yield insights on the feasibility and preliminary efficacy of integrated contingency management with stepped care to address unhealthy alcohol use among PWH.

CLINICALTRIALS

gov identifier: NCT03089320.

Preliminary Efficacy of a Theory-Informed Intervention to Increase COVID-19 Testing Uptake Among People Who Inject Drugs in San Diego County: Findings From a Pilot Randomized Controlled Trial

BACKGROUND

People who inject drugs (PWID) have low rates of COVID-19 testing yet are vulnerable to severe disease. In partnership with a mobile syringe service program (SSP) in San Diego County, CA, we developed the evidence-, community-, and Social Cognitive Theory-informed "LinkUP" intervention (tailored education, motivational interviewing, problem-solving, and planning) to increase COVID-19 testing uptake among PWID.

PURPOSE

To assess preliminary efficacy of LinkUP in increasing PWID COVID-19 testing in a pilot randomized controlled trial (RCT).

METHODS

We referred participants (PWID, ≥18 years old, San Diego County residents who had not recently undergone voluntary COVID-19 testing) to mobile SSP sites that had been randomized (by week) to offer the active LinkUP intervention or didactic attention-control conditions delivered by trained peer counselors. Following either condition, counselors offered on-site rapid COVID-19 antigen testing. Analyses estimated preliminary intervention efficacy and explored potential moderation.

RESULTS

Among 150 participants, median age was 40.5 years, 33.3% identified as Hispanic/Latinx, 64.7% were male, 73.3% were experiencing homelessness, and 44.7% had prior mandatory COVID-19 testing. The LinkUP intervention was significantly associated with higher COVID-19 testing uptake (p < .0001). Homelessness moderated intervention effects; LinkUP increased COVID-19 testing uptake more among participants experiencing homelessness (adjusted risk ratio [aRR]: 1.80; 95% CI: 1.56-2.09; p < .0001) than those not experiencing homelessness (aRR: 1.20; 95% CI: 1.01-1.43; p = .04).

CONCLUSIONS

Findings from this pilot RCT support the preliminary efficacy of the "LinkUP" intervention to increase COVID-19 testing among PWID and underscore the importance of academic-community partnerships and prevention service delivery through SSPs and other community-based organizations serving vulnerable populations.

Contingency Management and Pre-Exposure Prophylaxis Adherence Support Services (CoMPASS): A hybrid type 1 effectiveness-implementation study to promote HIV risk reduction among people who inject drugs

BACKGROUND

HIV disproportionally affects persons who inject drugs (PWID), but engagement with HIV pre-exposure prophylaxis (PrEP) is low. We describe the rationale and study design for a new study, "Contingency Management and Pre-Exposure Prophylaxis (PrEP) Adherence Support Services (CoMPASS)," a hybrid type 1 effectiveness-implementation trial to promote HIV risk reduction among PWID.

METHODS

In four community-based programs in the northeastern United States, PrEP-eligible PWID (target n = 526) are randomized to treatment as usual or Contingency Management (CM) and, as indicated, stepped up to PrEP Adherence Support Services (CoMPASS) over 24 weeks. During CM sessions, participants receive timely tangible rewards for verifiable activities demonstrating 1) PrEP initiation and adherence, and 2) engagement with medications for opioid use disorder (MOUD) and other OUD-related care. Participants who do not have high levels of biomarker-confirmed PrEP adherence at week 12 will be stepped up to receive PrEP Adherence Support Services (PASS) consisting of strengths-based case management over 12 weeks. Interventions are delivered by trained PrEP navigators, staff embedded within the respective sites. The primary outcome is sustained PrEP adherence by dried blood spot testing at 24 weeks. To inform future implementation, we are conducting implementation-focused process evaluations throughout the clinical trial.

CONCLUSIONS

Results from this protocol are anticipated to yield novel findings regarding the impact and scalability of CoMPASS to promote HIV prevention among PWID in partnership with community-based organizations. http://ClinicalTrials.gov identifier: NCT04738825.

Unhealthy Alcohol Use Is Associated With Suboptimal Adherence to Isoniazid Preventive Therapy in Persons With HIV in Southwestern Uganda

BACKGROUND

Unhealthy alcohol use is associated with increased progression to tuberculosis (TB) disease, but its effect on adherence to isoniazid (INH) preventive therapy is not known.

