COVID-19 vaccination acceptability and experiences among people who inject drugs in San Diego County

Uptake of COVID-19 Vaccination and Related Factors Among People who Inject Drugs, San Francisco, 2022

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.

Psychosocial experience of the Covid-19 crisis among people who use or inject drugs in Algeria: A community-based qualitative study

The COVID-19 crisis had a global impact and many marginalised groups, such as people who use or inject drugs, are more vulnerable to the SARS-CoV-2 virus and its consequences due to their pre-existing health inequalities. Moreover, people who use/inject drugs are also criminalised in some countries such as Algeria. This analysis aimed to explore the psychosocial experience of the COVID-19 crisis among people who use/inject drugs in Algeria. Twenty-nine qualitative interviews were conducted in 2021 with a community-based approach. Results of the thematic content analysis showed the intersectional effects of the COVID-19 crisis among people who use or inject drugs through the experience of a double crisis: one related to COVID-19 and the second to their specific difficulties related to drug use. Addressing social inequalities in health of people who use or inject drugs, through better recognition of their rights and needs, is crucial to improving their health.

Covid-19 Vaccine Hesitancy and Under-Vaccination among Marginalized Populations in the United States and Canada: A Scoping Review

BACKGROUND

Amid persistent disparities in Covid-19 vaccination and burgeoning research on vaccine hesitancy (VH), we conducted a scoping review to identify multilevel determinants of Covid-19 VH and under-vaccination among marginalized populations in the U.S. and Canada.

METHODS

Using the scoping review methodology developed by the Joanna Briggs Institute, we designed a search string and explored 7 databases to identify peer-reviewed articles published from January 1, 2020-October 25, 2022. We combine frequency analysis and narrative synthesis to describe factors influencing Covid-19 VH and under-vaccination among marginalized populations.

RESULTS

The search captured 11,374 non-duplicated records, scoped to 103 peer-reviewed articles. Among 14 marginalized populations identified, African American/Black, Latinx, LGBTQ+, American Indian/Indigenous, people with disabilities, and justice-involved people were the predominant focus. Thirty-two factors emerged as influencing Covid-19 VH, with structural racism/stigma and institutional mistrust (structural)(n = 71) most prevalent, followed by vaccine safety (vaccine-specific)(n = 62), side effects (vaccine-specific)(n = 50), trust in individual healthcare provider (social/community)(n = 38), and perceived risk of infection (individual)(n = 33). Structural factors predominated across populations, including structural racism/stigma and institutional mistrust, barriers to Covid-19 vaccine access due to limited supply/availability, distance/lack of transportation, no/low paid sick days, low internet/digital technology access, and lack of culturally- and linguistically-appropriate information.

DISCUSSION

We identified multilevel and complex drivers of Covid-19 under-vaccination among marginalized populations. Distinguishing vaccine-specific, individual, and social/community factors that may fuel decisional ambivalence, more appropriately defined as VH, from structural racism/structural stigma and systemic/institutional barriers to vaccination access may better support evidence-informed interventions to promote equity in access to vaccines and informed decision-making among marginalized populations.

COVID-19 vaccine implementation at a syringe services program: experiences of frontline staff

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.

Syringe services program staff and participant perspectives on changing drug consumption behaviors in response to xylazine adulteration

BACKGROUND

Xylazine is an increasingly common adulterant in the North American unregulated drug supply that is associated with adverse health outcomes (e.g., skin infections, overdose). However, there are significant knowledge gaps regarding how xylazine was initially identified and how syringe services program (SSP) staff and clients (people who use drugs) responded to its emergence.

METHODS

From June-July 2023, we conducted qualitative interviews with medical (e.g., clinicians) and frontline SSP staff (e.g., outreach workers) and adult clients with a history of injection drug use at a Miami-based SSP. Inductive memos identified emergent codes; thematic analysis involving team consensus established final themes.

RESULTS

From interviews with SSP staff (n = 8) and clients (n = 17), xylazine emergence was identified at different times, in various ways. Initially, during summer 2022, clients identified a "tranquilizer-like substance" that worsened sedation and withdrawal and caused wounds. SSP medical staff later identified this adulterant as xylazine by treating new medical cases and through diverse information-sharing networks that included professional societies and news sources; however, frontline SSP staff and clients needed additional educational resources about xylazine and its side effects. With limited guidance on how to reduce harm from xylazine, SSP clients altered their drug consumption routes, reduced drug use, and relied on peers' experiences with the drug supply to protect themselves. Some individuals also reported preferring xylazine-adulterated opioids and increasing their drug use, including the use of stimulants to avoid over sedation.

