The University of Miami Infectious Disease Elimination Act Syringe Services Program: A Blueprint for Student Advocacy, Education, and Innovation

Improving access to HIV care among people who inject drugs through tele-harm reduction: a qualitative analysis of perceived discrimination and stigma

BACKGROUND

Tele-harm reduction (THR) is a telehealth-enhanced, peer-led, harm reduction intervention delivered within a trusted syringe services program (SSP) venue. The primary goal of THR is to facilitate linkage to care and rapid, enduring virologic suppression among people who inject drugs (PWID) with HIV. An SSP in Miami, Florida, developed THR to circumvent pervasive stigma within the traditional healthcare system.

METHODS

During intervention development, we conducted in-depth interviews with PWID with HIV (n = 25) to identify barriers and facilitators to care via THR. We employed a general inductive approach to transcripts guided by iterative readings of the raw data to derive the concepts, themes, and interpretations of the THR intervention.

RESULTS

Of the 25 PWID interviewed, 15 were in HIV care and adherent to medication; 4 were in HIV care but non-adherent; and 6 were not in care. Themes that emerged from the qualitative analysis included the trust and confidence PWID have with SSP clinicians as opposed to professionals within the traditional healthcare system. Several barriers to treatment were reported among PWID, including perceived and actual discrimination by friends and family, negative internalized behaviors, denial of HIV status, and fear of engaging in care. Facilitators to HIV care included empathy and respect by SSP staff, flexibility of telehealth location, and an overall destigmatizing approach.

CONCLUSION

PWID identified barriers and facilitators to receipt of HIV care through the THR intervention. Interviews helped inform THR intervention development, centered on PWID in the destigmatizing environment of an SSP.

Building a strong foundation from the ground up: the impact of a medical student substance use disorder organization on curriculum and community

Due to the increasing rates of substance use disorders (SUDs), accidental overdoses, and associated high mortality rates, there is an urgent need for well-trained physicians who can grasp these complex issues and help struggling patients. Preparing these physicians occurs through targeted education and clinical exposure in conjunction with medical school curricula in the field of addiction medicine. Medical students can often feel overwhelmed by the medical school curriculum and changes to the curriculum take time, money, and administrative commitment to ratify. Implementing a student organization dedicated to SUD education can be a solution to provide clinical exposure, education and student autonomy in their medical school experience. At Wayne State University School of Medicine, Detroit vs. Addiction (DvA) is a student-run organization that is filling the gap in SUD education for medical students whilst providing assistance to the community. DvA not only extends clinical education for physicians in training, but it also provides the medical school with an opportunity to allow students to create a blueprint for education initiatives that can be incorporated as a mainstay in the school's technical trainings. Herein, we describe the evolution of this organization and its activities.

Untold Risk: HIV Transmission Behaviors in Miami's Historically Black Communities

Advances in HIV prevention therapies have led to significant reductions in HIV transmission across the USA. However, these resources have not been equally utilized across all populations, with Black communities in the Southeastern USA experiencing among the greatest HIV disparities in the nation. Tailoring HIV programs to align with the cultural norms of minority communities is one approach that can increase uptake of HIV prevention services. However, accomplishing this requires a rich understanding of the unique risk factors and the context of HIV transmission among men and women within culturally distinct communities. To further our understanding, we examined HIV risk behaviors among Black adults living in geographic HIV hotspots of Miami-Dade County. Between December 2016 and April 2019, data on HIV risk behaviors use a standardized HIV assessment developed by the Florida Department of Health. Chi-square and t-test analyses were conducted to examine differences in population demographics and risk factors, and logistic regression was used to test for predictors of HIV status. Results indicate that a significant portion of participants had prior experience with HIV testing, a known protective factor against HIV transmission. Despite this, much of the sample also reported recent engagement in high-risk sexual behaviors. These findings emphasize the need for intervention development within the context of population-specific behaviors. Future research should further consider the importance of transmission behaviors among clusters of demographically similar populations at high risk for or living with HIV.