METHODS

This was a prospective study of persons with HIV with latent TB in southwestern Uganda reporting any current (previous 3 months) alcohol use or no alcohol consumption in the previous year (2:1 ratio). All received INH. We defined suboptimal adherence as <90% of days with at least 1 Medication Event Monitoring System cap opening, over the previous 90 days. Alcohol use was categorized as follows: none: no self-report and phosphatidylethanol (PEth) <8 ng/mL; moderate: Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) 1-2 (women) or 1-3 (men) and/or PEth 8 ≥ 50 ng/mL; and unhealthy: AUDIT-C ≥3 (women) or ≥4 (men) and/or PEth ≥50 ng/mL. We used generalized estimating equation logistic regression analyses to assess the association between the level of alcohol use and suboptimal INH adherence.

RESULTS

Three hundred two persons were enrolled; 279 were on INH for 3 or more months. The prevalence of suboptimal INH adherence was 31.3% at 3 months and 43.9% at 6 months. The odds of suboptimal INH adherence were higher for unhealthy (adjusted odds ratio, 2.78; 95% confidence interval: 1.62 to 4.76) and moderate (adjusted odds ratio, 1.59; 95% confidence interval: 0.94 to 2.71) compared with no alcohol consumption.

CONCLUSIONS

Suboptimal adherence to INH at 3 and 6 months was high among prospective study of persons with HIV and associated with unhealthy alcohol use. Adherence support and alcohol reduction strategies are needed for this group at high risk for active TB.

SEROPREVALENCE OF HBsAg, Anti-HBs, Anti-HCV, and Anti-HIV IN PATIENTS WITH ALCOHOL AND SUBSTANCE ABUSE IN AN AMATEM CLINIC IN EASTERN TURKIYE: A SIX-YEAR RETROSPECTIVE EVALUATION

Aim Substance abuse and concomitant infections are important causes of morbidity and mortality. Yet, the number of epidemiological studies regarding infectious diseases in people with substance abuse are limited in our country. In this study, the aim was to investigate the frequency of illegal alcohol and substance use in an Alcohol and Drug Research, Treatment and Training Centres (AMATEM) clinic in Turkey as well as the HBsAg, anti-HBs, anti-HCV, and anti-HIV parameters between the years of 2016-2021. Material and Method HBsAg, anti-HBs, anti-HCV, and anti-HIV tests were conducted using the ELISA technique in 6881 alcohol and substance use disorder (ASUD). Urine samples from ASUD’s were analyzed for alcohol, cannabis, and cocaine metabolites. The results were evaluated retrospectively. Results All of the 6881 ASUD’s were male with a mean age of 32.18±9.66 years. Of the 6881 ASUD’s included in the study, 4107 (59.7%) were opioid addicts; 1479 (21.5%) were mixed drug addicts; 897 (13%) were alcohol addicts; and the rest were addicts with other types of substance use. The mean age of the alcohol users was 45.33±13.03 and the mean age of opioid users was 29.90±7.13. The percentage of opioid addiction in 2016 was 71.2% which dropped to 28.7% in 2021. Meanwhile, the percentage of alcohol addiction was 13.6% in 2016 and increased to 21.4% in 2021; and the percentage of mixed drug use was 8.7% in 2016 and increased to 36.8% in 2021. HBsAg-positivity in opioid users (56.7%) was higher compared to cannabis users (2.6%) and mixed drug users (22.3%). Anti-HCV positivity of opioid users (69.4%) was found to be higher compared to alcohol (9.4%), cannabis (2%), and mixed drug (16.2%) users, and this finding was statistically significant (p=0.0001). Anti-HBs positivity of opioid users (63.1%) was found to be higher compared to alcohol (9.9%), cannabis (3%), and mixed drug (21%) users, and this finding was statistically significant (p=0.0001). Anti-HIV was determined negative in all ASUD’s. The highest rates of HBsAg, anti-HCV and anti-HBs positivity were found in the 26-30 years of age. Conclusion These findings indicate a high prevalence of intravenous substance abuse in the 26-30 years age group in our region as well as the high HBV and HCV rates in this patient group.