CONCLUSIONS

Xylazine's emergence characterizes the current era of unprecedented shifts in the unregulated drug supply. We found that xylazine spurred important behavioral changes among people who use drugs (e.g., transitioning from injecting to smoking). Incorporating these experiences into early drug warning surveillance systems and scaling up drug-checking services and safer smoking supply distribution could help mitigate significant health harms caused by xylazine and other emergent adulterants.

Protective or potentially harmful? Altering drug consumption behaviors in response to xylazine adulteration

Background

Xylazine is an increasingly common adulterant in the North American unregulated drug supply that is associated with adverse health outcomes (e.g., skin infections, overdose). However, there are significant knowledge gaps regarding how xylazine was initially identified and how syringe services program (SSP) staff and clients (people who use drugs) responded to its emergence.

Methods

From June-July 2023, we conducted qualitative interviews with medical (e.g., clinicians) and frontline SSP staff (e.g., outreach workers) and adult clients with a history of injection drug use at a Miami-based SSP. Inductive memos identified emergent codes; thematic analysis involving team consensus established final themes.

Results

From interviews with SSP staff (n = 8) and clients (n = 17), xylazine emergence was identified at different times, in various ways. Initially, during summer 2022, clients identified a "tranquilizer-like substance" that worsened sedation and withdrawal and caused wounds. SSP medical staff later identified this adulterant as xylazine by treating new medical cases and through diverse information-sharing networks that included professional societies and news sources; however, frontline SSP staff and clients needed additional educational resources about xylazine and its side effects. With limited guidance on how to reduce harm from xylazine, SSP clients altered their drug consumption routes, reduced drug use, and relied on peers' experiences with the drug supply to protect themselves. Some individuals also reported preferring xylazine-adulterated opioids and increasing their drug use, including the use of stimulants to avoid over sedation.

Conclusions

Xylazine's emergence characterizes the current era of unprecedented shifts in the unregulated drug supply. We found that xylazine spurred important behavioral changes among people who use drugs (e.g., transitioning from injecting to smoking). Incorporating these experiences into early drug warning surveillance systems and scaling up drug-checking services and safer smoking supply distribution could help mitigate significant health harms caused by xylazine and other emergent adulterants.

Vaccination coverage among people who inject drugs: A systematic review

BACKGROUND

People who inject drugs may be at excess risk of acquiring vaccine-preventable diseases and negative associated health outcomes, but experience barriers to vaccination. We aimed to determine vaccination coverage among people who inject drugs globally.

METHODOLOGY

We conducted systematic searches of the peer-reviewed and grey literature, date limited from January 2008 to August 2023, focusing on diseases for which people who inject drugs are at elevated risk for and for which an adult vaccination dose is recommended (COVID-19, hepatitis A, hepatitis B, human papillomavirus, influenza, pneumococcal disease, tetanus). To summarise available data, we conducted a narrative synthesis.

RESULTS

We included 78 studies/reports comprising 117 estimates of vaccination coverage across 36 countries. Most estimates were obtained from high income countries (80%, n=94). We located estimates for hepatitis B vaccination in 33 countries, which included 18 countries with data on serological evidence of vaccine-derived hepatitis B immunity (range: 6-53%) and 22 countries with self-report data for vaccine uptake (<1-96%). Data for other vaccines were scarcer: reported hepatitis A vaccination coverage ranged 3-89% (five countries), COVID-19 ranged 4-84% (five countries), while we located estimates from fewer than five countries for influenza, tetanus, pneumococcal disease, and human papillomavirus.

CONCLUSION

Estimates were sparse but where available indicative of suboptimal vaccination coverage among people who inject drugs. Improving the consistency, timeliness, and geographic coverage of vaccine uptake data among this population is essential to inform efforts to increase uptake.