Program Adaptations to Provide Harm Reduction Services During the COVID-19 Pandemic: A Qualitative Study of Syringe Services Programs in the U.S

Syringe services programs (SSPs) are essential to preventing injection drug use-related infections and overdose death among people who use drugs (PWUD). The novel coronavirus (COVID-19) pandemic initially impeded SSPs' operations. To effectively support these programs, information is needed regarding SSPs' experiences adapting their services and the challenges posed by COVID-19. We conducted qualitative interviews with leadership and staff from a sample of 31 U.S. SSPs. Respondents discussed urgent concerns including reduced reach of services, suspended HIV/hepatitis C testing, high COVID-19 risk among PWUD, and negative impacts of isolation on overdose and mental health. They also noted opportunities to improve future services for PWUD, including shifting to evidence-based distribution practices and maintaining regulatory changes that increased access to opioid use disorder medications post-pandemic. Findings can inform efforts to support SSPs in restoring and expanding services, and provide insight into SSPs' role in engaging PWUD during the COVID-19 response and future emergencies.

Implementation and first-year operating costs of an academic medical center-based syringe services program

BACKGROUND

Syringe services programs (SSPs) remain highly effective, cost-saving interventions for the prevention of blood-borne infections among people who inject drugs. However, there have been restrictions regarding financial resources allocated to these programs, particularly in the US South. This study aimed to provide cost data regarding the implementation and first-year operations of an academic-based SSP utilizing fixed and mobile strategies, including the integration of onsite wound care.

METHODS

We conducted a micro-costing study that retrospectively collected detailed resource utilization and unit cost data for both the fixed and mobile SSP strategies, including onsite wound care, from both healthcare and societal perspectives. A three-step approach was used to identify, measure, and value intervention costs, and cost components were categorized into implementation, variable program, and time-dependent costs. Sensitivity analysis was performed to examine the impact of SSP operational changes (i.e., needs-based distribution and opt-out HIV/HCV testing) on the cost-per-participant. Cost data we presented as overall cost and cost-per-participant adjusted to 2017 US dollars.

RESULTS

A total of 452 and 129 participants enrolled in fixed and mobile SSP services, respectively. The total cost associated with implementation and first year operations for the fixed site was $407,217.22 or $729.72 per participant and $311,625.52 or $2415.70 per participant for the mobile unit. The largest cost component for both modalities was time-dependent costs (personnel and overhead), while intervention materials (syringes, injection equipment, naloxone) were less than 15% of the total program cost.

DISCUSSION/CONCLUSION

Implementation and operation of new SSP models continue to be low cost compared to treatment for the multitude of harms PWID face without access to evidence-based prevention. Future cost-effectiveness and cost-benefit analyses integrating a comprehensive SSP model within an academic institution, including onsite wound care and other medical services, will provide a more comprehensive understanding of this model, and state-level policy action must be taken to lift the prohibition of state and local funds for the implementation, sustainability, and maintenance of these programs in Florida.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.

Developing and validating an opioid overdose prevention and response curriculum for undergraduate medical education

Introduction: As rates of overdose and substance use disorders (SUDs) increase, medical schools are starting to incorporate more content on SUDs and harm reduction in undergraduate medical education (UME). Initial data suggest these additions may improve medical student knowledge and attitudes toward patients with SUDs; however, there is no standard curriculum. Methods: This project uses a six-step approach to UME curricular development to identify needs and goals regarding SUDs and opioid overdose at a large single-campus medical school in the United States. We first developed and delivered a pilot curriculum to a small group of medical students. Pilot results and a larger survey led to implementing a one-hour Opioid Overdose Prevention and Response (OOPR) Training for first-year students. Effects of training were tracked using baseline and post-training surveys examining knowledge and attitudes toward opioid overdose and patients with SUDs. Results: Needs assessment indicated desire and need for training. The pilot study (N = 66) resulted in significantly improved knowledge regarding opioid overdose; 100% of students enjoyed training and believed others should receive it. The larger replication study surveyed all incoming students (N = 266) to gauge initial knowledge and experiences with these topics. Results prompted enhancement of the OOPR Training curriculum, which was delivered to half of the first-year class. Post-training survey results replicated the pilot study findings. The majority (95.2%) of students enjoyed training and 98.4% believed all students should receive it. Conclusion: Delivering a thorough curriculum on SUDs and harm reduction in UME is critical. Although many schools are implementing training, there is no standard curriculum. We outline a low-resource training intervention for OOPR. Our findings identified key features to include in these UME curricula. This approach provides a replicable template for schools seeking to develop brief educational interventions and identify essential content for curricula in SUDs and harm reduction.