Use of financial incentives to increase adult vaccination coverage: A narrative review of lessons learned from COVID-19 and other adult vaccination efforts

To encourage COVID-19 vaccination, governments have offered a wide range of incentives to their populations ranging from cash to cows. Often these programs were rolled out at scale before assessing potential effectiveness. To inform future policy, we conducted a narrative review to understand the evidence base informing these programs and the extent to which they are effective. While we found evidence on cash transfers increasing both the coverage and intention to be vaccinated for COVID-19 and other adult vaccines, improvements in coverage were limited. With mixed evidence, lottery programs did not appear to have a consistent meaningful impact on vaccination for COVID-19, and no evidence was identified on the positive effects of other non-cash incentives for COVID-19 or other adult vaccines. We conclude that the impact of cash transfers in incentivizing adult vaccination is marginal and their effectiveness in addressing vaccine hesitancy remains inconclusive.

Willingness of people who inject drugs to participate in a randomised controlled trial involving financial incentives to initiate hepatitis C treatment

BACKGROUND

Evidence regarding the acceptability of contingency management is limited. We investigated the willingness of people who inject drugs to participate in a randomised controlled trial (RCT) involving financial incentives to initiate HCV treatment.

METHODS

ETHOS Engage is an observational cohort study of people with a history of injecting drug use who either injected in the past six months or receive opioid agonist therapy (OAT) in Australia. We assessed willingness to participate in a RCT with financial incentives and factors associated with preference for entire incentive ($60) at first clinic visit versus delayed incentive with logistic regression.

RESULTS

93% (593/635) of eligible participants agreed to participate in an RCT with financial incentives of which 24% were Aboriginal or Torres Strait Islander, 84% had completed secondary school, and 59% injected drugs in the prior month. Willingness to participate in an RCT increased by amount offered: unspecified (72%), $20 (75%), $60 (80%), and $100 (85%). The preferred incentive distribution method over three clinical visits was entire incentive at first clinical visit (32%). Among those with a preferred distribution method (n = 369), factors associated with entire incentive at first clinic visit were being Aboriginal or Torres Strait Islander (aOR 1.75; 95% CI 1.05-2.94), completion of secondary school (aOR 0.46; 95% CI 0.26-0.83) and mainly injected heroin in month prior (aOR 1.82; 95% CI 1.03-3.20).

CONCLUSION

Most participants were willing to participate in an RCT involving financial incentives to initiate treatment but differed regarding distribution. Study findings inform implementation of incentives in clinical practice.

Contingency Management and SARS-CoV-2 Testing Among People Who Inject Drugs

OBJECTIVES

People who inject drugs (PWID) are especially vulnerable to morbidity and mortality as a result of SARS-CoV-2 infection because of social and physical health vulnerabilities. Routine testing for SARS-CoV-2 is critical to reduce transmission. Contingency management-the provision of tangible rewards to reinforce positive behavior-can promote the use of health services among PWID. Evidence is scarce on the utility of contingency management to promote SARS-CoV-2 testing. The objective of this study was to evaluate the effectiveness of contingency management to increase testing among PWID.

METHODS

SARS-CoV-2 testing was implemented at 9 syringe exchange program sites in partnership with an Oregon-based nonprofit organization for 5 weeks without contingency management and for 6 weeks with contingency management (a $10 financial incentive for testing) from February 1 through mid-April 2021. We measured rates of testing among syringe exchange program clients before and after implementation of contingency management.

RESULTS

Before contingency management, SARS-CoV-2 testing occurred during approximately 131 of 1410 (9.3%) client encounters, and 123 of 997 (12.3%) unique clients were tested. During contingency management, testing occurred during approximately 571 of 1756 (32.5%) client encounters, and 407 of 1151 (35.4%) unique clients were tested. Rates of testing increased from 0.04 (SD, 0.04) before contingency management implementation to 0.25 (SD, 0.15) after implementation (t₈ = -3.88; P = .005; Cohen d = 1.46).

CONCLUSIONS

Contingency management facilitated uptake of SARS-CoV-2 testing among PWID. Contingency management may be an effective strategy for improving communicable disease testing beyond testing for SARS-CoV-2 and for improving vaccine uptake among PWID and warrants additional research.

A SMARTTT approach to Treating Tobacco use disorder in persons with HIV (SMARTTT): Rationale and design for a hybrid type 1 effectiveness-implementation study

BACKGROUND

Tobacco use disorder is a leading threat to the health of persons with HIV (PWH) on antiretroviral treatment and identifying optimal treatment approaches to promote abstinence is critical. We describe the rationale, aims, and design for a new study, "A SMART Approach to Treating Tobacco Use Disorder in Persons with HIV (SMARTTT)," a sequential multiple assignment randomized trial.