Time-to-completion of COVID-19 vaccination primary series varies by HIV viral load status among people who inject drugs in Baltimore, Maryland

People who inject drugs (PWID) may have diminished access to essential preventive services like COVID-19 vaccination given structural and substance use barriers. We aimed to assess the role of HIV on COVID-19 vaccination uptake among adult PWID participating in the ALIVE cohort study in Baltimore, Maryland who were alive as of April 2021. We abstracted COVID-19 vaccination data from electronic medical records via the regional health information exchange. We used Kaplan-Meier method to estimate time from universal vaccine eligibility (April 6, 2021) to completion of the COVID-19 vaccination primary series (1 dose J&J or 2 doses mRNA) by HIV viral load status (uninfected, PWH [HIV-RNA < 400 copies/mL], PWH [HIV-RNA ≥ 400 copies/mL]) and Cox Proportional Hazards regression to adjust for potential confounders. Our sample (N = 960) was primarily black (77%) and male (65%) with 31% reporting recent injection drug use. Among 265 (27%) people living with HIV (PWH) in our sample, 84% were virally suppressed. As of February 22, 2022, 539 (56%) completed the primary series, 131 (14%) received a single dose of mRNA vaccine and 290 (30%) remained unvaccinated. Compared to PWID without HIV, virally suppressed PWH were more likely to complete the primary series (Adjusted Hazard Ratio [aHR]:1.23,95% Confidence Interval [95 %CI]:1.07,1.50), while PWH who were not virally suppressed were less likely (aHR:0.72,95 %CI:0.45,1.16), although this was not statistically significant. We conclude that among PWID, HIV infection and viral suppression is associated with quicker vaccination uptake, likely due to HIV care engagement. Targeted improvements along the HIV care continuum may bolster vaccine uptake.

Vaccine decision making among people who inject drugs: Improving on the WHO's 3C model of vaccine hesitancy

The objectives of this study were to 1) identify vaccination rates among PWID in Oregon at a time when vaccines were easily accessible, 2) quantitatively identify convergence with demographic correlates of vaccination willingness and uptake to promote generalizability, and 3) explore the factors PWID were considering when deciding whether or not to receive the COVID-19 vaccine. We conducted a mixed-methods study design including 260 quantitative surveys and 41 in-depth qualitative interviews with PWID, conducted July - September 2021 at syringe services programs in Lane County, Oregon. Among the 260 survey respondents, 37.3% indicated that they had received a COVID-19 vaccine by October 1, 2021. In the same period, an estimated 70.1% of the total Lane County population had completed their COVID-19 vaccinations (not including booster rounds). We explored alignment with the WHO's 3C model of vaccine hesitancy and identified, instead, five common factors as key motivators for vaccine decisions: confidence, convenience, concern, communication, and community implications among PWID. Interviews with PWID describe systemic barriers which prevented them from accessing healthcare resources. We highlight that our proposed 5C model may more accurately depict how PWID navigate vaccine decisions by incorporating the ways that social inequities, infrastructural barriers, and community values influence an individual's vaccine deliberation.

Prevalence and correlates of SARS-CoV-2 seropositivity among people who inject drugs in Baltimore, Maryland

Background

SARS-CoV-2 serosurveys can help characterize disparities in SARS-CoV-2 infection and identify gaps in population immunity. Data on SARS-CoV-2 seroprevalence among people who inject drugs (PWID) are limited.

Methods

We conducted a cross-sectional study between December 2020 and July 2022 among 561 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study-a community-based cohort of current and former PWID in Baltimore, Maryland. Serum samples were assayed for infection-induced anti-nucleocapsid (anti-N) and infection and/or vaccination-induced anti-spike-1 (anti-S) SARS-CoV-2 IgG. We estimated adjusted prevalence ratios (aPR) via modified Poisson regression models.

Results

The median age was 59 years, 35% were female, 84% were non-Hispanic Black, and 16% reported recent injection drug use. Anti-N antibody prevalence was 26% and anti-S antibody prevalence was 63%. Anti-N and anti-S antibody prevalence increased over time. Being employed (aPR=1.53 [95%CI=1.11-2.11]) was associated with higher anti-N prevalence, while a cancer history (aPR=0.40 [95%CI=0.17-0.90]) was associated with lower anti-N prevalence. HIV infection was associated with higher anti-S prevalence (aPR=1.13 [95%CI=1.02-1.27]), while younger age and experiencing homelessness (aPR=0.78 [95%CI=0.60-0.99]) were factors associated with lower anti-S prevalence. Substance use-related behaviors were not significantly associated with anti-N or anti-S prevalence.

Conclusions

SARS-CoV-2 seroprevalence increased over time among current and former PWID, suggesting cumulative increases in the incidence of SARS-CoV-2 infection and vaccination; however, there were disparities in infection-induced seroprevalence and infection and/or vaccine-induced seroprevalence within this study sample. Dedicated prevention and vaccination programs are needed to prevent disparities in infection and gaps in population immunity among PWID during emerging epidemics.

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.