METHODS

In HIV clinics within three health systems in the northeastern United States, PWH with tobacco use disorder are randomized to nicotine replacement therapy (NRT) with or without contingency management (NRT vs. NRT + CM). Participants with response (defined as exhaled carbon monoxide (eCO)-confirmed smoking abstinence at week 12), continue the same treatment for another 12 weeks. Participants with non-response, are re-randomized to either switch medications from NRT to varenicline or intensify treatment to a higher CM reward schedule. Interventions are delivered by clinical pharmacists embedded in HIV clinics. The primary outcome is eCO-confirmed smoking abstinence; secondary outcomes include CD4 cell count, HIV viral load suppression, and the Veterans Aging Cohort Study (VACS) Index 2.0 score (a validated measure of morbidity and mortality based on laboratory data). Consistent with a hybrid type 1 effectiveness-implementation design and grounded in implementation science frameworks, we will conduct an implementation-focused process evaluation in parallel. Study protocol adaptations related to the COVID-19 pandemic have been made.

CONCLUSIONS

SMARTTT is expected to generate novel findings regarding the impact, cost, and implementation of an adaptive clinical pharmacist-delivered intervention involving medications and CM to promote smoking abstinence among PWH. ClinicalTrials.govidentifier:NCT04490057.

Evaluation of the scale-up of HIV testing among people who inject drugs in Scotland in the context of an ongoing HIV outbreak

BACKGROUND

A large outbreak of HIV among people who inject drugs (PWID) has been ongoing in Glasgow city centre (GCC), Scotland since early 2015. The outbreak is associated with high levels of homelessness, cocaine injecting and injecting in public places. A key component of the public health response was the scale-up of HIV testing in a range of services engaged with PWID. Our aims were to: 1) evaluate the extent of and change in HIV testing over the course of the outbreak and 2) examine factors associated with reporting an HIV test.

METHODS

Self-report of an HIV test in the last 12 months was collected for 15,081 PWID interviewed in six national cross-sectional bio-behavioural surveys during 2008-2018. Multi-variate logistic regression was undertaken to determine trends in HIV testing by region of recruitment (GCC; rest of Glasgow; other Scottish city centres (SCC); and rest of Scotland) and outbreak period (pre: 2008-14; early: 2015-16; ongoing: 2017-18).

RESULTS

HIV testing increased across all regions and was most pronounced in GCC comparing the ongoing (67%) to the pre-outbreak period (33%) (aOR=4.68, 95% CI 3.23 to 6.77, p<0.001). However, compared to other SCCs pre-outbreak (with 46% reporting testing), those recruited in GCC had a lower odds of HIV testing early outbreak (aOR=0.37, 95% CI 0.27 to 0.54, p<0.001) and more modest increased odds in the ongoing outbreak period (aOR=1.41, 95% CI 0.97 to 2.05, p=0.069). Among PWID recruited in the whole of Glasgow in the ongoing phase, reporting an HIV test was associated with injecting cocaine or in public places (aOR=2.20, 95% CI 1.53 to 3.17, p<0.001), receipt of methadone (aOR=1.48, 95% CI 1.01 to 2.17, p=0.042) and incarceration in the last year (aOR=1.72, 95% CI 1.18 to 2.51, p=0.004).

CONCLUSIONS

Relatively low levels of HIV testing pre- and early-outbreak likely hindered efforts to control the spread of infection among PWID in Glasgow. Uptake has since increased with expansion of testing across multiple settings, particularly among those at high risk of infection. Further effort is needed to ensure the vast majority of PWID are regularly tested, not just in the epicentre of the outbreak but in other areas with low population prevalence of infection.

Looking to the empirical literature on the potential for financial incentives to enhance adherence with COVID-19 vaccination

COVID-19 vaccination efforts are underway offering hope for saving lives and eliminating the pandemic. The most promising vaccines require two injections separated 3-4 weeks apart. To achieve heard immunity, 70-90% of the population or perhaps more must be inoculated. Anticipation of adherence challenges has generated commentaries on strategies to enhance adherence including financial incentives. A notable gap in these commentaries is any discussion of the scientific evidence regarding the efficacy of financial incentives for increasing vaccine adherence. This commentary addresses that gap. There is a body of controlled trials on incentivizing vaccine adherence, mostly to the hepatitis B virus (HBV) vaccine among injection drug users (IDUs). Prevalence of HBV infection is increasing as part of the opioid addiction crisis. The HBV vaccine entails a three-dose regimen (typically 0, 1, and 6 months) which has created adherence challenges among IDUs. Systematic literature reviews document significant benefit of financial incentives. For example, a 2019 meta-analysis (Tressler & Bhandari, 2019) examined 11 controlled trials examining HBV-vaccine adherence strategies, including financial incentives, accelerated dosing schedules, and case-management/enhanced services. Financial incentives were most effective resulting in a 7-fold increase in adherence to the vaccination regimen relative to no financial incentives (OR, 7.01; 95% CI, 2.88-17.06). Additional reviews provide further support for the efficacy of financial incentives for promoting adherence with vaccination (HBV & influenza). Overall, this literature suggests that financial incentives could be helpful in promoting the high levels of adherence to COVID-19 vaccines that experts project will be necessary for herd immunity.

Self-efficacy as a mediator of patient navigation interventions to engage persons living with HIV and substance use

BACKGROUND

People living with HIV who report substance use (PLWH-SU) face many barriers to care, resulting in an increased risk for poor health outcomes and the potential for ongoing disease transmission. This study evaluates the mechanisms by which Patient Navigation (PN) and Contingency Management (CM) interventions may work to address barriers to care and improve HIV outcomes in this population.

METHODS

Mediation analysis was conducted using data from a randomized, multi-site trial testing PN interventions to improve HIV care outcomes among 801 hospitalized PLHW-SU. Direct and indirect effects of PN and PN + CM were evaluated through five potential mediators-psychosocial conditions, healthcare avoidance, financial hardship, system barriers, and self-efficacy for HIV treatment adherence-on engagement in HIV care and viral suppression.

RESULTS

The PN + CM intervention had an indirect effect on improving engagement in HIV care at 6 months by increasing self-efficacy for HIV treatment adherence (β = 0.042, 95% CI = 0.008, 0.086). PN + CM also led to increases in viral suppression at 6 months (β = 0.090, 95% CI = 0.023, 0.168) and 12 months (β = 0.069, 95% CI = 0.009, 0.129) via increases in self-efficacy, although the direct effects were not significant. No mediating effects were observed for PN alone.

CONCLUSION

PN + CM interventions for PLWH-SU can increase an individual's self-efficacy for HIV treatment adherence, which in turn improves engagement in care at 6 months and may contribute to viral suppression over 12 months. Building self-efficacy may be a key factor in the success of such interventions and should be considered as a primary goal of PN + CM in practice.

Increasing Prenatal Care Compliance in At-Risk Black Women: Findings from a RCT of Patient Navigation and Behavioral Incentives

BACKGROUND

In the USA, infant mortality remains a major public health concern, particularly for Black women and their infants who continue to experience disproportionately high mortality rates. Prenatal care is a key determinant of infant health, with inadequate prenatal care increasing risk for prematurity, stillbirth, neonatal loss, and infant death. The aim of the present study was to determine if concurrent delivery of patient navigation and behavioral incentives to at-risk Black pregnant women could improve prenatal care attendance and associated maternal and infant outcomes.

METHODS

Participants were 150 Black pregnant women recruited at first prenatal visit and screening at risk for adverse maternal and infant outcomes. Women were randomized to either the patient navigation + behavioral incentives intervention (PNBI) or assessment + standard care control (ASC) group. All were followed throughout pregnancy and 12-week postpartum. Group comparisons were made using intention-to-treat and per-protocol sensitivity analyses.

RESULTS

While no group differences were found in prenatal care visits, the average number of visits for both groups (9.3 for PNBI and 8.9 for ASC) approached the American College of Obstetricians and Gynecologists (ACOG) recommended guidelines. There were also no group differences in maternal and infant outcomes. Both intention-to-treat and per-protocol sensitivity analyses, however, consistently found PNBI women attended more postpartum visits than ASC controls (p = 0.002).

CONCLUSIONS

Given ACOG's redefining of the postpartum period as the fourth trimester, study findings suggest PNBI may facilitate prevention and intervention efforts to more successfully reduce health disparities in outcomes for both mother and infant.

Contingency management for individuals with chronic health conditions: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Contingency management (CM) interventions involve providing reinforcement for engaging in a desired behavior, and have been shown to increase treatment adherence and promote abstinence in the treatment of substance use disorders. This review was conducted to systematically review the literature on the effectiveness of CM when applied to a range of medical conditions outside of substance use disorders.

METHOD

The authors identified a total of 24 randomized studies examining the effects of CM on four outcomes: weight change, physical activity, medication/device adherence, and viral load that were included in the qualitative summary, and 20 studies included in the meta-analysis.

RESULTS

CM was associated with positive outcomes for physical activity and medication/device adherence compared to control conditions. Findings with weight loss and viral load were more mixed, and evidence for publication bias was found for both outcomes. The effects of CM tend to dissipate when the contingency is removed. Heterogeneity was observed across most outcomes.

LIMITATIONS AND CONCLUSIONS

This review provides preliminary support for the use of CM in increasing physical activity and improving adherence to medication for chronic health conditions while reinforcement is ongoing. Future studies should examine potential moderators and identify strategies to maintain these changes over time.

Interest in reducing methamphetamine and opioid use among syringe services program participants in Washington State

BACKGROUND

Methamphetamine use is increasing, and opioid use remains elevated in the US. Understanding interest in reducing/stopping substance use among people who inject drugs (PWID), as well as types of help wanted, can inform interventions.

METHODS

Data from the 2019 Washington State Syringe Exchange Survey were used in logistic regression analyses to assess if demographics, substance use, and concern about anxiety or depression were associated with interest in reducing/stopping substance use among people whose main drug was methamphetamine or opioids. Types of help wanted to reduce/stop use are reported.

RESULTS

Of 583 participants included, 76 % reported opioids were their main drug, of whom 82 % were interested in reducing/stopping their opioid use. 24 % reported methamphetamine as their main drug, of whom 46 % were interested in reducing/stopping their methamphetamine use. Among those whose main drug was an opioid, female gender (AOR:2.19, p = .023) and concern about depression (AOR:3.04, p = .002) were associated with interest in reducing/stopping opioid use. Among participants whose main drug was methamphetamine, being in jail in the past year and having an infection likely related to injection (e.g., abscess) in the past year were associated with over twice the odds of interest in reducing/stopping methamphetamine use (AOR:2.14, p = .056 and 2.43, p = .052, respectively); however, these findings were not significant. Several types of help to reduce/stop use were endorsed.

CONCLUSION

There were high, though differing, levels of interest in reducing/stopping opioid or methamphetamine use and in a range of support services. PWID should be asked about interest in reducing/stopping use and provided appropriate support.

Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1

OBJECTIVES

We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care.

METHODS

We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis.

RESULTS

We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care.

CONCLUSIONS

Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.

COVID-19 and Substance Use Disorders: Recommendations to a Comprehensive Healthcare Response. An International Society of Addiction Medicine Practice and Policy Interest Group Position Paper

Coronavirus Disease 2019 (COVID-19) is escalating all over the world and has higher morbidities and mortalities in certain vulnerable populations. People Who Use Drugs (PWUD) are a marginalized and stigmatized group with weaker immunity responses, vulnerability to stress, poor health conditions, high-risk behaviors, and lower access to health care services. These conditions put them at a higher risk of COVID-19 infection and its complications. In this paper, an international group of experts on addiction medicine, infectious diseases, and disaster psychiatry explore the possible raised concerns in this issue and provide recommendations to manage the comorbidity of COVID-19 and Substance Use Disorder (SUD).

Effectiveness of interventions for reducing TB incidence in countries with low TB incidence: a systematic review of reviews

AIMS

What is the evidence base for the effectiveness of interventions to reduce tuberculosis (TB) incidence in countries which have low TB incidence?

METHODS

We conducted a systematic review of interventions for TB control and prevention relevant to low TB incidence settings (<10 cases per 100 000 population). Our analysis was stratified according to "direct" or "indirect" effects on TB incidence. Review quality was assessed using AMSTAR2 criteria. We summarised the strength of review level evidence for interventions as "sufficient", "tentative", "insufficient" or "no" using a framework based on the consistency of evidence within and between reviews.

RESULTS

We found sufficient review level evidence for direct effects on TB incidence/case prevention of vaccination and treatment of latent TB infection. We also found sufficient evidence of beneficial indirect effects attributable to drug susceptibility testing and adverse indirect effects (measured as sub-optimal treatment outcomes) in relation to use of standardised first-line drug regimens for isoniazid-resistant TB and intermittent dosing regimens. We found insufficient review level evidence for direct or indirect effects of interventions in other areas, including screening, adherence, multidrug-resistant TB, and healthcare-associated infection.

DISCUSSION

Our review has shown a need for stronger evidence to support expert opinion and country experience when formulating TB control policy.

Assessing the Use and Impact of Points and Rewards across Four Federal Probation Districts: A Contingency Management Approach

Contingency management (CM) is a well-acknowledged behavioral approach for incentivizing changes in behavior and attitudes. A version of CM was piloted in four federal probation districts to determine whether systematically awarding points and rewards for key behaviors could be implemented and impact recidivism rates. A case controlled match design was conducted with a CM sample (referred to as Justice Steps (JSTEPS)) (n=128) who were individually matched to a comparison sample (n=128) on six variables related to recidivism. Analyses compared the number of technical violations and new arrests between JSTEPS participants and a historical comparison sample. Using Kaplan-Meier survival analysis, results indicate JSTEPS sites using early CM rewarding strategies tend have delayed recidivism than others. A research agenda is outlined.

A systematic review of community-based interventions to improve oral chronic disease medication regimen adherence among individuals with substance use disorder

BACKGROUND

Poor medication adherence has been shown to cause medical complications, death, and increased healthcare costs and may be of particular importance in patients with substance use disorder (SUD). Concerns regarding adherence in this population may influence a healthcare provider's decision to prescribe a medication requiring high adherence. Guidance defining best practices that promote adherence among individuals with SUD is lacking.

METHODS

A review of English articles in Medline and PsycINFO databases, published between October 1, 1994 and October 31, 2017, was conducted in order to identify studies of interventions intended to improve adherence to oral chronic disease medication regimens among patients with SUD. Randomized controlled trials, quasi-experimental study designs, and case series were included. Article quality was assessed.

RESULTS

A total of 854 abstracts were retrieved, of which 24 met inclusion criteria. Adherence interventions were categorized as those: 1) addressing the chronic disease state; 2) addressing SUD; or 3) both. Studies varied greatly with respect to intervention length, method of measuring adherence, and quality. Statistically significant improvement in adherence was observed in 12 of 24 studies (50%). Specific interventions that improved adherence included incentive-based interventions, directly observed therapy, and telephonic/home visits. Counseling-based interventions such motivational interviewing and cognitive behavioral therapy presented mixed results.

CONCLUSIONS

While effective interventions were identified, heterogeneity of study designs and study quality preclude determination of optimal interventions to promote adherence in this population. Further evaluation with sound study design may inform the development of best practices for treating chronic disease in patients with SUD.

Prescribing Opioids as an Incentive to Retain Patients in Medical Care: A Qualitative Investigation into Clinician Awareness and Perceptions

HIV treatment retention remains a significant public health concern. Our qualitative analysis used emergent data from a larger HIV treatment study to explore clinician perspectives on prescribing opioids to incentivize retention in HIV care. Data from individual interviews with 29 HIV and substance use clinicians were analyzed using thematic analysis. Prescribing opioids as a retention strategy emerged as a theme. Nine of 11 HIV clinicians reported prior knowledge of this practice; only one of 12 substance use clinicians indicated prior knowledge. Positive perceptions included: harm reduction approach, increased appointment attendance, and sustained engagement in HIV care. Negative perceptions included: addiction potential, increased engagement not leading to better health outcomes, and prescriptions becoming the appointment focus. Some clinicians used prescriptions as a strategy to improve treatment retention, which may be particularly problematic in light of the current opioid epidemic. Understanding motives, outcomes, and clinical decision-making processes is needed.

Contingency Management: New Directions and Remaining Challenges for An Evidence-Based Intervention

This article introduces the special issue on contingency management (CM), an efficacious intervention for the treatment of substance use disorders with low uptake in clinical settings that is not commensurate with evidence for efficacy. In this special issue of the Journal of Substance Abuse Treatment, we present 16 articles representing the latest research in efficacy, implementation, and technological advances related to CM. Combined, this collection of articles highlights the diverse populations, settings, and applications of CM in the treatment of substance use disorders. We conclude by highlighting directions for future research, particularly those that may increase CM's appeal and uptake in routine clinical care.